Individual and neighborhood socioeconomic status in relation to breast cancer incidence in African-American women

Impact of Neighborhood Disadvantage on Tumor Biology and Breast Cancer Survival

OBJECTIVE

The aim of this study was to evaluate the association between neighborhood disadvantage and Oncotype DX score, a surrogate for tumor biology, among a national cohort.

BACKGROUND

Women living in disadvantaged neighborhoods have shorter breast cancer (BC) survival, even after accounting for individual-level, tumor, and treatment characteristics. This suggests unaccounted social and biological mechanisms by which neighborhood disadvantage may impact BC survival.

METHODS

This cross-sectional study included stage I and II, ER + /HER2 - BC patients with Oncotype DX score data from the National Cancer Database (NCDB) from 2004 to 2019. Multivariate regression models tested the association of neighborhood-level income on Oncotype DX score controlling for age, race/ethnicity, insurance, clinical stage, and education. Cox regression assessed overall survival.

RESULTS

Of the 294,283 total BC patients selected, the majority were non-Hispanic White (n=237,197, 80.6%) with 7.6% non-Hispanic Black (n=22,495) and 4.5% other (n=13,383). 27.1% (n=797,254) of the population lived in the disadvantaged neighborhoods with an annual neighborhood-level income of <$48,000, while 59.62% (n=175,305) lived in advantaged neighborhoods with a neighborhood-level income of >$48,000. On multivariable analysis controlling for age, race/ethnicity, insurance status, neighborhood-level education, and pathologic stage, patients in disadvantaged neighborhoods had greater odds of high-risk versus low-risk Oncotype DX scores compared with those in advantaged neighborhoods [odds ratio=1.04 (1.01-1.07), P =0.0067].

CONCLUSION AND RELEVANCE

This study takes a translational epidemiologic approach to identify that women living in the most disadvantaged neighborhoods have more aggressive tumor biology, as determined by the Oncotype DX score.

Associations Between Neighborhood-Level Income and Triple-Negative Breast Cancer in a Majority-Minority Population

BACKGROUND

Previous studies on disparities in triple-negative breast cancer (TNBC) focus on race/ethnicity, with few exploring the impact of contextual factors such as neighborhood-level income. This study evaluates the effect of neighborhood-level income on disparities in TNBC among a racially and ethnically diverse cohort, after accounting for granular individual-level risk factors of TNBC.

PATIENTS AND METHODS

Patients with stage I-IV breast cancer from 2005 to 2017 were identified from our local tumor registry. The primary outcome was diagnosis of TNBC. Using 5-years estimates from the American Community Survey, we obtained median household income for each census tract which was categorized into quartiles. Mixed effects logistic regression was conducted and stratified by race and ethnicity, controlling for individual-level sociodemographic, comorbidities, and tumor characteristics.

RESULTS

Among 5377 breast cancer registry patients, 16.5% were diagnosed with TNBC. The majority were Hispanic (50.1%) followed by non-Hispanic Black (NHB) (28.0%). After controlling for individual-level covariables including race and ethnicity, comorbidities, and tumor characteristics, women from low-income neighborhoods had increased odds of TNBC compared with other breast cancer subtypes, compared with those in high-income neighborhoods [odds ratio (OR) 1.33; 95% confidence interval (CI) 1.04, 1.70, p < 0.001]. In stratified analyses, NHB patients from low-income neighborhoods had two times the odds of TNBC diagnosis compared with those from high-income neighborhoods (OR 2.11; 95% CI 1.02, 4.37).

CONCLUSION

We found that living in a low-income neighborhood is associated with an increased odds of TNBC independent of granular individual-level TNBC risk factors, particularly NHB race. More striking, NHB living in low-income neighborhoods had increased odds of TNBC compared with NHB living in high-income neighborhoods. Our results suggest potential unaccounted gene-environment and/or social (api)genomic interactions between neighborhood-level income and TNBC subtype development.

Research on Health Disparities: Strategies and Findings From the Black Women's Health Study

The American Journal of Epidemiology has been a platform for findings from the Black Women's Health Study (BWHS) that are relevant to health disparities. Topics addressed have included methods of follow-up of a large cohort of Black women, disparities in health-care delivery, modifiable risk factors for health conditions that disproportionately affect Black women, associations with exposures that are highly prevalent in Black women, and methods for genetic research. BWHS papers have also highlighted the importance of considering social context, including perceived experiences of racism, in understanding health disparities. In the future, BWHS investigators will contribute to documentation of the role that structural racism plays in health disparities.

Social Risk Factors That Increase Cardiovascular and Breast Cancer Risk

PURPOSE OF REVIEW

Cardiovascular disease (CVD) and breast cancer (BC) are significant causes of mortality globally, imposing a substantial health burden. This review article aims to examine the shared risk factors and social determinants that contribute to the high prevalence of both diseases, with a focus on social risk factors.

RECENT FINDINGS

The common risk factors for CVD and BC, such as hypertension, diabetes, obesity, aging, and physical inactivity, are discussed, emphasizing their modifiability. Adhering to ideal cardiovascular health behaviors has shown a trend toward lower BC incidence. Increased risk of CVD-related mortality is significantly impacted by age and race in BC patients, especially those over 45 years old. Additionally, racial disparities in both diseases highlight the need for targeted interventions. Social determinants of health, including socioeconomic status, education, employment, and neighborhood context, significantly impact outcomes for both CVD and BC. Addressing social factors is vital in reducing the burden of both CVD and BC and improving overall health equity.

Neighborhood Disadvantage, African Genetic Ancestry, Cancer Subtype, and Mortality Among Breast Cancer Survivors

Importance

Racial disparities in breast cancer (BC) survival arise from multilevel causes, which may exert influence at different stages of BC progression. Clarifying the importance of genetic and social factors could help prioritize interventions.

Objective

To jointly examine associations between African genetic ancestry, social environment, and mortality from any cause and BC in Black BC survivors.

Design, Setting, and Participants

This population-based cohort study enrolled self-identified Black women aged 20 to 75 years with histologically confirmed BC from June 2005 to May 2019 and followed them up until death or censoring in September 2021. Participants lived in 10 New Jersey counties. Data were analyzed between December 2022 and April 2023.

Exposures

A neighborhood socioeconomic status (nSES) index composed of census tract measures (education, income, wealth, employment status, and occupation) was linked to residential addresses at diagnosis. Percentage African ancestry was estimated using the ADMIXTURE program.

Main Outcomes and Measures

Sequentially adjusted (age adjusted: age and interview year; fully adjusted: age adjusted with individual SES, lifestyle factors, and comorbidities) logistic regression models were fit to estimate associations with tumor subtypes (estrogen receptor-negative [ER-] vs estrogen receptor-positive [ER+]; triple-negative breast cancer [TNBC] vs luminal A), and Cox models were fit for associations with all-cause mortality (ACM) and breast cancer-specific mortality (BCSM). Models for BCSM were fit using Fine-Gray competing risks models, and robust standard errors were used to account for census tract-level clustering.

Results

Among 1575 participants, median (IQR) African ancestry was 85% (76%-90%), and median (IQR) age was 55 (46-63) years. A 10-percentage point increase in African ancestry was associated with higher odds of ER- vs ER+ (adjusted odds ratio [aOR], 1.08; 95% CI, 0.98-1.18) and TNBC vs luminal (aOR, 1.15; 95% CI, 1.02-1.31) tumors, but not with ACM or BCSM. A 1-IQR increase in nSES was associated with lower ACM (adjusted hazard ratio [aHR], 0.76; 95% CI, 0.63-0.93), and the HR for BCSM was less than 1 but not statistically significant (aHR, 0.81; 95% CI, 0.62-1.04) in age-adjusted models, but associations attenuated following further adjustment for potential mediators (individual SES, lifestyles, comorbidities).

