Mortgage Lending Bias and Breast Cancer Survival Among Older Women in the United States

Abstract

Purpose: The objective was to examine the relationship between contemporary redlining (mortgage lending bias on the basis of property location) and survival among older women with breast cancer in the United States.

Methods: A redlining index using Home Mortgage Disclosure Act data (2007-2013) was linked by census tract with a SEER-Medicare cohort of 27,516 women age 66-90 years with an initial diagnosis of stage I-IV breast cancer in 2007-2009 and follow-up through 2015. Cox proportional hazards models were used to examine the relationship between redlining and both all-cause and breast cancer-specific mortality, accounting for covariates.

Results: Overall, 34% of non-Hispanic White, 57% of Hispanic, and 79% of non-Hispanic Black individuals lived in redlined tracts. As the redlining index increased, women experienced poorer survival. This effect was strongest for women with no comorbid conditions, who comprised 54% of the sample. For redlining index values of 1 (low), 2 (moderate), and 3 (high), as compared with 0.5 (least), hazard ratios (HRs) (and 95% CIs) for all-cause mortality were HR = 1.10 (1.06 to 1.14), HR = 1.27 (1.17 to 1.38), and HR = 1.39 (1.25 to 1.55), respectively, among women with no comorbidities. A similar pattern was found for breast cancer-specific mortality.

Conclusion: Contemporary redlining is associated with poorer breast cancer survival. The impact of this bias is emphasized by the pronounced effect even among women with health insurance (Medicare) and no comorbid conditions. The magnitude of this neighborhood level effect demands an increased focus on upstream determinants of health to support comprehensive patient care. The housing sector actively reveals structural racism and economic disinvestment and is an actionable policy target to mitigate adverse upstream health determinants for the benefit of patients with cancer.

FIG 1.

All-cause mortality (A) and breast cancer–specific mortality (B) by tract redlining index category: 0-0.5 (least), 0.5-1.0 (low), 1.0-2.0 (moderate), and > 2.0 (high).

FIG 1.

All-cause mortality (A) and breast cancer–specific mortality (B) by tract redlining index category: 0-0.5 (least), 0.5-1.0 (low), 1.0-2.0 (moderate), and > 2.0 (high).

FIG 2.

Relationship of HR with redlining by comorbidity for (A) all-cause and (B) breast cancer–specific mortality with frequency distribution of redlining in the cohort. HRs for the redlining index at values along the x-axis are shown versus the redlining index value of 0.5, for each comorbidity level. HR, hazard ratio.

FIG A1.

Spatial distribution of MSAs within SEER registries' boundary. MSAs, metropolitan statistical areas.

FIG A2.

Histograms of logged redlining in base 2 (A) and of redlining (B). Minimum and maximum values displayed are rounded to the nearest 100th but fall within these established breaks.