Abstract B077: Understanding the relationship between neighborhood deprivation and breast cancer mortality among Black and White women

Neighborhood deprivation has been associated with increased breast cancer mortality among White women, but findings are inconsistent among Black women, who experience different neighborhood contexts. Accounting for interactions among neighborhood deprivation, race, and other neighborhood characteristics may enhance understanding of the association. To investigate whether neighborhood deprivation is associated with breast cancer mortality among Black and White women and whether interactions with rurality, residential mobility, and racial composition, which are markers of access, social cohesion, and segregation, respectively, modify the association. This population-based cohort study used Georgia Cancer Registry (GCR) data on women with breast cancer diagnosed in 2010 to 2017 and followed-up until December 31, 2022. Data were analyzed between January 2023 and October 2023. The study included non-Hispanic Black and White women with invasive early-stage (I-IIIA) breast cancer diagnosed between 2010 and 2017 and identified through the GCR. The Neighborhood Deprivation Index (NDI), assessed in quintiles, was derived through principal component analysis of 2011 to 2015 block group-level American Community Survey (ACS) data. Rurality, neighborhood residential mobility, and racial composition were measured using Georgia Public Health Department or ACS data. The primary outcome was breast cancer-specific mortality identified by the GCR through linkage to the Georgia vital statistics registry and National Death Index. Cox proportional hazards regression was used to estimate age-adjusted and multivariable-adjusted hazard ratios (HRs) and 95% CIs for the association between neighborhood deprivation and breast cancer mortality. Among the 36 795 patients with breast cancer (mean [SD] age at diagnosis, 60.3 [13.1] years), 11 044 (30.0%) were non-Hispanic Black, and 25 751 (70.0%) were non-Hispanic White. During follow-up, 2942 breast cancer deaths occurred (1214 [41.3%] non-Hispanic Black women; 1728 [58.7%] non-Hispanic White women). NDI was associated with an increase in breast cancer mortality (quintile 5 vs 1, HR, 1.36; 95% CI, 1.19-1.55) in Cox proportional hazards models. The association was present only among non-Hispanic White women (quintile 5 vs 1, HR, 1.47; 95% CI, 1.21-1.79). Similar race-specific patterns were observed in jointly stratified analyses, such that NDI was associated with increased breast cancer mortality among non-Hispanic White women, but not non-Hispanic Black women, irrespective of the additional neighborhood characteristics considered. In this cohort study, neighborhood deprivation was associated with increased breast cancer mortality among non-Hispanic White women. Neighborhood racial composition, residential mobility, and rurality did not explain the lack of association among non-Hispanic Black women, suggesting that factors beyond those explored here may contribute to breast cancer mortality in this racial group.

Background: Neighborhood deprivation is hypothesized as a potential driver of racial disparities in breast cancer mortality. However, research shows that neighborhood deprivation is associated with increased breast cancer mortality among White women, but has little to no association among Black women. No study has previously considered the intersections of race, social cohesion, or urban/rural status in the association between neighborhood deprivation and breast cancer mortality. Methods: Neighborhood deprivation was examined in relation to breast cancer mortality among 31,358 non-Hispanic Black and non-Hispanic White women diagnosed with invasive breast cancer (stage I-IIIA) between 2010-2017, followed through 2019, and identified by the Georgia Cancer Registry. Two composite scores, the Area Deprivation Index (ADI) and neighborhood deprivation index (NDI), were used to characterize neighborhood deprivation. A third composite score, the Yost index, was assessed as a measure of neighborhood socioeconomic status (SES). Each composite score was composed of factors representing six domains: poverty, income, occupation, housing, employment, and education. Data on ADI were obtained from the Neighborhood Atlas and was assessed in deciles. American Community Survey data from 2011-2015 and principal components analysis were used to derive the NDI and Yost index. Both measures were assessed in quartiles. Each composite variable was measured at the block group level and linked to patient data. Cox proportional hazards regression was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association between each composite variable and breast cancer mortality, overall and by race/ethnicity. Intersectionality will be examined by considering the joint effects of race/ethnicity, social cohesion, and urban/rural status. Results: During the 9-year follow-up period, 2,353 (1,347 non-Hispanic White, 1,006 non-Hispanic Black) women died from breast cancer. Regardless of which composite score was assessed, living in the most deprived or lowest SES neighborhoods was associated with an increased risk of breast cancer mortality in models adjusted for age and race (ADI decile 10 vs. 1: HR=1.57, 95% CI 1.26-1.96; NDI quartile 4 vs. 1: HR=1.43, 95% CI 1.26-1.63; Yost index quartile 1 vs 4: HR= 1.34, 95% CI 1.18-1.51). Stratification by race/ethnicity showed associations were slightly stronger among non-Hispanic White women but null among non-Hispanic Black women. Results from analyses examining the joint effects of race/ethnicity, social cohesion, and urban/rural status are forthcoming and will be presented in December. Conclusions: Consistent with previous studies, our study found that living in a deprived neighborhood may increase breast cancer mortality among non-Hispanic White women, but not non-Hispanic Black women. Investigating the association with an intersectionality framework may help identify subgroups of women who are particularly susceptible to the adverse impact of neighborhood deprivation on breast cancer mortality. Citation Format: Lauren E. Barber, Jasmine M. Miller-Kleinhenz, Maret L. Maliniak, Leah Moubadder, Jeffrey Switchenko, Lauren E. McCullough. Neighborhood deprivation and breast cancer mortality among Black and White women [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD1-03.

