Abstract SS1-01: Where you live matters: Impact of economic, racial/ethnic, and racialized economic residential segregation on breast cancer survival
Authors: Goel Neha , Kelly Kristin N , Yadegarynia Sina , Choi Seraphina , Kesmodel Susan B , Westrick Ashly 
Published: February 2021

Abstract
Background:Racial and economic residential segregation remains a problem within the United States (US). Although advances in screening, detection, diagnosis, and treatment have reduced overall breast cancer mortality, well-documented socioeconomic and racial/ethnic survival disparities persist. The objective of this study was to analyze the effect of economic and racial/ethnic residential segregation as measured by the Index of Concentration at the Extremes (ICE) on breast cancer survival in South Florida.
Methods:Patients treated at our medical campus with stage I-IV breast cancer from 2005-2017 were identified from our local tumor registry. Census tracts were used as neighborhood proxies. Using 5-year estimates from the American Community Survey, 5 ICE variables were computed: economic (high vs. low), race/ethnicity (non-Hispanic White (NHW) vs. non-Hispanic Black (NHB) and NHW vs. Hispanic) and racialized economic (low-income NHB vs high-income NHW and low-income Hispanics vs. high-income NHW) segregation. ICE captures spatial socioeconmic and racial/ethnic segregation by literally mapping a critical dimension of social inequality not otherwise captured by metrics that characterize areas solely in terms of the proportion of the population at a specified socioeconomic level or identified as belonging to a particular racial/ethnic group. Random effects frailty models were conducted for all patients and then stratified by race/ethnicity controlling for sociodemographics, tumor characteristics, and NCCN-guideline appropriate treatment.
Results:The study population included 6,145 breast cancer patients. 52.6% were Hispanic, 26.3% were NHW, and 17.2% were NHB. After controlling for multiple covariates, those living in extreme economically disadvantaged neighborhoods had a statistically significant increased mortality compared to those living in more economically advantaged neighborhoods (HR: 1.58 95%CI: 1.29, 1.92, p&lt;0.001), Table 1. Patients living in an economically disadvantaged NHB neighborhood also had a statistically significant increased mortality compared to those living in more economically advantaged NHW neighborhoods (HR: 2.0 95% CI: 1.54, 2.60, p&lt;0.001). In race-stratified analyses, an NHW person living in a predominantly economically disadvantaged NHB neighborhood had increased mortality compared to a NHW person living in an economically advantaged NHW neighborhood (HR: 2.02 95%CI: 1.19-3.41, p&lt; 0.0071) controlling for tumor subtype and NCCN-guideline appropriate treatment.
Conclusion:This is the first study to evaluate breast cancer survival by ICE, which identifies inequitable associations by conveying extreme concentrations of both economic deprivation/privilege and racial/ethnic segregation. Our study suggests that breast cancer survival disparities is partly influenced by extreme racial/ethnic and economic segregation. Even when accounting for sociodemographics, tumor characteristics, and NCCN-guideline appropriate treatment, survival disparities remained, suggesting potential social and environmental factors impacting survival. To address these disparities, effective interventions are needed that account for the social and environmental contexts in which cancer patients live and are treated.
Table 1: Breast Cancer Hazard Ratio by Economic, Racial/Ethnic, and Racialized Economic Residential Segregation Residential SegregationType of Segregation (ICE)QuartileModel 1Model 2Model3HR (95% CI)HR (95% CI)HR (95% CI)Economic SegregationQ11.83 (1.1, 3.03)*1.64 (0.89, 3.02)1.58 (1.29, 1.92)*Economic SegregationQ22.36 (1.48, 3.76)*2.45 (1.38, 4.34)*1.44 (1.16, 1.79)*Economic SegregationQ31.16 (0.72, 1.8)1.08 (0.61, 1.9)1.16 (0.94, 1.44)Economic SegregationQ4111NHB SegregationQ11.6 (0.9, 2.84)1.42 (0.72, 2.82)1.41 (0.96, 2.07)NHB SegregationQ20.92 (0.52, 1.6)0.91 (0.47, 1.77)1 (0.68, 1.48)NHB SegregationQ30.61 (0.29, 1.26)0.85 (0.37, 1.94)0.82 (0.52, 1.31)NHB SegregationQ4111Hispanic SegregationQ11.38 (0.83, 2.28)1.13 (0.61, 2.08)1.36 (1.12, 1.66)*Hispanic SegregationQ279 (0.47, 1.32)0.74 (0.4, 1.38)0.86 (0.67, 1.08)Hispanic SegregationQ30.94 (0.59, 1.49)0.98 (0.57, 1.67)1.05 (0.86, 1.29)Hispanic SegregationQ4111NHB Economic SegregationQ12.68 (1.6, 4.47)*2.02 (1.09, 3.74)2 (1.54, 2.6)*NHB Economic SegregationQ21.85 (1.15, 2.97)*1.39 (0.79, 2.44)1.56 (1.22, 2.02)*NHB Economic SegregationQ31.2 (0.69, 2.07)1.09 (0.58, 2.06)1.19 (0.88, 1.6)NHB Economic SegregationQ4111Hispanic Economic SegregationQ11.91 (1.19, 3.07)*1.45 (0.83, 2.54)1.64 (1.24, 2.15)*Hispanic Economic SegregationQ21.45 (0.8, 2.62)1.06 (0.52, 2.17)1.44 (1.06, 1.96)*Hispanic Economic SegregationQ31.26 (1.73, 2.18)0.95 (0.49, 1.84)1.11 (0.8, 1.54)Hispanic Economic SegregationQ4111Model 1: Adjusted for ICE, race/ethnicity, age, insuranceModel 2: Adjusted for Model 1 covariates plus receptor status, clinical stageModel 3: Adjusted for Model 1 and 2 covariates plus stage appropriate treatmentQ1: Most disadvantaged neighborhoods; Q4: Reference: most advantaged neighborhoods.*p &lt; 0.05
Citation Format: Neha Goel, Kristin N Kelly, Sina Yadegarynia, Seraphina Choi, Susan B Kesmodel, Ashly Westrick. Where you live matters: Impact of economic, racial/ethnic, and racialized economic residential segregation on breast cancer survival [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr SS1-01.