ImportanceNeighborhood-level disadvantage is an important factor in the creation and persistence of underresourced neighborhoods with an undue burden of disparate breast cancer–specific survival outcomes. Although studies have evaluated neighborhood-level disadvantage and breast cancer–specific survival after accounting for individual-level socioeconomic status (SES) in large national cancer databases, these studies are limited by age, socioeconomic, and racial and ethnic diversity.ObjectiveTo investigate neighborhood SES (using a validated comprehensive composite measure) and breast cancer–specific survival in a majority-minority population.Design, Setting, and ParticipantsThis retrospective multi-institutional cohort study included patients with stage I to IV breast cancer treated at a National Cancer Institute–designated cancer center and sister safety-net hospital from January 10, 2007, to September 9, 2016. Mean (SD) follow-up time was 60.3 (41.4) months. Data analysis was performed from March 2022 to March 2023.ExposuresNeighborhood SES was measured using the Area Deprivation Index (tertiles), a validated comprehensive composite measure of neighborhood SES.Main Outcomes and MeasuresThe primary outcome was breast cancer–specific survival. Random effects frailty models for breast cancer–specific survival were performed controlling for individual-level sociodemographic, comorbidity, breast cancer risk factor, access to care, tumor, and National Comprehensive Cancer Network guideline-concordant treatment characteristics. The Area Deprivation Index was calculated for each patient at the census block group level and categorized into tertiles (T1-T3).ResultsA total of 5027 women with breast cancer were included: 55.8% were Hispanic, 17.5% were non-Hispanic Black, and 27.0% were non-Hispanic White. Mean (SD) age was 55.5 (11.7) years. Women living in the most disadvantaged neighborhoods (T3) had shorter breast cancer–specific survival compared with those living in the most advantaged neighborhoods (T1) after controlling for individual-level sociodemographic, comorbidity, breast cancer risk factor, access to care, tumor, and National Comprehensive Cancer Network guideline-concordant treatment characteristics (T3 vs T1: hazard ratio, 1.29; 95% CI, 1.01-1.65; P < .04).Conclusions and RelevanceIn this cohort study, a shorter breast cancer–specific survival in women from disadvantaged neighborhoods compared with advantaged neighborhoods was identified, even after controlling for individual-level sociodemographic, comorbidity, breast cancer risk factor, access to care, tumor, and National Comprehensive Cancer Network guideline-concordant treatment characteristics. The findings suggest potential unaccounted mechanisms, including unmeasured social determinants of health and access to care measures. This study also lays the foundation for future research to evaluate whether social adversity from living in a disadvantaged neighborhood is associated with more aggressive tumor biologic factors, and ultimately shorter breast cancer-specific survival, through social genomic and/or epigenomic alterations.

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Background: Despite advances in diagnosis and treatment, racial and economic disparities in breast cancer-specific survival persist and this is exacerbated by later stage at presentation. It is essential to assess the factors that contribute to later stage at presentation to target racial and socioeconomic disparities in breast cancer mortality. The objective of this study was to analyze the effect of neighborhood socioeconomic status (SES) and race/ethnicity, as measured by the Index of Concentration at the Extremes (ICE), on breast cancer stage at presentation in a diverse metropolitan area that mirrors the projected demographics of many US regions. Methods: Patients treated at our medical campus, comprised of a safety-net hospital and an academic cancer center, with stage I-IV breast cancer from 2005-2017 were identified from our tumor registry. Census tracts were used as neighborhood proxies. Using 5-year estimates from the American Community Survey, 5 ICE variables were computed: economic (high vs. low), race/ethnicity (non-Hispanic White (NHW) vs. non-Hispanic Black (NHB) and NHW vs. Hispanic) and racialized economic (low-income NHB vs high-income NHW and low-income Hispanics vs. high-income NHW) segregation. ICE uniquely captures spatial economic and racial/ethnic segregation by mapping social inequality not otherwise captured by evaluating a population of a specific socioeconomic level or belonging to a particular racial/ethnic group. We used five separate models based on each of the ICE variables to evaluate economic and racial/ethnic segregation. Model 1 captures economic segregation (high vs. low), Model 2 captures racial segregation (NHB vs. NHW), Model 3 evaluates racialized economic segregation (low-income NHB vs high-income NHW), Model 4 captures segregation by Hispanic ethnicity (Hispanic vs. Non-Hispanic), and Model 5 captures ethnic and economic segregation (low-income Hispanics vs. high-income NHW). Our main outcome was breast cancer stage at presentation categorized as early (Stage I and II) vs. late (Stage III and IV) disease. All models controlled for the following covariates: race/ethnicity, age, insurance status, tumor subtype, and comorbidities including hypertension, diabetes, coronary artery disease, and hyperlipidemia. Results: The study population included 6,145 breast cancer patients. 