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      Effects of socioeconomic status and race on survival and treatment in metastatic breast cancer

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          Abstract

          Race and socioeconomic factors affect outcomes in breast cancer. We aimed to assess the effect of race and neighborhood socioeconomic status (SES) on overall survival and treatment patterns in patients with metastatic breast cancer (MBC). This is a retrospective cohort study involving patients ( N = 1246) with distant breast cancer metastases diagnosed at UPMC Magee Women’s Breast Cancer Clinic from 2000–2017. Overall survival and treatment patterns were compared between races (Blacks and whites) and SES groups (defined using Area Deprivation Index). Low SES, but not tumor characteristics, was associated with Black race ( P < 0.001) in the study population. Low SES (Median [Interquartile Range, IQR] survival 2.3[2.2–2.5] years vs high SES 2.7[2.5–3.1] years, P = 0.01) and Black race (Median [IQR] survival 1.8[1.3–2.3] years, vs white 2.5[2.3–2.7] years P = 0.008) separately were associated with worse overall survival in patients with MBC. In the Cox Proportional Hazard model with SES, race, age, subtype, number of metastases, visceral metastasis, and year of diagnosis as covariates, low SES (Hazard ratio 1.19[1.04–1.35], P = 0.01), but not Black race (Hazard ratio 1.19[0.96–1.49], P = 0.12), independently predicted overall survival in MBC. Moreover, patients from low SES neighborhoods and Black race received fewer lines of chemotherapy than high SES and whites. In conclusion, low neighborhood SES is associated with worse outcomes in patients with MBC. Poor outcomes in Black patients with MBC, at least in part is driven by socioeconomic factors. Future studies should delineate the interplay between neighborhood SES, race, and their effects on tumor biology in MBC.

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          Most cited references19

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          Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study.

          Measures of socioeconomic disadvantage may enable improved targeting of programs to prevent rehospitalizations, but obtaining such information directly from patients can be difficult. Measures of U.S. neighborhood socioeconomic disadvantage are more readily available but are rarely used clinically.
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            Area deprivation and widening inequalities in US mortality, 1969-1998.

            G. Singh (2003)
            This study examined age-, sex-, and race-specific gradients in US mortality by area deprivation between 1969 and 1998. A census-based area deprivation index was linked to county mortality data. Area deprivation gradients in US mortality increased substantially during 1969 through 1998. The gradients were steepest for men and women aged 25 to 44 years and those younger than 25 years, with higher mortality rates observed in more deprived areas. Although area gradients were less pronounced for women in each age group, they rose sharply for women aged 25 to 44 and 45 to 64 years. Areal inequalities in mortality widened because of slower mortality declines in more deprived areas. Future research needs to examine population-level social, behavioral, and medical care factors that may account for the increasing gradient.
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              Ethnicity and breast cancer: factors influencing differences in incidence and outcome.

              The lower breast cancer incidence in minority women and the higher breast cancer mortality in African American women than in white women are largely unexplained. The influence of breast cancer risk factors on these differences has received little attention. Racial/ethnic differences in breast cancer incidence and outcome were examined in 156,570 postmenopausal women participating in the Women's Health Initiative. Detailed information on breast cancer risk factors including mammography was collected, and participants were followed prospectively for breast cancer incidence, pathological breast cancer characteristics, and breast cancer mortality. Comparisons of breast cancer incidence and mortality across racial/ethnic groups were estimated as hazard ratios (HRs) and 95% confidence intervals (CIs) from Cox proportional hazard models. Tumor characteristics were compared as odds ratios (ORs) and 95% confidence intervals in logistic regression models. After median follow-up of 6.3 years, 3938 breast cancers were diagnosed. Age-adjusted incidences for all minority groups (i.e., African American, Hispanic, American Indian/Alaskan Native, and Asian/Pacific Islander) were lower than for white women, but adjustment for breast cancer risk factors accounted for the differences for all but African Americans (HR = 0.75, 95% CI = 0.61 to 0.92) corresponding to 29 cases and 44 cases per 10,000 person years for African American and white women, respectively. Breast cancers in African American women had unfavorable characteristics; 32% of those in African Americans but only 10% in whites were both high grade and estrogen receptor negative (adjusted OR = 4.70, 95% CI = 3.12 to 7.09). Moreover, after adjustment for prognostic factors, African American women had higher mortality after breast cancer than white women (HR = 1.79, 95% CI = 1.05 to 3.05) corresponding to nine and six deaths per 10 000 person-years from diagnosis in African American and white women, respectively. Differences in breast cancer incidence rates between most racial/ethnic groups were largely explained by risk factor distribution except in African Americans. However, breast cancers in African American women more commonly had characteristics of poor prognosis, which may contribute to their increased mortality after diagnosis.
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                Author and article information

                Contributors
                brufskyam@upmc.edu
                Journal
                NPJ Breast Cancer
                NPJ Breast Cancer
                NPJ Breast Cancer
                Nature Publishing Group UK (London )
                2374-4677
                1 November 2023
                1 November 2023
                2023
                : 9
                : 90
                Affiliations
                [1 ]UPMC Hillman Cancer Center, ( https://ror.org/03bw34a45) Pittsburgh, PA USA
                [2 ]Women’s Cancer Research Center (WCRC), UPMC, ( https://ror.org/011htkb76) Pittsburgh, PA USA
                [3 ]University of Pittsburgh, ( https://ror.org/01an3r305) Pittsburgh, PA USA
                [4 ]Magee-Womens Research Institute, ( https://ror.org/00rnw4e09) Pittsburgh, PA USA
                Author information
                http://orcid.org/0000-0002-2537-6923
                http://orcid.org/0000-0001-9917-514X
                http://orcid.org/0000-0001-8080-7960
                Article
                595
                10.1038/s41523-023-00595-2
                10620133
                37914742
                720c2207-cdff-4e2f-aeed-79c9c4ac0709
                © The Author(s) 2023

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

                History
                : 1 April 2023
                : 17 October 2023
                Funding
                Funded by: FundRef https://doi.org/10.13039/100001006, Breast Cancer Research Foundation (BCRF);
                Funded by: FundRef https://doi.org/10.13039/100009634, Susan G. Komen (Susan G. Komen Breast Cancer Foundation);
                Funded by: FundRef https://doi.org/10.13039/100012386, Magee-Womens Research Institute (MWRI);
                Categories
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                Custom metadata
                © Springer Nature Limited 2023

                breast cancer
                breast cancer

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