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Neighborhood Contexts and Healthcare Utilization in Patients with Breast Cancer Receiving Chemotherapy
Samilia Obeng-Gyasi1, Demond Handley2,3,4, Jesse J Plascak5,6
1Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, Ohio.
Background:
Racialized economic segregation is linked to higher cancer-specific mortality; however, its impact on healthcare utilization (HCU) remains unclear. This study used the metric Index of Concentration at the Extremes (ICE) and evaluated the association between racial residential segregation (ICErace), racialized economic segregation (ICErace + income), and HCU among patients with breast cancer receiving chemotherapy.
Methods:
Patients ≥18 years who received chemotherapy and surgical management for stage I to III breast cancer (2012-2020) were identified in the electronic health record. Census tract-level ICErace and ICErace + income were derived from the 2008 to 2012 American Community Survey. HCU was defined as hospitalizations or emergency room visits during chemotherapy. General estimating equations with robust variance estimated associations between segregation indices and HCU. Mediation analyses examined the effect of ICErace + income on HCU.
Results:
Among 2,037 women (mean age, 53.7 ± 11.9 years), 10.6% were Black, 84.6% were White, and 4.8% were other. Higher concentrations of White residents were associated with reduced HCU risk [ICErace fifth quintile; risk ratio (RR) = 0.44; 95% confidence interval (CI), 0.32-0.59; reference: first quintile). A significant interaction was observed between ICErace and race (P = 0.009). The relationship between ICErace + income and HCU was nonlinear: HCU risk decreased progressively from the fifth percentile (RR = 0.97; 95% CI, 0.92-0.99) to the 63rd percentile (RR = 0.69; 95% CI, 0.49-0.99). Most of the ICErace + income effect on HCU was direct (OR = 0.88; 95% CI, 0.83-0.93), with minimal mediation by comorbidities (2.0%).
Conclusions:
Residence in racially and economically segregated census tracts is associated with greater HCU.
Impact:
These findings highlight structural racism as a determinant of cancer treatment burden, emphasizing the importance of neighborhood context in disparities and care delivery.
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