Background: Breast cancer (BC) mortality disparities have persisted between non-Hispanic Black (NHB) and non-Hispanic White (NHW) women, even those diagnosed with prognostically favorable BC. The Oncotype Dx Recurrence score (ODX) test is a gene expression panel that can be used to identify estrogen receptor (ER)-positive BC with aggressive tumor biology. Previous studies have found that Black women are more likely to have higher ODX scores than White women and socioeconomic factors (e.g., area-level income, urbanicity) are associated with higher ODX scores. We explored race-stratified associations of neighborhood deprivation and ODX to help elucidate the interplay between race, place, and tumor biology. Methods: Neighborhood deprivation was examined in relation to ODX scores among 7,100 NHB and NHW women diagnosed with ER-positive BC (stage I–IIIA and ≤3 lymph nodes) between 2010–2017, followed through 2022, and identified by the Georgia Cancer Registry. The neighborhood deprivation index (NDI) was used to characterize neighborhood deprivation. Principal component analysis of block group-level American Community Survey data representing six domains (poverty, income, occupation, housing, employment, and education) was used to derive the NDI composite score. NDI was assessed in quartiles and linked to patient residence at the time of diagnosis. Three cut-points were used for ODX scores (low <18, intermediate 18–30, high ≥31). Prevalence ratios (PR) and 95% confidence intervals (CI) were calculated to determine the prevalence of ODX scores based on NDI by race/ethnicity. Results: This study included 1651 NHB and 5449 NHW women. There were 4152 (58.5%) with a low ODX Score and 514 (7.2%) with a high ODX score; 2773 (39.1%) resided in the least deprived neighborhoods (NDI quartile 1) and 928 (13.1%) resided in the most deprived neighborhood (NDI quartile 4). Living in the most deprived neighborhood was associated with an increased prevalence of high ODX scores in models adjusted for age, race, and stage (PR=1.23, 95% CI 0.97–1.62). Stratification by race showed associations were stronger among NHW women (PR=1.41, 95% CI 1.02–1.95) but null among NHB women (PR= 0.91, 95% CI 0.59-1.39). Overall, NHB women were more likely to have a high ODX compared to NHW women. The highest prevalence of a high ODX was observed among NHB women living in the least deprived neighborhoods (PR=1.92, 95% CI 1.34–2.77). Conclusions: Findings from this study suggest that living in a deprived neighborhood increases the prevalence of high ODX among NHW women but not NHB women. NHB women in the least deprived neighborhoods had the greatest prevalence of high ODX scores. The intersection between race, neighborhood, and tumor biology needs more nuanced investigation of the social-structural drivers of disparate BC outcomes. Citation Format: Jasmine M. Miller-Kleinhenz, Lauren E. Barber, Lindsay J. Collin, Maret L. Maliniak, Demetria J. Smith-Graziani, Lauren E. McCollough. Neighborhood Deprivation and Oncotype DX Recurrence Scores among Black and White Women: the interplay between race, place, and tumor biology [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A055.

