Multiple mediation analysis of racial disparity in breast cancer survival |
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| Institution: | 1. University of Central Florida College of Medicine, Orlando, FL, USA;2. University of Central Florida College of Health Professions and Sciences, Orlando, FL, USA;3. Stetson University, Public Health Program, Deland, FL, USA;1. Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Germany;2. School of Public Health, Department of Epidemiology, Boston University, Boston, USA;3. Cancer Registry of North Rhine-Westphalia, Bochum, Germany;4. Saarland Cancer Registry, Saarbrücken, Germany;5. CaritasKlinikum Saarbrücken St. Theresia, Saarbrücken, Germany;1. Faculty of Medicine, University of Iceland, Reykjavik, Iceland;2. Department of Pathology, Landspitali University Hospital of Iceland, Reykjavik, Iceland;3. Division of Gastroenterology and Hepatology, Department of Internal Medicine, Landspitali University Hospital of Iceland, Reykjavik, Iceland;1. School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia;2. Victorian Melanoma Service, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia;3. Department of Anatomical Pathology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia;4. Gastrointestinal and Other Cancers Research Group, Division of Cancer Prevention, National Cancer Institute, NIH, Bethesda, MD, USA;5. Walter Reed National Military Medical Center (WRNMM) Uniformed Services University (USU) Department of Surgery, Bethesda, MD, USA;6. The Walter & Eliza Hall Institute of Medical Research, University of Melbourne,1 G Royal Parade, Parkville, Victoria 3052, Australia;7. Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Massachusetts, USA;8. Department of Medical Oncology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia;1. Department of Collective Health; Graduate Program in Collective Health, Federal University of Rio Grande do Norte, UFRN. Public Health Department, 1787 Senador Salgado Filho Ave., 59010-000, Lagoa Nova, Natal-RN, Brazil;2. Division of Surveillance and Data Analysis; Brazilian National Institute Cancer (INCA), Ministry of Health. 125 Marques de Pombal Street, 20230-240, Rio de Janeiro-RJ, Brazil;3. Escola de Saúde; Universidade Federal do Rio Grande do Norte – UFRN. s/n Senador Salgado Filho Ave. 59075-000, Lagoa Nova, Natal-RN, Brazil;4. Research group on Methodology, Methods, Models and Outcomes of Health and Social Sciences (M3O). Faculty of Health Science and Welfare. Centre for Health and Social Care Research (CESS). University of Vic-Central University of Catalonia (UVic-UCC);1. Cancer Control Office, King Hussein Cancer Center, Amman 11941, Jordan;2. Section of Pulmonary and Critical Care, Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan;3. Pharmacy Student, University of Jordan, Amman 11972, Jordan;4. Volunteer Research Program at King Hussein Cancer Center, Amman 11941, Jordan;5. Medical Student, University of Jordan, Amman 11972, Jordan;1. Maccabi Institute for Research and Innovation (Maccabitech), Maccabi Healthcare Services, HaMered 27, Tel Aviv, 68125, Israel;2. MSD Israel, Merck Sharp & Dohme (Israel-1996) Company Ltd. 34 Hacharash St. P.O.B 7340, Hod Hasharon 45240, Israel;3. Institute of Oncology, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel;4. Department of Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel;5. Sackler Faculty of Medicine, Tel Aviv University, Israel |
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| Abstract: | BackgroundRacial (Black vs. White) disparities in breast cancer survival have proven difficult to mitigate. Targeted strategies aimed at the primary factors driving the disparity offer the greatest potential for success. The purpose of this study was to use multiple mediation analysis to identify the most important mediators of the racial disparity in breast cancer survival.MethodsThis was a retrospective cohort study of non-Hispanic Black and non-Hispanic White women diagnosed with invasive breast cancer in Florida between 2004 and 2015. Cox regression was used to obtain unadjusted and adjusted hazard ratios (HR) with 95% confidence intervals (CI) for the association of race with 5- and 10-year breast cancer death. Multiple mediation analysis of tumor (advanced disease stage, tumor grade, hormone receptor status) and treatment-related factors (receipt of surgery, chemotherapy, radiotherapy, and hormone therapy) was used to determine the most important mediators of the survival disparity.ResultsThe study population consisted of 101,872 women of whom 87.0% (n = 88,617) were White and 13.0% were Black (n = 13,255). Black women experienced 2.3 times (HR, 2.27; 95% CI, 2.16–2.38) the rate of 5-year breast cancer death over the follow-up period, which decreased to a 38% increased rate (HR, 1.38; 95% CI, 1.31–1.45) after adjustment for age and the mediators of interest. Combined, all examined mediators explained 73% of the racial disparity in 5-year breast cancer survival. The most important mediators were: (1) advanced disease stage (44.8%), (2) nonreceipt of surgery (34.2%), and (3) tumor grade (18.2%) and hormone receptor status (17.6%). Similar results were obtained for 10-year breast cancer death.ConclusionThese results suggest that additional efforts to increase uptake of screening mammography in hard-to-reach women, and, following diagnosis, access to and receipt of surgery may offer the greatest potential to reduce racial disparities in breast cancer survival for women in Florida. |
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| Keywords: | Breast cancer Epidemiology Racial disparity Survival Mediation analysis |
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