Conclusions and Relevance

In this cohort study of Black female BC survivors, higher African ancestry was associated with aggressive tumor subtypes. Compared with genetic ancestry, mediating pathways related to social environments may be more important for survival in these patients.

Neighborhood and racial influences on triple negative breast cancer: evidence from Northeast Ohio

PURPOSE

Triple negative breast cancer (TNBC) is an aggressive subtype of breast cancer (BC) with higher recurrence rates and poorer prognoses and most prevalent among non-Hispanic Black women. Studies of multiple health conditions and care processes suggest that neighborhood socioeconomic position is a key driver of health disparities. We examined roles of patients' neighborhood-level characteristics and race on prevalence, stage at diagnosis, and mortality among patients diagnosed with BC at a large safety-net healthcare system in Northeast Ohio.

METHODS

We used tumor registry to identify BC cases from 2007 to 2020 and electronic health records and American Community Survey for individual- and area-level factors. We performed multivariable regression analyses to estimate associations between neighborhood-level characteristics, measured by the Area Deprivation Index (ADI), race and comparative TNBC prevalence, stage at diagnosis, and total mortality.

RESULTS

TNBC was more common among non-Hispanic Black (53.7%) vs. non-Hispanic white patients (46.4%). Race and ADI were individually significant predictors of TNBC prevalence, stage at diagnosis, and total mortality. Race remained significantly associated with TNBC subtype, adjusting for covariates. Accounting for TNBC status, a more disadvantaged neighborhood was significantly associated with a worse stage at diagnosis and higher death rates.

CONCLUSION

Our findings suggest that both neighborhood socioeconomic position and race are strongly associated with TNBC vs. other BC subtypes. The burden of TNBC appears to be highest among Black women in the most socioeconomically disadvantaged neighborhoods. Our study suggests a complex interplay of social conditions and biological disease characteristics contributing to racial disparities in BC outcomes.

Association of Neighborhood-Level Household Income With 21-Gene Recurrence Score and Survival Among Patients With Estrogen Receptor-Positive Breast Cancer

IMPORTANCE

While low income has been associated with a higher incidence of triple-negative breast cancer, its association with 21-gene recurrence score (RS) among patients with estrogen receptor (ER)-positive breast cancer remains unclear.

OBJECTIVE

To evaluate the association of household income with RS and overall survival (OS) among patients with ER-positive breast cancer.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the National Cancer Database. Eligible participants included women diagnosed between 2010 and 2018 with ER-positive, pT1-3N0-1aM0 breast cancer who received surgery followed by adjuvant endocrine therapy with or without chemotherapy. Data analysis was performed from July 2022 to September 2022.

EXPOSURES

Low vs high neighborhood-level household income levels defined as below vs above the median household income of $50 353 based on each patient's zip code.

MAIN OUTCOMES AND MEASURES

RS (a score ranged from 0 to 100 based on gene expression signatures indicating the risk of distant metastasis, with RS of 25 or below indicating non-high risk and RS above 25 indicating high risk) and OS.

RESULTS

Among 119 478 women (median [IQR] age, 60 [52-67] years; 4737 [4.0%] Asian and Pacific Islander, 9226 [7.7%] Black, 7245 [6.1%] Hispanic, 98 270 [82.2%] non-Hispanic White), 82 198 (68.8%) and 37 280 (31.2%) patients had high and low income, respectively. Logistic multivariable analysis (MVA) showed that, compared with high income, low income was associated with higher RS (adjusted odds ratio [aOR], 1.11; 95% CI, 1.06-1.16). Cox MVA showed that low income was also associated with worse OS (adjusted hazards ratio [aHR], 1.18; 95% CI, 1.11-1.25). Interaction term analysis showed a statistically significant interaction between income levels and RS (interaction P < .001). On subgroup analysis, significant findings were noted among those with RS below 26 (aHR, 1.21; 95% CI, 1.13-1.29), while there was no significant OS difference between income levels among others with RS of 26 or higher (aHR, 1.08; 95% CI, 0.96-1.22).

CONCLUSIONS AND RELEVANCE

Our study suggested that low household income was independently associated with higher 21-gene recurrence scores and significantly worse survival outcomes among those with scores below 26, but not 26 or higher. Further studies are warranted to investigate the association between socioeconomic determinants of health and intrinsic tumor biology among patients with breast cancer.

Neighborhood disadvantage and lung cancer risk in a national cohort of never smoking Black women

BACKGROUND

Compared to women of other races who have never smoked, Black women have a higher risk of lung cancer. Whether neighborhood disadvantage, which Black women experience at higher rates than other women, is linked to never-smoking lung cancer risk remains unclear. This study investigates the association of neighborhood disadvantage and lung cancer risk in Black never-smoking women.

METHODS AND MATERIALS

This research utilized data from the Black Women's Health Study, a prospective cohort of 59,000 Black women recruited from across the US in 1995 and followed by biennial questionnaires. Associations of lung cancer incidence with neighborhood-level factors (including two composite variables derived from Census Bureau data: neighborhood socioeconomic status and neighborhood concentrated disadvantage), secondhand smoke exposure, and PM_2.5 were estimated using Fine-Gray subdistribution hazard models.

RESULTS

Among 37,650 never-smokers, 77 were diagnosed with lung cancer during follow-up from 1995 to 2018. The adjusted subdistribution hazard ratio (sHR) of lung cancer incidence with ten unit increase in neighborhood concentrated disadvantage index was 1.30 (95 % CI: 1.04, 1.63, p = 0.023). Exposure to secondhand smoke at work was associated with increased risk (sHR = 1.93, 95 % CI: 1.21, 3.10, p = 0.006), but exposure to secondhand smoke at home and PM_2.5 was not.

CONCLUSION

Worse neighborhood concentrated disadvantage was associated with increased lung cancer risk in Black women who never smoked. These findings suggest that non-tobacco-related factors in disadvantaged neighborhoods may be linked to lung cancer risk in Black women and that these factors must be understood and targeted to achieve health equity.

Comparing spatial patterns of 11 common cancers in Mainland China

Background

A stronger spatial clustering of cancer burden indicates stronger environmental and human behavioral effects. However, which common cancers in China have stronger spatial clustering and knowledge gaps regarding the environmental and human behavioral effects have yet to be investigated. This study aimed to compare the spatial clustering degree and hotspot patterns of 11 common cancers in mainland China and discuss the potential environmental and behavioral risks underlying the patterns.

Methods

Cancer incidence data recorded at 339 registries in 2014 was obtained from the “China Cancer Registry Annual Report 2017”. We calculated the spatial clustering degree of the common cancers using the global Moran’s Index and identified the hotspot patterns using the hotspot analysis.

Results

We found that esophagus, stomach and liver cancer have a significantly higher spatial clustering degree (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$p<0.05$$\end{document}p<0.05) than others. When by sex, female esophagus, male stomach, male esophagus, male liver and female lung cancer had significantly higher spatial clustering degree (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$p<0.001$$\end{document}p<0.001). The spatial clustering degree of male liver was significantly higher than that of female liver cancer (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$p<0.001$$\end{document}p<0.001), whereas the spatial clustering degree of female lung was significantly higher than that of male lung cancer (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$p<0.001$$\end{document}p<0.001). The high-risk areas of esophagus and stomach cancer were mainly in North China, Huai River Basin, Yangtze River Delta and Shaanxi Province. The hotspots for liver and male liver cancer were mainly in Southeast China and south Hunan. Hotspots of female lung cancer were mainly located in the Pearl River Delta, Shandong, North and Northeast China. The Yangtze River Delta and the Pearl River Delta were high-risk areas for multiple cancers.