Background: Triple negative breast cancer (TNBC) accounts for 15% of all breast cancers and is one of the most aggressive disease subtypes. Disparities in TNBC exist, where US Black women and women living in urban environments are more likely to be diagnosed with TNBC than their White or rural counterparts. Reasons for these disparities are not completely understood. Social determinants of health, such as the neighborhood environment, have been implicated as potential contributors to breast cancer disparities. To improve our understanding of disparities in TNBC, we examined neighborhood deprivation in relation to breast cancer subtype, according to race and rurality. Methods: We identified 40,095 non-Hispanic Black and White women diagnosed with invasive breast cancer in 2010-2017 in the Georgia Cancer Registry. Neighborhood deprivation was measured by the Neighborhood Deprivation Index (NDI), a composite measure of neighborhood poverty, income, housing, unemployment, occupation, and education derived through principal component analysis using 2011-2015 block group-level American Community Survey data. Georgia Department of Public Health data were used to measure county-level rurality. We estimated case-only multivariable odds ratios (OR) and 95% confidence intervals (CI) for the separate associations between NDI, in quintiles, and each breast cancer subtype (TNBC, ERBB2+, or luminal B vs. luminal A breast cancer), overall and according to race and rurality. Results: Of the 40,095 non-Hispanic Black (31.5%) and White (68.5%) women, 5,328 were diagnosed with TNBC, 1,926 with ERBB2+, 4,958 with luminal B, and 27,883 with luminal A breast cancer. Compared to living in the least deprived neighborhoods, living in the most deprived neighborhoods was associated with a 33% (OR= 1.33, 95% CI 1.19-1.48) increased odds of TNBC vs. luminal A breast cancer. Race and rurality did not modify the association. However, estimates were less pronounced among non-Hispanic Black (OR=1.18, 95% CI 1.00-1.39) compared to non-Hispanic White (OR=1.40, 95% CI 1.18- 1.65) women and among women living in urban (OR=1.33, 95% CI 1.18-1.50) compared to rural (OR=1.52, 95% CI 1.15-2.03) counties. Neighborhood deprivation was associated with an increase in ERBB2+ breast cancer (OR=1.19, 95% CI 1.00-1.40), which was confined to non- Hispanic White women (OR=1.29, 95% CI 1.00-1.66) and women living in urban counties (OR=1.25, 95% CI 1.04-1.52). The OR for luminal B breast cancer was 1.08 (95% CI 0.96- 1.21). Although race did not modify this relationship, an association was observed only among women living in urban counties (OR=1.14, 95% CI 1.00-1.29). Conclusions: In this population of Georgia breast cancer patients, neighborhood deprivation was associated with an increase in TNBC, regardless of race or rurality. The weaker associations among non-Hispanic Black women and women living in urban counties suggests that other factors, in addition to neighborhood deprivation, may play an important role in TNBC development among Black women and women residing in urban environments. Citation Format: Lauren E. Barber, Jasmine M. Miller-Kleinhenz, Maret L. Maliniak, Leah Moubadder, Jeffrey M. Switchenko, Lauren E. McCullough. Understanding the role of neighborhood deprivation in racial and urban-rural disparities in triple negative breast cancer [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A037.

