Objective:To understand the impact of Black race on breast cancer (BC) presentation, treatment, and survival among Hispanics.Summary of Background Data:It is well-documented that non-Hispanic Blacks (NHB) present with late-stage disease, are less likely to complete treatment, and have worse survival compared to their non-Hispanic White (NHW) counterparts. However, no data evaluates whether this disparity extends to Hispanic Blacks (HB) and Hispanic Whites (HW). Given our location in Miami, gateway to Latin America and the Caribbean, we have the diversity to evaluate BC outcomes in HB and HW.Methods:Retrospective cohort study of stage I-IV BC patients treated at our institution from 2005–2017. Kaplan-Meier survival curves were generated and compared using the log-rank test. Multivariable survival models were computed using Cox proportional hazards regression.Results:Race/ethnicity distribution of 5951 patients: 28% NHW, 51% HW, 3% HB, and 18% NHB. HB were more economically disadvantaged, had more aggressive disease, and less treatment compliant compared to HW. 5-year OS by race/ethnicity was: 85% NHW, 84.8% HW, 79.4% HB, and 72.7% NHB (P < 0.001). After adjusting for covariates, NHB was an independent predictor of worse OS [hazard ratio:1.25 (95% confidence interval: 1.01–1.52), P < 0.041)].Conclusions:In this first comprehensive analysis of HB and HW, HB have worse OS compared to HW, suggesting that race/ethnicity is a complex variable acting as a proxy for tumor and host biology, as well as individual and neighborhood-level factors impacted by structural racism. This study identifies markers of vulnerability associated with Black race and markers of resiliency associated with Hispanic ethnicity to narrow a persistent BC survival gap.
ImportanceNeighborhood-level disadvantage is an important factor in the creation and persistence of underresourced neighborhoods with an undue burden of disparate breast cancer–specific survival outcomes. Although studies have evaluated neighborhood-level disadvantage and breast cancer–specific survival after accounting for individual-level socioeconomic status (SES) in large national cancer databases, these studies are limited by age, socioeconomic, and racial and ethnic diversity.ObjectiveTo investigate neighborhood SES (using a validated comprehensive composite measure) and breast cancer–specific survival in a majority-minority population.Design, Setting, and ParticipantsThis retrospective multi-institutional cohort study included patients with stage I to IV breast cancer treated at a National Cancer Institute–designated cancer center and sister safety-net hospital from January 10, 2007, to September 9, 2016. Mean (SD) follow-up time was 60.3 (41.4) months. Data analysis was performed from March 2022 to March 2023.ExposuresNeighborhood SES was measured using the Area Deprivation Index (tertiles), a validated comprehensive composite measure of neighborhood SES.Main Outcomes and MeasuresThe primary outcome was breast cancer–specific survival. Random effects frailty models for breast cancer–specific survival were performed controlling for individual-level sociodemographic, comorbidity, breast cancer risk factor, access to care, tumor, and National Comprehensive Cancer Network guideline-concordant treatment characteristics. The Area Deprivation Index was calculated for each patient at the census block group level and categorized into tertiles (T1-T3).ResultsA total of 5027 women with breast cancer were included: 55.8% were Hispanic, 17.5% were non-Hispanic Black, and 27.0% were non-Hispanic White. Mean (SD) age was 55.5 (11.7) years. Women living in the most disadvantaged neighborhoods (T3) had shorter breast cancer–specific survival compared with those living in the most advantaged neighborhoods (T1) after controlling for individual-level sociodemographic, comorbidity, breast cancer risk factor, access to care, tumor, and National Comprehensive Cancer Network guideline-concordant treatment characteristics (T3 vs T1: hazard ratio, 1.29; 95% CI, 1.01-1.65; P &lt; .04).Conclusions and RelevanceIn this cohort study, a shorter breast cancer–specific survival in women from disadvantaged neighborhoods compared with advantaged neighborhoods was identified, even after controlling for individual-level sociodemographic, comorbidity, breast cancer risk factor, access to care, tumor, and National Comprehensive Cancer Network guideline-concordant treatment characteristics. The findings suggest potential unaccounted mechanisms, including unmeasured social determinants of health and access to care measures. This study also lays the foundation for future research to evaluate whether social adversity from living in a disadvantaged neighborhood is associated with more aggressive tumor biologic factors, and ultimately shorter breast cancer-specific survival, through social genomic and/or epigenomic alterations.
