Low neighborhood socioeconomic status is associated with higher mortality and increased surgery utilization among metastatic breast cancer patients

Abstract

Purpose Low socioeconomic status (SES) is associated with advanced stage, lower-quality care, and higher mortality among breast cancer patients. The purpose of this study is to examine the association between neighborhood SES (nSES), surgical management, and disease-specific mortality in de novo metastatic breast cancer (MBC) patients in the Surveillance, Epidemiology, and End Results (SEER) Program. Methods MBC patients ages 18 to 85+ years diagnosed from 2010 through 2016 were identified in SEER. The cohort was divided into low, middle, and high nSES based on the NCI census tract-level index. Univariable and multivariable analyses were used to examine the relationship between nSES, surgery, and disease specific mortality in MBC patients. Results There were 24,532 de novo MBC patients who met study criteria, with 28.7 % undergoing surgery. Over the study period, surgery utilization decreased across all nSES groups. However, lower nSES was associated with a higher odds of undergoing surgery (low OR 1.25 [1.15–1.36] p < 0.001; middle OR 1.09 [1.01–1.18] p = 0.022; ref high). Living in an area with lower SES was associated with a worse disease specific mortality (low HR 1.24 [1.25, 1.44; ], middle 1.20 [1.1–1.29]: ref high). Specifically, there was a 9.26 month mean survival differences between the lowest (41.02 ± 0.47 months) and highest (50.28 ± 0.47 months) nSES groups. Conclusion These results suggest area of residence may contribute to differences in surgical management and clinical outcomes among de novo MBC patients. Future studies should examine the contributions of patient characteristics and preferences within the context of surgeon recommendations.

Neighborhood Disadvantage and Breast Cancer–Specific Survival

“…16 Previous analyses also have methodologic limitations associated with confounding between neighborhood and individual-level factors or their design independently assesses only these measures of disadvantage rather than their joint outcome. 15,17 Moreover, these studies predominantly use national cancer databases that have limited data on key variables, such as age (eg, only include individuals aged Ն65 years), SES (eg, do not include uninsured, Medicare-ineligible populations), and racial and ethnic diversity (eg, only 5% of patients are Hispanic) along with an inability to capture National Comprehensive Cancer Network (NCCN) guideline-concordant treatment. 18,19 To overcome these data and methodologic limitations, we sought to assess whether there is an association between a robust validated measure of neighborhood disadvantage (Area Deprivation Index [ADI]) and breast cancer-specific survival in a diverse sociodemographic and racial and ethnic population with individual-level sociodemographic, comorbidity, breast cancer risk factor, access to care, tumor, and NCCN guideline-concordant treatment information not available in national cancer databases.…”

“…Studies have found associations between neighborhood-level measures, such as socioeconomic status (SES), with disparities in breast cancer survival . However, many measures of neighborhood SES previously used do not encapsulate the various domains and complexities that contribute to neighborhood disadvantage .…”

Neighborhood socioeconomic status and low‐value breast cancer care

“…in patients from low SES areas may limit access to institutions that are more likely to follow the most current guidelines. 54 The results from our study highlight the need for additional research elucidating the pathways between nSES and surgical management. Specifically, qualitative analytical tools such as intersectionality--describes the impact of multiple social identities (e.g., Black race, female gender, and class) on discrimination and disadvantage, provide a much needed contextual framework.…”

“…Similarly, the interplay of multiple social determinants of health (transportation, personal finances, workplace flexibility, stress, etc.) in patients from low SES areas may limit access to institutions that are more likely to follow the most current guidelines 54 . The results from our study highlight the need for additional research elucidating the pathways between nSES and surgical management.…”

Association Between Surgery Preference and Receipt in Ductal Carcinoma In Situ After Breast Magnetic Resonance Imaging

“…A previous study noted that, when accounting for neighborhood socioeconomic status, Black women were more likely to adhere to endocrine therapy compared with White women . In women with metastatic breast cancer, neighborhood socioeconomic status rather than race was associated with the probability of receiving surgery . In the present study, ADI, which is a measure of neighborhood socioeconomic status, was not associated with either preferred or received surgery.…”