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Black women living in southern states have the highest breast cancer mortality rate in the United States. The prognosis of de novo metastatic breast cancer is poor. Given these mortality rates, we are the first to link nationally representative data on breast cancer mortality hot spots counties with high breast cancer mortality rates with cancer mortality data in the United States and investigate the association of geographic breast cancer mortality hot spots with de novo metastatic breast cancer mortality among Black women.

Among patients, 5.

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Additional adjustment for county-level characteristics did not impact mortality. Living in a breast cancer mortality hot spot was not associated with de novo metastatic breast Langston OK sexy women mortality among Black women. Future research should begin to examine variation in both individual and population-level determinants, as well as in molecular and genetic determinants that underlie the aggressive nature of de novo metastatic breast cancer.

Breast cancer is the most common cancer among women in the United States, with the highest incidence in White women. Yet, racial and ethnic disparities in breast cancer mortality rates persist 12. Across all racial and ethnic groups, the stage of diagnosis is associated with survival. However, 5-year breast cancer—specific survival rates decrease as patients are diagnosed beyond AJCC stage I 3. These improvements may be partly attributed to advances in the molecular-level characterizations of breast cancer, use of hormone therapy, and targeted treatment strategies 7.

As seen across racial and ethnic groups, geographic disparities in breast cancer outcomes exist across the United States 9. Historical factors, such as Jim Crow laws, housing and zoning policies, and migration patterns, have created swaths of racially segregated areas that still exist today 10 There has been an emergence of interdisciplinary researchers interested in the intersection of race and geographical location on health outcomes.

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Disease-specific geographic hot spots are the spatial aggregation of cases in an identifiable subpopulation based on geographic excess risks A breast cancer mortality hot spot is a county identified as high risk for breast cancer mortality. Hot spots of breast cancer mortality among Black women were found primarily in rural southern counties near the Mississippi River and counties in the northern coastal North Carolina and southern Virginia areas of the United States However, to our knowledge, no study has investigated associations between geographic hot spots and mortality among Black women with de novo metastatic breast cancer.

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Thus, we are the first to link nationally representative data on breast cancer mortality hot spots with incident-based mortality data on de novo metastatic breast cancer in the United States and examine the association of geographic breast cancer mortality hot spots with de novo metastatic breast cancer mortality among Black women. Understanding this association can help medical and public health experts tailor programs and maximize resources to improve survivorship rates for this vulnerable group.

This study was considered exempt by the institutional review board of Washington University School of Medicine because we used existing secondary data that are publicly available and nonidentifiable. Thus, our sample consisted of Black women with de novo metastatic breast cancer for final analysis.

Individual demographic and clinical characteristics in SEER were used as potential covariates including age at diagnosis, year of diagnosis, marital status, tumor histology, tumor grade, hormone receptor status, the first course of treatments surgery, radiation, and chemotherapyand SEER registry. In brief, patients in metro counties with codes were classified as urban, and all nonmetro counties with codes were classified as rural.

Flowchart of eligible individuals, SEER 18 registries Although a variety of approaches exist for spatial disease clustering, we used the aggregation of 3 separate local and global spatial clustering methods to identify counties that were hot spots for breast cancer mortality.

This cluster identification method has been described in detail ly Langston OK sexy women1718and the use of this conservative approach helps avoid spurious obtained from simply relying on one method. Briefly, we Langston OK sexy women county-level breast cancer mortality into 2 groups—hot spots or non—hot spots—based on a statistically ificant higher observed vs expected breast cancer mortality rate.

All other contiguous US counties were categorized as non—hot spots. From CHR and ACS, we considered estimates of the county-level proportions of race and ethnicity, completed college, household income, obesity, smoking, excessive drinking, persons who could not see a doctor because of costs, limited access to healthy foods, mammography screening, physical inactivity, access to exercise opportunities, unemployment, uninsured, the ratio of primary care physicians per persons, and rurality.

