Association of Race and Area Deprivation With Breast Cancer Survival Among Black and White Women in the State of Georgia

Abstract

Importance: Increasing evidence suggests that low socioeconomic status and geographic residence in disadvantaged neighborhoods contribute to disparities in breast cancer outcomes. However, little epidemiological research has sought to better understand these disparities within the context of location.

Objective: To examine the association between neighborhood deprivation and racial disparities in mortality among Black and White patients with breast cancer in the state of Georgia.

Design, setting, and participants: This population-based cohort study collected demographic and geographic data from patients diagnosed with breast cancer between January 1, 2004, and February 11, 2020, in 3 large health care systems in Georgia. A total of 19 580 patients with breast cancer were included: 12 976 from Piedmont Healthcare, 2285 from Grady Health System, and 4319 from Emory Healthcare. Data were analyzed from October 2, 2020, to August 11, 2022.

Exposures: Area deprivation index (ADI) scores were assigned to each patient based on their residential census block group. The ADI was categorized into quartile groups, and associations between ADI and race and ADI × race interaction were examined.

Main outcomes and measures: Cox proportional hazards regression models were used to compute hazard ratios (HRs) and 95% CIs associating ADI with overall mortality by race. Kaplan-Meier curves were used to visualize mortality stratified across racial and ADI groups.

Results: Of the 19 580 patients included in the analysis (mean [SD] age at diagnosis, 58.8 [13.2] years), 3777 (19.3%) died during the course of the study. Area deprivation index contributed differently to breast cancer outcomes for Black and White women. In multivariable-adjusted models, living in a neighborhood with a greater ADI (more deprivation) was associated with increased mortality for White patients with breast cancer; compared with the ADI quartile of less than 25 (least deprived), increased mortality HRs were found in quartiles of 25 to 49 (1.22 [95% CI, 1.07-1.39]), 50 to 74 (1.32 [95% CI, 1.13-1.53]), and 75 or greater (1.33 [95% CI, 1.07-1.65]). However, an increase in the ADI quartile group was not associated with changes in mortality for Black patients with breast cancer (quartile 25 to 49: HR, 0.81 [95% CI, 0.61-1.07]; quartile 50 to 74: HR, 0.91 [95% CI, 0.70-1.18]; and quartile ≥75: HR, 1.05 [95% CI, 0.70-1.36]). In neighborhoods with an ADI of 75 or greater, no racial disparity was observed in mortality (HR, 1.11 [95% CI, 0.92-1.36]).

Conclusions and relevance: Black women with breast cancer had higher mortality than White women in Georgia, but this disparity was not explained by ADI: among Black patients, low ADI was not associated with lower mortality. This lack of association warrants further investigation to inform community-level approaches that may mitigate the existing disparities in breast cancer outcomes in Georgia.

Figure 1.. Associations Between Area Depriviation Index (ADI) and Probability of Patient Mortality for Black and White Patients With Breast Cancer

Data are shown as Kaplan-Meier curves. The lowest ADI quartile (<25) indicates the lowest level of neighborhood deprivation; the highest ADI quartile (≥75), the greatest level. HR indicates hazard ratio.

Figure 2.. Association Between Race and Mortality Across All Area Deprivation Index (ADI) Categories

Kaplan-Meier curves depict mortality probability for Black and White women stratified by ADI group. The lowest ADI quartile (<25) indicates the lowest level of neighborhood deprivation; the highest ADI quartile (≥75), the greatest level.

Figure 3.. Visualization of Area Deprivation, Survival Probability, and Patient Race

Mapping area deprivation, survival probability, and patient race revealed pronounced geographic disparities and spatial coincidence among these 3 variables. The lowest area deprivation index quartile (<25) indicates lowest level of neighborhood deprivation; the highest area deprivation index quartile (≥75), greatest level.