Impacts of Neighborhood Characteristics on Treatment and Outcomes in Women with Ductal Carcinoma In Situ of the Breast

Abstract

This study examines associations of neighborhood characteristics with treatment and outcomes of ductal carcinoma (DCIS) of the breast. From the Missouri Cancer Registry, we identified 9,195 women with DCIS diagnosed between 1996 and 2011. A composite index using U.S. Census data and American Community Survey data was developed to assess census tract-level socioeconomic deprivation, and rural-urban commuting area codes were used to define rural census tracts. ORs and 95% confidence intervals (CIs) of the treatment were estimated using logistic regression. Hazard ratios (HRs) of DCIS outcomes were estimated using Cox proportional hazards regression. Women in the most socioeconomically deprived census tracts were more likely than those in the least deprived to have mastectomy (OR = 1.44; 95% CI, 1.25-1.66; < 0.0001), no surgery (OR = 1.54; 95% CI, 1.02-2.30; = 0.04), no radiotherapy post-breast conserving surgery (OR = 1.90; 95% CI, 1.56-2.31; <0.0001), delayed radiotherapy (OR = 1.26; 95% CI, 1.01-1.57; = 0.02), and ipsilateral breast tumors (HR = 1.59; 95% CI, 1.07-2.38; = 0.03). There was no significant difference in risk of contralateral breast tumors. Compared with urban women, rural women had significantly higher odds of underutilization of radiotherapy (OR = 1.29; 95% CI, 1.08-1.53). Rural locations were not associated with risk of ipsilateral or contralateral breast tumors. Neighborhood socioeconomic deprivation was associated with higher risks of suboptimal treatment and ipsilateral breast tumors. While DCIS treatment significantly varied by rural/urban locations, we did not observe any statistically significant rural-urban differences in risks of second breast tumors. Neighborhood attributes may affect treatment and outcomes of patients with DCIS.

Relationship between insurance status and outcomes for patients with breast cancer in Missouri

“…Neighborhood socioeconomic deprivation and rurality were assessed on the basis of the census tract of a patient's residence at diagnosis. The composite socioeconomic deprivation indices for 2000 and 2010 were calculated separately on the basis of 21 variables from the 2000 and 2010 US Census, as described previously 12‐14 . On the basis of their nationwide distribution, index scores were divided into tertiles, with a higher tertile suggesting greater socioeconomic deprivation.…”

“…On the basis of their nationwide distribution, index scores were divided into tertiles, with a higher tertile suggesting greater socioeconomic deprivation. Rural counties were defined as nonmetropolitan areas and were determined with the rural‐urban commuting area (RUCA) codes (4, 4.2, 5, 5.2, 6, 6.1, 7, 7.2, 7.3, 7.4, 8, 8.2, 8.3, 8.4, 9, 9.1, 9.2, 10, 10.2, 10.3, 10.4, 10.5, or 10.6) from the US Department of Agriculture 14 . The 2000 deprivation index and the 2000 RUCA codes were linked to the cases diagnosed between 2007 and 2009, and the 2010 deprivation index and the 2010 RUCA codes were linked to the cases diagnosed after 2009.…”

Rural Cancer Control: Bridging the Chasm in Geographic Health Inequity

“…McDougall and colleagues studied colorectal cancer survivors in New Mexico and found that those who lived in rural areas were more likely to experience financial hardship and less likely to adhere to recommended follow-up care, highlighting the importance that place plays in affordable, accessible survivorship care (11). To examine the associations of neighborhood characteristics in Missouri with treatment and outcomes of ductal carcinoma in situ, Zhang, Liu, and colleagues used census tract-level socioeconomic deprivation and rural-urban commuting area codes to define rurality; although differences in treatment, but not outcome, were found, the authors suggest that larger studies using nuanced definitions of rurality are needed to refine our understanding the contribution of place to outcome (12). It is noteworthy that the definition, location, and composition of "rural" differ across the United States and these may affect the interpretation of the study findings included in this special issue.…”

“…Although geography alone cannot predict cancer risk, it can impact prevention, screening, diagnosis, and treatment opportunities. The articles in this special CEBP Focus issue on rural cancer control explore geographic disparities across the cancer control continuum in several distinct rural communities and map out potential paths to reach geographic health equity (7)(8)(9)(10)(11)(12).…”

Overcoming Barriers in Ductal Carcinoma In Situ Management: From Overtreatment to Optimal Treatment

“…51 Explanations for racial differences in clinical outcomes are most likely a complex interplay between treatmentrelated disparities and socioenvironmental exposures. 80,81 Future research should leverage concepts such as allostatic load--a composite measure of physiologic dysregulation secondary to adverse socially patterned exposures (eg, poverty 82 )-to understand the implications of race and socioenvironmental factors on epidemiology, 83 treatment receipt, tolerability, and mortality, and identify targets for precision therapy, including biobehavioral intervention. 84 In future studies, several barriers must also be addressed to allow translational studies to improve DCIS management.…”