Long-term cancer survivor awareness and learning preferences for cardio- oncologic risks: A qualitative study

Long-term cancer survivor awareness and learning preferences for cardio- oncologic risks: A qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Long-term cancer survivor awareness and learning preferences for cardio- oncologic risks: A qualitative study Carolyn Smith-Morris, Marisel Ponton, Shelia Patterson, Arthur S Hong, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8670497/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Purpose: To understand general CVD risk awareness and learning preferences of cancer survivors, with particular attention to the learning needs of long-term (>5 year) survivors. Methods: We performed a qualitative sub-study of participants recruited from 14 community educational and health events in an underserved are of Dallas, TX from July 2023 – May 2024. Recorded interviews were transcribed verbatim, analyzed in two phases (framework analysis then systematic coding) to identify themes. Results: Twenty-six cancer survivors ranging in age from 30 to 82 (average age of 64.5 years) were interviewed, a large majority being long-term (>5 year) survivors and African American. Participants had diverse types of cancer, predominantly breast or prostate. Triangulation methods produced 3 themes: (1) Although a majority (73%) of participants self-reported knowledge about CVD risks after cancer treatment, narratives revealed a substantial lack of clarity about individual cardio-oncologic risk factors, such as the latent risks from chemotherapy or radiation. (2) Participants expressed trust and satisfaction with communications from their cancer treatment team with most (77%) stating that greater CVD risk understanding would not have changed their oncology treatment decisions. (3) For learning about CVD risks, participants preferred conversations with healthcare providers at multiple time points, before and after oncology treatment, as well as written materials that could be preserved and consulted later in the survivorship period. Conclusion: Survivors initially over-estimated their knowledge of CVD risks related to their cancer treatment and relied on their clinicians to raise concerns. Survivors’ awareness of CVD risks may be improved through targeted communications by clinicians, particular for long-term survivors, supplemented by durable reference materials. Greater attention to long-term CVD risk awareness in cancer survivors may improve CVD prevention among cancer survivors. Cancer Survivorship Patient Education Prevention Introduction Cancer survivors are at increased risk for cardiovascular disease (CVD), due in part to the cardiotoxicity of cancer treatments and shared cardiovascular and oncological disease risk factors 1-6 . Cardiotoxicity has been linked to common treatments for breast cancer, including chemotherapy, molecularly targeted therapies, hormonal therapies, radiotherapy involving the heart field, and newer immunotherapies 7-10 . Also, men with prostate cancer are 4.5 times more likely to die due to other causes than cancer, mostly due to CVD. 11,12 These differences in cardiotoxicity are compounded by social and economic factors that follow racial and ethnic patterns with higher prevalence cancers, such as breast and prostate cancer, having the widest disparities in cancer mortality along racial lines 13,14 . Cancer survivors have limited awareness of their CVD risks and cardio-oncology care resources 15 despite more than a decade of calls for “dynamic partnership” between oncologists and cardiologists 16 and the creation of cardio-oncology practice guidelines promoting patient education of CVD risks 17,18 . Research has shown CVD risk factors such as obesity, hypertension, and inactivity are higher among cancer survivors than the general adult population 15,19 . Because many of these chronic risk factors require daily behavioral effort to manage, patient awareness and activation regarding management of these risks is especially important 20 . As the survivorship period lengthens and standard survivorship plans have ended 15 , patients may forget risk information, become generally less active 4 , and face other barriers to prevention behaviors 21 . Cardio-oncology focused patient education, if it occurs, is most visible at discharge (e.g., after surgery) 22,23 , in part due to the need to avoid “information overload” during oncology treatment 24,25 . But there is limited research on survivor knowledge of CVD risks 15,26-28 and essentially no understanding of patient retention of information over the survivorship continuum 29 . Optimal educational content, mode, and timing for cardio-oncology education across survivorship are also obscure 30,31 . Long-term (>5 year) survivors may require novel educational strategies because learning preferences change with age 32,33 , time since treatment 34 , technological skills 35 , and other psychological 36-38 and behavioral variables 26,31,39 . Further research is needed to understand survivor self-assessed awareness, information needs 40 , and concerns 41,42 to promote beneficial lifestyle and behaviors 43,44 across a potentially long survivorship continuum. To understand cancer survivors’ self-assessed awareness of CVD risk and their information needs and preferences, we conducted a mixed method study with survey and interview components. The current report summarizes thematic findings from qualitative interviews conducted with predominantly long-term (>5 year) participants in community and virtual settings. Survey results are reported elsewhere. Our overall goal in this study was to characterize survivors’ current self-reported knowledge of CVD risks and best strategies for addressing their informational needs throughout the survivorship lifespan. Methods Design. Using a phenomenological approach 4,45 to survivor experience and perceptions of risk 46 , with interview questions secondarily attentive to socioecological theory’s 47,48 multiple influential levels of patient contexts (from individual to societal), we conducted a qualitative study as part of a larger mixed methods study. We used semi-structured interviews in community or video conference settings. Objectives of the interviews were to assess survivor (a) awareness of their cardiovascular risks (whether specific treatment related risks, if any, or general concerns about obesity, hypertension, or inactivity), (b) engagement in prevention behaviors, and (c) preferences for health education. Setting. The larger mixed methods study was an online survey with participants recruited through our community-based cancer survivor organizations (50 Hoops and the Oak Cliff Bible Fellowship), social media announcements, and direct emails to registered patients in the University of Texas Southwestern Medical Center cardio-oncology clinic. The sample for this qualitative interview study was drawn from participants recruited through more than 14 educational and screening events with our partner, community-based cancer survivor organizations in a historically underserved area of southern Dallas. These included tabling sessions at 2 large community health fairs, video lectures to community groups on cardio-oncology topics, and several presentations of our work in community settings. This mix of strategies 49 enabled a diversity in the gender, age, race/ethnicity, and types of cancer of our participants while reflecting the demographic make-up of this sector in our service area. Participants. Interview participants were drawn from the larger study sample and met the same inclusion criteria, namely: adult, English-speaking persons, recruited through the partner organizations, who had been diagnosed with any form of cancer. We invited 26 participants enrolled in our larger, mixed-methods study to complete interviews. This sample size is not only adequate for identifying a high number of themes in qualitative analysis, but sufficient to capture all variance of meaning within themes. 50 Participants were eligible for interview if they had completed the survey methods and lived in the Dallas area zip code. However, word-of-mouth recruitment through our southern Dallas partner produced a sample predominantly from southern Dallas. Interview participants ranged in age from 30-82 (with an average age of 64.5 years), were majority African American (65%), and reported a prior diagnosis of the following cancers: breast (n=11); prostate (7); lung (2); stomach (1); melanoma (2); pancreatic (1); bladder (1); and colon and prostate (1). The majority of our sample (n=16) were also long-term survivors, having completed cancer treatment 10 or more years ago, while 6 had completed treatment within the last 5 years, and 4 were still in active treatment. (See Table 1) Table 1. Sample Characteristics Data Collection. Following an informed consent procedure that was approved by the UT Southwestern Medical Center Institutional Review Board (STU# 2023-0839), interviews lasted between 20 and 60 minutes, were recorded, then transcribed verbatim. Interviews were conducted by CSM, MP or another skilled research assistant (HH, see acknowledgements) under the supervision of CSM, a PhD medical anthropologist and licensed professional counselor. Interviews were held in quiet and private locations selected by the participants, including church spaces or in their homes via video conference. In consultation with our multi-disciplinary investigative team of qualitative research specialists, clinicians, and community members, CSM designed the Interview Guide informed by phenomenological 45,46 and socioecological theoretical perspectives 47,48 and based on knowledge of the cardio-oncology literature. Two pilot interviews were conducted to refine questions and sequencing. The final guide is provided in Table 2. Table 2. Interview Guide Data Analysis. Transcripts were analyzed in two phases by CSM, MP, or other skilled research assistants under the supervision of CSM (HH and KR, see acknowledgements). First, we employed framework analysis 51 on a selection of interview responses to understand patterns across the sample on interval (e.g., How many years since cancer diagnosis?) and ordinal (e.g., Who talked to you about post-treatment care?) content in narrative responses. Second, we performed systematic coding of the transcribed narratives which produced a codebook of 12 codes: 7 parent and 5 child codes. (See Table 3) At least two independent coders used NVivo software 52 to code the first 13 transcripts. At this point, inter-rater reliability scores reached .7 53 , the codebook was considered final (i.e., no new open coding or hierarchy changes), and a single coder was used thereafter. Additional post hoc coding was made to organize large code sets. Final analysis to determine major themes was made via inductive and deductive analysis of patterns and salience or importance to research goals 54,55 . That is, our systematic analysis of the coded data included triangulation 54,56 of various data points (i.e., within code applications, content of the narratives themselves, and code co-occurrences) and the use of both inductive and deductive reasoning to recognize patterns in the data set. Table 3. Codebook with Definitions and # of Unique Excerpts Themes Our analysis produced three major themes: (1) relying on doctors to raise/address CVD risks; (2) CVD as a (non-)factor in oncology decision-making; and (3) learning preferences for CVD risk information. We report each in turn below. Relying on Doctors to Raise/Address Cardio-Oncology Risks We asked a series of questions about participants’ receipt and knowledge of information related to CVD risk, particularly risks related to their oncology treatments (See Table 1). We were concerned not with an objective test of knowledge, but with participants experience and self-assessed awareness of risks, whether specific to their own treatment, if any, or their general concerns about obesity, hypertension, or inactivity. In general, participants thought their awareness of CVD risk information was high. In the earliest part of the interview, when we asked directly whether the understood their cancer treatment-related risks for CVD, most participants expressed they had been well informed by their clinicians, felt able to ask questions and make informed decisions about their cancer treatment risks and effects, and expressed satisfaction with their treatment. However, later questions probed for detail about participant knowledge of their CVD risk, and this narrative content revealed greater complexities including confusion and some revision to their original responses. More specifically, in response to our question #3, “Did a health professional talk to you about your post-oncology treatment needs?”, 19 of 26 participants (73%) affirmed that their clinician had spoken with them. However, only 17 participants (65%) affirmed that they knew their risks for post-oncology CVD. fewer still (16 or 62%) said they understood the possible impacts of their oncology treatments to their heart. And many of their responses were very general about CVD risk (e.g., “I’m not aware of any.”). These results likely reflect some social desirability response 57 . But the narratives convey participant confusion on this topic. INTERVIEWER Do you think your cardiovascular risk changed after your cancer treatment? INT04: No, not particularly, because I feel fine. INT06: No, I've not had any cardiovascular risk. ... Well, it was Dr. --- and I had another doctor who I don't visit at all but she was my oncologist and she just said that it's possible that I might get weakness of the heart or that kind of thing, but that they would monitor me and everything like that, that from the chemo and the radiation treatments that I got, that I might suffer some small thing. But they didn't make a big deal of it. Finally, when we asked, “What do you know about the impacts and risks of your cancer treatments?”, only 12 participants (46%) could clearly indicate their awareness of CVD risks with information or specific narratives about risk from their doctor. These participants were usually under the care of a doctor (often a cardiologist) and actively monitoring their CVD risk. Their responses conveyed a high level of trust that their doctor would know their risk and provide the right recommendations when the time comes, as in this example: INT12: I don't know where the risks are for my heart. If the risks were more in radiation, [I would have learned about them] right before we made that plan. INT16: Well, if there had been any risks associated with my form of treatment, I think my surgeon would have mentioned them to me as well as my cardiologist, because I did have to get cardiology approval or prior to the surgery. Clearly, knowledge of oncology-related CVD risk is a complex and evolving subject; one that even one nurse-patient did not fully understand: INT04: I didn't know. I, of course, know about breast cancer, but I didn't know the different types of [it]. And, you know, because I was told that with my cancer, the triple negative, a lot of African American females get that, get this type. It doesn't mean that I knew everything because I'm a nurse. I didn't, you know? Or else, I probably did, and just, it just went out the window somewhere, you know? Given this complexity, our phenomenological, narrative data convey a known challenge in post-oncology patient education. We asked participants to describe their receipt and knowledge of information related to CVD risk, particularly risks related to their oncology treatments. The semi-structured interview format, along with active probing by our interviewers, helped reveal differences between participants’ first responses (often “yes” to knowing their oncology-related