We compared hot spots vs non—hot spot counties and presented the medians and interquartile ranges for the county-level characteristics because of the nonparametric distribution of continuous variables Table 2. We examined the proportional hazards assumption for breast cancer—specific survival and overall survival by Schoenfeld residuals and by graphically assessing the log-log plots of survival.

Survival time was estimated from the date of diagnosis to the last date of follow-up or death. We performed a sequential model-building approach to examine possible confounders on the association between hot spot residence and mortality. The contribution of individual-level covariates, tumor factors, and treatments for multivariable models was assessed by a measure of the relative change in hazard ratios Multivariable-adjusted model 1 was adjusted for individual-level factors age, year of diagnosis, marital status, and SEER registriestumor-level factors tumor histology, tumor grade, and hormone receptor statusand treatments surgery, chemotherapy, and radiation therapy.

We performed statistical analyses using SAS version 9. All statistical tests were 2-sided, and P values less than. County-level characteristics by breast cancer mortality hot spot classification among Black women from SEER 18 registries,linked with American Community Survey and County Health Rankings county-level data.

Patients residing in counties with high breast cancer mortality fulfilling all 3 criteria for geographic clustering. Spearman correlation with being a county-level breast cancer mortality hot spot. Index that ranges from 0 worst to 10 bestdepending on the access to healthy foods by considering the distance an individual lives from a grocery store or supermarket.

Among Black women diagnosed with de novo metastatic breast cancer over the year study period, approximately 5. The mean age of all patients was Compared with women living in non—hot spot counties, women residing in hot spot counties were more likely to be diagnosed between and Comparison of participant and tumor characteristics by breast cancer mortality hot spot classification among Black women diagnosed as de novo metastatic breast cancer from SEER 18 registries, County-level characteristics by hot spot classification are presented in Table 2.

Black women living in hot spot counties with de novo metastatic breast cancer diagnosis were statistically ificantly more likely than women living in non—hot spot counties to reside in areas with greater proportions of White residents Moreover, hot spot counties were statistically ificantly less likely than non—hot spot counties to have greater proportions of Hispanic 5.

We observed similar after additionally adjusting for county-level proportions, including completed college education, population with obesity, current smoking status, physically inactive, and access to exercise opportunities, in multivariable model 2. Individual-level factors reduced the hazard ratio by 3. In total, adjustment for all covariates explained 6. Additionally, the hazard ratios for overall mortality were similar to findings for breast cancer—specific mortality Table 3.

Multivariable hazard ratios for breast cancer—specific mortality and overall mortality among Black women diagnosis with de novo metastatic breast cancer from SEER 18 registries, Model 1 was adjusted for age at diagnosis, year of diagnosis, marital status, tumor histology, tumor grade, hormone receptor status, treatments surgery, radiation, and chemotherapyand SEER registry. Model 2 was additionally adjusted for county-level proportions for completed college education, population with obesity, current smoking status, physically inactive, and access to exercise opportunities in addition to model 1.

Model 3 was adjusted for all individual-level, tumor-level, and county-level variables. Among 45 women, 30 were Whites For this analysis, we identified 80 of 2. In this study, we are the first to link nationally representative data on breast cancer mortality hot spots with incident-based mortality data on de novo metastatic breast cancer among Black women in the United States. We observed that Black women diagnosed with de novo metastatic breast cancer had similar risk of death regardless of residence in county-level hot spots of breast cancer mortality.

The incidence of distant-stage breast cancer has increased over the past few decades This increase may be partly explained by the more complete staging of advanced tumors 24 and increased use of advanced imaging to detect asymptomatic metastases 8. The prevalence of metastatic breast cancer in the United States from to was estimated that there will be women living with metastatic breast cancer by In comparison, another report of data from 2 breast-specific practices suggested that race and ethnicity may not contribute to the survival of patients diagnosed with de novo metastatic breast cancer Differences in age distribution, race and ethnicity, comorbidities, and tumor factors could lead to survival differences between large SEER data and small practices.