We thank Gabriel and colleagues for their appreciation of our investigation of redlining and lending bias as important contributors to breast cancer mortality (1). In their letter, Gabriel and colleagues raised questions regarding the role of redlining and lending bias on specific factors preceding diagnosis and following diagnosis that may identify targets for intervention, thereby reducing disparities.In our study, we examined the association between redlining, lending bias, and breast cancer mortality (1). We were unable to explore how these place-based measures of structural racism impact access to primary care and screening programs. As noted by the authors, stage IV diagnoses were more common among women who resided in redlined neighborhoods, likely reflecting reduced access to care in these areas. A recent study in Massachusetts reported that historic redlining was associated with late stage at diagnosis for multiple cancer sites (2). Additional research would benefit from investigation into how neighborhood deprivation affects screening and diagnostic delay.Gabriel and colleagues inquired whether components of care were associated with worse outcomes in our cohort. We have investigated previously the impact of guideline-concordant care on racial disparities in breast cancer mortality (3). We found that non-Hispanic Black (NHB) women were more likely to receive guideline-concordant care compared with non-Hispanic White (NHW) women, and that failure to receive guideline-concordant care was associated with increased breast cancer mortality. Yet, NHB women had a 2-fold increase in breast cancer mortality compared with their NHW counterparts. To our knowledge, neighborhood deprivation indices have not been examined in relation to the receipt of guideline-concordant care, treatment delays, or quality of care, which are important to identify actionable targets. Although our study also supports the need for larger systemic changes (4).Gabriel and colleagues noted the association between redlining and breast cancer mortality was less pronounced among NHB women compared with NHW women (HR, 1.13 vs. 1.39), suggesting that redlining has a stronger association with breast cancer mortality than race. Table 3 provides both the common referent and race-stratified estimates. The former highlights that NHW women experienced similarly poor outcomes if they live in redlined neighborhoods. However, NHB women in nonredlined neighborhoods did not confer the same benefit. NHB women had more than a 2-fold increase in breast cancer mortality, regardless of the location of residence, which likely reflects the historic context of these systemic inequities. Our findings underscore the need to fully characterize residential history to understand the role of structural racism on breast cancer mortality (4).L.J. Collin reports grants from NCI during the conduct of the study and NIH outside the submitted work. No disclosures were reported by the other author.This this work was supported, in part, by the Komen Foundation (CCR19608510 to L.E McCullough). L.J. Collin was supported, in part, by the NCI (F31CA239566) and the National Center for Advancing Translational Sciences (TL1TR002540) of the NIH.

Background: Breastfeeding has been associated with a reduced risk of breast cancer (BC), particularly with Triple Negative BC (TNBC). The risk of TNBC is higher among premenopausal women, Black/African American (AA) women, and poorer women. Notably there are significant disparities in breastfeeding, where non-Hispanic Black (NHB) women and poorer women are less likely to breastfeed in the United States. Studies have identified historical racial trauma, unsupportive work and hospital policies, breast milk formula advertising, and knowledge and beliefs about breast feeding as factors that contribute to breast feeding practices. However, there is a paucity of research on pregnancy related medical conditions (PMCs) that potentially impact initiation and duration of breastfeeding. The purpose of this study is to evaluate racial and socioeconomic differences in breastfeeding, and if PMCs impact breastfeeding practices in a population-based sample of non-Hispanic Black and White women. Method: Data are from the Young Women’s History and Health Study (YWHHS), a population- based case-control study of invasive BC among non-Hispanic Black (NHB) and non-Hispanic White (NHW) women aged 20-49 years residing in Metropolitan Detroit and Los Angeles County, 2010-2015. The analytic sample here includes the first pregnancy of control participants with singleton live births (n=675). Area-based control participants were sampled from the 2010 Census. Interviews assessed complete reproductive histories, including breastfeeding history (never, <6 months, and ≥6 months), PMCs experienced during pregnancy, self-reported race, and household financial struggles before age 13 years (to approximate childhood socioeconomic position (chSEP)). PMCs examined included: 1) premature birth, 2) diabetes or pre-diabetes related PMCs, 3) blood pressure-related PMCs, and 4) BMI ≥ 25 kg/m2 at age 18 years. Weighted percentages were evaluated with a chi-square test and considered significant at p < 0.05. Analyses were further stratified by race/ethnicity and chSEP. Result: NHB women were 2.4 times significantly more likely to never breastfeed than NHW women (W% =52.0 (NHB) and 21.3 (NHW), p=<0.0001). Similarly, women with lower compared to higher chSEP were 1.5 times significantly more likely to never breastfeed (W% = 42.7 (lower chSEP) and 28.5 (higher chSEP), p=0.003). Those with BMI ≥ 25 kg/m2 at age 18 years (p<0.001) alone, and with one or more PMCs (p=0.01) were also less likely to breastfeed. When stratified by race/ethnicity the pattern of breastfeeding did not differ significantly by any PMC within NHB and NHW women. When stratified by chSEP, however, BMI ≥ 25 kg/m2 at age 18 years (p = 0.004) and having one or more PMCs (p=0.03) were significantly associated with never breastfeeding among those with higher chSEP. Conclusion: NHB women and women with lower chSEP were substantially less likely to breastfeed. Additionally, BMI ≥ 25 kg/m2 at age 18 and PMCs were associated with lower frequency of breastfeeding overall and among those with higher chSEP. Citation Format: Meheret B. Gebreegziabher, Lydia R. Post, Chris C. Cho, Zhenzhen Zhang, Kelly A. Hirko, Dorothy R. Pathak, Ann S. Hamilton, Ann G. Schwartz, Ellen M. Velie. Racial and socioeconomic disparities in breast feeding and the impact of pregnancy-related medical conditions among a population-based sample of non-Hispanic Black and White women [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A014.