52.6% were Hispanic, 26.3% were NHW, and 17.2% were NHB. Those living in the most economically marginalized neighborhoods (Quartiles 1 and 2) had significantly increased odds of presenting with later stage disease [ORQ1 1.36 (1.13-1.64), ORQ2 1.43 (1.18-1.75); p< 0.05]. Those living in the most racial/ethnic and economically marginalized neighborhoods (Quartile 1 of Models 3 and 5) had statistically significantly increased odds of presenting with later stage after controlling for all covariates compared to a NHW living in more economically advantaged neighborhoods [ORModel3 1.55 (1.21-1.99), ORModel5 1.43 (1.11-1.85); p< 0.05]. Conclusions: This study is the first to evaluate stage at presentation by ICE, which allows us to uniquely evaluate how residential racial and economic segregation may influence breast cancer disparities. Our study shows that patients in the most economically and racial/ethnically marginalized neighborhoods were more likely to present with later stage disease. This suggests that structural racism is influencing stage at presentation, and therefore effecting racial and economic disparities in breast cancer, even when accounting for demographics and tumor characteristics. To address these disparities, effective interventions are needed that account for the social and environmental contexts in which cancer patients live and can access care. Table 1: Odds Ratios for Later Stage at Presentation with Breast Cancer by Different Types of Residential Segregation Model 1: Economic segregation (high-income vs low-income) Model 2: NHB vs NHW segregation Model 3: NHB and economic segregation (low-income NHB vs high-income NHW) Model 4: Hispanic vs NHW segregation Model 5: Hispanic and economic segregation (low-income Hispanics vs. high-income NHW) Q1: Most disadvantaged neighborhoods; Q4: Reference: most advantaged neighborhoods. *p < 0.05 Citation Format: Alexandra Hernandez, Brianna L Cohen, Ashly Westrick, Cheyenne Thompson, Susan Kesmodel, Neha Goel. The Impact of Structural Racism on Breast Cancer Stage at Presentation [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 PD1-01.

Radiation-induced sarcoma of the breast is a rare complication that is primarily treated with surgical resection but in patients with advanced disease, a multimodality treatment approach is often required. This case report discusses a 37-year-old female with a history of a pT3N3M0, estrogen receptor (ER)+, progesterone receptor (PR)+, human epidermal growth factor receptor 2 (HER2)+, right breast cancer, and a germline tumor protein (TP) p53 mutation who underwent right modified radical mastectomy, adjuvant systemic therapy, and radiation therapy, and subsequently developed a radiation-induced sarcoma.The patient is a 37-year-old female who has a history of pT3N3M0, ER/PR+, HER2+, and right breast cancer diagnosed in 2014. At the time of diagnosis, she had locally advanced disease and underwent right modified radical mastectomy followed by adjuvant chemotherapy, radiation, delayed right breast implant-based reconstruction, and left breast augmentation with mastopexy. Upon completion of adjuvant chemotherapy, she was started on hormonal therapy. In February 2020, she underwent genetic testing given her early onset of breast cancer and was found to have a germline TP53 mutation. Routine MRI for breast implant evaluation showed two irregular enhancing masses with an additional satellite lesion in the right breast. Right breast ultrasound (US)-guided biopsy revealed two separate foci of high-grade pleomorphic fibroblastic/myofibroblastic sarcoma. Further staging workup with a whole-body MRI was negative for evidence of metastatic disease. Her case was discussed in multidisciplinary sarcoma tumor board and consensus was for surgical resection. She underwent radical resection of the right chest wall masses and subcutaneous tissue, removal of right breast implant and capsulectomy, and left breast mastectomy with left breast implant removal and capsulectomy. The final pathology revealed two separate foci of high-grade pleomorphic fibroblastic/myofibroblastic sarcoma, 1.2 cm and 1.1 cm in their greatest dimensions with negative margins. Her case was re-discussed in multidisciplinary sarcoma tumor board and due to T1 size of the tumors and the negative resection margins, close surveillance with annual whole-body MRI and quarterly chest MRI imaging was recommended.In patients with a germline TP53 mutation and breast cancer, the utilization of adjuvant radiotherapy should be considered cautiously given the increased risk of radiation-associated sarcoma.