BackgroundAlthough advances in screening, detection, diagnosis, and treatment have reduced overall breast cancer mortality, well-documented socioeconomic and racial/ethnic disparities persist. The objective of this study was to utilize the area deprivation index (ADI), a compositive measure of neighborhood disadvantage, on breast cancer survival in South Florida, predominantly consisting of Miami-Dade County residents. The ADI is based on a measure created by the Health Resources & Services Administration (HRSA) over three decades ago, and has since been refined, adapted, and validated to the Census Block Group neighborhood level. The ADI score (1-10) includes factors from the domains of income/employment (e.g., median family income), education (e.g., % population >25 with <9 years of education), housing (e.g., % occupied housing without complete plumbing), and household characteristics (e.g., % single-parent households with children <18). MethodsPatients treated at our medical campus, comprised of both a safety-net hospital and an adjacent academic cancer center, with stage I-IV breast cancer from 2005-2017 were identified from our local tumor registry. Our main outcome of interest was breast cancer-specific survival (BCSS). The ADI was calculated for each patient at the census block group level using the University of Wisconsin Neighborhood Atlas (https://www.neighborhoodatlas.medicine.wisc.edu/mapping) and categorized into tertiles. Random effects frailty models were conducted, controlling for patient and tumor characteristics [grade, stage, receptor status (ER+/HER-, ER+/HER2+, ER-HER2+, ER-/HER2-)], and NCCN-guideline appropriate treatment. ResultsThe study population was 5,377 breast cancer patients with 55.5% being Hispanic, 27.0% being non-Hispanic White (NHW), and 17.5% being non-Hispanic Black (NHB). The distribution of NHB was highest in the most disadvantaged neighborhoods compared to NHW and Hispanics (p<0.001). In addition, more uninsured patients lived in the most disadvantaged neighborhoods compared to those with any type of insurance. After controlling for multiple covariates including comorbidities, race/ethnicity, insurance status, and tumor subtype, we found that those individuals living in the most disadvantaged neighborhoods (highest ADI tertile) had a significantly increased hazard of breast cancer specific death compared to those living in the most advantaged neighborhoods (T2: HR: 1.27 95% CI: 1.00, 1.63, p<0.05 and T3: HR: 1.5 95% CI 1.17, 1.91, p<0.05). ConclusionThis study is the first to evaluate BCSS through the lens of the ADI, a composite measure of neighborhood advantage and disadvantage using census block group data reflective of social determinants of health domains spanning income, education, employment, and housing quality. Our study suggests that breast cancer survival disparities are partly influenced by neighborhood disadvantage. Even when accounting for sociodemographics, tumor characteristics, and NCCN-guideline appropriate treatment, survival disparities remained, suggesting potential social and environmental factors impacting survival. To address these disparities, effective interventions are. needed that account for the social and environmental contexts in which cancer patients live and are treated. Table: ADI (Tertiles) and Breast Cancer-Specific SurvivalHR (95% CI)Area Deprivation Index (vs. most advantaged)ADI Tertile 21.27 (1.00, 1.63)ADI Tertile 3 (more disadvantaged)1.50 (1.17, 1.91)Race (vs. NHW)Hispanic0.94 (0.72, 1.22)NHB1.71 (1.27, 2.31)Age1.02 (1.01, 1.02)Insurance (vs. Private)Government1.49 (1.19, 1.86)Insurance, NOS0.97 (0.62, 1.51)Uninsured1.15 (0.87, 1.52)Unknown1.19 (0.78, 1.82)Receptor Status (vs. ER+/HER2-)ER+/HER2+1.40 (1.06, 1.86)ER-/HER2-2.11 (1.70, 2.60)ER-/HER2+1.20 (0.85, 1.69)Unknown0.88 (0.51, 1.51)Body Mass Index (vs. Normal Weight (18.5 – 24.9)Underweight (Less than 18.5)1.40 (0.72, 2.72)Overweight (25.0 – 29.9)0.70 (0.56, 0.88)Obese (> 29.9)0.79 (0.63, 0.98)Hypertension0.84 (0.67, 1.03)Diabetes Mellitus1.02 (0.74, 1.40)NCCN-guideline concordant Treatment0.84 (0.75, 0.94) Citation Format: Neha Goel, Seraphina Choi, Sina Yadegarynia, Kristin Rojas, Susan Kesmodel, Erin Kobetz, Ashly Westrick. Neighborhood disadvantage predicts worse breast cancer-specific survival [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-12-08.
Background The coronavirus (COVID‐19) pandemic led to disruptions in operative and hospital capabilities as the country triaged resources and canceled elective procedures. This study details the operative experience of a safety‐net hospital for cancer‐related operations during a 3‐month period at the height of the pandemic. Methods Patients operated on for or diagnosed with malignancies of the abdomen, breast, skin, or soft‐tissue (September 3, 2020–September 6, 2020) were identified from operative/clinic schedules. Sociodemographics, tumor and treatment characteristics, and COVID‐19 information was identified through retrospective chart review of a prospectively maintained database. Descriptive statistics were calculated. Results Fifty patients evaluated within this window underwent oncologic surgery. Median age was 61 (interquartile range: 53–68), 56% were female, 86% were White, and 66% were Hispanic. The majority (28%) were for colon cancer. Only two patients tested positive for COVID‐19 preoperatively or within 30 days of their operation. There were no mortalities during the 1‐year study period. Conclusion During the COVID‐19 pandemic, many hospitals and operative centers limited interventions to preserve resources, but oncologic procedures continued at many large‐volume academic cancer centers. This study underscores the importance of continuing to offer surgery during the pandemic for surgical oncology cases at safety‐net hospitals to minimize delays in time‐sensitive oncologic treatment.
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