Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, WI.
Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI.
J Clin Oncol. 2021 Sep 1;39(25):2749-2757. doi: 10.1200/JCO.21.00112. Epub 2021 Jun 15.
The objective was to examine the relationship between contemporary redlining (mortgage lending bias on the basis of property location) and survival among older women with breast cancer in the United States.
A redlining index using Home Mortgage Disclosure Act data (2007-2013) was linked by census tract with a SEER-Medicare cohort of 27,516 women age 66-90 years with an initial diagnosis of stage I-IV breast cancer in 2007-2009 and follow-up through 2015. Cox proportional hazards models were used to examine the relationship between redlining and both all-cause and breast cancer-specific mortality, accounting for covariates.
Overall, 34% of non-Hispanic White, 57% of Hispanic, and 79% of non-Hispanic Black individuals lived in redlined tracts. As the redlining index increased, women experienced poorer survival. This effect was strongest for women with no comorbid conditions, who comprised 54% of the sample. For redlining index values of 1 (low), 2 (moderate), and 3 (high), as compared with 0.5 (least), hazard ratios (HRs) (and 95% CIs) for all-cause mortality were HR = 1.10 (1.06 to 1.14), HR = 1.27 (1.17 to 1.38), and HR = 1.39 (1.25 to 1.55), respectively, among women with no comorbidities. A similar pattern was found for breast cancer-specific mortality.
Contemporary redlining is associated with poorer breast cancer survival. The impact of this bias is emphasized by the pronounced effect even among women with health insurance (Medicare) and no comorbid conditions. The magnitude of this neighborhood level effect demands an increased focus on upstream determinants of health to support comprehensive patient care. The housing sector actively reveals structural racism and economic disinvestment and is an actionable policy target to mitigate adverse upstream health determinants for the benefit of patients with cancer.
本研究旨在探讨美国当代红线政策（基于房产位置的抵押贷款借贷偏见）与老年乳腺癌女性生存之间的关系。
本研究使用《住房抵押贷款披露法案》（2007-2013 年）数据构建了一个红线指数，并按普查区与 SEER-医疗保险队列相链接，该队列纳入了 27516 名年龄在 66-90 岁、2007-2009 年初始诊断为 I-IV 期乳腺癌且在 2015 年前接受随访的女性。采用 Cox 比例风险模型，同时考虑协变量，检验红线政策与全因死亡率和乳腺癌特异性死亡率之间的关系。
总体而言，34%的非西班牙裔白人、57%的西班牙裔和 79%的非西班牙裔黑人居住在红线划定的区域。随着红线指数的增加，女性的生存状况越差。这一效应在没有合并症的女性中最为明显，占总样本的 54%。对于红线指数值为 1（低）、2（中）和 3（高）的女性，与指数值为 0.5（最低）的女性相比，全因死亡率的危险比（HR）（95%置信区间）分别为 HR = 1.10（1.06-1.14）、HR = 1.27（1.17-1.38）和 HR = 1.39（1.25-1.55）。在没有合并症的女性中，乳腺癌特异性死亡率也呈现出类似的模式。
当代红线政策与乳腺癌生存不良有关。即使在有医疗保险（医疗保险）且没有合并症的女性中，这种偏见的影响也很显著。这种邻里水平的影响的显著程度需要增加对健康的上游决定因素的关注，以支持全面的患者护理。住房部门积极揭示结构性种族主义和经济投资不足，是减轻癌症患者不利上游健康决定因素的可行政策目标。