More than treatment refusal: an NCDB analysis of the impact of endometrial cancer treatment refusal on racial survival disparities

Impact of subgroup analysis on estimates of infertility

US Black women are twice as likely to be diagnosed with triple-negative breast cancer (TNBC), an aggressive subtype, as White women. Adverse neighborhood characteristics may contribute to the disparity. This study examined neighborhood deprivation in relation to TNBC, according to race and rurality. The authors identified 40,095 non-Hispanic Black and White women diagnosed with invasive breast cancer in 2010-2017 in the Georgia Cancer Registry. The Neighborhood Deprivation Index (NDI), a composite measure, was calculated using 2011-2015 block group-level American Community Survey data. County-level rurality was measured via Georgia Department of Public Health data. We estimated multivariable odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between NDI, in quintiles, and each breast cancer subtype (TNBC, HER2-enriched, luminal B vs. luminal A breast cancer), overall, and according to race and rurality. Compared to least deprived neighborhoods, living in the most deprived neighborhoods was associated with a 33% (OR,1.33; 95% CI, 1.19-1.48) increased odds of TNBC versus luminal A breast cancer. Race and rurality did not modify the association. However, estimates were less pronounced among non-Hispanic Black women (OR,1.18; 95% CI, 1.00-1.39 vs. OR,1.40; 95% CI, 1.18-1.65 among non-Hispanic White women) and women living in urban counties (OR,1.33; 95% CI, 1.18-1.50 vs. OR,1.52; 95% CI, 1.15-2.03 in rural counties). In this study, neighborhood deprivation was associated with increased odds of TNBC, regardless of race or rurality. Given Black women are more likely to live in deprived neighborhoods, neighborhood deprivation may contribute to racial disparities in TNBC occurrence.

Disparities in preterm birth by race and ethnic group have been demonstrated in the United States. Recent research has focused on the impact of neighborhood context on racial disparities in pregnancy outcomes. The authors utilized vital-record birth certificate data and US Census data from eight geographic areas in four states (Maryland, Michigan, North Carolina, and Pennsylvania) to examine the relation between neighborhood deprivation and preterm birth among non-Hispanic White and Black women. The years covered by the data varied by site and ranged from 1995 to 2001. Results were adjusted for maternal age and education, and specific attention was paid to racial and geographic differences in the relation between neighborhood deprivation and preterm birth. Preterm birth rates were higher for non-Hispanic Blacks (10.42-15.97%) than for non-Hispanic Whites (5.77-9.13%), and neighborhood deprivation index values varied substantially across the eight areas. A significant association was found between neighborhood deprivation and risk of preterm birth; for the first quintile of the deprivation index versus the fifth, the adjusted summary odds ratio was 1.57 (95% confidence interval: 1.41, 1.74) for non-Hispanic Whites and 1.15 (95% confidence interval: 1.08, 1.23) for non-Hispanic Blacks. In this study, deprivation at the neighborhood level was significantly associated with increased risk of preterm birth among both non-Hispanic White women and non-Hispanic Black women.

