Assessment of Racial Disparity in Survival Outcomes for Early Hormone Receptor–Positive Breast Cancer After Adjusting for Insurance Status and Neighborhood Deprivation

Abstract

IMPORTANCE Racial disparities in survival outcomes among Black women with hormone receptor-positive breast cancer have been reported. However, the association between individual-level and neighborhood-level social determinants of health on such disparities has not been well studied.OBJECTIVE To evaluate the association between race and clinical outcomes (ie, relapse-free interval and overall survival) adjusting for individual insurance coverage and neighborhood deprivation index (NDI), measured using zip code of residence, in women with breast cancer.DESIGN, SETTING, AND PARTICIPANTS This was a post hoc analysis of 9719 women with breast cancer in the Trial Assigning Individualized Options for Treatment, a randomized clinical trial conducted from April 7, 2006, to October 6, 2010. All participants received a diagnosis of hormone receptor-positive, ERBB2-negative, axillary node-negative breast cancer. The present data analysis was conducted from April 1 to October 22, 2021. MAIN OUTCOMES AND MEASURESA multivariate model was developed to evaluate the association between race and relapse-free interval and overall survival adjusting for insurance and NDI level at study entry, early discontinuation of endocrine therapy 4 years after initiation, and clinicopathologic characteristics of cancer. Median follow-up for clinical outcomes was 96 months.RESULTS A total of 9719 women (4.2% [n = 405] Asian; 7.1% [n = 693] Black; 84.3% [n = 8189] White; 4.4% [n = 403] others/not specified) were included; 9.1% of included women [n = 889] were Hispanic or Latino. Median (SD) age was 56 (9.2) years. In multivariate models, Black race compared with White race was associated with statistically significant shorter relapse-free interval (hazard ratio [HR], 1.39; 95% CI, 1.05-1.84; P = .02) and overall survival (HR, 1.49; 95% CI, 1.10-2.99; P = .009), adjusting for insurance and NDI level at study entry and other factors. Although uninsured status was not associated with clinical outcomes, patients with Medicare (HR, 1.30; 95% CI, 1.01-1.68; P = .04) and Medicaid (HR, 1.44; 95% CI, 1.01-2.05; P = .05) had shorter overall survival compared with those with private insurance. Participants living in neighborhoods in the highest NDI quartile experienced shorter overall survival compared with those in the lowest quartile (HR, 1.34; 95% CI, 1.01-1.77; P = .04), regardless of self-identified race. CONCLUSIONS AND RELEVANCEThe findings of this post hoc analysis of a randomized clinical trial suggest that Black women with breast cancer have significantly shorter relapse-free interval and overall survival compared with White women. Early discontinuation of endocrine therapy, clinicopathologic characteristics, insurance coverage, and NDI do not fully explain the observed disparity.

Racial Differences in Patient-Reported Symptoms and Adherence to Adjuvant Endocrine Therapy Among Women With Early-Stage, Hormone Receptor–Positive Breast Cancer

“… 11 , 16 , 17 , 18 , 19 , 20 , 21 , 22 Race is a social construct, 23 and observed differences in health experiences and outcomes by marginalized groups must be understood in the broader context of structural racism and other factors that differentially place minorities at increased risks for high symptom burden, enduring disparities in treatment adherence, and breast cancer outcomes. 24 , 25 …”

“…Differences in socioeconomic status, higher rates of exposure to environmental risk factors, lower access to health care, and explicit and implicit clinician bias driven by centuries of racism, oppression, and disinvestment, rather than biological differences, contribute to higher symptom burden among Black women . Race is a social construct, and observed differences in health experiences and outcomes by marginalized groups must be understood in the broader context of structural racism and other factors that differentially place minorities at increased risks for high symptom burden, enduring disparities in treatment adherence, and breast cancer outcomes …”

Upregulation of TIMM8A is correlated with prognosis and immune regulation in BC

“…In the management of hormone receptor-positive individuals, endocrine therapy is extremely important. According to certain accounts, various hormone levels alter a patient’s prognosis ( 17 – 19 ). We found that upregulation of TIMM8A was inversely correlated with hormone receptor status.…”

Racial disparities in overall survival after the introduction of cyclin-dependent kinase 4/6 inhibitors for patients with hormone receptor-positive, HER2-negative metastatic breast cancer

“…Prior studies have demonstrated that Black women are diagnosed at more advanced stages [28] and are more likely to discontinue chemotherapy [29]. Studies have reported that early discontinuation of therapy, clinicopathological characteristics, and insurance might not completely explain the survival differences between NHB and NHW women [9,30]. In a population study, Huang reported that patients with MBC in the lowest socioeconomic status (SES) quintile had a signi cantly increased risk of breast cancer death compared to those in the highest SES quintile (sHR 1.22, 95%CI 1.17-1.26).…”