These mixed and limited studies support our exploration of breast cancer mortality hot spots and de novo metastatic breast cancer mortality among Black women, despite our null findings. There is limited knowledge on both the geographic and racial patterns in de novo metastatic breast cancer in the United States.

However, in a recent systematic review, Landrine and colleagues 35 found that living in segregated African American communities was associated with higher odds of late-stage breast cancer. Russell and colleagues 37 Langston OK sexy women that among women in Georgia, segregation was associated with a twofold increased risk of death attributed to breast cancer for Black women, but not among White women. However, these racial segregation associations are complex because racial enclaves for Black women may lead to key survivorship and quality-of-life benefits such as increased social support, more culturally relevant care, more willingness to access care, and less exposure to stress from racism To this end, because of the limited research surrounding the association between social determinants of health and de novo metastatic breast cancer specifically, future studies should continue to explore the social determinants of this disease and attempt to provide the geospatial distribution of metastatic breast cancer among the entire US population, which will provide insight into the highest areas of need for this increasing public health concern.

This could be due to other complex biology related to the aggressive phenotype of de novo metastatic breast cancer. Many cell cycle components contribute to a more aggressive tumor phenotype and poorer prognosis among Black breast cancer patients 38such as higher mitotic index; overexpression of cyclin E, p16, p53; and lower expression of cyclin D1 A better understanding of the key molecular determinants and genetic alterations that underlie clinical behavior in Black patients may also elucidate the higher mortality of de novo metastatic breast cancer.

Our study is strengthened by the use of nationally representative data to define mortality hot spots, as well as survival follow-up in SEER, which includes clinical and demographic data. Additionally, we were able to for individual and population-level factors through multilevel modeling.

Last, SEER lacks data on comorbid conditions, where Black women were more likely than White women to have higher comorbidity scores Hot spots of breast cancer mortality for Black women were not associated with de novo metastatic breast cancer mortality. Our exploration adds to the limited evidence on geographic and racial patterns in metastatic breast cancer disease and mortality in Black women. P30 CA Role of the funders: The Langston OK sexy women had no role in the de of the study; the collection, analysis, and interpretation of the data; the writing of the manuscript; and the decision to submit the manuscript for publication.

Disclosures: The authors declare no potential conflicts of interest. Author contributions: JXM conceived and deed the study. JXM and YH conducted the analysis. JXM and YH contributed to the interpretation of the data.

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Patient data supporting all the tables and supplementary files in the published article will be made available on request from the corresponding author. Cancer statistics, CA Cancer J Clin. Google Scholar. Breast cancer statistics, Validation study of the American t Committee on Cancer Eighth Edition prognostic stage compared with the anatomic stage in breast cancer.

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Metastatic breast cancer survival improvement restricted by regional disparity: Surveillance, Epidemiology, and End and institutional analysis: to Prognostic impact of metastatic pattern in stage IV breast cancer at initial diagnosis. Breast Cancer Res Treat. Epub Dec Survival differences among women with de novo stage IV and relapsed breast cancer.

Ann Oncol. Breast cancer. Nat Rev Dis Primers. American Cancer Society. Google Preview. Efficient mapping and geographic disparities in breast cancer mortality at the county-level by race and age in the U. Spat Spatiotemporal Epidemiol. Williams DRCollins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Reports. Siriwardhana C, Wickramage K. Forced migration and mental health: prolonged internal displacement, return migration and resilience.

Int Health. Wartenberg D. Investigating disease clusters: why, when and how? Mapping hot spots of breast cancer mortality in the United States: place matters for Blacks and Hispanics.

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Cancer Causes Control. Underlying mortality data provided by NCHS. Accessed February 4, Centers for Disease Control and Prevention. About underlying causes of death, Defining sepsis mortality clusters in the United States. Crit Care Med. Multiple cluster analysis for the identification of high-risk census tracts for out-of-hospital cardiac arrest OHCA in Denver, Colorado. Anselin L. Local indicators of spatial association—LISA.

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Langston OK sexy women