Conclusions

The top highly clustered cancer types in mainland China included esophagus, stomach and liver cancer and, by sex, female esophagus, male stomach, male esophagus, male liver and female lung cancer. Among them, knowledge of their spatial patterns and environmental and behavioral risk factors is generally limited. Potential factors such as unhealthy diets, water pollution and climate factors have been suggested, and further investigation and validation are urgently needed, particularly for male liver cancer. This study identified the knowledge gap in understanding the spatial pattern of cancer burdens in China and offered insights into targeted cancer monitoring and control.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13926-y.

Systematic review of neighborhood socioeconomic indices studied across the cancer control continuum

BACKGROUND

There is extensive interest in understanding how neighborhood socioeconomic status (nSES) may affect cancer incidence or survival. However, variability regarding items included and approaches used to form a composite nSES index presents challenges in summarizing overall associations with cancer. Given recent calls for standardized measures of neighborhood sociodemographic effects in cancer disparity research, the objective of this systematic review was to identify and compare existing nSES indices studied across the cancer continuum (incidence, screening, diagnosis, treatment, survival/mortality) and summarize associations by race/ethnicity and cancer site to inform future cancer disparity studies.

METHODS

Using PRISMA guidelines, peer-reviewed articles published between 2010 and 2019 containing keywords related to nSES and cancer were identified in PubMed.

RESULTS

Twenty-four nSES indices were identified from 75 studies. In general, findings indicated a significant association between nSES and cancer outcomes (n = 64/75 studies; 85.33%), with 42/64 (65.63%) adjusting for highly-correlated individual SES factors (e.g., education). However, the direction of association differed by cancer site, race/ethnicity, and nSES index.

CONCLUSIONS

This review highlights several methodologic and conceptual issues surrounding nSES measurement and potential associations with cancer disparities. Recommendations pertaining to the selection of nSES measures are provided, which may help inform disparity-related disease processes and improve the identification of vulnerable populations in need of intervention.

Neighborhood Contexts and Breast Cancer Among Asian American Women

BACKGROUND

This study examines how neighborhood socioeconomic status (nSES) and ethnic composition are associated with breast cancer risk for Asian American women.

METHODS

We linked individual level data from a population-based case-control study of breast cancer among Asian American women with neighborhood level data in the Greater San Francisco Bay Area (cases: n = 118, controls: n = 390). Multivariable logistic regression models examined the association between nSES, ethnic composition, and odds of having breast cancer.

RESULTS

Asian American women living in neighborhoods with high nSES and high ethnic composition had the highest odds of breast cancer, compared to those living in neighborhoods with high nSES and low ethnic composition (OR = 0.34, 95% CI [0.16-0.75]) or in neighborhoods with low nSES and high ethnic composition (OR = 0.37, 95% CI [0.17-0.83]).

DISCUSSION

Neighborhood socioeconomic and ethnic contexts are associated with breast cancer for Asian American women. We discuss explanations and avenues for future research.

OUP accepted manuscript

Background

Methods

Results

Conclusion

Neighborhood disadvantage and individual-level life stressors in relation to breast cancer incidence in US Black women

BACKGROUND

Research on psychosocial stress and risk of breast cancer has produced conflicting results. Few studies have assessed this relation by breast cancer subtype or specifically among Black women, who experience unique chronic stressors.

METHODS

We used prospective data from the Black Women's Health Study, an ongoing cohort study of 59,000 US Black women, to assess neighborhood- and individual-level psychosocial factors in relation to risk of breast cancer. We used factor analysis to derive two neighborhood score variables after linking participant addresses to US Census data (2000 and 2010) on education, employment, income and poverty, female-headed households, and Black race for all households in each residential block group. We used Cox proportional hazards regression to estimate hazard ratios (HR) and 95% confidence intervals (CI) adjusted for established breast cancer risk factors.

RESULTS

During follow-up from 1995 to 2017, there were 2167 incident invasive breast cancer cases (1259 estrogen receptor positive (ER +); 687 ER negative (ER-)). For ER- breast cancer, HRs were 1.26 (95% CI 1.00-1.58) for women living in the highest quartile of neighborhood disadvantage relative to women in the lowest quartile, and 1.24 (95% CI 0.98-1.57) for lowest versus highest quartile of neighborhood socioeconomic status (SES). For ER+ breast cancer, living in the lowest quartile of neighborhood SES was associated with a reduced risk of ER+ breast cancer (HR = 0.83, 95% CI 0.70-0.98). With respect to individual-level factors, childhood sexual abuse (sexual assault ≥ 4 times vs. no abuse: HR = 1.35, 95% CI 1.01-1.79) and marital status (married/living together vs. single: HR = 1.29, 95% CI 1.08-1.53) were associated with higher risk of ER+, but not ER- breast cancer.

CONCLUSION

Neighborhood disadvantage and lower neighborhood SES were associated with an approximately 25% increased risk of ER- breast cancer in this large cohort of Black women, even after control for multiple behaviors and lifestyle factors. Further research is need to understand the underlying reasons for these associations. Possible contributing factors are biologic responses to the chronic stress/distress experienced by individuals who reside in neighborhoods characterized by high levels of noise, crime and unemployment or the direct effects of environmental toxins.

Trends in breast cancer incidence rates by race/ethnicity: Patterns by stage, socioeconomic position, and geography in the United States, 1999-2017

BACKGROUND

The incidence rate of breast cancer has been increasing over time across race/ethnicity in the United States. It is unclear whether these trends differ among stage, poverty, and geography subgroups.

METHODS

Using data from the North American Association of Central Cancer Registries, this study estimated trends in age-adjusted breast cancer incidence rates among women aged 50 to 84 years from 1999 to 2017 by race/ethnicity (non-Hispanic Black, non-Hispanic White, and Hispanic) and across subgroups (stage, county-level poverty, county urban/rural status, and geographic region [West, Midwest, South, and Northeast]).

RESULTS

From 2004 to 2017, breast cancer incidence rates increased across race/ethnicity and subgroups, with the greatest average annual percent increases observed for non-Hispanic Black women, overall (0.9%) and those living in lower poverty areas (0.8%), rural areas (1.2%), and all regions except the West (0.8%-1.0%). Stronger increases among non-Hispanic Black women were observed for local-stage disease and for some subgroups of distant-stage disease. Non-Hispanic Black women had the smallest decrease in regional-stage disease across most subgroups. Similarly, Hispanic women had the strongest increases in some subgroups, including areas with higher poverty (0.6%-1.2%) and in the West (0.8%), for local- and distant-stage disease.

CONCLUSIONS

These trends highlight concerns for an increasing burden of breast cancer among subpopulations, with some already experiencing disparate breast cancer mortality rates, and they highlight the need for targeted breast cancer prevention and efforts to reduce mortality disparities in areas with increasing incidence.

Identifying key barriers to effective breast cancer control in rural settings

Breast cancer is the most common cancer and the second most common cause of cancer mortality among women in the United States. Efforts to promote breast cancer control in rural settings face specific challenges. Access to breast cancer screening, diagnosis, and treatment services is impaired by shortages of primary care and specialist providers, and geographic distance from medical facilities. Women in rural areas have comparable breast cancer mortality rates compared to women in urban settings, but this is due in large part to lower incidence rates and masks a substantial rural/urban disparity in breast cancer survival among women diagnosed with breast cancer. Mammography screening utilization rates are slightly lower among rural women than their urban counterparts, with a corresponding increase in late stage breast cancer. Differences in breast cancer survival persist after controlling for stage at diagnosis, largely due to disparities in access to treatment. Travel distance to treatment centers is the most substantial barrier to improved breast cancer outcomes in rural areas. While numerous interventions have been demonstrated in controlled studies to be effective in promoting treatment access and adherence, widespread dissemination in public health and clinical practice remains lacking. Efforts to improve breast cancer control in rural areas should focus on implementation strategies for improving access to breast cancer treatments.

