Hispanic and Immigrant Paradoxes in U.S. Breast Cancer Mortality: Impact of Neighborhood Poverty and Hispanic Density

Abstract

To test the Hispanic and Immigrant Paradoxes—i.e., survival advantages despite a worse risk factor profile—and the modifying role of neighborhood context, we examined associations between patient ethnicity, birthplace, neighborhood Hispanic density and neighborhood poverty among 166,254 female breast cancer patients diagnosed 1995–2009 in Texas, U.S. Of all, 79.9% were non-Hispanic White, 15.8% Hispanic U.S.-born, and 4.2% Hispanic foreign-born. We imputed birthplace for the 60.7% of Hispanics missing birthplace data using multiple imputation. Shared frailty Cox proportional hazard models (patients nested within census tracts) adjusted for age, diagnosis year, stage, grade, histology, urban/rural residence, and local mammography capacity. Whites (vs. U.S.-born Hispanics) had increased all-cause and breast cancer mortality. Foreign-born (vs. U.S.-born) Hispanics had increased all-cause and breast cancer mortality. Living in higher Hispanic density neighborhoods was generally associated with increased mortality, although associations differed slightly in magnitude and significance by ethnicity, birthplace, and neighborhood poverty. We found no evidence of an Immigrant Paradox and some evidence of a Hispanic Paradox where protective effects were limited to U.S.-born Hispanics. Contrary to prior studies, foreign birthplace and residence in higher Hispanic density neighborhoods were associated with increased mortality. More research on intersections between ethnicity, birthplace and neighborhood context are needed.

Nativity, ethnic enclave residence, and breast cancer survival among Latinas: Variations between California and Texas

“…Latinas living in neighborhoods with lower SES faced worse survival from both causes in both states. This finding is consistent with a large body of literature demonstrating worse survival among patients with cancer who are living in neighborhoods with low SES, regardless of how nSES is measured …”

“…Differences in methodology, including nativity imputation methods, may explain these discrepancies. Consistent with prior research, we also demonstrated that foreign‐born Latinas were more likely to live in ethnic enclaves and neighborhoods with low SES …”

“…Prior studies demonstrated inconsistent findings. Foreign‐born Latinas with breast cancer had worse survival in a Texas study, slightly improved all‐cause (but not cause‐specific) survival in one California study, and survival that was equivalent to that of US‐born Latinas in another California study . Differences in methodology, including nativity imputation methods, may explain these discrepancies.…”

“…Five of the reviewed studies examined associations between Latinx ethnic density with the survival of Latinas with breast cancer. Associations varied, with 2 null studies and others documenting both increased (1 study) and decreased (2 studies) survival among Latinas residing within ethnic enclaves compared with Latinas residing in nonenclave areas . These studies applied various measures of neighborhood ethnic density or ethnic enclave residence and different analytic strategies, including adjustments for patient nativity and nSES.…”

Ethnic density and cancer: A review of the evidence

“…50 The remaining studies all utilized measures of ethnic composition, but no clear pattern of findings emerged. One study reported a positive association, 53 but two reported no association with breast cancer mortality. 15,54 A study of women with cervical cancer reported no association of Hispanic ethnic density with mortality.…”