Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, Florida.
Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida.
JAMA Netw Open. 2023 Apr 3;6(4):e238908. doi: 10.1001/jamanetworkopen.2023.8908.
Neighborhood-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.
To investigate neighborhood SES (using a validated comprehensive composite measure) and breast cancer-specific survival in a majority-minority population.
DESIGN, SETTING, AND PARTICIPANTS: This 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.
Neighborhood SES was measured using the Area Deprivation Index (tertiles), a validated comprehensive composite measure of neighborhood SES.
The 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).
A 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 < .04).
In 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.
邻里层面的劣势是造成资源匮乏的邻里环境形成和持续存在的一个重要因素，这些邻里环境的居民承担着不成比例的乳腺癌特异性生存结果方面的负担。尽管有研究在大型国家癌症数据库中评估了邻里层面的劣势和乳腺癌特异性生存，并考虑了个体层面的社会经济地位（SES），但这些研究受到年龄、社会经济以及种族和民族多样性的限制。
在以少数族裔为主的人群中，调查社会经济地位（采用经过验证的综合复合衡量标准）与乳腺癌特异性生存之间的关系。
设计、地点和参与者：这是一项回顾性多机构队列研究，纳入了 2007 年 1 月 10 日至 2016 年 9 月 9 日在一家美国国立癌症研究所指定的癌症中心和姐妹级安全网医院接受治疗的 I 期至 IV 期乳腺癌患者。平均（SD）随访时间为 60.3（41.4）个月。数据分析于 2023 年 3 月至 2023 年 3 月进行。
使用区域剥夺指数（三分位数）衡量邻里 SES，这是一种经过验证的邻里 SES 的综合复合衡量标准。
主要结局是乳腺癌特异性生存。控制个体层面的社会人口统计学、合并症、乳腺癌风险因素、获得护理、肿瘤和国家综合癌症网络指南一致的治疗特征后，采用随机效应脆弱性模型进行乳腺癌特异性生存分析。为每位患者在普查块组层面计算区域剥夺指数，并分为三分位数（T1-T3）。
共纳入 5027 名患有乳腺癌的女性：55.8%为西班牙裔，17.5%为非西班牙裔黑人，27.0%为非西班牙裔白人。平均（SD）年龄为 55.5（11.7）岁。与居住在最有利邻里（T1）的女性相比，居住在最不利邻里（T3）的女性乳腺癌特异性生存更短，这在控制个体层面的社会人口统计学、合并症、乳腺癌风险因素、获得护理、肿瘤和国家综合癌症网络指南一致的治疗特征后依然如此（T3 与 T1：风险比，1.29；95%CI，1.01-1.65；P < .04）。
在这项队列研究中，即使在控制了个体层面的社会人口统计学、合并症、乳腺癌风险因素、获得护理、肿瘤和国家综合癌症网络指南一致的治疗特征后，来自劣势邻里的女性与优势邻里的女性相比，乳腺癌特异性生存更短。这一发现表明可能存在未被发现的机制，包括社会健康决定因素和获得护理措施方面的未被测量因素。这项研究还为未来的研究奠定了基础，以评估生活在劣势邻里环境中的社会逆境是否与更具侵袭性的肿瘤生物学因素相关，最终导致乳腺癌特异性生存缩短，这可能通过社会基因组和/或表观基因组的改变而发生。
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