CVD risks) and later, more elaborated narratives suggesting less complete knowledge. In the end, only 12 of 26 (46%) individuals clearly described their CVD risks in any detail and knew whether they were related to their oncology treatment. And patterns across narratives revealed high participant trust in their doctors, and a relative lack of oncology-related CVD risk knowledge among those who were not under active supervision of a doctor. CVD as (Non-)Factor in Oncology Decision-Making The second major theme addresses whether CVD risks factored into participants’ oncology decisions. We did not ask explicitly why participants underwent certain treatments. Instead, we captured participant views about the relative importance of CVD risks in their oncology treatment decisions. Most participants (n=20) said that CVD knowledge or lack of it would not have changed their decision to undergo cancer treatment. They described having had “no choice” due to the urgency of the situation or their primary concern being to survive the cancer, and that all other concerns being secondary or “irrelevant”. INT02: But literally like this is like life or death and I wanted it out of my body. My doctors were like, we need a I need the data so I can make an informed decision and we need to act like immediately because again, we didn't know if this lump had appeared like two months ago or was it six months ago. INT04: They didn't give me a chance to even think about an option. INT08: I was like between a brick and a hard place. I didn't want to cancel the spread. My only option -- I didn't have another option. INT10: All I was concerned [about was] I'll get the cancer out. INT15: I just wanted a treatment for the prostate cancer. As of that point in time, I didn't put into consideration of my heart. This urgency in many oncology cases may have been a substantial but reasonable barrier to better patient understanding of oncology-related CVD risks. But whether education was provided later, after oncology treatment, we take up in the next section. Thus, only a few participants said that oncology-related CVD risks might have been a factor on their oncology treatment decisions. Their narratives suggest that greater attention to patient education may have made a difference to them, as to this man: INT09: I'm not sure if it would have made a difference in my choice to take the prostate gland out. The only option we had was with radiation seed implants, watching/wait, or some of the freezing thing. Unless they said having prostatectomy would leave you with a damaged heart or something, then I would obviously considered that. But there was never a part of the discussion. ...I've learned the hard way that side effects are certainly important to ask about. One woman with breast cancer pointed out a lack of communication between her different doctors. She felt that the overlaps between the different specialties was not discussed with her: INT14: I had the option of a lumpectomy, or mastectomy, which is either take it, just take the cancer out or take everything. ...Everything else wasn't really optional. ... But sometimes I feel like they don't really communicate with each other... Like my surgeon only talked about surgery. My oncologist doctor only talked about like the oncology part, the cancer part of it. My radiation doctor only talked about the effects of the radiation. Like, they never really crossed. When they spoke to me about things, they just stuck with their part of the treatment.... But while this participant felt her doctors did not communicate with each other, she found the potential for overlapping concerns to be too complex for her to think about: INT14: Don't tell me anything because I don't wanna have to change my mind. ...Ohh it was enough, like I had enough to think about without having to consider something else, so not knowing for me was better because you know? Only 2 participants said that additional information “maybe/possibly” would have led them to a different decision about oncology treatment. For example: INT24: I think because if maybe they would have maybe gave me an in depth knowledge about the risk and that would have maybe influenced my decision. And only one participant said “definitely”, they would have wanted to know but were not told by their oncologist. INT20: Oh, I didn't. No one mentioned anything about heart damage as a result of having that type of cancer or other procedures. No, I never heard of anything like that. ... Well, if it's gonna be some heart damage, definitely, I would have considered some other treatment. Finally, 3 participants did not clearly answer this question. Overall, these data make clear that “too much information” is an important concern for many patients facing oncology treatment, especially if their cancer is deemed by physicians to require urgent action. Learning Preferences for CVD Risk Information We posed a number of questions to understand the learning preferences of our participants for information about oncology-related CVD risk. (See Table 4) Table 4. Learning Preferences. Fifteen (58%) reported that a conversation with their health professional was their preferred source of CVD risk information, and most were satisfied with the information they received. INT24: It was an impressive conversation which I was able to express myself to the person as to how. And I was also getting a kind of emotional comfort and a word of advice from the person. ... I prefer meeting the person in a one-on-one conversation, that will give the patient that comfort. INT25: So it felt like a [inaudible] communication will be better so that they could actually detect my mood, know the atmosphere in which I was surrounded and know the best way to digest me and make me feel comfortable going for the surgery. And when asked the ideal time to bring up information about oncology-related CVD risk, most (n=17) participants (65%) preferred these conversations to happen before oncology treatment began: INT19: As far as the cancer, [the] doctor was not forthcoming in all the risks. So, I think more information, at least so we could be prepared. You know, even if he did go through the treatment the way he did, at least knowing more of what to expect. INT03: So, for me it was because I could just hit it, and just go with it and at the same time just boom, boom, boom. Because I wanted to know everything I could about what was going on with me. Six participants wanted conversation at multiple time points, to compensate for their own poor memory or concentration when they were fearful about the cancer diagnosis. For example: INT13: And then when I finished, I would like to hear it again. So that would have given me a chance to have it at the initial stage, and I probably would not have heard it very well but I would have heard something. Again, when I went for therapy, [it] would have been reiterated and then it would have been probably on my frontal lobe, I would have remembered. And then before my dismissal, it would have been a good time to have it again. And then that way I could connect those pieces. INT23: Somehow they should break some of this down, like even after you should have a post visit to talk about all these things. Participants expressed preferences for how they would like to receive CVD information. A majority (n=23) preferred conversation or 1:1 with their provider. Ten also liked written materials, 6 requested online, video or telephone formats, and only 2 mentioned in-person, community-based events as a preferred format. The sub-group (n=10 of 26, or 39%) wanted written materials suggested these as a supplement to 1:1 conversations: INT13: I would like it in a one to one personal [conversation]. And then giving it to me and in writing so I could read it later. I think a lot of times. INT22: I would have preferred it in a different format like after the one-on-one conversation probably maybe get a hard copy or a soft copy PDF file of everything. Because it was a long conversation, so most of the things I might forget it. And one suggestion in particular, for a personalized and hardbound book about their condition and their treatments, stood out among our participants’ narratives, given the lifelong need for information of many cancer survivors: INT12: The other thing that I got, and now what I'm going to do is I'm going to go back and look to see if I just didn't read that section... but I was blown away that I got in the mail like a bound book. They had my name on the front, my on-call or my surgeon's name and picture on the front of the book.... It's like 300 pages. It's a bound proper book. Finally, there was substantial variation in learning needs and preferences over time, depending on their anxiety about receipt of a diagnosis, the duration of treatment, and their life expectancy following treatment, as these participants explain: INTERVIEWER: Did you prefer to know about your risk of cardiovascular when deciding, like when they were telling you about treatments. INT04: I really wasn't interested in that at that time. INT09: No, I've had no discussion about that [oncology-related CVD risk]. The only time I've heard about that is when [de-identified] and when you were doing this study. And so we've been working with them with different things. So, that's the first I've heard that there might be a connection between cancer and cardiovascular. INT05: Your mind is not fully open to what they are telling you. Sometimes, initially you're thinking, you are going to die. And so now, once you get past that stage, well, maybe you ...can process the information that you're receiving. Discussion Given the apparent inconsistencies in CVD risk knowledge uncovered over the course of our interview - that is, the fact that 19 participants (73%) initially declared they knew their CVD risks but ultimately only 12 (46%) could clearly describe their own CVD risks in any detail - A systematic analysis of narratives from 26 majority long-term (>10 year) cancer survivors to understand their CVD risk knowledge and learning preferences yielded three thematic findings. First, differences between participants’ initial self-assessments of risk awareness and later narratives which lacked clarity about such risks were not surprising and may be partially attributable to social desirability influence 57 . However participants’ expressions of high reliance on doctors to bring risks to their attention when necessary 58-61 suggests to us a low level of activation 20,62 or a de-activated stage of change. 63 Providers may have inadequate time, educational facilities, or knowledge to facilitate adequate patient education 64,65 . Thus, survivor reliance on physicians alone, without their own behavioral and lifestyle prevention efforts, may contribute to survivors’ greater risk for CVD. An opportunity exists for cardio-oncology prevention education and/or activation among survivors 66,67 . Second, participants were satisfied with the information they received surrounding their oncology treatment and conveyed that one could have “too much information” when facing an oncology treatment decision. Thus, CVD risk education may be better place in the post-treatment period to avoid “information overload” 24,25 . Factors such as timing of education during or after oncology treatments 68,69 , readiness for learning 70,71 , and learning preferences for format and content 30,31 also affect survivor learning. Further, because of the increasing duration of cancer survivorship, diverse educational strategies may be required at different times in the survivorship period 41,72 in order to account for some of the unique barriers faced by long-term survivors 21,38 . Third, while conversation with one’s healthcare team was the favored learning format of most participants, several would have preferred conversation at multiple points in time including before and after treatment. Such preferences can place a high burden on providers{Yi, 2025, Primary care providers and their needs caring for cancer survivors: a qualitative study;Birken, 2019, Survivorship care plan implementation in US cancer programs: a national survey of cancer care providers}. Almost half of our majority-long-term survivors also wanted written materials for later consultation. Durable written materials, such as personalized bound books detailing one’s own diagnosis and treatment, may be especially useful for long-term survivor health literacy and patient-provider communications 73,74 . Our results also indicate survivor interest in online and virtual materials, which may alleviate some of the burden on providers to address this education and activation need. Finally, results of this study corroborate the limited reports on patient experience of shock and anxiety over learning of the risk or detection of CVD 66 . Our qualitative data also provide narratives expressing patient concern over lack of information on cardiotoxicity, their need for health education, and a lack of collaboration between oncologists and cardiologists 67 . Overall, survivors’ high sense of risk awareness coupled with a relatively poor ability to discuss risks (whether specific treatment related risks, if any, or general concerns about obesity, hypertension, or inactivity) suggests an opportunity to improve survivor awareness and, possibly, preventive behaviors. Improving survivor CVD knowledge may support better communication with healthcare teams and survivor participation in cardio-oncology prevention and treatment 29,75 . Limitations Our participants were predominantly survivors of breast or prostate cancers, and a predominantly African American sampled from a limited geographic area. These factors limit the generalizability of our findings to other cancer types or other groups. Also, while our phenomenological study design produced diverse perspectives on survivor risk awareness and learning preferences, we did not objectively test participants’ CVD risk knowledge. Conclusion This mixed methods study of cancer survivor’ knowledge of CVD risk and their educational needs and preferences yielded important and actionable details about survivor health literacy, and their diverse learning needs and preferences over potentially long survivorship periods. To inform more effective patient education, further research is needed to design and test effective health literacy strategies for long-term survivors at high risk for CVD. Declarations Acknowledgements: We gratefully acknowledge the Oak Cliff Bible Fellowship and 50 Hoops Legends for their partnership; funding from the Harold C. Simmons Comprehensive Cancer Center, Office of Community Outreach, Engagement & Equity, and from an award by the UT Southwestern Center for Translational Science Award. Thanks also to Lee Patterson, Hamid Sediqe, Libby Gracia, Zahria Griggs, Kendall Roark, Hira Hasan, Syed Ahsan, Hamid Sediqe, Vivian Palacios, and Egzona Tan for invaluable community outreach and research assistance. Author CRediT Statement: Smith-Morris - conceptualization, methodology, investigation, data curation, writing - original draft, writing - review and editing, visualization, supervision, project administration, and funding acquisition; Ponton - investigation, data curation, writing - review and editing, project administration; Patterson – conceptualization, methodology, writing – review and editing, and funding acquisition; Hong – conceptualization, writing – review and editing; Taylor – writing – review and editing; Hahm - writing - review and editing; Kim – conceptualization, writing - review and editing; Zaha – conceptualization, writing – review and editing, supervision, project administration, and funding acquisition. Author Disclosure Statement: The authors have no relationships, activities, or interests related to the content of this manuscript to declare. Funding Information: This research was funded by an award from the Harold C. Simmons Comprehensive Cancer Center, Office of Community Outreach, Engagement & Equity and the Cancer Center Support Grant (P30CA142543); and from the UT Southwestern Center for Translational Science Award (Community Engagement Planning Grant, UL1TR003163). Dr Zaha has received support from the Cancer Prevention Research Institute of Texas, award RP180404. Institutional Review Board Statement: Informed consent was obtained from all participants involved in the study. The human investigations were performed in accordance with the Declaration of Helsinki, and after the protocol was approved by the Institutional Review Board of The University of Texas Southwestern Medical Center (STU#20230839). References Greenlee H, Iribarren C, Rana JS, et al. Risk of cardiovascular disease in women with and without breast cancer: the pathways heart study. Journal of Clinical Oncology . 