Area-level Factors Influence Late Breast Cancer Mortality in Black and White Women Restricted; Files Only
Fei, Fan (Spring 2026)
Abstract
Background: ER-positive breast cancer survivors remain at risk of late breast cancer–specific mortality (LBCM), with persistent racial disparities. Area-level factors, including neighborhood socioeconomic status (nSES) and rurality, may influence these outcomes, but evidence among long-term survivors is limited.
Methods: We conducted a cohort study using Surveillance, Epidemiology, and End Results (SEER) 17 registries (2006–2020), including 238,042 women with ER-positive breast cancer who survived at least 5 years. Primary exposures were census tract–level nSES (Yost index) and rural-urban designation. Breast cancer-specific mortality was the primary outcome. Cox proportional hazards models estimated hazard ratios (HRs) and 95% confidence intervals (CIs), with stratified and joint analyses by race.
Results: Women in the lowest nSES quintile(Q1) had higher LBCM risk compared with those in the highest quintile(Q5) (HR=1.39; 95% CI: 1.31–1.48), after adjusting for age, race, rurality and marital status. Stratified analyses showed a monotonic increase in mortality with corresponding increase in nSES gradient among NHW women (Q1vs.5 HR=1.42; 95% CI: 1.32–1.52). Among NHB women, only those in the lowest quintile showed a higher estimated mortality risk (Q1vs.5 HR=1.26; 95% CI: 1.07–1.49). Comparing across race and nSES, NHB women living in the most advantaged neighborhoods had a similar mortality risk to NHW women living in the most deprived neighborhoods (NHB Q5 vs. NHW Q5 HR=1.43, 95% CI: 1.24–1.66; NHW Q1 vs. NHW Q5 HR=1.42, 95% CI: 1.33–1.53). Rurality was not independently associated with LBCM after adjusting for nSES.
Conclusions: Neighborhood deprivation contributes to late mortality among ER-positive survivors, with racial disparities persisting even in socioeconomically advantaged areas. Improving long-term outcomes requires sustained efforts to ensure guideline-concordant follow-up care and endocrine therapy adherence in high-deprivation neighborhoods, reduce psychosocial stressors, and address structural inequities that drive racial disparities beyond socioeconomic context.
Table of Contents
Chapter 1: Introduction
1.1 Introduction and Rationale
1.2 Background: Area-Level Factors and Race in Breast Cancer Mortality
1.3 Theoretical Framework
1.4 Purpose and Problem Statement
1.5 Research Aims
1.6 Significance
1.7 Definition of Terms
Chapter 2: Review of the Literature
2.1 Epidemiology of Breast Cancer and the Importance of Late Mortality
2.2 Racial Disparities in Breast Cancer-Specific Late Mortality
2.3 Current Evidence on Late Breast Cancer-Specific Mortality
2.4 Area-level Factors and Breast Cancer-specific Mortality
2.5 The Interaction of Area-level Factors and Race on Breast Cancer Mortality
2.6 Theoretical Framework on Area-level Determinants of Late Breast Cancer Mortality
2.7 Conclusion
Chapter 3: Methodology and Student Contribution
3.1 Introduction
3.2 Study Design
3.3 Sampling and Recruitment
3.4 Measures
3.5 Data Analysis Methodology
Chapter 4: Journal Article
4.1 Abstract
4.2 Introduction
4.3 Methods
4.4 Results
4.5 Discussion
4.6 Strengths and limitations
4.7 Conclusion
4.8 Tables and Figures
Chapter 5: Discussion, Public Health Implications, and Conclusions
5.1 Discussion
5.2 Strengths and limitations
5.3 Conclusion and Public Health Implication
References
About this Master's Thesis
| School | |
|---|---|
| Department | |
| Degree | |
| Submission | |
| Language |
|
| Research Field | |
| Keyword | |
| Committee Chair / Thesis Advisor | |
| Committee Members |
Primary PDF
| Thumbnail | Title | Date Uploaded | Actions |
|---|---|---|---|
|
|
File download under embargo until 21 May 2028 | 2026-04-22 16:52:44 -0400 | File download under embargo until 21 May 2028 |
Supplemental Files
| Thumbnail | Title | Date Uploaded | Actions |
|---|