Neighborhood Social Environmental Factors and Breast Cancer Subtypes among Black Women

BACKGROUND

The disproportionate burden of more aggressive breast cancer subtypes among African American/Black women may stem from multilevel determinants. However, data are limited regarding the impacts of neighborhood social environmental characteristics among Black women.

METHODS

We evaluated the association between neighborhood-level socioeconomic status (nSES) and breast cancer subtypes in the Women's Circle of Health and Women's Circle of Health Follow-up Study, which included 1,220 Black women diagnosed from 2005 to 2017 with invasive breast cancer. nSES at diagnosis was measured using NCI's census tract-level SES index. We used multilevel multinomial logistic regression models to estimate the association of nSES with breast cancer subtypes [triple-negative breast cancer (TNBC), HER2-positive vs. luminal A], adjusting for individual-level SES, body mass index, and reproductive factors. We tested for interactions by neighborhood racial composition.

RESULTS

Compared with census tracts characterized as high nSES, the relative risk ratios (RRR) for TNBC were 1.81 [95% confidence interval (CI): 1.20-2.71] and 1.95 (95% CI: 1.27-2.99) for women residing in areas with intermediate and low nSES, respectively (P trend = 0.002). Neighborhood racial composition modified the association between nSES and TNBC; the highest relative risk of TNBC was among women residing in low nSES areas with low proportions of Black residents.

CONCLUSIONS

Black women residing in socioeconomically disadvantaged neighborhoods may have an increased risk of TNBC, particularly in areas with lower proportions of Black residents.

IMPACT

Places people live may influence breast tumor biology. A deeper understanding of multilevel pathways contributing to tumor biology is needed.

Education level and breast cancer incidence: a meta-analysis of cohort studies

OBJECTIVE

We aimed to examine the association between education level and breast cancer incidence by a meta-analysis of cohort studies.

METHODS

Relevant studies were identified by searching PubMed, Web of Science, and Scopus databases on June 10, 2018. Reference lists from the obtained articles were also reviewed. We included cohort studies reporting relative risks with 95% CIs for the association between education level and breast cancer incidence. Either a fixed- or random-effects model was used to calculate the pooled risk estimates.

RESULTS

We identified 18 cohort studies with more than 10 million women. Compared with women with a lower education level, women with a higher education level had a significantly higher risk of developing breast cancer (pooled relative risk 1.22 [95% CI, 1.14-1.30]). The results did not differ by study area or reference group. The association remained in studies that adjusted for age at first birth and parity, but was attenuated and no longer significant when the analysis was restricted to studies that adjusted for alcohol use, to studies that adjusted for age at menopause, or to studies that adjusted for hormone therapy.

CONCLUSIONS

A higher education level may be associated with an increased risk of developing breast cancer, in which alcohol use, age at menopause, and hormone therapy may, at least partially, play a mediating role.

A Low Literacy, Multimedia Health Information Technology Intervention to Enhance Patient-Centered Cancer Care in Safety Net Settings Increased Cancer Knowledge in a Randomized Controlled Trial

We tested whether a low-literacy-friendly, multimedia information and assessment system used in daily clinical practice enhanced patient-centered care and improved patient outcomes. This was a prospective, parallel-group, randomized controlled trial with 2 arms, CancerHelp-Talking Touchscreen (CancerHelp-TT) versus control, among adults with Stage I-III breast or colorectal cancer receiving chemotherapy and/or radiation therapy in safety net settings. Each patient was assessed for outcomes at 4 timepoints: after starting treatment (baseline), during treatment, immediately after treatment, and at follow-up assessment. The primary outcomes were health beliefs, cancer knowledge, self-efficacy, and satisfaction with communication about cancer and its treatments. Health-related quality of life (HRQOL) was a secondary outcome. A total of 129 patients participated in the study (65 intervention and 64 control), and approximately 50% of these completed the study. Patients randomized to receive the CancerHelp-TT program had a significantly larger increase in their cancer knowledge in comparison to those randomized to the control arm (effect size = .48, P = .05). While effect sizes for differences between randomized groups in self-efficacy, health beliefs, HRQOL, and satisfaction with communication were small (.10-.48), there was a consistent trend that participants in the intervention group showed larger increases over time in all outcomes compared to the control group. The CancerHelp-TT software was favorably rated by intervention participants. The CancerHelp-TT program showed promise to increase vulnerable cancer patients' cancer knowledge and adaptive health beliefs and attitudes. However, vulnerable patients may need additional interventional support in settings outside cancer clinics.

Association of Cancer History and Health Care Utilization Among Female Immigrants Using NHANES 2007-2016 Data

BACKGROUND

Despite health disparities in preventive care among adult female immigrants, the extent to which their health service utilization is influenced by a cancer history remains largely unknown.

METHODS

Using Andersen's behavioral model, 2007-2016 National Health and Nutrition Examination Survey data were analyzed to examine the influence of a cancer history on health service utilization among adult immigrant women. Multivariate logistic regression models assessed factors related to past year health care utilization, operationalized as an outpatient doctor's visit and an inpatient overnight hospital stay.

RESULTS

Once other factors were considered, a past cancer history increased the likelihood of a past year inpatient overnight hospital stay, but was not associated with a past year outpatient doctor's visit.

DISCUSSION

An outpatient doctor's visit for adult female immigrant cancer survivors would provide an opportunity for essential preventive health services. They must be educated about the importance of ongoing outpatient care for cancer surveillance and health maintenance.

A prospective study of yogurt and other dairy consumption in relation to incidence of type 2 diabetes among black women in the USA

BACKGROUND

Yogurt consumption and low-fat dairy consumption have been associated with reduced incidence of type 2 diabetes (T2D) in some studies.

OBJECTIVE

We assessed the relation of yogurt and other dairy consumption to incidence of T2D in black women, a population group with a disproportionately high incidence of T2D.

METHODS

The Black Women's Health Study has followed 59,000 US black women since 1995 through biennial questionnaires which update health information. Each questionnaire inquired about doctor-diagnosed diabetes in the previous 2 y. FFQs completed by participants in 1995 and 2001 provided information on yogurt and other dietary intake. HRs with 95% CIs for yogurt (nonfrozen or frozen) and other dairy consumption in relation to incident T2D (n = 8061 cases) were estimated with Cox proportional hazards regression, controlling for risk factors for T2D.

RESULTS

The HR for consumption of ≥1 serving of yogurt/d relative to <1 serving/mo was 0.99 (95% CI: 0.87, 1.13, P trend = 0.65) after control for dietary and nondietary risk factors for T2D. The multivariable HR was 0.97 (95% CI: 0.75, 1.27; P trend = 0.74) for 2 or more servings/d of low-fat dairy other than yogurt relative to <1 serving/mo and 1.06 (95% CI: 0.91, 1.25, P trend = 0.36) for 2 or more servings/d of regular dairy relative to <1 serving/mo.

CONCLUSION

Results from this study do not support an inverse association of yogurt consumption or other dairy consumption with T2D risk in black women.

Using Latent Class Modeling to Jointly Characterize Economic Stress and Multipollutant Exposure

BACKGROUND

Work is needed to better understand how joint exposure to environmental and economic factors influence cancer. We hypothesize that environmental exposures vary with socioeconomic status (SES) and urban/rural locations, and areas with minority populations coincide with high economic disadvantage and pollution.

METHODS

To model joint exposure to pollution and SES, we develop a latent class mixture model (LCMM) with three latent variables (SES Advantage, SES Disadvantage, and Air Pollution) and compare the LCMM fit with K-means clustering. We ran an ANOVA to test for high exposure levels in non-Hispanic black populations. The analysis is at the census tract level for the state of North Carolina.