2022;40(15):1647-1658. Gupta D, Lee Chuy K, Yang JC, Bates M, Lombardo M, Steingart RM. Cardiovascular and metabolic effects of androgen-deprivation therapy for prostate cancer. Journal of oncology practice . 2018;14(10):580-587. Gong J, Payne D, Caron J, et al. Reduced cardiorespiratory fitness and increased cardiovascular mortality after prolonged androgen deprivation therapy for prostate cancer. Cardio Oncology . 2020;2(4):553-563. Huizinga F, Kieboom EAM, de Greef MHG, et al. Cancer survivors’ experiences of a physical activity program in primary care: a qualitative study. Journal of Cancer Survivorship . 2025;19(5):1544-1553. Anderson AS, Martin RM, Renehan AG, et al. Cancer survivorship, excess body fatness and weight-loss intervention—where are we in 2020? British journal of cancer . 2021;124(6):1057-1065. Grimmett C, Corbett T, Brunet J, et al. Systematic review and meta-analysis of maintenance of physical activity behaviour change in cancer survivors. International Journal of Behavioral Nutrition and Physical Activity . 2019;16(1):37. Lee Chuy K, Yu AF. Cardiotoxicity of contemporary breast cancer treatments. Current treatment options in oncology . 2019;20(6):51. Loap P, Kirov K, Kirova Y. Cardiotoxicity in breast cancer patients treated with radiation therapy: From evidences to controversies. Critical Reviews in Oncology/Hematology . 2020;156:103121. Bikiewicz A, Banach M, von Haehling S, Maciejewski M, Bielecka‐Dabrowa A. Adjuvant breast cancer treatments cardiotoxicity and modern methods of detection and prevention of cardiac complications. ESC heart failure . 2021;8(4):2397-2418. Gonciar D, Mocan L, Zlibut A, Mocan T, Agoston-Coldea L. Cardiotoxicity in HER2-positive breast cancer patients. Heart failure reviews . 2021;26(4):919-935. Ye Y, Zheng Y, Miao Q, Ruan H, Zhang X. Causes of death among prostate cancer patients aged 40 years and older in the United States. Frontiers in Oncology . 2022;12:914875. Luo Z, Chi K, Zhao H, et al. Cardiovascular mortality by cancer risk stratification in patients with localized prostate cancer: a SEER-based study. Frontiers in Cardiovascular Medicine . 2023;10:1130691. Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA: a cancer journal for clinicians . 2023;73(1) Chowdhury-Paulino IM, Ericsson C, Vince Jr R, Spratt DE, George DJ, Mucci LA. Racial disparities in prostate cancer among black men: epidemiology and outcomes. Prostate cancer and prostatic diseases . 2022;25(3):397-402. Weaver KE, Foraker RE, Alfano CM, et al. Cardiovascular risk factors among long-term survivors of breast, prostate, colorectal, and gynecologic cancers: a gap in survivorship care? Journal of cancer survivorship . 2013;7(2):253-261. Curigliano G, Cardinale D, Suter T, et al. Cardiovascular toxicity induced by chemotherapy, targeted agents and radiotherapy: ESMO Clinical Practice Guidelines. Annals of oncology . 2012;23:vii155-vii166. Lyon AR, Lopez-Fernandez T, Couch LS, et al. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS) Developed by the task force on cardio-oncology of the European Society of Cardiology (ESC). European Heart Journal-Cardiovascular Imaging . 2022;23(10):e333-e465. Gilchrist SC, Barac A, Ades PA, et al. Cardio-oncology rehabilitation to manage cardiovascular outcomes in cancer patients and survivors: a scientific statement from the American Heart Association. Circulation . 2019;139(21):e997-e1012. Bikomeye JC, Awoyinka I, Kwarteng JL, Beyer AM, Rine S, Beyer KMM. Disparities in cardiovascular disease-related outcomes among cancer survivors in the United States: a systematic review of the literature. Heart, Lung and Circulation . 2024;33(5):576-604. Jang SY, Lee ES. Patient Activation in Cancer Patients: Concept Analysis. Korean Journal of Adult Nursing . 2024;36(1):15-27. Klok JM, Duijts SFA, Engelen V, et al. Experienced financial toxicity among long-term cancer survivors: results from a national cross-sectional survey. Journal of Cancer Survivorship . 2024:1-10. Weaver KE, Dressler EV, Smith S, et al. Cardiovascular health assessment in routine cancer follow-up in community settings: survivor risk awareness and perspectives. BMC cancer . 2024;24(1):158. Abd Elfattah Atia Elasrag G, E Masry S, E Aboalizm S. Effect of Discharge Training Program on Patient Outcomes Following Oncology Surgery. Egyptian Journal of Health Care . 2021;12(4):1413-1421. Chae J, Lee C-j, Jensen JD. Correlates of cancer information overload: focusing on individual ability and motivation. Health communication . 2016;31(5):626-634. Jensen JD, Carcioppolo N, King AJ, Scherr CL, Jones CL, Niederdeppe J. The cancer information overload (CIO) scale: Establishing predictive and discriminant validity. Patient education and counseling . 2014;94(1):90-96. Biasillo G, Cipolla CM, Cardinale D. Cardio-oncology: gaps in knowledge, goals, advances, and educational efforts. Current oncology reports . 2017;19(8):55. Asteggiano R, Aboyans V, Lee G, Salinger S, Richter D. Cardiology care delivered to cancer patients: The results of a questionnaire survey by the Council for Cardio Oncology and Council for Cardiology Practice of the European Society of Cardiology. Oxford University Press; 2020. Birken SA, Raskin S, Zhang Y, Lane G, Zizzi A, Pratt-Chapman M. Survivorship care plan implementation in US cancer programs: a national survey of cancer care providers. Journal of Cancer Education . 2019;34(3):614-622. Taylor LL, Hong AS, Hahm K, Kim D, Smith-Morris C, Zaha VG. Health Literacy, Individual and Community Engagement, and Cardiovascular Risks and Disparities: JACC: CardioOncology State-of-the-Art Review. Cardio Oncology . 2024;6(3):363-380. Perdomo M, Davies C, Levenhagen K, Ryans K, Gilchrist L. Patient education for breast cancer–related lymphedema: a systematic review. Journal of Cancer Survivorship . 2023;17(2):384-398. Oh S, Choi H, Oh EG, Lee JY. Effectiveness of discharge education using teach-back method on readmission among heart failure patients: A systematic review and meta-analysis. Patient Education and Counseling . 2023;107:107559. Smith DP, Supramaniam R, King MT, Ward J, Berry M, Armstrong BK. Age, health, and education determine supportive care needs of men younger than 70 years with prostate cancer. Journal of Clinical Oncology . 2007;25(18):2560-2566. Jansen J, van Weert J, van Dulmen S, Heeren T, Bensing J. Patient education about treatment in cancer care: an overview of the literature on older patients' needs. Cancer nursing . 2007;30(4):251-260. White J, Dixon S. Nurse led Patient Education Programme for patients undergoing a lung resection for primary lung cancer. Journal of thoracic disease . 2015;7(Suppl 2):S131. McAlpine H, Joubert L, Martin-Sanchez F, Merolli M, Drummond KJ. A systematic review of types and efficacy of online interventions for cancer patients. Patient education and counseling . 2015;98(3):283-295. Golubić M, Schneeberger D, Kirkpatrick K, et al. Comprehensive Lifestyle Modification Intervention to Improve Chronic Disease Risk Factors and Quality of Life in Cancer Survivors. Article. Journal of Alternative and Complementary Medicine . 2018;24(11):1085-1091. doi:10.1089/acm.2018.0193 Zivanov CN, Owoade IA, Mann EJ, et al. Understanding colorectal cancer-related stigma and its impact on cancer survivors in South-West Nigeria: a qualitative study of patients, caregivers, and healthcare professionals. Journal of Cancer Survivorship . 2025:1-15. Agasi-Idenburg SC, Joosten MMJ, Hoedjes M, Buffart LM, Kampshoff CS, Stuiver MM. Can’t I continue to exercise here? Exploring experiences, barriers, and facilitators for physical therapists and survivors of cancer to promote exercise maintenance. Journal of Cancer Survivorship . 2025:1-13. Parent S, Pituskin E, Paterson DI. The cardio-oncology program: a multidisciplinary approach to the care of cancer patients with cardiovascular disease. Canadian Journal of Cardiology . 2016;32(7):847-851. Bylund CL, Mullis MD, Alpert J, et al. Clinician communication with patients about cancer misinformation: a qualitative study. JCO Oncology Practice . 2023;19(3):e389-e396. Smith-Morris C. Introduction: Diagnosis as the Threshold to 21st Century Health. Diagnostic Controversy . Routledge; 2015:11-34. Jutel AG. When the Penny Drops: Diagnosis and the Transformative Moment. In: Jutel AG, Dew K, eds. Social Issues in Diagnosis: An Introduction for Students and Clinicians . Johns Hopkins University Press; 2014:78-92. Schneeberger D, Golubíc M, Moore HCF, et al. Lifestyle Medicine-Focused Shared Medical Appointments to Improve Risk Factors for Chronic Diseases and Quality of Life in Breast Cancer Survivors. Article. Journal of Alternative and Complementary Medicine . 2019;25(1):40-47. doi:10.1089/acm.2018.0154 Hardcastle SJ, Hancox J, Hattar A, Maxwell-Smith C, Thøgersen-Ntoumani C, Hagger MS. Motivating the unmotivated: how can health behavior be changed in those unwilling to change? : Frontiers Media SA; 2015. p. 835. Desjarlais R, Jason Throop C. Phenomenological approaches in anthropology. Annual review of anthropology . 2011;40(1):87-102. Pascal J. Phenomenology as a research method for social work contexts: Understanding the lived experience of cancer survival. Currents: Scholarship in the Human Services . 2010;9(2) Sallis JF, Owen N, Fisher E. Ecological models of health behavior. Health behavior: Theory, research, and practice . 2015;5(43-64) Kilanowski JF. Breadth of the socio-ecological model. Journal of agromedicine . 2017;22(4):295-297. Franklin M, Lewis S, Smith AL. Complexities in supportive care for people with metastatic breast cancer: a qualitative study. Journal of Cancer Survivorship . 2024:1-11. Wutich A, Beresford M, Bernard HR. Sample Sizes for 10 Types of Qualitative Data Analysis: An Integrative Review, Empirical Guidance, and Next Steps. International Journal of Qualitative Methods . 2024;23:16094069241296206. Goldsmith LJ. Using Framework Analysis in Applied Qualitative Research. Qualitative report . 2021;26(6) Lumivero. NVivo. Lumivero Denver, CO, USA; 2023. Saldaña J. The coding manual for qualitative researchers . Sage; 2015. Schlunegger MC, Zumstein-Shaha M, Palm R. Methodologic and Data-Analysis Triangulation in Case Studies: A Scoping Review. Western Journal of Nursing Research . 2024;46(8):611-622. Miliken GA, Johnson DE. Analysis of Messy Data, Volume I: Designed Experiments. New York: VanNostrund Reinhold . 1984; Carter N. The use of triangulation in qualitative research. Number 5/September 2014 . 2014;41(5):545-547. Bispo Júnior JP. Social desirability bias in qualitative health research. Revista de saude publica . 2022;56:101. Gifford SM. The meaning of lumps: a case study of the ambiguities of risk. Anthropology and epidemiology: interdisciplinary approaches to the study of health and disease . Springer; 1986:213-246. Panter-Brick C. Health, risk, and resilience: Interdisciplinary concepts and applications. Annual Review of Anthropology . 2014;43(1):431-448. Manderson L. Anthropologies of Cancer and Risk, Uncertain and Disruption. In: Singer M, Erickson PI, eds. A Companion to Medical Anthropology . John Wiley & Sons; 2011:323-338. Smith-Morris C, ed. Diagnostic Controversy: Cultural Perspectives on Competing Knowledge in Healthcare . Routledge Press; 2015. Kanter JW, Manos RC, Bowe WM, Baruch DE, Busch AM, Rusch LC. What is behavioral activation?: A review of the empirical literature. Clinical psychology review . 2010;30(6):608-620. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. American journal of health promotion . 1997;12(1):38-48. Ghorbani R, Soleimani M, Zeinali M-R, Davaji M. Iranian nurses and nursing students' attitudes on barriers and facilitators to patient education: A survey study. Nurse education in practice . 2014;14(5):551-556. Yi JC, Walsh CA, Chow EJ, Baker KS, Mendoza JA, Cole A. Primary care providers and their needs caring for cancer survivors: a qualitative study. Journal of Cancer Survivorship . 2025:1-7. White J, Byles J, Williams T, Untaru R, Ngo DTM, Sverdlov AL. Early access to a cardio-oncology clinic in an Australian context: a qualitative exploration of patient experiences. Cardio-Oncology . 2022;8(1):14. Clark RA, Marin TS, Mccarthy AL, et al. Cardiotoxicity after cancer treatment: a process map of the patient treatment journey. Cardio-Oncology . 2019-12-01 2019;5(1)doi:10.1186/s40959-019-0046-5 Sutherland J, McLaughlan L. The Timing of Breast Cancer Patient Education: Its Influence on Satisfaction. Radiation therapist . 2013;22(2) Fredericks S. Timing for delivering individualized patient education intervention to coronary artery bypass graft patients: An RCT. European Journal of Cardiovascular Nursing . 2009;8(2):144-150. Marshall K, Patterson F, Fleming J, Gustafsson L, Atresh S. “Be ready to learn”: a qualitative study of the patient perspective of falls and fall prevention following discharge from a spinal injuries unit. Disability and rehabilitation . 2024;46(14):3108-3115. Maddox EN, Forte M, Boozer RW. Learning readiness: An underappreciated yet vital dimension in experiential learning. Rowlands G, Protheroe J, Saboga-Nunes L, Van den Broucke S, Levin-Zamir D, Okan O. Health literacy and chronic conditions: A life course perspective. International handbook of health literacy . Policy Press; 2019:183-198. Helitzer D, Hollis C, Cotner J, Oestreicher N. Health literacy demands of written health information materials: an assessment of cervical cancer prevention materials. Cancer control . 2009;16(1):70-78. Schuitevoerder D, Fortino J, Vetto JT. Hard copy durable patient cancer education materials: do they still matter? Journal of Cancer Education . 2017;32(3):487-490. Gruman J, Rovner MH, French ME, et al. From patient education to patient engagement: implications for the field of patient education. Patient education and counseling . 