Background: Delays in follow-up after breast cancer screening are thought to contribute to disparities in breast cancer outcomes. The primary objective of this study is to determine the impact of race/ethnicity and type of health insurance on the diagnostic delay time, defined as the number of days from abnormal screening to definitive diagnosis. Methods: This is a retrospective study of 976 women examined for breast cancer between 1998 and 2009 at six hospitals and clinics located in the District of Columbia. We used a full-factorial ANOVA model to test for significant differences in diagnostic delay time among non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic women with private, government, or no health insurance. A log transformation was taken on the diagnostic delay time to normalize our data, and geometric means were estimated and compared. Results: The average geometric mean (95% CI) diagnostic delay times were as follows: among those with private insurance, 15.9 (12.2,20.6) days for NHW, 27.0 (22.4,32.6) days for NHB, and 51.4 (34.8,76.0) days for Hispanic women; among those with government insurance, 11.9 (7.3,19.3) days for NHW, 39.5 (32.2,48.6) days for NHB, and 71.6 (47.8,107.1) days for Hispanic women; and among those without insurance, 44.5 (16.4,120.6) days for NHW, 59.7 (38.8,91.8) days for NHB, and 66.4 (55.8,79.1) days for Hispanic women. In fitting a full-factorial ANOVA model, we found that NHW women with government insurance had a significantly shorter delay in diagnosis than NHB (p=0.0003) and Hispanic (p<0.0001) women with government insurance. We also found that NHW women with private insurance had a significantly shorter delay in diagnosis than NHB (p=0.03) and Hispanic (p<0.0001) women with private insurance. However, there were no significant differences within the uninsured women (p>0.05). Finally, we found that NHB women with private insurance had a significantly shorter delay in diagnosis than uninsured NHB women (p=0.03). Conclusions: NHB and Hispanic women with government or private insurance waited more than twice as long to reach their definitive diagnosis than NHW women with government or private insurance. Uninsured NHB women waited more than twice as long to reach their definitive diagnosis than NHB women with private insurance. Having private health insurance markedly increased the speed of diagnostic resolution in NHB women; however, the speed of diagnostic resolution remained significantly longer for NHB women with private insurance than for NHW women with private insurance. These results suggest that while both insurance and race/ethnicity affect diagnostic resolution, health insurance may not be the primary barrier to optimal diagnostic resolution in NHB women. It will be important to determine what other factors serve as the primary barriers, as well as if these delays affect the final breast cancer outcome for the patients. Funding Mechanism: Grant Number 1 U01 CA116937; Patient Navigation Research Program (PNRP), Center for Research on Cancer Health Disparities (CRCHD), National Cancer Institute (NCI). Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):PR-10.

In the US, breast cancer mortality is 40% greater among Black than White women. The mortality disparity varies geographically and has persisted despite improvements in survival. Georgia is one of six states where breast cancer recently surpassed lung cancer as the leading cause of cancer death among Black but not White women, is a large and diverse state, and thus, an ideal setting to study race disparities. Our work in the Atlanta Metro area has shown that the mortality disparity is pronounced among patients with clinically favorable subtypes, low Oncotype DX® recurrence scores, guideline-concordant care, and similar access to surgical facilities. The disparity also persists among patients with private insurance and those living in areas of low poverty, suggesting clinical and sociodemographic differences do not fully account for the observed disparity. Recent evidence suggests area-level factors may contribute to the disparity. Our group reported that neighborhood-level redlining (i.e., mortgage denial based on place) is associated with an increase in breast cancer mortality while neighborhood-level lending bias (i.e., mortgage denial based on race) is associated with a decrease in breast cancer mortality. In Atlanta, Black patients are more likely to live in redlined areas and less likely to live in areas with lending bias, than White patients, further suggesting place is an important driver of disparities. We investigated the role of other area-level factors on race-specific mortality in Georgia. Race-specific standardized mortality ratios were computed for each county in Georgia. Observed breast cancer deaths among non-Hispanic White (NHW) and non-Hispanic Black (NHB) women within 5 years of a stage I-III breast cancer diagnosis (2005-2013) were obtained from the Georgia Cancer Registry. County-level characteristics were derived from the American Community Survey and Georgia Department of Public Health. A Bayesian model-based approach was used to stabilize local estimates and estimate associations with area-level factors. Smoothed estimates of relative disparity ranged from 1.2 to 1.7, with pronounced disparity for counties surrounding the Atlanta and Savannah metropolitan areas and least pronounced disparity in Metro Albany counties. Among NHB women, living in a rural (versus non-rural) county was associated with a nearly 20% increase in breast cancer mortality (RR=1.19, 95% credible interval (CI): 0.96, 1.48); an association not observed in NHW patients (RR=0.93, 95% CI: 0.79, 1.07). In contrast, a 10-point increase in the percent of adults with ≤high school education was associated with a 10% increase (95% CI: 1.05, 1.17) in mortality for NHW patients only. The race disparity in Georgia is not evenly distributed across counties. We identified area-level characteristics associated with race-specific mortality. Identifying other area-level drivers of breast cancer mortality is an important area of inquiry. Citation Format: Rebecca Nash, Lindsay J. Collin, Jeffrey Switchenko, Lauren E. McCullough. Area-level drivers of the breast cancer mortality race disparity in Georgia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3672.