RESULTS

The LCMM was a better and more nuanced fit to the data than K-means clustering. Our LCMM had two sublevels (low, high) within each latent class. The worst levels of exposure (high SES disadvantage, low SES advantage, high pollution) are found in 22% of census tracts, while the best levels (low SES disadvantage, high SES advantage, low pollution) are found in 5.7%. Overall, 34.1% of the census tracts exhibit high disadvantage, 66.3% have low advantage, and 59.2% have high mixtures of toxic pollutants. Areas with higher SES disadvantage had significantly higher non-Hispanic black population density (NHBPD; P < 0.001), and NHBPD was higher in areas with higher pollution (P < 0.001).

CONCLUSIONS

Joint exposure to air toxins and SES varies with rural/urban location and coincides with minority populations.

IMPACT

Our model can be extended to provide a holistic modeling framework for estimating disparities in cancer survival.See all articles in this CEBP Focus section, "Environmental Carcinogenesis: Pathways to Prevention."

Associations between breast cancer subtype and neighborhood socioeconomic and racial composition among Black and White women

PURPOSE

Studies of Black-White differences in breast cancer subtype often emphasize potential ancestry-associated genetic or lifestyle risk factors without fully considering how the social or economic implications of race in the U.S. may influence risk. We assess whether neighborhood racial composition and/or socioeconomic status are associated with odds of triple-negative breast cancer (TNBC) diagnosis relative to the less-aggressive hormone receptor-positive/HER2-negative subtype (HR+ /HER-), and whether the observed relationships vary across women's race and age groups.

METHODS

We use multilevel generalized estimating equation models to evaluate odds of TNBC vs. HR+ /HER2- subtypes in a population-based cohort of 7291 Black and 74,208 White women diagnosed with breast cancer from 2006 to 2014. Final models include both neighborhood-level variables, adjusting for individual demographics and tumor characteristics.

RESULTS

Relative to the HR+ /HER- subtype, we found modestly lower odds of TNBC subtype among White women with higher neighborhood median household income (statistically significant within the 45-64 age group, OR = 0.981 per $10,000 increase). Among Black women, both higher neighborhood income and higher percentages of Black neighborhood residents were associated with lower odds of TNBC relative to HR+ /HER2-. The largest reduction was observed among Black women diagnosed at age ≥ 65 (OR = 0.938 per $10,000 increase; OR = 0.942 per 10% increase in Black residents).

CONCLUSION

The relationships between neighborhood composition, neighborhood socioeconomic status, and odds of TNBC differ by race and age. Racially patterned social factors warrant further exploration in breast cancer subtype disparities research.

Do multiple environmental factors impact four cancers in women in the contiguous United States?

BACKGROUND

Though there has been an increasing concern about the effects that environmental exposures have on cancer, limited knowledge exists regarding multiple environmental factors on cancers in women.

METHODS

We performed a spatial autoregressive model to examine the association between the Environmental Quality Index (EQI) and mortalities of four cancers in women (breast, cervical, ovarian and uterine cancer) based on county-level data, and explored these associations by urbanicity. The EQI, which included five domains (air, water, land, built environment and sociodemographic domain) estimated from 2000 to 2005 data, was obtained from the United States Environmental Protection Agency. The mortality rates for 3107 counties in the US in 2014 were obtained from the Institute for Health Metrics and Evaluation.

RESULTS

We found that each unit increase in the overall EQI was positively associated with the increased mortality of breast, ovarian and uterine cancer (2.5%, 3.6% and 3.1% respectively), but was negatively associated with cervical cancer mortality. Among the environmental domains, the air and sociodemographic EQIs were positively associated with increased risks of breast, ovarian and uterine cancers. Additionally, built environment EQI was associated with breast and ovarian cancers; land EQI was associated with uterine and ovarian cancers. The sociodemographic EQI was negatively associated with cervical cancer mortality. Furthermore, we have developed a novel Environmental Quality Health Index (EQHI) in identifying environment-health risk of cancers in women at county level.

CONCLUSIONS

Our findings suggest that breast, ovarian, and uterine cancer mortalities are positively associated with multiple environmental factors, while cervical cancer mortality is mainly negatively associated with sociodemographic factors. The novel EQHI might help identify spatially-based environment-cancer risk.

Higher Breast Cancer Risk Among Immigrant Asian American Women Than Among US-Born Asian American Women

INTRODUCTION

Given rising rates of breast cancer in parts of Asia, immigrant Asian American women in the United States may have higher rates of breast cancer than previously anticipated. This study examined breast cancer risk among Asian American women by nativity and percentage of life lived in the United States, accounting for established breast cancer risk factors.

METHODS

We analyzed a breast cancer case-control data set of Asian American women living in the San Francisco Bay Area; this data set included 132 cases of women with breast cancer selected from a Surveillance, Epidemiology, and End Results cancer registry and 438 Asian American women without diagnosed breast cancer matched to cases by age and country of origin. We used logistic regression to compare 3 Asian American groups: US-born, immigrants who lived 50% or more of their life in the United States, and immigrants who lived less than 50% of their life in the United States.

RESULTS

In the minimally adjusted and fully adjusted models, both groups of immigrant Asian American women had higher risk of breast cancer than US-born Asian American women. In the fully adjusted model, compared with US-born Asian American women, immigrant Asian American women who lived more than 50% of their life in United States were on average 3 times as likely (odds ratio = 3.00; 95% confidence interval, 1.56-5.75) and immigrants who lived less than 50% of their life in United States were on average 2.46 times as likely (odds ratio = 2.46; 95% confidence interval, 1.21-4.99) to have breast cancer. We found no difference in fully adjusted odds ratios of having breast cancer between the 2 immigrant groups.

CONCLUSION

This study provides preliminary evidence that breast cancer risk among immigrant Asian American women may be higher than among their US-born counterparts.

"For lack of knowledge, our people will perish": Using focus group methodology to explore African-American communities' perceptions of breast cancer and the environment

Among women living in the United States, breast cancer is the second leading cause of cancer death. Disproportionate racial disparities in breast cancer exist, with African American (AA) women consistently having the highest rates of breast cancer related mortality despite lower incidence. This study attends to the Institute of Medicine's (IOM) call to action recommending the identification of effective strategies for communicating accurate and reliable breast cancer risk information to diverse audiences. Using focus group methodology, this study explores how AAs perceive and decipher information related to breast cancer and its relationship to their environment. Six focus groups were conducted. The sample (n = 50) was African American, 98% female, with an average age of 50.1 years. The focus group protocol consisted of open-ended questions designed to elicit information about participants' perceptions of their environment and its link to breast cancer. Focus groups were audio recorded and professionally transcribed. Analysis of the focus group transcripts revealed themes pertaining to these categories: (1) general knowledge and beliefs about breast cancer, (2) perceived environmental risks factors for breast cancer, (3) importance of seeking knowledge about breast cancer and the environment, and (4) recommended communication strategies. The emergent themes reflect the knowledge participants possessed about breast cancer and environmental risk factors, in addition to concerns about the importance of possessing accurate information, and how culturally appropriate health communication strategies can be used to disseminate breast cancer knowledge in the community. Findings from this study can be used for culturally appropriate communication about breast cancer and the environment with AA communities.

Standardised mortality rate for cerebrovascular diseases in the Slovak Republic from 1996 to 2013 in the context of income inequalities and its international comparison

Non-communicable diseases represent one of the greatest challenges for health policymakers. The main objective of this study is to analyse the development of standardised mortality rates for cerebrovascular disease, which is one of the most common causes of deaths, in relation to income inequality in individual regions of the Slovak Republic. Direct standardisation was applied using data from the Slovak mortality database, covering the time period from 1996 to 2013. The standardised mortality rate declined by 4.23% in the Slovak Republic. However, since 1996, the rate has been higher by almost 33% in men than in women. Standardised mortality rates were lower in the northern part of the Slovak Republic than in the southern part. The regression models demonstrated an impact of the observed income-related dimensions on these rates. The income quintile ratio and Gini coefficient appeared to be the most influencing variables. The results of the analysis highlight valuable baseline information for creating new support programmes aimed at eliminating health inequalities in relation to health and social policy.

