In a study reported in the Journal of Clinical Oncology, Beyer et al found that redlining (mortgage lending bias on the basis of property location) was associated with overall survival among older U.S. women with breast cancer, with an increasing redlining index (higher likelihood of mortgage loan denial) being associated with increasingly poor survival.
Study Details
In the study, a redlining index using Home Mortgage Disclosure Act data (2007–2013) was linked by census tract within metropolitan statistical areas (MSAs) with a Surveillance, Epidemiology, and End Results (SEER)-Medicare cohort of 27,516 women aged 66 to 90 years with an initial diagnosis of stage I to IV breast cancer between 2007 and 2009 and follow-up through 2015. In the redlining index, a value of 1 indicates an equal chance of receipt and denial of mortgage loans, with higher index values indicating increasingly greater odds of denial.
Key Findings
Overall, 39.4% of the cohort lived in a redlined census tract (index value ≥ 1) and 9.1% in tracts with an index value ≥ 2; 34% of White, 57% of Hispanic, and 79% of Black women resided in redlined tracts.
In a multivariate analysis controlling for age, stage, comorbidity, hormone receptor status, and MSA, an increasing redlining index was significantly associated with an increased risk of all-cause mortality (hazard ratio [HR] = 1.26, 95% confidence interval [CI] = 1.16–1.38, P < .001).
The association was strongest among the 54% of women in the cohort with no comorbid conditions. In an analysis controlling for age, stage, hormone receptor status, and MSA, compared with those living in tracts with a redlining index of 0.5 (more likely to receive than be denied mortgage loans), hazard ratios for all-cause mortality were 1.10 (95% CI = 1.06–1.14) for an index of 1, 1.27 (95% CI = 1.17–1.38) for an index of 2, and 1.39 (95% CI = 1.25–1.55) for an index of 3.
In a multivariate analysis, an increasing redlining index was also associated with an increased risk of breast cancer–specific mortality (HR = 1.20, 95% CI = 1.05–1.37, P = .006). The analysis among women with no comorbid conditions showed hazard ratios vs redlining index of 0.5 of 1.08 (95% CI = 1.02–1.13) for an index of 1, 1.20 (95% CI = 1.05–1.37) for an index of 2, and 1.28 (95% CI = 1.06–1.55) for an index of 3.
The investigators concluded: “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.”
Kirsten M.M. Beyer, PhD, of the Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, is the corresponding author of the Journal of Clinical Oncology article.
Disclosure: The study was supported by grants from the National Cancer Institute and Health Resources and Services Administration. For full disclosures of the study authors, visit ascopubs.org.
