Center for Data and Knowledge Integration for Health, Fiocruz, Salvador, Brazil.
Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
JAMA Netw Open. 2024 Jan 2;7(1):e2353100. doi: 10.1001/jamanetworkopen.2023.53100.
Women living in income-segregated areas are less likely to receive adequate breast cancer care and access community resources, which may heighten breast cancer mortality risk.
To investigate the association between income segregation and breast cancer mortality and whether this association is attenuated by receipt of the Bolsa Família program (BFP), the world's largest conditional cash-transfer program.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study was conducted using data from the 100 Million Brazilian Cohort, which were linked with nationwide mortality registries (2004-2015). Data were analyzed from December 2021 to June 2023. Study participants were women aged 18 to 100 years.
Women's income segregation (high, medium, or low) at the municipality level was obtained using income data from the 2010 Brazilian census and assessed using dissimilarity index values in tertiles (low [0.01-0.25], medium [0.26-0.32], and high [0.33-0.73]).
The main outcome was breast cancer mortality. Mortality rate ratios (MRRs) for the association of segregation with breast cancer deaths were estimated using Poisson regression adjusted for age, race, education, municipality area size, population density, area of residence (rural or urban), and year of enrollment. Multiplicative interactions of segregation and BFP receipt (yes or no) in the association with mortality (2004-2015) were assessed.
Data on 21 680 930 women (mean [SD] age, 36.1 [15.3] years) were analyzed. Breast cancer mortality was greater among women living in municipalities with high (adjusted MRR [aMRR], 1.18; 95% CI, 1.13-1.24) and medium (aMRR, 1.08; 95% CI, 1.03-1.12) compared with low segregation. Women who did not receive BFP had higher breast cancer mortality than BFP recipients (aMRR, 1.17; 95% CI, 1.12-1.22). By BFP strata, women who did not receive BFP and lived in municipalities with high income segregation had a 24% greater risk of death from breast cancer compared with those living in municipalities with low income segregation (aMRR, 1.24: 95% CI, 1.14-1.34); women who received BFP and were living in areas with high income segregation had a 13% higher risk of death from breast cancer compared with those living in municipalities with low income segregation (aMRR, 1.13; 95% CI, 1.07-1.19; P for interaction = .008). Stratified by the amount of time receiving the benefit, segregation (high vs low) was associated with an increase in mortality risk for women receiving BFP for less time but not for those receiving it for more time (<4 years: aMRR, 1.16; 95% CI, 1.07-1.27; 4-11 years: aMRR, 1.09; 95% CI, 1.00-1.17; P for interaction <.001).
These findings suggest that place-based inequities in breast cancer mortality associated with income segregation may be mitigated with BFP receipt, possibly via improved income and access to preventive cancer care services among women, which may be associated with early detection and treatment and ultimately reduced mortality.
重要性：生活在收入隔离地区的女性获得足够的乳腺癌护理和社区资源的机会较少，这可能会增加乳腺癌的死亡率。
目的：调查收入隔离与乳腺癌死亡率之间的关联，以及该关联是否会因接受世界上最大的有条件现金转移支付计划——巴西家庭福利计划（Bolsa Família program，BFP）而减弱。
设计、地点和参与者：这项队列研究使用了来自 1 亿巴西人队列的数据，这些数据与全国死亡率登记处（2004-2015 年）相关联。数据于 2021 年 12 月至 2023 年 6 月进行分析。研究参与者为年龄在 18 至 100 岁的女性。
暴露：通过 2010 年巴西人口普查的收入数据获得女性在市一级的收入隔离（高、中、低），并使用离散指数值进行评估（低[0.01-0.25]、中[0.26-0.32]和高[0.33-0.73]）。
主要结果和措施：主要结局是乳腺癌的死亡率。使用泊松回归调整年龄、种族、教育程度、市辖区面积大小、人口密度、居住地（农村或城市）和登记年份，估计隔离与乳腺癌死亡相关的死亡率比值（MRR）。评估了隔离和 BFP 接受（是或否）与死亡率（2004-2015 年）之间关联的乘法交互作用。
结果：分析了 21680930 名女性的数据（平均[标准差]年龄，36.1[15.3]岁）。与低隔离的女性相比，生活在高（调整后的 MRR [aMRR]，1.18；95%CI，1.13-1.24）和中（aMRR，1.08；95%CI，1.03-1.12）隔离的女性乳腺癌死亡率更高。与接受 BFP 的女性相比，未接受 BFP 的女性乳腺癌死亡率更高（aMRR，1.17；95%CI，1.12-1.22）。按 BFP 分层，与生活在低收入隔离的女性相比，未接受 BFP 且生活在高收入隔离的女性死于乳腺癌的风险增加了 24%（aMRR，1.24：95%CI，1.14-1.34）；而接受 BFP 且生活在高收入隔离地区的女性死于乳腺癌的风险则增加了 13%（aMRR，1.13；95%CI，1.07-1.19；P 值为 0.008）。按接受福利的时间长短分层，对于接受 BFP 时间较短的女性，隔离（高与低）与死亡率风险的增加相关，但对于接受 BFP 时间较长的女性则不相关（<4 年：aMRR，1.16；95%CI，1.07-1.27；4-11 年：aMRR，1.09；95%CI，1.00-1.17；P 值<.001）。
结论和相关性：这些发现表明，与收入隔离相关的乳腺癌死亡率的地方不平等可能会因接受 BFP 而得到缓解，这可能是通过提高女性的收入和获得预防性癌症护理服务来实现的，这可能与早期发现和治疗有关，最终降低死亡率。