Disparities in cancer incidence by area-level socioeconomic status in the French West Indies

PURPOSE

Social inequalities in cancer incidence and mortality have been reported in France, but no data are available for the French overseas territories. Our objective was to explore the association between cancer incidence and the socioeconomic level of the residence area in the French West Indies.

METHODS

Cancer incidence data were obtained from the cancer registries of Guadeloupe and Martinique (2009-2010). To assess socioeconomic status, we developed a specific index of social deprivation from census data at a small area level. We used Bayesian methods to evaluate the association between cancer incidence and the deprivation index, for all cancers combined and for the major cancer sites.

RESULTS

There was no clear association between area-based deprivation and the incidence of all cancers combined. In men, higher area deprivation was associated with a higher incidence of prostate cancer (relative risk (RR) 1.25, 95% credible interval (CI) 1.04-1.49; RR 1.08, CI 0.91-1.29 in the categories of intermediate and high deprivation, respectively, compared to low deprivation), but was not associated with respiratory cancer. Women living in the most deprived areas had a higher incidence of stomach (RR 1.77, CI 1.12-2.89), breast (RR 1.15, CI 0.90-1.45), and cervical (RR 1.13, CI 0.63-2.01) cancers and a lower incidence of respiratory cancer (RR 0.65, CI 0.38-1.11).

CONCLUSION

These first results in the French West Indies suggest specific patterns for some cancer sites that need to be further investigated.

Outdoor Light at Night and Breast Cancer Incidence in the Nurses' Health Study II

BACKGROUND

Animal and epidemiologic studies suggest that exposure to light at night (LAN) may disrupt circadian patterns and decrease nocturnal secretion of melatonin, which may disturb estrogen regulation, leading to increased breast cancer risk.

OBJECTIVES

We examined the association between residential outdoor LAN and breast cancer incidence using data from the nationwide U.S.-based Nurses' Health Study II cohort.

METHODS

We followed 109,672 women from 1989 through 2013. Cumulative LAN exposure was estimated using time-varying satellite data for a composite of persistent nighttime illumination at ∼1 km² scale for each residence during follow-up. Incident invasive breast cancer cases were confirmed by medical record review. We used Cox proportional hazard models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs), adjusting for anthropometric, reproductive, lifestyle, and socioeconomic risk factors.

RESULTS

Over 2,187,425 person-years, we identified 3,549 incident breast cancer cases. Based on a fully adjusted model, the estimated HR for incident breast cancer with an interquartile range (IQR) (31.6 nW/cm²/sr) increase in cumulative average outdoor LAN was 1.05 (95% CI: 1.00, 1.11). An association between LAN and breast cancer appeared to be limited to women who were premenopausal at the time of a case [HR=1.07 (95% CI: 1.01, 1.14) based on 1,973 cases vs. HR=1.00 (95% CI: 0.91, 1.09) based on 1,172 cases in postmenopausal women; p-interaction=0.08]. The LAN-breast cancer association was observed only in past and current smokers at the end of follow-up [HR=1.00 (95% CI: 0.94, 1.07) based on 2,215 cases in never smokers; HR=1.10 (95% CI: 1.01, 1.19) based on 1,034 cases in past smokers vs. HR=1.21 (95% CI: 1.07, 1.37) for 300 cases in current smokers; p-interaction=0.08].

CONCLUSIONS

Although further work is required to confirm our results and to clarify potential mechanisms, our findings suggest that exposure to residential outdoor light at night may contribute to invasive breast cancer risk. https://doi.org/10.1289/EHP935.

Racial/Ethnic Differences in the Impact of Neighborhood Social and Built Environment on Breast Cancer Risk: The Neighborhoods and Breast Cancer Study

Background: Neighborhood socioeconomic status (nSES) has been found to be associated with breast cancer risk. It remains unclear whether this association applies across racial/ethnic groups independent of individual-level factors and is attributable to other neighborhood characteristics.Methods: We examined the independent and joint associations of education and nSES with odds of breast cancer. Residential addresses were geocoded for 2,838 cases and 3,117 controls and linked to nSES and social and built environment characteristics. We estimated ORs and 95% confidence intervals (CI) using multilevel logistic regression controlling for individual-level breast cancer risk factors and assessed the extent to which nSES associations were due to neighborhood characteristics.Results: Women living in the highest versus lowest nSES quintile had a nearly 2-fold greater odds of breast cancer, with elevated odds (adjusted ORs, 95% CI) for non-Hispanic whites (NHWs; 2.27; 1.45-3.56), African Americans (1.74; 1.07-2.83), U.S.-born Hispanics (1.82; 1.19-2.79), and foreign-born Hispanics (1.83; 1.06-3.17). Considering education and nSES jointly, ORs were increased for low education/high nSES NHWs (1.83; 1.14-2.95), high education/high nSES NHWs (1.64; 1.06-2.54), and high education/high nSES foreign-born Hispanics (2.17; 1.52-3.09) relative to their race/ethnicity/nativity-specific low education/low nSES counterparts. Adjustment for urban and mixed-land use characteristics attenuated the nSES associations for most racial/ethnic/nativity groups except NHWs.Conclusions: Our study provides empirical evidence for a role of neighborhood environments in breast cancer risk, specifically social and built environment attributes.Impact: Considering the role of neighborhood characteristics among diverse populations may offer insights to understand racial/ethnic disparities in breast cancer risk. Cancer Epidemiol Biomarkers Prev; 26(4); 541-52. ©2017 AACR.

Contextual Impact of Neighborhood Obesogenic Factors on Postmenopausal Breast Cancer: The Multiethnic Cohort

Background: While obesity is well-understood to increase breast cancer risk, the role of the neighborhood obesogenic environment, encompassing social and built environment attributes that influence body size, is poorly understood.Methods: Using principal components factor analysis, five composite factors [neighborhood socioeconomic status (nSES), urban, mixed-land development, unhealthy food environment, parks] on the basis of geospatial data were developed to characterize the obesogenic environment for 48,247 postmenopausal women in the Multiethnic Cohort, residing predominately in Los Angeles County. We used Cox proportional hazards regression to examine the association between neighborhood obesogenic factors and breast cancer risk (n = 2,341 cases after 17 years of follow-up), adjusting for body mass index (BMI), weight gain since age 21, education, established risk factors, other neighborhood factors, and clustering by block group.Results: Lower nSES was associated with lower breast cancer risk [quintile 1 vs. 5: HR, 0.79; 95% confidence interval (CI), 0.66-0.95], with a more pronounced association observed in Latinos (quintile 1 vs. 5: HR, 0.60; 95% CI, 0.43-0.85). More urban environments were associated with lower breast cancer risk in Japanese Americans (quintile 5 vs. 1: HR, 0.49; 95% CI, 0.26-0.90), and lower mixed-land development was associated with higher breast cancer risk in Latinos (quintile 1 vs. 5: HR, 1.46; 95% CI, 1.10-1.93).Conclusions: Obesogenic neighborhood environment factors, especially nSES, urbanicity, and mixed-land development, were differentially and independently associated with breast cancer risk in this multiethnic population.Impact: These findings highlight the need for additional studies of the driving contextual aspects of nSES that influence breast cancer risk. Cancer Epidemiol Biomarkers Prev; 26(4); 480-9. ©2017 AACRSee all the articles in this CEBP Focus section, "Geospatial Approaches to Cancer Control and Population Sciences."