Inequities created by historical and contemporary mortgage discriminatory policies have implications for health disparities. The role of persistent mortgage discrimination (PMD) in breast cancer (BC) outcomes has not been studied. To estimate the race-specific association of historical redlining (HRL) with the development of BC subtypes and late-stage disease and a novel measure of PMD in BC mortality. This population-based cohort study used Georgia Cancer Registry data. A total of 1764 non-Hispanic Black and White women with a BC diagnosis and residing in an area graded by the Home Owners' Loan Corporation (HOLC) in Georgia were included. Patients were excluded if they did not have a known subtype or a derived American Joint Committee on Cancer stage or if diagnosed solely by death certificate or autopsy. Participants were diagnosed with a first primary BC between January 1, 2010, to December 31, 2017, and were followed through December 31, 2019. Data were analyzed between May 1, 2022, and August 31, 2023. Scores for HRL were examined dichotomously as less than 2.5 (ie, nonredlined) vs 2.5 or greater (ie, redlined). Contemporary mortgage discrimination (CMD) scores were calculated, and PMD index was created using the combination of HRL and CMD scores. Estrogen receptor (ER) status, late stage at diagnosis, and BC-specific death. This study included 1764 women diagnosed with BC within census tracts that were HOLC graded in Georgia. Of these, 856 women (48.5%) were non-Hispanic Black and 908 (51.5%) were non-Hispanic White; 1148 (65.1%) were diagnosed at 55 years or older; 538 (30.5%) resided in tracts with HRL scores less than 2.5; and 1226 (69.5%) resided in tracts with HRL scores 2.5 or greater. Living in HRL areas with HRL scores 2.5 or greater was associated with a 62% increased odds of ER-negative BC among non-Hispanic Black women (odds ratio [OR], 1.62 [95% CI, 1.01-2.60]), a 97% increased odds of late-stage diagnosis among non-Hispanic White women (OR, 1.97 [95% CI, 1.15-3.36]), and a 60% increase in BC mortality overall (hazard ratio, 1.60 [95% CI, 1.17-2.18]). Similarly, PMD was associated with BC mortality among non-Hispanic White women but not among non-Hispanic Black women. The findings of this cohort study suggest that historical racist policies and persistent discrimination have modern-day implications for BC outcomes that differ by race. These findings emphasize the need for a more nuanced investigation of the social and structural drivers of disparate BC outcomes.

