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

项目摘要/摘要 意义重大。尽管国家和慈善机构的努力试图减少和消除乳腺癌 (BC)在过去的几十年里，死亡率差距不仅持续存在，而且还在扩大。另外， 由于对复发数据的捕获不完整，以前没有任何调查确定卑诗省差异的驱动因素 早期(I-IIIA)疾病诊断后复发。在格鲁吉亚，那里的经济和种族/民族 差异是美国最大的之一，卑诗省结果差异的来源尚未解决， 而且很可能是从细胞到社会的多个层面上的因果因素和促成因素的相互作用。 大约40%的BC幸存者在他们的一生中会复发，临床数据表明 少数族裔和低收入妇女复发的风险较高。鉴于复发的高终生风险，假设 不列颠哥伦比亚省复发的种族/民族差异，并记录了人口领域的死亡率差异，现在 是确定导致BC预后不平等的潜在途径的关键时刻。创新。 我们的建议是创新的，因为它将是第一个按人口统计估计BC复发风险和比率的方案 特征，在BC结果差异中考虑交叉性，并使用多层分解 确定潜在干预目标的方法。接近。集成多个数据流(例如， 出院、行政索赔、医院和人口普查数据)与来自大型、多样化的癌症登记数据 人口，我们将确定种族/民族、社会经济地位和城市/农村的近、中、远决定因素 复发和特定于BC的死亡率之间的差异，以及检查复发及其治疗 不同种族、社会经济地位和城市/农村特征的死亡率差异的调节因素。数据将来自 在佐治亚州(2013-2017)，约有30,000名妇女被诊断出患有第一初级I-IIIA BC期并随后 长达12年。冲击力。以前在这一领域的研究都有一致的缺点，包括(1) 在人口层面上对复发的确定不足；(2)检查一个或几个因素而没有 核算多个级别的共享贡献；以及(3)探索交叉点的能力不足 身份。我们的研究将首次考察种族/民族、社会经济地位和城市/农村的多层次贡献者 患有早期疾病的妇女在BC复发和死亡率方面的差异。我们创新的多- 级别分解方法将使我们不再仅仅记录差异，而是确定可修改的 在受影响社区的社会背景下确定目标，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.