2010;78(3):350-356. Tables Table 1. Sample Characteristics. Participant Characteristic Results Total 26 Age Range 30-82 Avg. 64.5 Gender Male 11 Female 15 Ethnicity Black (17) White (2) Unreported (7) Cancer types (self-reported) Breast (11) Prostate (7) Lung (2) Stomach (1) Melanoma (2) Pancreatic (1) Bladder (1) Colon and prostate (1) Time since completion of cancer treatment (self-reported) Still active (4) 5 years (6) 10 years or more (16) Table 2. Interview Guide Interview Guide Tell me about your understanding of your risks for cardiovascular disease? What do you know about the impacts and risks of your cancer treatments? Did your cardiovascular risk change after your cancer treatment? Yes/No Who, if anyone, explained this to you? If so, how did it change? When you were under treatment for your cancer, did any health professionals talk to you about your post-treatment needs? Was the impact of your cancer treatment on your heart discussed? By whom? What do you remember learning? How was the information conveyed to you? Would you have preferred it in a different manner/format, time or from a different person? What is your biggest concern today about the changes you may need to make for your health? Can you please discuss how you felt learning new information about your health risks when you were going through cancer treatment. How do you feel about learning new information about your health risks now? Enjoy, avoid, etc. What should clinicians know about your process of learning? Your preferences for when, where, by whom? 8. As a cancer survivor, do you approach your health differently now? Please explain. Table 3. Codebook with Definitions and # of Unique Excerpts. Code Definition # Unique Excerpts Changed Risk (for CVD) Discussions about their changed CVD risk, or participant reaction to learning about their potentially higher CVD risk; may include learning early or late about these dangers; may include no change in CVD or CVD was not discussed as the opposite of changed CVD. 207 Knowledge Participant narratives about general disease knowledge (e.g., other risk factors, family history), shared knowledge (e.g., experience of others going through treatment). Existing awareness and understanding of their CVD risk, lack of risk knowledge, absence of knowledge. 121 Format Passages that address the medium (e.g., pamphlets, conversation with provider, other), language, delivered by (e.g., which healthcare provider). 105 Agency Discussions about actively (with agency) participating in any treatment decision-making, including asking questions (of any health care personnel), or seeking information from any source; a demonstration of agency or participation in decision-making. 101 Reaction (to Diagnosis, Treatment) Reaction to or experience of oncology treatment in general; can include emotion or practical actions; this code can remain very broad. 83 Content Passages that indicate information desired (e.g., more info about race and cancer); also used for lack of content (absence of info) from a given source or opportunity. 70 Timing Passages about when they received (or prefer to receive) information; could be a time of day, or during an appointment; anything that marks the timing of receiving information. 68 Factor (in decision-making) Passages in which a participant describes something, including CVD knowledge, as a factor in their decision to undergo oncology treatment, or decision about which oncology treatment to undergo. 67 Stage of Treatment Narratives about the current or past status of their cancer treatment, or how long ago it was; recent or in the remote past; any time-related indications of readiness for information. 59 Confusion Narrative about confusion due to absence of knowledge about disease, risk, treatment options, etc.; feelings due to the absence of knowledge. 46 Surprise Participants surprised associated with their oncology treatments or CVD risk; focus is on patients being under-informed within the context of getting cancer; should not refer to emotion/feelings generally about receiving a cancer diagnosis. 21 Rush Any passages that indicate rushed decisions; inability to ask all the questions one wanted to ask. 18 Table 4. Learning Preferences. How was the information about CVD risk conveyed to you? Conversation w health professional Online research Pamphlets from clinic It was not conveyed to me 15 1 2 8 Would you have preferred it in a different manner or format? Conversation/more conversation More written material/details Webinar No/Was satisfied with format 7 5 1 13 When is it best to bring up this information about oncology-related CVD risk? Before treatment Multiple times/Before, during, and/or after treatment Not asked/No answer 17 6 3 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 17 May, 2026 Reviews received at journal 24 Feb, 2026 Reviewers agreed at journal 24 Feb, 2026 Reviewers invited by journal 21 Feb, 2026 Editor assigned by journal 23 Jan, 2026 Submission checks completed at journal 23 Jan, 2026 First submitted to journal 22 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8670497","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":579427435,"identity":"f847e299-5083-4a82-98b1-1a10aab31a71","order_by":0,"name":"Carolyn Smith-Morris","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABZ0lEQVRIie3Sv0vDQBQH8HcEkuUkm1yItP/CSUARkfhnOPYotJM/ptJBQkrgXIKuKfkn/BMigU5t5kIcIoG4Vrp0qK2vhcZSka6C+cIdL4/3IUdyAFWq/MHoLm4ZrrpLXAUgxpK48CGXNlbq1mRZswi3Bi4ekZ4H8L4mpC+ZcEFZj7Edwi83BEeRLNdd5UAybP5CtNFbJuQr8MP4Ib+DtHYaxt70AonObgc57TqObo4imHTiDaFtiwtZQD0UPS+A1DpKhDSvJbONoKlZdBgz4/GmQYKkJNBSmZD4mCI5WKQioEQqSMjzuKmijRgfUo5HLYlebBEK8Yp407OSLBxmr8jnN7lq/SSuSUriKoxTJKQkbFwovJHElCMJkVgMD2b4Qyb6fn5izgexEeBbXvykvfmVTy2S4deo1cN2NkVSY1TLJ7Mus3VNFEZw7+i6T4+zWed8+woQFeieWxLtNuZ7QJUqVar873wByyKKhuj/e0YAAAAASUVORK5CYII=","orcid":"","institution":"The University of Texas Southwestern Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Carolyn","middleName":"","lastName":"Smith-Morris","suffix":""},{"id":579427436,"identity":"34cfa8c1-a236-48f5-9658-74edd6567891","order_by":1,"name":"Marisel Ponton","email":"","orcid":"","institution":"The University of Texas Southwestern Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Marisel","middleName":"","lastName":"Ponton","suffix":""},{"id":579427437,"identity":"7db75270-20e5-46ad-8dec-af650630fe9f","order_by":2,"name":"Shelia Patterson","email":"","orcid":"","institution":"Hoops Legends","correspondingAuthor":false,"prefix":"","firstName":"Shelia","middleName":"","lastName":"Patterson","suffix":""},{"id":579427438,"identity":"96010017-b9b7-49d3-b285-94419b34674f","order_by":3,"name":"Arthur S Hong","email":"","orcid":"","institution":"The University of Texas Southwestern Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Arthur","middleName":"S","lastName":"Hong","suffix":""},{"id":579427439,"identity":"fdf6d334-7f3d-4901-8647-16f58cceeec4","order_by":4,"name":"Lauren Taylor","email":"","orcid":"","institution":"The University of Texas Southwestern Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Lauren","middleName":"","lastName":"Taylor","suffix":""},{"id":579427440,"identity":"e024f050-3b78-4ad3-afdb-beda2865c57f","order_by":5,"name":"Kristine J Hahm","email":"","orcid":"","institution":"University of Texas at Dallas","correspondingAuthor":false,"prefix":"","firstName":"Kristine","middleName":"J","lastName":"Hahm","suffix":""},{"id":579427441,"identity":"cf491b7e-4c4b-4177-84d4-9763e93e95ef","order_by":6,"name":"Dohyeong Kim","email":"","orcid":"","institution":"University of Texas at Dallas","correspondingAuthor":false,"prefix":"","firstName":"Dohyeong","middleName":"","lastName":"Kim","suffix":""},{"id":579427442,"identity":"34e4012d-8d15-4fd3-b434-019b940ff4f2","order_by":7,"name":"Vlad Zaha","email":"","orcid":"","institution":"The University of Texas Southwestern Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Vlad","middleName":"","lastName":"Zaha","suffix":""}],"badges":[],"createdAt":"2026-01-22 13:55:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8670497/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8670497/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101186612,"identity":"64b0f71a-31c7-4a9f-a291-5fac3ab4ae0d","added_by":"auto","created_at":"2026-01-27 06:15:22","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":4605368,"visible":true,"origin":"","legend":"","description":"","filename":"COEEQualJCSMANUSCRIPT.docx","url":"https://assets-eu.researchsquare.com/files/rs-8670497/v1/f18c02e821630653b80812e2.docx"},{"id":101186606,"identity":"49db0094-c365-494c-bbd0-bb40612db1fe","added_by":"auto","created_at":"2026-01-27 06:15:19","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":40781,"visible":true,"origin":"","legend":"","description":"","filename":"COEEQualJCSTABLES.docx","url":"https://assets-eu.researchsquare.com/files/rs-8670497/v1/7c0d0c11d9def3639f363c71.docx"},{"id":101186607,"identity":"026b47c4-0e5c-4ba0-b299-43df1bf3fd67","added_by":"auto","created_at":"2026-01-27 06:15:19","extension":"json","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10417,"visible":true,"origin":"","legend":"","description":"","filename":"1ca2c64405184a968a1a6ef6be7a3e7f.json","url":"https://assets-eu.researchsquare.com/files/rs-8670497/v1/61a6244c2b070df3e2d06aae.json"},{"id":101206871,"identity":"570a0b63-9c7a-422b-afd6-940107db5245","added_by":"auto","created_at":"2026-01-27 09:56:54","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":105363,"visible":true,"origin":"","legend":"","description":"","filename":"1ca2c64405184a968a1a6ef6be7a3e7f1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8670497/v1/12c603561af54bc670f82461.xml"},{"id":101186611,"identity":"fca01e6d-58b8-49e7-8c79-efee83a92493","added_by":"auto","created_at":"2026-01-27 06:15:20","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":101753,"visible":true,"origin":"","legend":"","description":"","filename":"1ca2c64405184a968a1a6ef6be7a3e7f1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8670497/v1/87883d7033ef9322dae5faef.xml"},{"id":101186610,"identity":"d0a71886-9b0d-4ed9-80d4-321c57145935","added_by":"auto","created_at":"2026-01-27 06:15:20","extension":"html","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":114462,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8670497/v1/f8fa2b6a4943e5d59fe86756.html"},{"id":101208670,"identity":"3774554f-d1e8-4fa5-9699-e1a1034e3dc1","added_by":"auto","created_at":"2026-01-27 10:10:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":791283,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8670497/v1/dad56c92-a5bc-4eeb-a050-064c70401b2b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Long-term cancer survivor awareness and learning preferences for cardio- oncologic risks: A qualitative study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCancer survivors are at increased risk for cardiovascular disease (CVD), due in part to the cardiotoxicity of cancer treatments and shared cardiovascular and oncological disease risk factors\u003csup\u003e1-6\u003c/sup\u003e. Cardiotoxicity has been linked to common treatments for breast cancer, including chemotherapy, molecularly targeted therapies, hormonal therapies, radiotherapy involving the heart field, and newer immunotherapies\u003csup\u003e7-10\u003c/sup\u003e. Also, men with prostate cancer are 4.5 times more likely to die due to other causes than cancer, mostly due to CVD.\u003csup\u003e11,12\u003c/sup\u003e These differences in cardiotoxicity are compounded by social and economic factors that follow racial and ethnic patterns with higher prevalence cancers, such as breast and prostate cancer, having the widest disparities in cancer mortality along racial lines\u003csup\u003e13,14\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCancer survivors have limited awareness of their CVD risks and cardio-oncology care resources\u003csup\u003e15\u003c/sup\u003e despite more than a decade of calls for “dynamic partnership” between oncologists and cardiologists\u003csup\u003e16\u003c/sup\u003e and the creation of cardio-oncology practice guidelines promoting patient education of CVD risks\u003csup\u003e17,18\u003c/sup\u003e. Research has shown CVD risk factors such as obesity, hypertension, and inactivity are higher among cancer survivors than the general adult population\u003csup\u003e15,19\u003c/sup\u003e. Because many of these chronic risk factors require daily behavioral effort to manage, patient awareness and activation regarding management of these risks is especially important\u003csup\u003e20\u003c/sup\u003e. As the survivorship period lengthens and standard survivorship plans have ended\u003csup\u003e15\u003c/sup\u003e, patients may forget risk information, become generally less active\u003csup\u003e4\u003c/sup\u003e, and face other barriers to prevention behaviors\u003csup\u003e21\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eCardio-oncology focused patient education, if it occurs, is most visible at discharge (e.g., after surgery)\u003csup\u003e22,23\u003c/sup\u003e, in part due to the need to avoid “information overload” during oncology treatment\u003csup\u003e24,25\u003c/sup\u003e. But there is limited research on survivor knowledge of CVD risks\u003csup\u003e15,26-28\u003c/sup\u003e and essentially no understanding of patient retention of information over the survivorship continuum\u003csup\u003e29\u003c/sup\u003e. Optimal educational content, mode, and timing for cardio-oncology education across survivorship are also obscure\u003csup\u003e30,31\u003c/sup\u003e. Long-term (\u0026gt;5 year) survivors may require novel educational strategies because learning preferences change with age\u003csup\u003e32,33\u003c/sup\u003e, time since treatment\u003csup\u003e34\u003c/sup\u003e, technological skills\u003csup\u003e35\u003c/sup\u003e, and other psychological\u003csup\u003e36-38\u003c/sup\u003e and behavioral variables\u003csup\u003e26,31,39\u003c/sup\u003e. Further research is needed to understand survivor self-assessed awareness, information needs\u003csup\u003e40\u003c/sup\u003e, and concerns\u003csup\u003e41,42\u003c/sup\u003eto promote beneficial lifestyle and behaviors\u003csup\u003e43,44\u003c/sup\u003e across a potentially long survivorship continuum.\u003c/p\u003e\n\u003cp\u003eTo understand cancer survivors’ self-assessed awareness of CVD risk and their information needs and preferences, we conducted a mixed method study with survey and interview components. The current report summarizes thematic findings from qualitative interviews conducted with predominantly long-term (\u0026gt;5 year) participants in community and virtual settings. Survey results are reported elsewhere. Our overall goal in this study was to characterize survivors’ current self-reported knowledge of CVD risks and best strategies for addressing their informational needs throughout the survivorship lifespan.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cu\u003eDesign.\u003c/u\u003e Using a phenomenological approach\u003csup\u003e4,45\u003c/sup\u003e to survivor experience and perceptions of risk\u003csup\u003e46\u003c/sup\u003e, with interview questions secondarily attentive to socioecological theory’s\u003csup\u003e47,48\u003c/sup\u003e multiple influential levels of patient contexts (from individual to societal), we conducted a qualitative study as part of a larger mixed methods study. We used semi-structured interviews in community or video conference settings. Objectives of the interviews were to assess survivor (a) awareness of their cardiovascular risks (whether specific treatment related risks, if any, or general concerns about obesity, hypertension, or inactivity), (b) engagement in prevention behaviors, and (c) preferences for health education.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eSetting.\u003c/u\u003e The larger mixed methods study was an online survey with participants recruited through our community-based cancer survivor organizations (50 Hoops and the Oak Cliff Bible Fellowship), social media announcements, and direct emails to registered patients in the University of Texas Southwestern Medical Center cardio-oncology clinic. The sample for this qualitative interview study was drawn from participants recruited through more than 14 educational and screening events with our partner, community-based cancer survivor organizations in a historically underserved area of southern Dallas. These included tabling sessions at 2 large community health fairs, video lectures to community groups on cardio-oncology topics, and several presentations of our work in community settings. This mix of strategies\u003csup\u003e49\u003c/sup\u003e enabled a diversity in the gender, age, race/ethnicity, and types of cancer of our participants while reflecting the demographic make-up of this sector in our service area.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eParticipants.