Abstract P5-14-05: Are neighborhood and community factors associated with refusing breast cancer surgery?
Authors: Relation Theresa , Bhattacharyya Oindrila , Fisher Jay , Li Yaming , Tsung Allan , Hamad Ahmad , Ndumele Amara , Oppong Bridget 
Published: March 2022

Abstract
Background: The importance of an individual’s community impacts cancer disparities and is intimately related to social determinants of health. Surgery refusal is associated with a high disease-specific mortality. Studies of factors associated with refusal of treatment for potentially curable breast cancer show personal factors including age, marital status, and insurance are at play. However, few studies have investigated whether community or area-based characteristics may affect receipt of surgery. Methods: We selected all women diagnosed with non-metastatic (Stage I-III) breast cancer in the Surveillance, Epidemiology, and End Results (SEER) database. We focused on those who refused surgery comparing racial and ethnic differences between Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Hispanic all races. Yost index calculated as neighborhood socio-economic status (nSES- divided into tertiles) and RUCA code-derived rural-urban status were based on an NCI census tract-level index, a composite score that includes income, education, housing, and employment; the remaining community factor measures were based on county-level index. Sociodemographic and community differences were analyzed using Pearson’s Chi-Square tests and analysis of variance. Multivariate logistic regression of predictors of refusal of surgery and Cox-proportional hazard model of disease-specific mortality were performed. A p-value of 0.05 was considered statistically significant. Results: 2,155 (0.7%) of 322,538 people refused surgery (NHW: 1,435 (66.6%), NHB: 353(16.3%), Hispanic all races: 166(7.7%)). Surgery refusers were more likely to live in areas with high poverty (&lt;200% level), lower education attainment, lower unemployment, higher percentage urban population, higher percentage foreign-born, higher rates of language isolation, and lower rates of women over 40 having undergone mammography in the previous two years. Multivariate analysis shows surgery refusal is associated with high percentage of having a bachelor’s degree or higher (OR: 1.29, 95% CI:1.05-1.60, p-value &lt;0.05), high percentage of poverty (&lt;200% of poverty) (OR: 1.50, 95% CI:1.04-2.16, p-value &lt;0.05), and high percentage of urban population (OR: 1.26, 95% CI:1.06-1.49, p-value &lt;0.01). Surgery refusal rates declined with increasing nSES. Breast cancer-specific mortality increased significantly for those who refused surgery (HR:3.92, 95% CI: 3.41-4.51, p-value &lt;0.01). Conclusion: Risk of refusing surgery for an otherwise curable breast cancer is associated with residence in communities with the lowest nSES. These are communities disproportionately populated by racial and ethnic minorities. Given the high mortality associated with refusing surgery, further investigation into the reasons why women decline treatment is necessary. For women living in impoverished communities, culturally sensitive education on benefits of care may be appropriate, while women of means may face different challenges such as utilization of alternative medicine.
Citation Format: Theresa Relation, Oindrila Bhattacharyya, Jay Fisher, Yaming Li, Allan Tsung, Ahmad Hamad, Amara Ndumele, Bridget Oppong. Are neighborhood and community factors associated with refusing breast cancer surgery? [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-14-05.