Background: Though incidence rates for invasive breast cancer overall have been historically lower for Black than White women, recent reports show that rates have converged between the two groups. We used the age-period-cohort framework to verify the current trends and to forecast future implications. Methods: Data from Surveillance, Epidemiology, and End-Results (SEER) Program 13 registries and the age-period-cohort forecasting model were used to observe current incidence rates (1992 to 2014) and to predict future trends (2015 to 2030) of invasive breast cancer by ER status among non-Hispanic White, Hispanic, and Black women, ages 30 to 84 years. Trends in the age-standardized incidence rate (ASR) were quantitated with the estimated annual percentage change (EAPC) in the ASR. Results: Observed invasive breast cancer incidence rates from 1992 through 2014 show convergence between White and Black women but not between non-Hispanic White and Black women. Observed incidence rates for ER-positive breast cancer are rising for all races, but rising faster among Black women with an EAPC = 0.77 [0.26, 1.29] %/year. In contrast, observed incidence rates for ER-negative breast cancer are decreasing for all races, but decreasing slower among Black women with an EAPC = -2.00 [-2.55, -1.43] %/year. Forecasting for ER-positive and ER-negative breast cancers suggests a continuation of the observed trends without future convergence in overall breast cancer rates. Conclusions: Incidence rates between Black and White women did not converge when non-Hispanic White women were separated from Hispanic White women. Whenever possible, future comparative breast cancer analyses should always attempt to analyze discrete populations separately, given the complexities of differential risk factor exposures by race and/or ethnicity. A better understanding of breast cancer in general and by race may be accomplished by accurately describing the similarities and disparities among different ethnic groups. Citation Format: Brittny C. Davis Lynn, Philip S. Rosenberg, William F. Anderson. Current and future incidence rates of invasive breast cancer between Black and White women [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr A28.

Background: Black women with endometrial cancer (EC) experience significant disparities in treatment and survival. They undergo diagnostic evaluation, primary surgical management, and non-surgical treatment at statistically lower rates than non-Hispanic White (NHW) women. Black women are also more likely to present with advanced stage disease and aggressive tumor histology, including non-endometrioid EC subtypes, resulting in a 93% greater overall mortality rate than Whites. Research in other cancers show that Black patients receive guideline-concordant care less often than NHW women. To date, no study has assessed the relationship between race and receipt of comprehensive guideline-concordant therapy, nor have studies examined the impact of guideline- concordant treatment and survival according to race among women with EC. We investigated these associations among women diagnosed with non-endometrioid EC in the National Cancer Database. Methods: Our analysis included 21,696 NHW, 6,859 non-Hispanic Black (NHB), 1,752 Hispanic, and 922 Asian/Pacific Islander (AS/PI) women diagnosed with non-endometrioid EC between 2004 and 2014. We used year-specific National Comprehensive Cancer Network (NCCN) guidelines to classify treatment as guideline-concordant vs. not concordant. We used multivariable logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CIs) for the association between race and receipt of guideline-concordant treatment in models adjusted for age at diagnosis, stage, histology, comorbidity score, insurance type, and facility type. We used multivariable-adjusted Cox proportional hazards models to estimate hazards ratios (HRs) and 95% CIs for relationships between receipt of guideline-concordant treatment and overall survival stratified by race. Results: In the overall study population, 38.2% of women with non-endometrioid EC received NCCN guideline-concordant treatment. Compared to NHW women, NHB women (OR=1.05, 95% CI=0.99 to 1.11), Hispanic women (OR=1.10, 95% CI=0.99 to 1.23) and AS/PI women (OR=1.11, 95% CI=0.97 to 1.28) did not have significantly different odds of receiving guideline-concordant treatment in multivariable-adjusted models. Receipt of guideline-concordant treatment was significantly associated with improved survival among NHW (HR=0.84, 95% CI=0.80 to 0.87), NHB (HR=0.86, 95% CI=0.80 to 0.92), and Hispanic women (HR=0.85, 95% CI=0.72 to 1.00) but not among AS/PI women (HR=0.88, 95% CI=0.71 to 1.10). Conclusions: Almost two-thirds of women with non-endometrioid EC may not receive guideline-concordant treatment. We observed no difference in receipt of concordant care between racial groups. When received, guideline-concordant treatment was associated with improved survival in almost all racial groups. Therefore, instituting interventions to improve adherence to guideline-concordant treatment may contribute to reducing racial disparities in survival for women with non-endometrioid EC. Citation Format: Jhalak Dholakia, Elyse Reamer, Ritu Salani, Ashley Felix. Minority women with non-endometrioid endometrial cancer are not less likely to receive guideline-concordant treatment than White women [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A134.