\u003c/u\u003e Interview participants were drawn from the larger study sample and met the same inclusion criteria, namely: adult, English-speaking persons, recruited through the partner organizations, who had been diagnosed with any form of cancer.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe invited 26 participants enrolled in our larger, mixed-methods study to complete interviews. This sample size is not only adequate for identifying a high number of themes in qualitative analysis, but sufficient to capture all variance of meaning within themes.\u003csup\u003e50\u003c/sup\u003e Participants were eligible for interview if they had completed the survey methods and lived in the Dallas area zip code. However, word-of-mouth recruitment through our southern Dallas partner produced a sample predominantly from southern Dallas.\u003c/p\u003e\n\u003cp\u003eInterview participants ranged in age from 30-82 (with an average age of 64.5 years), were majority African American (65%), and reported a prior diagnosis of the following cancers: breast (n=11); prostate (7); lung (2); stomach (1); melanoma (2); pancreatic (1); bladder (1); and colon and prostate (1). The majority of our sample (n=16) were also long-term survivors, having completed cancer treatment 10 or more years ago, while 6 had completed treatment within the last 5 years, and 4 were still in active treatment. (See Table 1)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Sample Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eData Collection.\u003c/u\u003e Following an informed consent procedure that was approved by the UT Southwestern Medical Center Institutional Review Board (STU# 2023-0839), interviews lasted between 20 and 60 minutes, were recorded, then transcribed verbatim. Interviews were conducted by CSM, MP or another skilled research assistant (HH, see acknowledgements) under the supervision of CSM, a PhD medical anthropologist and licensed professional counselor. Interviews were held in quiet and private locations selected by the participants, including church spaces or in their homes via video conference. In consultation with our multi-disciplinary investigative team of qualitative research specialists, clinicians, and community members, CSM designed the Interview Guide informed by phenomenological\u003csup\u003e45,46\u003c/sup\u003e and socioecological theoretical perspectives\u003csup\u003e47,48\u003c/sup\u003e and based on knowledge of the cardio-oncology literature. Two pilot interviews were conducted to refine questions and sequencing. The final guide is provided in Table 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Interview Guide\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eData Analysis.\u003c/u\u003e Transcripts were analyzed in two phases by CSM, MP, or other skilled research assistants under the supervision of CSM (HH and KR, see acknowledgements). First, we employed framework analysis\u003csup\u003e51\u003c/sup\u003e on a selection of interview responses to understand patterns across the sample on interval (e.g., How many years since cancer diagnosis?) and ordinal (e.g., Who talked to you about post-treatment care?) content in narrative responses. Second, we performed systematic coding of the transcribed narratives which produced a codebook of 12 codes: 7 parent and 5 child codes. (See Table 3) At least two independent coders used NVivo software\u003csup\u003e52\u003c/sup\u003e to code the first 13 transcripts. At this point, inter-rater reliability scores reached .7\u003csup\u003e53\u003c/sup\u003e, the codebook was considered final (i.e., no new open coding or hierarchy changes), and a single coder was used thereafter. Additional post hoc coding was made to organize large code sets. Final analysis to determine major themes was made via inductive and deductive analysis of patterns and salience or importance to research goals\u003csup\u003e54,55\u003c/sup\u003e. That is, our systematic analysis of the coded data included triangulation\u003csup\u003e54,56\u003c/sup\u003e of various data points (i.e., within code applications, content of the narratives themselves, and code co-occurrences) and the use of both inductive and deductive reasoning to recognize patterns in the data set.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Codebook with Definitions and # of Unique Excerpts\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur analysis produced three major themes: (1) relying on doctors to raise/address CVD risks; (2) CVD as a (non-)factor in oncology decision-making; and (3) learning preferences for CVD risk information. We report each in turn below.\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cu\u003eRelying on Doctors to Raise/Address Cardio-Oncology Risks\u003c/u\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eWe asked a series of questions about participants’ receipt and knowledge of information related to CVD risk, particularly risks related to their oncology treatments (See Table 1). We were concerned not with an objective test of knowledge, but with participants experience and self-assessed awareness of risks, whether specific to their own treatment, if any, or their general concerns about obesity, hypertension, or inactivity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn general, participants thought their awareness of CVD risk information was high. In the earliest part of the interview, when we asked directly whether the understood their cancer treatment-related risks for CVD, most participants expressed they had been well informed by their clinicians, felt able to ask questions and make informed decisions about their cancer treatment risks and effects, and expressed satisfaction with their treatment. However, later questions probed for detail about participant knowledge of their CVD risk, and this narrative content revealed greater complexities including confusion and some revision to their original responses.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMore specifically, in response to our question #3, “Did a health professional talk to you about your post-oncology treatment needs?”, 19 of 26 participants (73%) affirmed that their clinician had spoken with them. However, only 17 participants (65%) affirmed that they knew their risks for post-oncology CVD. fewer still (16 or 62%) said they understood the possible impacts of their oncology treatments to their heart. And many of their responses were very\u0026nbsp;general about CVD risk (e.g., “I’m not aware of any.”). These results likely reflect some social desirability response \u003csup\u003e57\u003c/sup\u003e. But the\u0026nbsp;narratives convey participant confusion on this topic.\u003c/p\u003e\n\u003cp\u003eINTERVIEWER Do you think your cardiovascular risk changed after your cancer treatment?\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINT04: No, not particularly, because I feel fine.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINT06: No, I've not had any cardiovascular risk. ... Well, it was Dr. --- and I had another doctor who I don't visit at all but she was my oncologist and she just said that it's possible that I might get weakness of the heart or that kind of thing, but that they would monitor me and everything like that, that from the chemo and the radiation treatments that I got, that I might suffer some small thing. But they didn't make a big deal of it. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, when we asked, “What do you know about the impacts and risks of your cancer treatments?”, only 12 participants (46%) could clearly indicate their awareness of CVD risks with information or specific narratives about risk from their doctor. These participants were usually under the care of a doctor (often a cardiologist) and actively monitoring their CVD risk. Their responses conveyed a high level of trust that their doctor would know their risk and provide the right recommendations when the time comes, as in this example:\u003c/p\u003e\n\u003cp\u003eINT12: I don't know where the risks are for my heart. If the risks were more in radiation, [I would have learned about them] right before we made that plan.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINT16: Well, if there had been any risks associated with my form of treatment, I think my surgeon would have mentioned them to me as well as my cardiologist, because I did have to get cardiology approval or prior to the surgery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClearly, knowledge of oncology-related CVD risk is a complex and evolving subject; one that even one nurse-patient did not fully understand:\u003c/p\u003e\n\u003cp\u003eINT04: I didn't know. I, of course, know about breast cancer, but I didn't know the different types of [it]. And, you know, because I was told that with my cancer, the triple negative, a lot of African American females get that, get this type. It doesn't mean that I knew everything because I'm a nurse. I didn't, you know? Or else, I probably did, and just, it just went out the window somewhere, you know?\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGiven this complexity, our phenomenological, narrative data convey a known challenge in post-oncology patient education. We asked participants to describe their receipt and knowledge of information related to CVD risk, particularly risks related to their oncology treatments. The semi-structured interview format, along with active probing by our interviewers, helped reveal differences between participants’ first responses (often “yes” to knowing their oncology-related CVD risks) and later, more elaborated narratives suggesting less complete knowledge. In the end, only 12 of 26 (46%) individuals clearly described their CVD risks in any detail and knew whether they were related to their oncology treatment. And patterns across narratives revealed high participant trust in their doctors, and a relative lack of oncology-related CVD risk knowledge among those who were not under active supervision of a doctor.\u003c/p\u003e\n\u003col start=\"2\" type=\"1\"\u003e\n \u003cli\u003e\u003cu\u003eCVD as (Non-)Factor in Oncology Decision-Making\u003c/u\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe second major theme addresses whether CVD risks factored into participants’ oncology decisions. We did not ask explicitly why participants underwent certain treatments. Instead, we captured participant views about the relative importance of CVD risks in their oncology treatment decisions. Most participants (n=20) said that CVD knowledge or lack of it would \u003cu\u003enot\u003c/u\u003e have changed their decision to undergo cancer treatment. They described having had “no choice” due to the urgency of the situation or their primary concern being to survive the cancer, and that all other concerns being secondary or “irrelevant”. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINT02: But literally like this is like life or death and I wanted it out of my body. My doctors were like, we need a I need the data so I can make an informed decision and we need to act like immediately because again, we didn't know if this lump had appeared like two months ago or was it six months ago. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINT04: They didn't give me a chance to even think about an option.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINT08: I was like between a brick and a hard place. I didn't want to cancel the spread. My only option -- I didn't have another option.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINT10: All I was concerned [about was] I'll get the cancer out.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINT15: I just wanted a treatment for the prostate cancer. As of that point in time, I didn't put into consideration of my heart.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis urgency in many oncology cases may have been a substantial but reasonable barrier to better patient understanding of oncology-related CVD risks. But whether education was provided later, after oncology treatment, we take up in the next section.\u003c/p\u003e\n\u003cp\u003eThus, only a few participants said that oncology-related CVD risks might have been a factor on their oncology treatment decisions. Their narratives suggest that greater attention to patient education may have made a difference to them, as to this man:\u003c/p\u003e\n\u003cp\u003eINT09: I'm not sure if it would have made a difference in my choice to take the prostate gland out. The only option we had was with radiation seed implants, watching/wait, or some of the freezing thing. Unless they said having prostatectomy would leave you with a damaged heart or something, then I would obviously considered that. But there was never a part of the discussion. \u0026nbsp;...I've learned the hard way that side effects are certainly important to ask about.\u003c/p\u003e\n\u003cp\u003eOne woman with breast cancer pointed out a lack of communication between her different doctors. She felt that the overlaps between the different specialties was not discussed with her:\u003c/p\u003e\n\u003cp\u003eINT14: I had the option of a lumpectomy, or mastectomy, which is either take it, just take the cancer out or take everything. ...Everything else wasn't really optional. ... But sometimes I feel like they don't really communicate with each other... Like my surgeon only talked about surgery. My oncologist doctor only talked about like the oncology part, the cancer part of it. My radiation doctor only talked about the effects of the radiation. Like, they never really crossed. When they spoke to me about things, they just stuck with their part of the treatment....\u003c/p\u003e\n\u003cp\u003eBut while this participant felt her doctors did not communicate with each other, she found the potential for overlapping concerns to be too complex for her to think about:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINT14: Don't tell me anything because I don't wanna have to change my mind. ...Ohh it was enough, like I had enough to think about without having to consider something else, so not knowing for me was better because you know?\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOnly 2 participants said that additional information “maybe/possibly” would have led them to a different decision about oncology treatment. For example:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINT24: I think because if maybe they would have maybe gave me an in depth knowledge about the risk and that would have maybe influenced my decision.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnd only one participant said “definitely”, they would have wanted to know but were not told by their oncologist.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINT20: Oh, I didn't. No one mentioned anything about heart damage as a result of having that type of cancer or other procedures. No, I never heard of anything like that. ... Well, if it's gonna be some heart damage, definitely, I would have considered some other treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, 3 participants did not clearly answer this question. Overall, these data make clear that “too much information” is an important concern for many patients facing oncology treatment, especially if their cancer is deemed by physicians to require urgent action.\u0026nbsp;\u003c/p\u003e\n\u003col start=\"3\" type=\"1\"\u003e\n \u003cli\u003e\u003cu\u003eLearning Preferences for CVD Risk Information\u003c/u\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eWe posed a number of questions to understand the learning preferences of our participants for information about oncology-related CVD risk. (See Table 4)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Learning Preferences.