Characterizing the Impact of Race and Contemporary Redlining on Receipt of Guideline-Concordant Locoregional Therapy Among Older Women with Breast Cancer

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IntroductionImproving locoregional control for breast cancer (BC) results in better overall survival. Contemporary redlining is associated with worse BC survival in older patients. Self-reported race is associated with survival, redlining, and access to care. We aim to examine the relationship between race, redlining, and the receipt of guideline concordant locoregional therapy (LRT) in older women with BC. MethodsWomen aged 66-90 years with Stage I-III BC diagnosed in 2010-2017 with known metropolitan statistical area were identified in SEER-Medicare. Redlining was estimated using Home Mortgage Disclosure Act data. Guideline-concordant LRT was assessed based on receipt of surgery and appropriate adjuvant radiation treatment. A logistic regression model was fitted to examine the relationship between redlining and receipt of guideline concordant LRT, accounting for covariates. Cluster bootstrap at the MSA-level was used. ResultsThe cohort included 64,987 women: 31% aged 66-70, 82% Non-Hispanic (NH) White, 12% with dual Medicaid/Medicare enrollment. 94% underwent surgical resection; 84% received guideline compliant LRT. NH Black race was associated with lower receipt of guideline concordant LRT compared to NH White (OR 0.78, 95% CI 0.71-0.84). No significant differences were noted between NH White and NH Asian or Hispanic women. Residing in high redlining areas was associated with lower odds of receiving guideline-concordant LRT compared to low redlining areas (OR 0.89, 95% CI 0.82-0.95, p = 0.002). ConclusionsIn this cohort of older women with BC, NH Black race and redlining, even after adjusting for several important clinical and demographic factors, were associated with a lower likelihood of receiving guideline-concordant LRT. This finding demonstrates the profound impact of interpersonal racism and redlining on receipt of cancer-directed therapies and highlights the need for further work to combat systemic inequities and interpersonal racism.