A prospective investigation of neighborhood socioeconomic deprivation and self-rated health in a large US cohort

BACKGROUND

Neighborhood characteristics play a critical role in health. Self-rated health (SRH) is an important indicator of quality of life and a strong predictor of premature death. Prospective study on neighborhood deprivation and SRH is limited.

METHODS

We examined neighborhood socioeconomic deprivation with reporting fair/poor SRH at follow-up (2004-2006) in 249,265 men and women (age 50-71) who reported SRH as good or better at baseline (1995-1996) in the NIH-AARP Health and Diet Study. Baseline addresses were geocoded and linked to 2000 Census. Census tract level variables were used to generate a socioeconomic deprivation index by principle component analysis.

RESULTS

Residents of more deprived neighborhoods had a higher risk of developing poor/fair SRH at follow-up, even after adjusting for individual-level factors (Odds ratio (95% confidence interval) _{Q5 vs Q1}: 1.26 (1.20, 1.32), p-trend: <0.0001). The results were largely consistent across subgroups with different demographics, health behaviors, and disease conditions and after excluding participants who moved away from their baseline address.

CONCLUSION

Neighborhood disadvantage predicts SRH over 10 years.

Statistical Assessment of Neighborhood Socioeconomic Deprivation Environment in Spatial Epidemiologic Studies

Neighborhood socioeconomic deprivation has been associated with health behaviors and outcomes. However, neighborhood socioeconomic status has been measured inconsistently across studies. It remains unclear whether appropriate socioeconomic indicators vary over geographic areas and geographic levels. The aim of this study is to compare the composite socioeconomic index to six socioeconomic indicators reflecting different aspects of socioeconomic environment by both geographic areas and levels. Using 2000 U.S. Census data, we performed a multivariate common factor analysis to identify significant socioeconomic resources and constructed 12 composite indexes at the county, the census tract, and the block group levels across the nation and for three states, respectively. We assessed the agreement between composite indexes and single socioeconomic variables. The component of the composite index varied across geographic areas. At a specific geographic region, the component of the composite index was similar at the levels of census tracts and block groups but different from that at the county level. The percentage of population below federal poverty line was a significant contributor to the composite index, regardless of geographic areas and levels. Compared with non-component socioeconomic indicators, component variables were more agreeable to the composite index. Based on these findings, we conclude that a composite index is better as a measure of neighborhood socioeconomic deprivation than a single indicator, and it should be constructed on an area- and unit-specific basis to accurately identify and quantify small-area socioeconomic inequalities over a specific study region.

Mediation of Racial and Ethnic Disparities in Estrogen/Progesterone Receptor-Negative Breast Cancer by Socioeconomic Position and Reproductive Factors

Hispanic and non-Hispanic black breast cancer patients are more likely than non-Hispanic white patients to be diagnosed with breast cancer that is negative for estrogen and progesterone receptors (ER/PR-negative). This disparity might be transmitted through socioeconomic and reproductive factors. Data on 746 recently diagnosed breast cancer patients (300 non-Hispanic white, 303 non-Hispanic black, 143 Hispanic) were obtained from the population-based Breast Cancer Care in Chicago Study (Chicago, Illinois, 2005-2008). Income, educational level, and census tract measures of concentrated disadvantage and affluence were combined into a single measure of socioeconomic position (SEP). Parity and age at first birth were combined into a single measure of reproductive factors (RPF). We constructed path models to estimate direct and indirect associations of SEP and RPF, and we estimated average marginal controlled direct associations. Compared with non-Hispanic white patients, non-Hispanic black patients and Hispanic patients were more likely to have ER/PR-negative disease (28% and 20% for non-Hispanic black patients and Hispanic patients, respectively, vs. 12% for non-Hispanic white patients; P ≤ 0.001). The ethnic disparity in ER/PR-negative breast cancer (prevalence difference = 0.13, 95% confidence interval: 0.07, 0.18) was reduced by approximately 60% (prevalence difference = 0.05, 95% confidence interval: -0.04, 0.13) after control for SEP and RPF. At least part of the ethnic disparity in the aggressiveness of breast tumors might be transmitted through social influences on tumor biology.

Risks of developing breast and colorectal cancer in association with incomes and geographic locations in Texas: a retrospective cohort study

BACKGROUND

No study has been conducted to investigate the spatial pattern and association of socioeconomic status (such as income) with breast and colorectal cancer incidence in Texas, United States. This study aimed to determine whether median household income was associated with the risk of developing breast and colorectal cancer in Texas and to identify higher cancer risks by race/ethnicity and geographic areas.

METHODS

This was a retrospective cohort study with an ecological component in using aggregated measures at the county level. We identified 243,677 women with breast cancer and 155,534 men and women with colorectal cancer residing in 254 counties in Texas in 1995-2011 from the public-use dataset of Texas Cancer Registry. The denominator population and median household income at the county level was obtained from the U.S. Bureau of the Census. Cancer incidence rates were calculated as number of cases per 100,000 persons and age-adjusted using the 2000 US population data. We used the ArcGIS v10.1 (geographic information system software) to identify multiple clustered counties with high and low cancer incidences in Texas.

RESULTS

Age-adjusted breast cancer incidence rate in the highest median income quintile group was 151.51 cases per 100,000 in 2008-2011 as compared to 98.95 cases per 100,000 in the lowest median income quintile group. The risk of colorectal cancer appeared to decrease with increasing median income in racial/ethnic population. Spatial analysis revealed the significant low breast cancer incidence cluster regions located in southwest US-Mexico border counties in Texas.

CONCLUSIONS

This study demonstrated that higher income was associated with an increased risk of breast cancer and a decreased risk of colorectal cancer in Texas. There were geographic variations with cancer incidence clustered in high risk areas in Texas. Future studies may need to explore more factors that might explain income and cancer risk associations and their geographic variations.

Neighborhood Socioeconomic Status in Relation to Serum Biomarkers in the Black Women's Health Study

Lower neighborhood socioeconomic status (SES) is associated with higher cardiovascular disease (CVD) risk. Black women have a higher CVD risk and are more likely to live in poor neighborhoods than white women. We examined the association of neighborhood SES with several CVD biomarkers using data from the Black Women's Health Study (BWHS), a follow-up study of US black women reporting high levels of education and income. Blood specimens of 418 BWHS participants were assayed for C-reactive protein (CRP), hemoglobin A1C (hgA1C), and high-density lipoprotein (HDL) cholesterol. US Census block group data were linked to the women's addresses to reflect neighborhood SES. Multivariable-adjusted mixed linear regression models that adjusted for person-level SES and for cardiovascular risk factors were used to assess CRP, hgA1C, and HDL levels in relation to quintiles of neighborhood SES. Women living in the poorest neighborhoods had the least favorable biomarker levels. As neighborhood SES increased, CRP decreased (P for trend = 0.01), hgA1C decreased (P for trend = 0.07), and HDL increased (P for trend = 0.19). These associations were present within strata of individual educational level. The present findings suggest that neighborhood environments may affect physiological processes within residents independently of individual SES.

Latent class model characterization of neighborhood socioeconomic status

PURPOSE

Neighborhood-level socioeconomic status (NSES) can influence breast cancer mortality and poorer health outcomes are observed in deprived neighborhoods. Commonly used NSES indexes are difficult to interpret. Latent class models allow for alternative characterization of NSES for use in studies of cancer causes and control.

METHODS

Breast cancer data was from a cohort of women diagnosed at an academic medical center in Philadelphia, PA. NSES variables were defined using Census data. Latent class modeling was used to characterize NSES.

RESULTS

Complete data was available for 1,664 breast cancer patients diagnosed between 1994 and 2002. Two separate latent variables, each with 2-classes (LC2) best represented NSES. LC2 demonstrated strong associations with race and tumor stage and size.

