Improving our understanding of breast cancer mortality disparities through recurrence: a multi-level approach among women in Georgia

项目总结/摘要 意义尽管国家和慈善机构一直在努力减少和消除乳腺癌 (BC)在过去的几十年里，死亡率的差异不仅持续存在，而且还在扩大。此外，本发明还 由于不完全捕获复发数据，以前的调查没有确定BC差异的驱动因素 诊断为早期（I-IIIA）疾病后复发。在格鲁吉亚，经济和种族/族裔 差异是美国最大的差异之一，BC结果差异的来源尚未解决， 并且很可能是从细胞到社会的多个层次上的因果和促成因素的相互作用引起的。 大约40%的BC幸存者在其一生中会复发，临床数据表明， 少数民族和低收入妇女复发的风险较高。鉴于复发的高终身风险，假设 复发性BC中的种族/民族差异，以及人口统计学领域中记录的死亡率差异，现在 是描述导致BC预后不公平的潜在途径的关键时间。创新 我们的建议是创新的，因为它将是第一个按人口统计来估计BC复发的风险和比率。 特点，考虑BC结果差异的交叉性，并使用多层次分解 确定潜在的干预目标。Approach.集成多个数据流（例如， 出院、行政索赔、医院和人口普查数据）与癌症登记数据， 人口，我们将确定近端，中间和远端的决定因素种族/民族，社会经济地位，和城市/农村 复发和BC特异性死亡率的差异，以及检查复发及其治疗， 不同种族、社会经济地位和城乡特征的死亡率差异的中介因素。数据将来自 在格鲁吉亚（2013-2017年），约30，000名女性被诊断患有第一个初级I-IIIA期BC， 长达12年冲击以前在这方面的研究有一致的缺点，包括（1） 在人群水平上对复发的确定不足;（2）检查一个或几个因素， 对多个层面的共同贡献进行会计核算;（3）没有足够的权力来探索 身份我们的研究，第一次，将检查多层次的贡献者种族/民族，社会经济地位，和城市/农村 早期疾病妇女BC复发率和死亡率的差异。我们的创新多- 层次分解方法将使我们超越仅仅记录差异， 在受影响社区的社会背景下确定具体目标，促进确定干预措施的优先次序。

PROJECT SUMMARY/ABSTRACT Significance. Although national and philanthropic efforts have sought to reduce and eliminate breast cancer (BC) mortality disparities over the past few decades, they have not only persisted—but widened. Additionally, due to incomplete capture of recurrence data, no previous investigation has identified drivers of disparities in BC recurrence following a diagnosis of early-stage (I–IIIA) disease. In Georgia, where economic and racial/ethnic disparities are among the greatest in the United States, the sources of BC outcome disparities are unresolved, and likely arise from the interplay of causal and contributing factors at multiple levels—from cell to society. Approximately 40% of all BC survivors will suffer a recurrence during their lifetime, and clinical data suggest a higher risk of recurrence in minority and low-income women. Given the high lifetime risk of recurrence, posited race/ethnic disparities in recurrent BC, and documented mortality disparities across demographic domains, now is the pivotal time to characterize underlying pathways contributing to inequities in BC prognosis. Innovation. Our proposal is innovative in that it will be the first to estimate risks and rates of BC recurrence by demographic characteristics, consider intersectionality in BC outcome disparities, and use a multilevel decomposition approach to identify potential targets for intervention. Approach. Integrating multiple data streams (e.g., discharge, administrative claims, hospital, and census data) with cancer registry data from a large, diverse population, we will identify proximal, intermediate, and distal determinants of race/ethnic, SES, and urban/rural disparities in both recurrence and BC-specific mortality, as well as examine recurrence and its treatments as mediators of disparities in mortality rates by race, SES, and urban/rural characteristics. Data will be from approximately 30,000 women diagnosed with a first primary stage I–IIIA BC in Georgia (2013–2017) and followed for up to 12 years. Impact. Previous research in this area has had consistent shortcomings including (1) insufficient ascertainment of recurrence at the population level; (2) examining one or few factors without accounting for shared contributions across multiple levels; and (3) inadequate power to explore intersections of identity. Our study, for the first time, will examine multi-level contributors to race/ethnic, SES, and urban/rural disparities in both BC recurrence and mortality among women with early-stage disease. Our innovative multi- level decomposition approach will move us beyond merely documenting disparities, to identifying modifiable targets within the social contexts of affected communities, facilitating prioritization of interventions.