ORIGINAL ARTICLES

Structural Racism and Breast Cancer-specific Survival

Impact of Economic and Racial Residential Segregation

Goel, Neha MD∗,†; Westrick, Ashly C. PhD, MPH‡; Bailey, Zinzi D. PhD§; Hernandez, Alexandra MD, MPH∗; Balise, Raymond R. PhD§; Goldfinger, Erica BS§; Antoni, Michael H. PhD¶,||; Stoler, Justin PhD, MPH§; Kesmodel, Susan B. MD∗,†; Kobetz, Erin N. PhD, MPH†,§,∗∗,††

Author Information

∗Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, FL

†Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL

‡Center for Social Epidemiology and Population Health, University of Michigan, Ann Arbor, MI

§Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL

Department of Psychology, University of Miami and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL

||Department of Psychiatry and Behavioral Sciences and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL

∗∗Department of Medicine, University of Miami Miller School of Medicine, Miami, FL

††Department of Medicine, Division of Computational Medicine and Population Health, University of Miami Miller School of Medicine, Miami, FL.

[email protected].

Dr. Goel is funded by an National Institute of Health Grant #K12CA226330, the American Surgical Association Foundation Fellowship Research Award, and the American Society of Clinical Oncology Career Development Award.

Design: Retrospective cohort study utilizing local tumor registry data from 2005 to 2017.

Author Contributions: Neha Goel, MD, Ashly C Westrick, PhD, MPH, Zinzi D Bailey, PhD, Alexandra Hernandez, MD, MPH, Raymond R Balise, PhD, Erica Goldfinger, BS, Michael H Antoni, PhD, Justin Stoler, PhD, MPH, Susan B Kesmodel, MD, and Erin N Kobetz, PhD, MPH all (1) Made substantial contributions to conception and design, acquisition of data, and analysis and interpretation of data, (2) Participated in drafting the article and revising it critically for important intellectual content, and (3) Gave final approval of the version to be published.

The authors report no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.annalsofsurgery.com).

Annals of Surgery 275(4):p 776-783, April 2022. | DOI: 10.1097/SLA.0000000000005375

Abstract

Objective: 

To analyze the effect of economic and racial/ethnic residential segregation on breast cancer-specific survival (BCSS) in South Florida, a diverse metropolitan area that mirrors the projected demographics of many United States regions.

Summary Background Data: 

Despite advances in diagnosis and treatment, racial and economic disparities in BCSS. This study evaluates these disparities through the lens of racial and economic residential segregation, which approximate the impact of structural racism.

Methods: 

Retrospective cohort study of stage I to IV breast cancer patients treated at our institution from 2005 to 2017. Our exposures include index of concentration at the extremes, a measurement of economic and racial neighborhood segregation, which was computed at the census-tract level using American Community Survey data. The primary outcome was BCSS.

Results: 

Random effects frailty models predicted that patients living in low-income neighborhoods had higher mortality compared to those living in high-income neighborhoods [hazard ratios (HR): 1.56, 95% confidence interval (CI): 1.23–2.00]. Patients living in low-income non-Hispanic Black and Hispanic neighborhoods had higher mortality compared to those living in high-income non-Hispanic White (NHW) neighborhoods (HR: 2.43, 95%CI: 1.72, 3.43) and (HR: 1.99, 95%CI: 1.39, 2.84), after controlling for patient characteristics, respectively. In adjusted race-stratified analysis, NHWs living in low-income non-Hispanic Black neighborhoods had higher mortality compared to NHWs living in high-income NHW neighborhoods (HR: 4.09, 95%CI: 2.34–7.06).

Conclusions: 

Extreme racial/ethnic and economic segregation were associated with lower BCSS. We add novel insight regarding NHW and Hispanics to a growing body of literature that demonstrate how the ecological effects of structural racism—expressed through poverty and residential segregation—shape cancer survival.

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

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