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We used Cox regression to assess associations between county-level median household income (proxy for socioeconomic status), rurality, and their joint effects on invasive SPC risk, adjusting for demographic and clinical factors. We examined risk for all SPCs, non-breast SPCs, and the three most common SPC sites (breast, lung\/bronchus, colorectal). Models were further stratified by index breast cancer characteristics.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      During 6.1 median years of follow-up, 65,954 survivors developed an SPC (42,400 non-breast; 23,554 breast, 8,338 lung\/bronchus, 5,442 colorectal). Survivors from lower-income counties had higher SPC risk (&lt;\u2009$50,000 vs.\u2009\u2265\u2009$75,000: HR\u2009=\u20091.07, 95% CI\u2009=\u20091.04\u20131.10), driven by lung\/bronchus (HR\u2009=\u20091.32, 95% CI\u2009=\u20091.23\u20131.42) and colorectal cancers (HR\u2009=\u20091.19, 95% CI\u2009=\u20091.09\u20131.31). Lung\/bronchus cancer risk was stronger among younger (age\u2009&lt;\u200950: HR\u2009=\u20091.95, 95% CI\u2009=\u20091.59\u20132.39, age\u2009\u2265\u200950: HR\u2009=\u20091.20, 95% CI\u2009=\u20091.12\u20131.28;\n                      <jats:italic>p<\/jats:italic>\n                      interaction\u2009&lt;\u20090.001) and Estrogen Receptor (ER)-negative survivors (ER negative: HR\u2009=\u20091.50, 95% CI\u2009=\u20091.31\u20131.72; ER positive: HR\u2009=\u20091.21, 95% CI\u2009=\u20091.12\u20131.30;\n                      <jats:italic>p<\/jats:italic>\n                      interaction\u2009=\u20090.02). Survivors from rural counties had higher SPC risk compared with most urban counties (HR range:1.07\u20131.12), especially for lung\/bronchus cancer in younger (age\u2009&lt;\u200950: HR\u2009=\u20091.66, 95% CI\u2009=\u20091.34\u20132.05, age\u2009\u2265\u200950: HR\u2009=\u20091.13, 95% CI\u2009=\u20091.06\u20131.21;\n                      <jats:italic>p<\/jats:italic>\n                      interaction\u2009=\u20090.001) and ER-negative survivors (ER negative: HR\u2009=\u20091.45, 95% CI\u2009=\u20091.26\u20131.67; ER positive: HR\u2009=\u20091.11, 95% CI\u2009=\u20091.03\u20131.20;\n                      <jats:italic>p<\/jats:italic>\n                      interaction\u2009=\u20090.001). Survivors in rural\/lower-income counties had the highest SPC risk compared with urban\/higher-income counties (HR-range: 1.20\u20131.23), particularly for lung\/bronchus cancer (HR\u2009=\u20091.57, 95% CI\u2009=\u20091.10\u20132.23).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Studies are needed to understand factors driving the impact of socioeconomic status and rurality (e.g., access to care) on SPC risk to inform preventive strategies for breast cancer survivors.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s10552-025-02054-8","type":"journal-article","created":{"date-parts":[[2025,9,4]],"date-time":"2025-09-04T07:05:32Z","timestamp":1756969532000},"page":"1813-1824","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["County-level socioeconomic status, rurality, and second primary cancer risk among breast cancer survivors in the United States"],"prefix":"10.1007","volume":"36","author":[{"given":"Katherine","family":"Ho","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carolyn","family":"Brandt","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jessica","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Geetanjali","family":"Datta","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Justin X.","family":"Moore","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lene H. 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