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFifteen (58%) reported that a conversation with their health professional was their preferred source of CVD risk information, and most were satisfied with the information they received.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINT24: It was an impressive conversation which I was able to express myself to the person as to how. And I was also getting a kind of emotional comfort and a word of advice from the person. ... I prefer meeting the person in a one-on-one conversation, that will give the patient that comfort.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINT25: So it felt like a [inaudible] communication will be better so that they could actually detect my mood, know the atmosphere in which I was surrounded and know the best way to digest me and make me feel comfortable going for the surgery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnd when asked the ideal time to bring up information about oncology-related CVD risk, most (n=17) participants (65%) preferred these conversations to happen\u003cem\u003e\u0026nbsp;before\u003c/em\u003e oncology treatment began:\u003c/p\u003e\n\u003cp\u003eINT19: As far as the cancer, [the] doctor was not forthcoming in all the risks. So, I think more information, at least so we could be prepared. You know, even if he did go through the treatment the way he did, at least knowing more of what to expect.\u003c/p\u003e\n\u003cp\u003eINT03: So, for me it was because I could just hit it, and just go with it and at the same time just boom, boom, boom. Because I wanted to know everything I could about what was going on with me.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSix participants wanted conversation at multiple time points, to compensate for their own poor memory or concentration when they were fearful about the cancer diagnosis. For example:\u003c/p\u003e\n\u003cp\u003eINT13: And then when I finished, I would like to hear it again. So that would have given me a chance to have it at the initial stage, and I probably would not have heard it very well but I would have heard something. Again, when I went for therapy, [it] would have been reiterated and then it would have been probably on my frontal lobe, I would have remembered. And then before my dismissal, it would have been a good time to have it again. And then that way I could connect those pieces.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINT23: Somehow they should break some of this down, like even after you should have a post visit to talk about all these things.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants expressed preferences for how they would like to receive CVD information. A majority (n=23) preferred conversation or 1:1 with their provider. Ten also liked written materials, 6 requested online, video or telephone formats, and only 2 mentioned in-person, community-based events as a preferred format.\u0026nbsp;The sub-group (n=10 of 26, or 39%) wanted written materials suggested these as a supplement to 1:1 conversations:\u003c/p\u003e\n\u003cp\u003eINT13: I would like it in a one to one personal [conversation]. And then giving it to me and in writing so I could read it later. I think a lot of times.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINT22: I would have preferred it in a different format like after the one-on-one conversation probably maybe get a hard copy or a soft copy PDF file of everything. Because it was a long conversation, so most of the things I might forget it.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnd one suggestion in particular, for a personalized and hardbound book about their condition and their treatments, stood out among our participants’ narratives, given the lifelong need for information of many cancer survivors:\u003c/p\u003e\n\u003cp\u003eINT12: The other thing that I got, and now what I'm going to do is I'm going to go back and look to see if I just didn't read that section... but I was blown away that I got in the mail like a bound book. They had my name on the front, my on-call or my surgeon's name and picture on the front of the book.... It's like 300 pages. It's a bound proper book.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, there was substantial variation in learning needs and preferences over time, depending on their anxiety about receipt of a diagnosis, the duration of treatment, and their life expectancy following treatment, as these participants explain:\u003c/p\u003e\n\u003cp\u003eINTERVIEWER: Did you prefer to know about your risk of cardiovascular when deciding, like when they were telling you about treatments.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINT04: I really wasn't interested in that at that time.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINT09: No, I've had no discussion about that [oncology-related CVD risk]. The only time I've heard about that is when [de-identified] and when you were doing this study. And so we've been working with them with different things. So, that's the first I've heard that there might be a connection between cancer and cardiovascular.\u003c/p\u003e\n\u003cp\u003eINT05: Your mind is not fully open to what they are telling you. Sometimes, initially you're thinking, you are going to die. And so now, once you get past that stage, well, maybe you ...can process the information that you're receiving.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eGiven the apparent inconsistencies in CVD risk knowledge uncovered over the course of our interview - that is, the fact that 19 participants (73%) initially declared they knew their CVD risks but ultimately only\u0026nbsp;12 (46%) could clearly describe their own CVD risks in any detail -\u003c/p\u003e\n\u003cp\u003eA systematic analysis of narratives from 26 majority long-term (\u0026gt;10 year) cancer survivors to understand their CVD risk knowledge and learning preferences yielded three thematic findings. First, differences between participants’ initial self-assessments of risk awareness and later narratives which lacked clarity about such risks were not surprising and may be partially attributable to social desirability influence\u003csup\u003e57\u003c/sup\u003e. However participants’ expressions of high reliance on doctors to bring risks to their attention when necessary\u003csup\u003e58-61\u003c/sup\u003e suggests to us a low level of activation\u003csup\u003e20,62\u003c/sup\u003e or a de-activated stage of change.\u003csup\u003e63\u003c/sup\u003e Providers may have inadequate time, educational facilities, or knowledge to facilitate adequate patient education\u003csup\u003e64,65\u003c/sup\u003e.\u0026nbsp;Thus, survivor reliance on physicians alone, without their own behavioral and lifestyle prevention efforts, may contribute to survivors’ greater risk for CVD. An opportunity exists for cardio-oncology prevention education and/or activation among survivors\u003csup\u003e66,67\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eSecond, participants were satisfied with the information they received surrounding their oncology treatment and conveyed that one could have “too much information” when facing an oncology treatment decision. Thus, CVD risk education may be better place in the post-treatment period to avoid “information overload”\u003csup\u003e24,25\u003c/sup\u003e. Factors such as timing of education during or after oncology treatments\u003csup\u003e68,69\u003c/sup\u003e, readiness for learning\u003csup\u003e70,71\u003c/sup\u003e, and learning preferences for format and content\u003csup\u003e30,31\u003c/sup\u003e also affect survivor learning. Further, because of the increasing duration of cancer survivorship, diverse educational strategies may be required at different times in the survivorship period\u003csup\u003e41,72\u003c/sup\u003e in order to account for some of the unique barriers faced by long-term survivors\u003csup\u003e21,38\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThird, while conversation with one’s healthcare team was the favored learning format of most participants, several would have preferred conversation at multiple points in time including before and after treatment. Such preferences can place a high burden on providers{Yi, 2025, Primary care providers and their needs caring for cancer survivors: a qualitative study;Birken, 2019, Survivorship care plan implementation in US cancer programs: a national survey of cancer care providers}. Almost half of our majority-long-term survivors also wanted written materials for later consultation. Durable written materials, such as personalized bound books detailing one’s own diagnosis and treatment, may be especially useful for long-term survivor health literacy and patient-provider communications\u003csup\u003e73,74\u003c/sup\u003e. Our results also indicate survivor interest in online and virtual materials, which may alleviate some of the burden on providers to address this education and activation need.\u003c/p\u003e\n\u003cp\u003eFinally, results of this study corroborate the limited reports on patient experience of shock and anxiety over learning of the risk or detection of CVD\u003csup\u003e66\u003c/sup\u003e. Our qualitative data also provide narratives expressing patient concern over lack of information on cardiotoxicity, their need for health education, and a lack of collaboration between oncologists and cardiologists\u003csup\u003e67\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOverall, survivors’ high sense of risk awareness coupled with a relatively poor ability to discuss risks (whether specific treatment related risks, if any, or general concerns about obesity, hypertension, or inactivity) suggests an opportunity to improve survivor awareness and, possibly, preventive behaviors. Improving survivor CVD knowledge may support better communication with healthcare teams and survivor participation in cardio-oncology prevention and treatment\u003csup\u003e29,75\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eLimitations\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eOur participants were predominantly survivors of breast or prostate cancers, and a predominantly African American sampled from a limited geographic area. These factors limit the generalizability of our findings to other cancer types or other groups. Also, while our phenomenological study design produced diverse perspectives on survivor risk awareness and learning preferences, we did not objectively test participants’ CVD risk knowledge.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis mixed methods study of cancer survivor\u0026rsquo; knowledge of CVD risk and their educational needs and preferences yielded important and actionable details about survivor health literacy, and their diverse learning needs and preferences over potentially long survivorship periods. To inform more effective patient education, further research is needed to design and test effective health literacy strategies for long-term survivors at high risk for CVD.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eWe gratefully acknowledge the Oak Cliff Bible Fellowship and 50 Hoops Legends for their partnership; funding from the Harold C. Simmons Comprehensive Cancer Center, Office of Community Outreach, Engagement \u0026amp; Equity, and from an award by the UT Southwestern Center for Translational Science Award. Thanks also to Lee Patterson, Hamid Sediqe, Libby Gracia, Zahria Griggs, Kendall Roark, Hira Hasan, Syed Ahsan, Hamid Sediqe, Vivian Palacios, and Egzona Tan for invaluable community outreach and research assistance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor CRediT Statement:\u0026nbsp;\u003c/strong\u003eSmith-Morris - conceptualization, methodology, investigation, data curation, writing - original draft, writing - review and editing, visualization, supervision, project administration, and funding acquisition; Ponton - investigation, data curation, writing - review and editing, project administration; Patterson – conceptualization, methodology, writing – review and editing, and funding acquisition; Hong – conceptualization, writing – review and editing; Taylor – writing – review and editing; Hahm - writing - review and editing; Kim – conceptualization, writing - review and editing; Zaha – conceptualization, writing – review and editing, supervision, project administration, and funding acquisition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Disclosure Statement:\u0026nbsp;\u003c/strong\u003eThe authors have no relationships, activities, or interests related to the content of this manuscript to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Information:\u0026nbsp;\u003c/strong\u003eThis research was funded by an award from the Harold C. Simmons Comprehensive Cancer Center, Office of Community Outreach, Engagement \u0026amp; Equity and the Cancer Center Support Grant (P30CA142543); and from the UT Southwestern Center for Translational Science Award (Community Engagement Planning Grant, UL1TR003163). Dr Zaha has received support from the Cancer Prevention Research Institute of Texas, award RP180404.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all participants involved in the study. The human investigations were performed in accordance with the Declaration of Helsinki, and after the protocol was approved by the Institutional Review Board of The University of Texas Southwestern Medical Center (STU#20230839).\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGreenlee H, Iribarren C, Rana JS, et al. Risk of cardiovascular disease in women with and without breast cancer: the pathways heart study. \u003cem\u003eJournal of Clinical Oncology\u003c/em\u003e. 2022;40(15):1647-1658. \u003c/li\u003e\n\u003cli\u003eGupta D, Lee Chuy K, Yang JC, Bates M, Lombardo M, Steingart RM. Cardiovascular and metabolic effects of androgen-deprivation therapy for prostate cancer. \u003cem\u003eJournal of oncology practice\u003c/em\u003e. 2018;14(10):580-587. \u003c/li\u003e\n\u003cli\u003eGong J, Payne D, Caron J, et al. Reduced cardiorespiratory fitness and increased cardiovascular mortality after prolonged androgen deprivation therapy for prostate cancer. \u003cem\u003eCardio Oncology\u003c/em\u003e. 2020;2(4):553-563. \u003c/li\u003e\n\u003cli\u003eHuizinga F, Kieboom EAM, de Greef MHG, et al. Cancer survivors\u0026rsquo; experiences of a physical activity program in primary care: a qualitative study. \u003cem\u003eJournal of Cancer Survivorship\u003c/em\u003e. 2025;19(5):1544-1553. \u003c/li\u003e\n\u003cli\u003eAnderson AS, Martin RM, Renehan AG, et al. Cancer survivorship, excess body fatness and weight-loss intervention\u0026mdash;where are we in 2020? \u003cem\u003eBritish journal of cancer\u003c/em\u003e. 2021;124(6):1057-1065. \u003c/li\u003e\n\u003cli\u003eGrimmett C, Corbett T, Brunet J, et al. Systematic review and meta-analysis of maintenance of physical activity behaviour change in cancer survivors. \u003cem\u003eInternational Journal of Behavioral Nutrition and Physical Activity\u003c/em\u003e. 2019;16(1):37. \u003c/li\u003e\n\u003cli\u003eLee Chuy K, Yu AF. Cardiotoxicity of contemporary breast cancer treatments. \u003cem\u003eCurrent treatment options in oncology\u003c/em\u003e. 2019;20(6):51. \u003c/li\u003e\n\u003cli\u003eLoap P, Kirov K, Kirova Y. Cardiotoxicity in breast cancer patients treated with radiation therapy: From evidences to controversies. \u003cem\u003eCritical Reviews in Oncology/Hematology\u003c/em\u003e. 2020;156:103121. \u003c/li\u003e\n\u003cli\u003eBikiewicz A, Banach M, von Haehling S, Maciejewski M, Bielecka‐Dabrowa A. Adjuvant breast cancer treatments cardiotoxicity and modern methods of detection and prevention of cardiac complications. \u003cem\u003eESC heart failure\u003c/em\u003e. 2021;8(4):2397-2418. \u003c/li\u003e\n\u003cli\u003eGonciar D, Mocan L, Zlibut A, Mocan T, Agoston-Coldea L. Cardiotoxicity in HER2-positive breast cancer patients. \u003cem\u003eHeart failure reviews\u003c/em\u003e. 2021;26(4):919-935. \u003c/li\u003e\n\u003cli\u003eYe Y, Zheng Y, Miao Q, Ruan H, Zhang X. Causes of death among prostate cancer patients aged 40 years and older in the United States. \u003cem\u003eFrontiers in Oncology\u003c/em\u003e. 2022;12:914875. \u003c/li\u003e\n\u003cli\u003eLuo Z, Chi K, Zhao H, et al. Cardiovascular mortality by cancer risk stratification in patients with localized prostate cancer: a SEER-based study. \u003cem\u003eFrontiers in Cardiovascular Medicine\u003c/em\u003e. 2023;10:1130691. \u003c/li\u003e\n\u003cli\u003eSiegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. \u003cem\u003eCA: a cancer journal for clinicians\u003c/em\u003e. 2023;73(1)\u003c/li\u003e\n\u003cli\u003eChowdhury-Paulino IM, Ericsson C, Vince Jr R, Spratt DE, George DJ, Mucci LA. Racial disparities in prostate cancer among black men: epidemiology and outcomes. \u003cem\u003eProstate cancer and prostatic diseases\u003c/em\u003e. 2022;25(3):397-402. \u003c/li\u003e\n\u003cli\u003eWeaver KE, Foraker RE, Alfano CM, et al. Cardiovascular risk factors among long-term survivors of breast, prostate, colorectal, and gynecologic cancers: a gap in survivorship care? \u003cem\u003eJournal of cancer survivorship\u003c/em\u003e. 2013;7(2):253-261. \u003c/li\u003e\n\u003cli\u003eCurigliano G, Cardinale D, Suter T, et al. Cardiovascular toxicity induced by chemotherapy, targeted agents and radiotherapy: ESMO Clinical Practice Guidelines. \u003cem\u003eAnnals of oncology\u003c/em\u003e. 2012;23:vii155-vii166. \u003c/li\u003e\n\u003cli\u003eLyon AR, Lopez-Fernandez T, Couch LS, et al. