Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.
Dana Farber Cancer Institute, ECOG-ACRIN Biostatistics Center, Boston, Massachusetts.
JAMA Oncol. 2022 Apr 1;8(4):579-586. doi: 10.1001/jamaoncol.2021.7656.
Racial disparities in survival outcomes among Black women with hormone receptor-positive breast cancer have been reported. However, the association between individual-level and neighborhood-level social determinants of health on such disparities has not been well studied.
To evaluate the association between race and clinical outcomes (ie, relapse-free interval and overall survival) adjusting for individual insurance coverage and neighborhood deprivation index (NDI), measured using zip code of residence, in women with breast cancer.
DESIGN, SETTING, AND PARTICIPANTS: This was a post hoc analysis of 9719 women with breast cancer in the Trial Assigning Individualized Options for Treatment, a randomized clinical trial conducted from April 7, 2006, to October 6, 2010. All participants received a diagnosis of hormone receptor-positive, ERBB2-negative, axillary node-negative breast cancer. The present data analysis was conducted from April 1 to October 22, 2021.
A multivariate model was developed to evaluate the association between race and relapse-free interval and overall survival adjusting for insurance and NDI level at study entry, early discontinuation of endocrine therapy 4 years after initiation, and clinicopathologic characteristics of cancer. Median follow-up for clinical outcomes was 96 months.
A total of 9719 women (4.2% [n = 405] Asian; 7.1% [n = 693] Black; 84.3% [n = 8189] White; 4.4% [n = 403] others/not specified) were included; 9.1% of included women [n = 889] were Hispanic or Latino. Median (SD) age was 56 (9.2) years. In multivariate models, Black race compared with White race was associated with statistically significant shorter relapse-free interval (hazard ratio [HR], 1.39; 95% CI, 1.05-1.84; P = .02) and overall survival (HR, 1.49; 95% CI, 1.10-2.99; P = .009), adjusting for insurance and NDI level at study entry and other factors. Although uninsured status was not associated with clinical outcomes, patients with Medicare (HR, 1.30; 95% CI, 1.01-1.68; P = .04) and Medicaid (HR, 1.44; 95% CI, 1.01-2.05; P = .05) had shorter overall survival compared with those with private insurance. Participants living in neighborhoods in the highest NDI quartile experienced shorter overall survival compared with those in the lowest quartile (HR, 1.34; 95% CI, 1.01-1.77; P = .04), regardless of self-identified race.
The findings of this post hoc analysis of a randomized clinical trial suggest that Black women with breast cancer have significantly shorter relapse-free interval and overall survival compared with White women. Early discontinuation of endocrine therapy, clinicopathologic characteristics, insurance coverage, and NDI do not fully explain the observed disparity.
ClinicalTrials.gov Identifier: NCT00310180.
已有报道称，黑种女性激素受体阳性乳腺癌患者的生存结果存在种族差异。然而，个体层面和社区层面健康决定因素对这些差异的影响尚未得到很好的研究。
通过评估居住邮编所测的个体保险覆盖范围和邻里剥夺指数（NDI），评估种族与乳腺癌患者的临床结果（即无复发生存期和总生存期）之间的关联。
设计、地点和参与者：这是一项事后分析，纳入了 9719 例激素受体阳性、ERBB2 阴性、腋窝淋巴结阴性乳腺癌患者，这些患者均参加了“分配个体化治疗选择试验”（一项 2006 年 4 月 7 日至 2010 年 10 月 6 日进行的随机临床试验）。所有参与者均被诊断为激素受体阳性、ERBB2 阴性、腋窝淋巴结阴性乳腺癌。本次数据分析于 2021 年 4 月 1 日至 10 月 22 日进行。
采用多变量模型评估种族与无复发生存期和总生存期之间的关联，模型调整了研究入组时的保险和 NDI 水平、内分泌治疗开始后 4 年内的早期停药，以及癌症的临床病理特征。临床结局的中位随访时间为 96 个月。
共纳入 9719 例女性（4.2%[n=405]为亚洲人；7.1%[n=693]为黑人；84.3%[n=8189]为白人；4.4%[n=403]为其他人/未指定；9.1%[n=889]为西班牙裔或拉丁裔）。56（9.2）岁为患者的中位年龄。在多变量模型中，与白人种族相比，黑人种族与无复发生存期较短显著相关（风险比[HR]，1.39；95%CI，1.05-1.84；P=0.02）和总生存期较短显著相关（HR，1.49；95%CI，1.10-2.99；P=0.009），调整了研究入组时的保险和 NDI 水平及其他因素。虽然无保险状态与临床结局无关，但与私人保险相比，医疗保险（HR，1.30；95%CI，1.01-1.68；P=0.04）和医疗补助（HR，1.44；95%CI，1.01-2.05；P=0.05）患者的总生存期更短。与居住在 NDI 最低四分位数的参与者相比，居住在 NDI 最高四分位数的参与者的总生存期更短（HR，1.34；95%CI，1.01-1.77；P=0.04），而与自我认定的种族无关。
这项随机临床试验的事后分析结果表明，与白人女性相比，黑人乳腺癌女性的无复发生存期和总生存期明显更短。早期停用内分泌治疗、临床病理特征、保险覆盖范围和 NDI 并不能完全解释观察到的差异。
ClinicalTrials.gov 标识符：NCT00310180。