CONCLUSIONS

Latent variable models identified specific characteristics associated with advantaged or disadvantaged neighborhoods, potentially improving our understanding of the impact of socioeconomic influence on breast cancer prognosis. Improved classification will enhance our ability to identify vulnerable populations and prioritize the targeting of cancer control efforts.

Neighborhood and Individual Socioeconomic Status and Asthma Incidence in African American Women

OBJECTIVE

Individual socioeconomic status (SES) has been associated with asthma incidence but whether neighborhood SES has an influence is unknown. We assessed the contributions of neighborhood socioeconomic status (SES), neighborhood housing density, neighborhood racial composition, and individual SES to the development of adult-onset asthma in Black women, accounting for other known or suspected risk factors.

DESIGN AND PARTICIPANTS

Prospective cohort study conducted among 47,779 African American women followed with biennial health questionnaires from 1995 to 2011.

METHODS AND MAIN OUTCOME MEASURES

Incident asthma was defined as new self-report of doctor-diagnosed asthma with concurrent use of asthma medication. We assessed neighborhood SES, indicated by census variables representing income, education, and wealth, and housing density and % African American population, as well as individual SES, indicated by highest education of participant/spouse. Cox proportional hazards models were used to derive multivariable hazard ratios (HRs) and 95% CIs for the association of individual SES and neighborhood variables with asthma incidence.

RESULTS

During a 16-year follow-up period, 1520 women reported incident asthma. Neighborhood factors were not associated with asthma incidence after control for individual SES, body mass index, and other factors. Compared with college graduates, the multivariable HR for asthma was 1.13 (95% CI 1.00-1.28) for women with some college education and 1.23 (95% CI 1.05-1.44) for women with no more than a high school education.

CONCLUSIONS

Individual SES, but not neighborhood SES or other neighborhood factors, was associated with the incidence of adult-onset asthma in this population of African American women.

Socioeconomic status and incidence of breast cancer by hormone receptor subtype

Recent developments in genetics and molecular biology have classified breast cancer into subtypes based on tumor markers of estrogen (ER), progesterone (PR) and human epidermal growth Factor-2 receptors (Her-2), with the basal-like (ER-, PR-, Her2-) subtype commonly referred to as "triple negative" breast cancer (TNBC) being the most aggressive. Prior studies have provided evidence that higher socio-economic status (SES) is associated with increased breast cancer risk, likely due to hormone related risk factors such as parity and hormonal contraceptive use. However, it is unclear if the relationship between SES and overall breast cancer incidence exists within each subtype, and if this association varies by race/ethnicity. Analysis was based on data obtained from the SEER database linked to 2008-2012 American Community Survey data, and restricted to women diagnosed with breast cancer in 2010. The NCI SES census tract SES index based on measures of income, poverty, unemployment, occupational class, education and house value, was examined and categorized into quintiles. Age-adjusted incidence rate ratios were calculated comparing the lowest to the highest SES groups by subtype, separately for each race/ethnic group. We identified 47,586 women with breast cancer diagnosed in 2010. The majority was diagnosed with Her2-/HR+ tumors (73 %), while 12 % had triple negative tumors (TNBC). There was a significant trend of higher incidence with increasing SES for Her2-/HR+ (IRR Highest vs. Lowest SES: 1.32, 95 % CI 1.27-1.39; p value trend: 0.01) and Her2+/HR+ tumors (IRR Highest vs. Lowest SES: 1.46, 95 % CI 1.27-1.68; p value trend: 0.01) among White cases. There was no association between SES and incidence of HR- subtypes (Her2+/HR- or TNBC). Similar associations were observed among Black, Hispanic and Asian or Pacific Islander cases. The positive association between SES and breast cancer incidence is primarily driven by hormone receptor positive tumors. To the extent that neighborhood SES is a proxy for individual SES, future studies are still needed to identify etiologic risk factors for other breast cancer subtypes.

Residential environment and breast cancer incidence and mortality: a systematic review and meta-analysis

BACKGROUND

Factors beyond the individual level such as those characterizing the residential environment may be important to breast cancer outcomes. We provide a systematic review and results of meta-analysis of the published empirical literature on the associations between breast cancer risk and mortality and features of the residential environment.

METHODS

Using PRISMA guidelines, we searched four electronic databases and manually searched the references of selected articles for studies that were published before June 2013. We selected English language articles that presented data on adult breast cancer incidence or mortality in relation to at least one area-based residential (ABR) independent variable.

RESULTS

We reviewed 31 eligible studies, and observed variations in ABR construct definition and measurement, study design, and analytic approach. The most common ABR measures were indicators of socioeconomic status (SES) (e.g., income, education, summary measures of several SES indicators or composite SES). We observed positive associations between breast cancer incidence and urbanization (Pooled RR for urban vs. rural: 1.09. 95% CI: 1.01, 1.19), ABR income (Pooled RR for highest vs. lowest ABR income: 1.17, 95% CI: 1.15, 1.19) and ABR composite SES (Pooled RR for highest vs. lowest ABR composite SES: 1.25, 95% CI: 1.08, 1.44). We did not observe consistent associations between any ABR measures and breast cancer mortality.

CONCLUSIONS

The findings suggest modest positive associations between urbanization and residential area socioeconomic environment and breast cancer incidence. Further studies should address conceptual and methodological gaps in the current publications to enable inference regarding the influence of the residential environment on breast cancer.

Investigation of gallic acid induced anticancer effect in human breast carcinoma MCF-7 cells

Gallic acid (GA), a polyhydroxylphenolic compound abundantly distributed in plants, fruits, and foods, has been reported to have various biological activities including an anticancer effect. In this study, we extensively investigated the anticancer effect of GA in human breast carcinoma MCF-7 cells. Our study indicated that treatment with GA resulted in inhibition of proliferation and induction of apoptosis in MCF-7 cells. Then, the molecular mechanism of GA's apoptotic action in MCF-7 cells was further investigated. The results revealed that GA induced apoptosis by triggering the extrinsic or Fas/FasL pathway as well as the intrinsic or mitochondrial pathway. Furthermore, the apoptotic signaling induced by GA was amplified by cross-link between the two pathways. Taken together, our findings may be useful for understanding the mechanism of action of GA on breast cancer cells and provide new insights into the possible application of such compound and its derivatives in breast cancer therapy.

The combined effect of individual and neighborhood socioeconomic status on nasopharyngeal cancer survival

Background

The relationship between individual and neighborhood socioeconomic status (SES) and mortality rates in patients with nasopharyngeal carcinoma (NPC) is unknown. This population-based study aimed to examine the association between SES and survival of patients with NPC in Taiwan.

Materials and Methods

A population-based follow-up study was conducted of 4691 patients diagnosed with NPC between 2002 and 2006. Each patient was traced to death or for 5 years. Individual SES was defined by enrollee job category. Neighborhood SES was based on household income dichotomized into advantaged and disadvantaged areas. Cox proportional hazards model was used to compare the death-free survival rates between the different SES groups after adjusting for possible confounding factors and risk factors.

Results

In NPC patients below the age of 65 years, 5-year overall survival rates were worst for those with low individual SES living in disadvantaged neighborhoods. After adjusting for patient characteristics (age, gender, Charlson Comorbidity Index Score), NPC patients with low individual SES residing in disadvantaged neighborhoods were found to have a 2-fold higher risk of mortality than patients with high individual SES residing in advantaged neighborhoods. We found no significant difference in mortality rates between different SES groups in NPC patients aged 65 and above.

Conclusions

Our findings indicate that NPC patients with low individual SES who live in disadvantaged neighborhoods have the higher risk of mortality than their more privileged counterparts. Public health strategies and welfare policies would be well advised to try to offset the inequalities in health care and pay more attention to addressing the needs of this vulnerable group.