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS) Developed by the task force on cardio-oncology of the European Society of Cardiology (ESC). \u003cem\u003eEuropean Heart Journal-Cardiovascular Imaging\u003c/em\u003e. 2022;23(10):e333-e465. \u003c/li\u003e\n\u003cli\u003eGilchrist SC, Barac A, Ades PA, et al. Cardio-oncology rehabilitation to manage cardiovascular outcomes in cancer patients and survivors: a scientific statement from the American Heart Association. \u003cem\u003eCirculation\u003c/em\u003e. 2019;139(21):e997-e1012. \u003c/li\u003e\n\u003cli\u003eBikomeye JC, Awoyinka I, Kwarteng JL, Beyer AM, Rine S, Beyer KMM. Disparities in cardiovascular disease-related outcomes among cancer survivors in the United States: a systematic review of the literature. \u003cem\u003eHeart, Lung and Circulation\u003c/em\u003e. 2024;33(5):576-604. \u003c/li\u003e\n\u003cli\u003eJang SY, Lee ES. Patient Activation in Cancer Patients: Concept Analysis. \u003cem\u003eKorean Journal of Adult Nursing\u003c/em\u003e. 2024;36(1):15-27. \u003c/li\u003e\n\u003cli\u003eKlok JM, Duijts SFA, Engelen V, et al. Experienced financial toxicity among long-term cancer survivors: results from a national cross-sectional survey. \u003cem\u003eJournal of Cancer Survivorship\u003c/em\u003e. 2024:1-10. \u003c/li\u003e\n\u003cli\u003eWeaver KE, Dressler EV, Smith S, et al. Cardiovascular health assessment in routine cancer follow-up in community settings: survivor risk awareness and perspectives. \u003cem\u003eBMC cancer\u003c/em\u003e. 2024;24(1):158. \u003c/li\u003e\n\u003cli\u003eAbd Elfattah Atia Elasrag G, E Masry S, E Aboalizm S. Effect of Discharge Training Program on Patient Outcomes Following Oncology Surgery. \u003cem\u003eEgyptian Journal of Health Care\u003c/em\u003e. 2021;12(4):1413-1421. \u003c/li\u003e\n\u003cli\u003eChae J, Lee C-j, Jensen JD. Correlates of cancer information overload: focusing on individual ability and motivation. \u003cem\u003eHealth communication\u003c/em\u003e. 2016;31(5):626-634. \u003c/li\u003e\n\u003cli\u003eJensen JD, Carcioppolo N, King AJ, Scherr CL, Jones CL, Niederdeppe J. The cancer information overload (CIO) scale: Establishing predictive and discriminant validity. \u003cem\u003ePatient education and counseling\u003c/em\u003e. 2014;94(1):90-96. \u003c/li\u003e\n\u003cli\u003eBiasillo G, Cipolla CM, Cardinale D. Cardio-oncology: gaps in knowledge, goals, advances, and educational efforts. \u003cem\u003eCurrent oncology reports\u003c/em\u003e. 2017;19(8):55. \u003c/li\u003e\n\u003cli\u003eAsteggiano R, Aboyans V, Lee G, Salinger S, Richter D. Cardiology care delivered to cancer patients: The results of a questionnaire survey by the Council for Cardio Oncology and Council for Cardiology Practice of the European Society of Cardiology. Oxford University Press; 2020.\u003c/li\u003e\n\u003cli\u003eBirken SA, Raskin S, Zhang Y, Lane G, Zizzi A, Pratt-Chapman M. Survivorship care plan implementation in US cancer programs: a national survey of cancer care providers. \u003cem\u003eJournal of Cancer Education\u003c/em\u003e. 2019;34(3):614-622. \u003c/li\u003e\n\u003cli\u003eTaylor LL, Hong AS, Hahm K, Kim D, Smith-Morris C, Zaha VG. Health Literacy, Individual and Community Engagement, and Cardiovascular Risks and Disparities: JACC: CardioOncology State-of-the-Art Review. \u003cem\u003eCardio Oncology\u003c/em\u003e. 2024;6(3):363-380. \u003c/li\u003e\n\u003cli\u003ePerdomo M, Davies C, Levenhagen K, Ryans K, Gilchrist L. Patient education for breast cancer\u0026ndash;related lymphedema: a systematic review. \u003cem\u003eJournal of Cancer Survivorship\u003c/em\u003e. 2023;17(2):384-398. \u003c/li\u003e\n\u003cli\u003eOh S, Choi H, Oh EG, Lee JY. Effectiveness of discharge education using teach-back method on readmission among heart failure patients: A systematic review and meta-analysis. \u003cem\u003ePatient Education and Counseling\u003c/em\u003e. 2023;107:107559. \u003c/li\u003e\n\u003cli\u003eSmith DP, Supramaniam R, King MT, Ward J, Berry M, Armstrong BK. Age, health, and education determine supportive care needs of men younger than 70 years with prostate cancer. \u003cem\u003eJournal of Clinical Oncology\u003c/em\u003e. 2007;25(18):2560-2566. \u003c/li\u003e\n\u003cli\u003eJansen J, van Weert J, van Dulmen S, Heeren T, Bensing J. Patient education about treatment in cancer care: an overview of the literature on older patients\u0026apos; needs. \u003cem\u003eCancer nursing\u003c/em\u003e. 2007;30(4):251-260. \u003c/li\u003e\n\u003cli\u003eWhite J, Dixon S. Nurse led Patient Education Programme for patients undergoing a lung resection for primary lung cancer. \u003cem\u003eJournal of thoracic disease\u003c/em\u003e. 2015;7(Suppl 2):S131. \u003c/li\u003e\n\u003cli\u003eMcAlpine H, Joubert L, Martin-Sanchez F, Merolli M, Drummond KJ. A systematic review of types and efficacy of online interventions for cancer patients. \u003cem\u003ePatient education and counseling\u003c/em\u003e. 2015;98(3):283-295. \u003c/li\u003e\n\u003cli\u003eGolubić M, Schneeberger D, Kirkpatrick K, et al. Comprehensive Lifestyle Modification Intervention to Improve Chronic Disease Risk Factors and Quality of Life in Cancer Survivors. Article. \u003cem\u003eJournal of Alternative and Complementary Medicine\u003c/em\u003e. 2018;24(11):1085-1091. doi:10.1089/acm.2018.0193\u003c/li\u003e\n\u003cli\u003eZivanov CN, Owoade IA, Mann EJ, et al. Understanding colorectal cancer-related stigma and its impact on cancer survivors in South-West Nigeria: a qualitative study of patients, caregivers, and healthcare professionals. \u003cem\u003eJournal of Cancer Survivorship\u003c/em\u003e. 2025:1-15. \u003c/li\u003e\n\u003cli\u003eAgasi-Idenburg SC, Joosten MMJ, Hoedjes M, Buffart LM, Kampshoff CS, Stuiver MM. Can\u0026rsquo;t I continue to exercise here? Exploring experiences, barriers, and facilitators for physical therapists and survivors of cancer to promote exercise maintenance. \u003cem\u003eJournal of Cancer Survivorship\u003c/em\u003e. 2025:1-13. \u003c/li\u003e\n\u003cli\u003eParent S, Pituskin E, Paterson DI. The cardio-oncology program: a multidisciplinary approach to the care of cancer patients with cardiovascular disease. \u003cem\u003eCanadian Journal of Cardiology\u003c/em\u003e. 2016;32(7):847-851. \u003c/li\u003e\n\u003cli\u003eBylund CL, Mullis MD, Alpert J, et al. Clinician communication with patients about cancer misinformation: a qualitative study. \u003cem\u003eJCO Oncology Practice\u003c/em\u003e. 2023;19(3):e389-e396. \u003c/li\u003e\n\u003cli\u003eSmith-Morris C. Introduction: Diagnosis as the Threshold to 21st Century Health. \u003cem\u003eDiagnostic Controversy\u003c/em\u003e. Routledge; 2015:11-34.\u003c/li\u003e\n\u003cli\u003eJutel AG. When the Penny Drops: Diagnosis and the Transformative Moment. In: Jutel AG, Dew K, eds. \u003cem\u003eSocial Issues in Diagnosis: An Introduction for Students and Clinicians\u003c/em\u003e. Johns Hopkins University Press; 2014:78-92.\u003c/li\u003e\n\u003cli\u003eSchneeberger D, Golub\u0026iacute;c M, Moore HCF, et al. Lifestyle Medicine-Focused Shared Medical Appointments to Improve Risk Factors for Chronic Diseases and Quality of Life in Breast Cancer Survivors. Article. \u003cem\u003eJournal of Alternative and Complementary Medicine\u003c/em\u003e. 2019;25(1):40-47. doi:10.1089/acm.2018.0154\u003c/li\u003e\n\u003cli\u003eHardcastle SJ, Hancox J, Hattar A, Maxwell-Smith C, Th\u0026oslash;gersen-Ntoumani C, Hagger MS. Motivating the unmotivated: how can health behavior be changed in those unwilling to change? : Frontiers Media SA; 2015. p. 835.\u003c/li\u003e\n\u003cli\u003eDesjarlais R, Jason Throop C. Phenomenological approaches in anthropology. \u003cem\u003eAnnual review of anthropology\u003c/em\u003e. 2011;40(1):87-102. \u003c/li\u003e\n\u003cli\u003ePascal J. Phenomenology as a research method for social work contexts: Understanding the lived experience of cancer survival. \u003cem\u003eCurrents: Scholarship in the Human Services\u003c/em\u003e. 2010;9(2)\u003c/li\u003e\n\u003cli\u003eSallis JF, Owen N, Fisher E. Ecological models of health behavior. \u003cem\u003eHealth behavior: Theory, research, and practice\u003c/em\u003e. 2015;5(43-64)\u003c/li\u003e\n\u003cli\u003eKilanowski JF. Breadth of the socio-ecological model. \u003cem\u003eJournal of agromedicine\u003c/em\u003e. 2017;22(4):295-297. \u003c/li\u003e\n\u003cli\u003eFranklin M, Lewis S, Smith AL. Complexities in supportive care for people with metastatic breast cancer: a qualitative study. \u003cem\u003eJournal of Cancer Survivorship\u003c/em\u003e. 2024:1-11. \u003c/li\u003e\n\u003cli\u003eWutich A, Beresford M, Bernard HR. Sample Sizes for 10 Types of Qualitative Data Analysis: An Integrative Review, Empirical Guidance, and Next Steps. \u003cem\u003eInternational Journal of Qualitative Methods\u003c/em\u003e. 2024;23:16094069241296206. \u003c/li\u003e\n\u003cli\u003eGoldsmith LJ. Using Framework Analysis in Applied Qualitative Research. \u003cem\u003eQualitative report\u003c/em\u003e. 2021;26(6)\u003c/li\u003e\n\u003cli\u003eLumivero. NVivo. Lumivero Denver, CO, USA; 2023.\u003c/li\u003e\n\u003cli\u003eSalda\u0026ntilde;a J. \u003cem\u003eThe coding manual for qualitative researchers\u003c/em\u003e. Sage; 2015.\u003c/li\u003e\n\u003cli\u003eSchlunegger MC, Zumstein-Shaha M, Palm R. Methodologic and Data-Analysis Triangulation in Case Studies: A Scoping Review. \u003cem\u003eWestern Journal of Nursing Research\u003c/em\u003e. 2024;46(8):611-622. \u003c/li\u003e\n\u003cli\u003eMiliken GA, Johnson DE. Analysis of Messy Data, Volume I: Designed Experiments. \u003cem\u003eNew York: VanNostrund Reinhold\u003c/em\u003e. 1984;\u003c/li\u003e\n\u003cli\u003eCarter N. The use of triangulation in qualitative research. \u003cem\u003eNumber 5/September 2014\u003c/em\u003e. 2014;41(5):545-547. \u003c/li\u003e\n\u003cli\u003eBispo J\u0026uacute;nior JP. Social desirability bias in qualitative health research. \u003cem\u003eRevista de saude publica\u003c/em\u003e. 2022;56:101. \u003c/li\u003e\n\u003cli\u003eGifford SM. The meaning of lumps: a case study of the ambiguities of risk. \u003cem\u003eAnthropology and epidemiology: interdisciplinary approaches to the study of health and disease\u003c/em\u003e. Springer; 1986:213-246.\u003c/li\u003e\n\u003cli\u003ePanter-Brick C. Health, risk, and resilience: Interdisciplinary concepts and applications. \u003cem\u003eAnnual Review of Anthropology\u003c/em\u003e. 2014;43(1):431-448. \u003c/li\u003e\n\u003cli\u003eManderson L. Anthropologies of Cancer and Risk, Uncertain and Disruption. In: Singer M, Erickson PI, eds. \u003cem\u003eA Companion to Medical Anthropology\u003c/em\u003e. John Wiley \u0026amp; Sons; 2011:323-338.\u003c/li\u003e\n\u003cli\u003eSmith-Morris C, ed. \u003cem\u003eDiagnostic Controversy: Cultural Perspectives on Competing Knowledge in Healthcare\u003c/em\u003e. Routledge Press; 2015.\u003c/li\u003e\n\u003cli\u003eKanter JW, Manos RC, Bowe WM, Baruch DE, Busch AM, Rusch LC. What is behavioral activation?: A review of the empirical literature. \u003cem\u003eClinical psychology review\u003c/em\u003e. 2010;30(6):608-620. \u003c/li\u003e\n\u003cli\u003eProchaska JO, Velicer WF. The transtheoretical model of health behavior change. \u003cem\u003eAmerican journal of health promotion\u003c/em\u003e. 1997;12(1):38-48. \u003c/li\u003e\n\u003cli\u003eGhorbani R, Soleimani M, Zeinali M-R, Davaji M. Iranian nurses and nursing students\u0026apos; attitudes on barriers and facilitators to patient education: A survey study. \u003cem\u003eNurse education in practice\u003c/em\u003e. 2014;14(5):551-556. \u003c/li\u003e\n\u003cli\u003eYi JC, Walsh CA, Chow EJ, Baker KS, Mendoza JA, Cole A. Primary care providers and their needs caring for cancer survivors: a qualitative study. \u003cem\u003eJournal of Cancer Survivorship\u003c/em\u003e. 2025:1-7. \u003c/li\u003e\n\u003cli\u003eWhite J, Byles J, Williams T, Untaru R, Ngo DTM, Sverdlov AL. Early access to a cardio-oncology clinic in an Australian context: a qualitative exploration of patient experiences. \u003cem\u003eCardio-Oncology\u003c/em\u003e. 2022;8(1):14. \u003c/li\u003e\n\u003cli\u003eClark RA, Marin TS, Mccarthy AL, et al. Cardiotoxicity after cancer treatment: a process map of the patient treatment journey. \u003cem\u003eCardio-Oncology\u003c/em\u003e. 2019-12-01 2019;5(1)doi:10.1186/s40959-019-0046-5\u003c/li\u003e\n\u003cli\u003eSutherland J, McLaughlan L. The Timing of Breast Cancer Patient Education: Its Influence on Satisfaction. \u003cem\u003eRadiation therapist\u003c/em\u003e. 2013;22(2)\u003c/li\u003e\n\u003cli\u003eFredericks S. Timing for delivering individualized patient education intervention to coronary artery bypass graft patients: An RCT. \u003cem\u003eEuropean Journal of Cardiovascular Nursing\u003c/em\u003e. 2009;8(2):144-150. \u003c/li\u003e\n\u003cli\u003eMarshall K, Patterson F, Fleming J, Gustafsson L, Atresh S. \u0026ldquo;Be ready to learn\u0026rdquo;: a qualitative study of the patient perspective of falls and fall prevention following discharge from a spinal injuries unit. \u003cem\u003eDisability and rehabilitation\u003c/em\u003e. 2024;46(14):3108-3115. \u003c/li\u003e\n\u003cli\u003eMaddox EN, Forte M, Boozer RW. Learning readiness: An underappreciated yet vital dimension in experiential learning. \u003c/li\u003e\n\u003cli\u003eRowlands G, Protheroe J, Saboga-Nunes L, Van den Broucke S, Levin-Zamir D, Okan O. Health literacy and chronic conditions: A life course perspective. \u003cem\u003eInternational handbook of health literacy\u003c/em\u003e. Policy Press; 2019:183-198.\u003c/li\u003e\n\u003cli\u003eHelitzer D, Hollis C, Cotner J, Oestreicher N. Health literacy demands of written health information materials: an assessment of cervical cancer prevention materials. \u003cem\u003eCancer control\u003c/em\u003e. 2009;16(1):70-78. \u003c/li\u003e\n\u003cli\u003eSchuitevoerder D, Fortino J, Vetto JT. Hard copy durable patient cancer education materials: do they still matter? \u003cem\u003eJournal of Cancer Education\u003c/em\u003e. 2017;32(3):487-490. \u003c/li\u003e\n\u003cli\u003eGruman J, Rovner MH, French ME, et al. From patient education to patient engagement: implications for the field of patient education. \u003cem\u003ePatient education and counseling\u003c/em\u003e. 2010;78(3):350-356. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Sample Characteristics.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.9537%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant Characteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49.0463%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.9537%;\"\u003e\n \u003cp\u003eTotal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49.0463%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.9537%;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49.0463%;\"\u003e\n \u003cp\u003eRange 30-82\u003c/p\u003e\n \u003cp\u003eAvg. 64.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.9537%;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49.0463%;\"\u003e\n \u003cp\u003eMale 11\u003c/p\u003e\n \u003cp\u003eFemale 15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.9537%;\"\u003e\n \u003cp\u003eEthnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49.0463%;\"\u003e\n \u003cp\u003eBlack (17)\u003c/p\u003e\n \u003cp\u003eWhite (2)\u003c/p\u003e\n \u003cp\u003eUnreported (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.9537%;\"\u003e\n \u003cp\u003eCancer types (self-reported)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49.0463%;\"\u003e\n \u003cp\u003eBreast (11)\u003c/p\u003e\n \u003cp\u003eProstate (7)\u003c/p\u003e\n \u003cp\u003eLung (2)\u003c/p\u003e\n \u003cp\u003eStomach (1)\u003c/p\u003e\n \u003cp\u003eMelanoma (2)\u003c/p\u003e\n \u003cp\u003ePancreatic (1)\u003c/p\u003e\n \u003cp\u003eBladder (1)\u003c/p\u003e\n \u003cp\u003eColon and prostate (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.9537%;\"\u003e\n \u003cp\u003eTime since completion of cancer treatment (self-reported)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49.0463%;\"\u003e\n \u003cp\u003eStill active (4)\u003c/p\u003e\n \u003cp\u003e5 years (6)\u003c/p\u003e\n \u003cp\u003e10 years or more (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Interview Guide\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterview Guide\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003col\u003e\n \u003cli\u003eTell me about your understanding of your risks for cardiovascular disease?\u003c/li\u003e\n \u003cli\u003eWhat do you know about the impacts and risks of your cancer treatments?\u003col\u003e\n \u003cli\u003eDid your cardiovascular risk change after your cancer treatment? Yes/No\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWho, if anyone, explained this to you?\u003c/li\u003e\n \u003cli\u003eIf so, how did it change?\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/li\u003e\n \u003cli\u003eWhen you were under treatment for your cancer, did any health professionals talk to you about your post-treatment needs?\u003c/li\u003e\n \u003cli\u003eWas the impact of your cancer treatment on your heart discussed? By whom? What do you remember learning?\u003col\u003e\n \u003cli\u003eHow was the information conveyed to you?\u003c/li\u003e\n \u003cli\u003eWould you have preferred it in a different manner/format, time or from a different person?\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/li\u003e\n \u003cli\u003eWhat is your biggest concern today about the changes you may need to make for your health?\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCan you please discuss how you felt learning new information about your health risks when you were going through cancer treatment.\u003col\u003e\n \u003cli\u003eHow do you feel about learning new information about your health risks now? Enjoy, avoid, etc.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/li\u003e\n \u003cli\u003eWhat should clinicians know about your process of learning? Your preferences for when, where, by whom?\u003c/li\u003e\n \u003cli\u003e8. \u0026nbsp; \u0026nbsp; As a cancer survivor, do you approach your health differently now? Please explain.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Codebook with Definitions and # of Unique Excerpts.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.6667%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCode\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.6667%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefinition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6667%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e# Unique Excerpts\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.6667%;\"\u003e\n \u003cp\u003eChanged Risk (for CVD)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.6667%;\"\u003e\n \u003cp\u003eDiscussions about their changed CVD risk, or participant reaction to learning about their potentially higher CVD risk; may include learning early or late about these dangers; may include no change in CVD or CVD was not discussed as the opposite of changed CVD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6667%;\"\u003e\n \u003cp\u003e207\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.6667%;\"\u003e\n \u003cp\u003eKnowledge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.6667%;\"\u003e\n \u003cp\u003eParticipant narratives about general disease knowledge (e.g., other risk factors, family history), shared knowledge (e.g., experience of others going through treatment). Existing awareness and understanding of their CVD risk, lack of risk knowledge, absence of knowledge.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6667%;\"\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.6667%;\"\u003e\n \u003cp\u003eFormat\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.6667%;\"\u003e\n \u003cp\u003ePassages that address the medium (e.g., pamphlets, conversation with provider, other), language, delivered by (e.g., which healthcare provider).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6667%;\"\u003e\n \u003cp\u003e105\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.6667%;\"\u003e\n \u003cp\u003eAgency\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.6667%;\"\u003e\n \u003cp\u003eDiscussions about actively (with agency) participating in any treatment decision-making, including asking questions (of any health care personnel), or seeking information from any source; a demonstration of agency or participation in decision-making.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6667%;\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.6667%;\"\u003e\n \u003cp\u003eReaction (to Diagnosis, Treatment)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.6667%;\"\u003e\n \u003cp\u003eReaction to or experience of oncology treatment in general; can include emotion or practical actions; this code can remain very broad.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6667%;\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.6667%;\"\u003e\n \u003cp\u003eContent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.6667%;\"\u003e\n \u003cp\u003ePassages that indicate information desired (e.g., more info about race and cancer); also used for lack of content (absence of info) from a given source or opportunity.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6667%;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.6667%;\"\u003e\n \u003cp\u003eTiming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.6667%;\"\u003e\n \u003cp\u003ePassages about when they received (or prefer to receive) information; could be a time of day, or during an appointment; anything that marks the timing of receiving information.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6667%;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.6667%;\"\u003e\n \u003cp\u003eFactor (in decision-making)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.6667%;\"\u003e\n \u003cp\u003ePassages in which a participant describes something, including CVD knowledge, as a factor in their decision to undergo oncology treatment, or decision about which oncology treatment to undergo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6667%;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.6667%;\"\u003e\n \u003cp\u003eStage of Treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.6667%;\"\u003e\n \u003cp\u003eNarratives about the current or past status of their cancer treatment, or how long ago it was; recent or in the remote past; any time-related indications of readiness for information.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6667%;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.6667%;\"\u003e\n \u003cp\u003eConfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.6667%;\"\u003e\n \u003cp\u003eNarrative about confusion due to absence of knowledge about disease, risk, treatment options, etc.; feelings due to the absence of knowledge.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6667%;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.6667%;\"\u003e\n \u003cp\u003eSurprise\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.6667%;\"\u003e\n \u003cp\u003eParticipants surprised associated with their oncology treatments or CVD risk; focus is on patients being under-informed within the context of getting cancer; should \u003cu\u003enot\u003c/u\u003e refer to emotion/feelings generally about receiving a cancer diagnosis.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6667%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.6667%;\"\u003e\n \u003cp\u003eRush\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.6667%;\"\u003e\n \u003cp\u003eAny passages that indicate rushed decisions; inability to ask all the questions one wanted to ask.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6667%;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Learning Preferences.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow was the information about CVD risk conveyed to you?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85.3881%;\"\u003e\n \u003cp\u003eConversation w health professional\u003c/p\u003e\n \u003cp\u003eOnline research\u003c/p\u003e\n \u003cp\u003ePamphlets from clinic\u003c/p\u003e\n \u003cp\u003eIt was not conveyed to me\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 14.6119%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWould you have preferred it in a different manner or format?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85.3881%;\"\u003e\n \u003cp\u003eConversation/more conversation\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMore written material/details\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWebinar\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo/Was satisfied with format\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 14.6119%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhen is it best to bring up this information about oncology-related CVD risk?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85.3881%;\"\u003e\n \u003cp\u003eBefore treatment\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMultiple times/Before, during, and/or after treatment\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNot asked/No answer\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 14.6119%;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cancer-survivorship","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcsu","sideBox":"Learn more about [Journal of Cancer Survivorship](https://www.springer.com/journal/11764)","snPcode":"11764","submissionUrl":"https://submission.nature.com/new-submission/11764/3","title":"Journal of Cancer Survivorship","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Cancer Survivorship, Patient Education, Prevention","lastPublishedDoi":"10.21203/rs.3.rs-8670497/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8670497/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eTo understand general CVD risk awareness and learning preferences of cancer survivors, with particular attention to the learning needs of long-term (\u0026gt;5 year) survivors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003eWe performed a qualitative sub-study of participants recruited from 14 community educational and health events in an underserved are of Dallas, TX from July 2023 – May 2024. Recorded interviews were transcribed verbatim, analyzed in two phases (framework analysis then systematic coding) to identify themes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eTwenty-six\u003cstrong\u003e \u003c/strong\u003ecancer survivors ranging in age from 30 to 82 (average age of 64.5 years) were interviewed, a large majority being long-term (\u0026gt;5 year) survivors and African American. Participants had diverse types of cancer, predominantly breast or prostate. Triangulation methods produced 3 themes: (1) Although a majority (73%) of participants self-reported knowledge about CVD risks after cancer treatment, narratives revealed a substantial lack of clarity about individual cardio-oncologic risk factors, such as the latent risks from chemotherapy or radiation. (2) Participants expressed trust and satisfaction with communications from their cancer treatment team with most (77%) stating that greater CVD risk understanding would not have changed their oncology treatment decisions. (3) For learning about CVD risks, participants preferred conversations with healthcare providers at multiple time points, before and after oncology treatment, as well as written materials that could be preserved and consulted later in the survivorship period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eSurvivors initially over-estimated their knowledge of CVD risks related to their cancer treatment and relied on their clinicians to raise concerns. Survivors’ awareness of CVD risks may be improved through targeted communications by clinicians, particular for long-term survivors, supplemented by durable reference materials. Greater attention to long-term CVD risk awareness in cancer survivors may improve CVD prevention among cancer survivors.\u003c/p\u003e","manuscriptTitle":"Long-term cancer survivor awareness and learning preferences for cardio- oncologic risks: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-27 06:15:14","doi":"10.21203/rs.3.rs-8670497/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"290177959300459019471120181718359641076","date":"2026-05-18T02:21:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-24T20:13:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"338580180398866047443043689939078511785","date":"2026-02-24T15:44:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-21T13:17:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-23T09:53:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-23T09:48:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cancer Survivorship","date":"2026-01-22T13:22:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cancer-survivorship","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcsu","sideBox":"Learn more about [Journal of Cancer Survivorship](https://www.springer.com/journal/11764)","snPcode":"11764","submissionUrl":"https://submission.nature.com/new-submission/11764/3","title":"Journal of Cancer Survivorship","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"24263ebf-a282-4ca5-b942-f73572f6d664","owner":[],"postedDate":"January 27th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"290177959300459019471120181718359641076","date":"2026-05-18T02:21:19+00:00","index":47,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-21T13:23:51+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-27 06:15:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8670497","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8670497","identity":"rs-8670497","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}