Elsevier

Annals of Epidemiology

Volume 57, May 2021, Pages 22-29
Annals of Epidemiology

Original article
Neighborhood archetypes and breast cancer survival in California

https://doi.org/10.1016/j.annepidem.2021.01.004Get rights and content

Highlights

  • Latent class analysis was used to classify California neighborhoods according to nine archetypes that distinguish neighborhoods according to demographics and household composition, immigration, nSES, walkability, residential mobility, commuting, rural/urban status, land use, and food environment.

  • Disparities in breast cancer survival according to neighborhood archetypes that vary by race/ethnicity were found.

  • By describing neighborhood archetypes that differentiate survival following breast cancer diagnosis, the study provides direction for policy and clinical practice addressing contextually-rooted social determinants of health.

Abstract

Purpose

Previous studies on neighborhoods and breast cancer survival examined neighborhood variables as unidimensional measures (e.g. walkability or deprivation) individually and thus cannot inform how the multitude of highly correlated neighborhood domains interact to impact breast cancer survival. Neighborhood archetypes were developed that consider interactions among a broad range of neighborhood social and built environment attributes and examine their associations with breast cancer survival.

Methods

Archetypes were measured using latent class analysis (LCA) fit to California census tract-level data. Thirty-nine social and built environment attributes relevant to eight neighborhood domains (socioeconomic status (SES), urbanicity, demographics, housing, land use, commuting and traffic, residential mobility, and food environment) were included.  The archetypes were linked to cancer registry data on breast cancer cases (diagnosed 1996–2005 with follow-up through Dec 31, 2017) to evaluate their associations with overall and breast cancer-specific survival using Cox proportional hazards models. Analyses were stratified by race/ethnicity.

Results

California neighborhoods were best described by nine archetypal patterns that were differentially associated with overall and breast cancer-specific survival. The lowest risk of overall death was observed in the upper middle class suburb (reference) and high status neighborhoods, while the highest was observed among inner city residents with a 39% greater risk of death (95% CI = 1.35 to 1.44). Results were similar for breast cancer-specific survival. Stratified analyses indicated that differences in survival by neighborhood archetypes varied according to individuals’ race/ethnicity.

Conclusions

By describing neighborhood archetypes that differentiate survival following breast cancer diagnosis, the study provides direction for policy and clinical practice addressing contextually-rooted social determinants of health including SES, unhealthy food environments, and greenspace.

Introduction

Breast cancer is the most common cancer and the second-leading cause of cancer deaths among women in the United States (U.S.).1 Neighborhoods shape individuals’ exposures to health-related risks and access to resources; they have an additional and distinct effect on cancer outcomes apart from individual-level characteristics.[2], [3], [4], [5] The impact of neighborhoods on cancer mortality is of increasing importance, since while cancer mortality has declined steadily over the past three decades, socioeconomic and geographic disparities in mortality have increased.6 Thus, there is a growing interest in health disparities research for more sophisticated neighborhood measures and a more thorough understanding of how and why neighborhoods matter to individuals’ health.[7], [8], [9]

Most published studies of neighborhoods and breast cancer survival have reported associations of lower neighborhood socioeconomic status (nSES) or greater neighborhood deprivation with risk of death, independent of patient tumor and sociodemographic characteristics.5,[10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22] More recent work, including work from our group, has considered additional domains of neighborhood built and social environments (e.g., food environment, walkability, and ethnic enclave).5,18,[21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33] Although few of these measures have been independently associated with overall or breast cancer-specific survival, a joint effect for ethnic enclave and nSES has been observed, which highlights the importance of considering interactions among neighborhood domains.26,27 Accordingly, understanding the full impact of neighborhoods on breast cancer survival necessitates an approach that informs how these and other often highly correlated neighborhood attributes, measured as individual indicators (e.g., poverty) or unidimensional indices (e.g., nSES or walkability) interact.[34], [35], [36], [37], [38] Consequently, we suggest reconsidering how neighborhoods are assessed in epidemiologic studies to fully capture, and ultimately more effectively intervene on, their potential health impact.39

Combining multiple neighborhood characteristics into archetypes is conceptually a more meaningful approach to identifying neighborhoods where residents have lower survival and to inform contextually-mediated interventions. Latent variable models, including latent class analysis (LCA), provide a statistically rigorous methodological approach to measuring archetypes40 as they allow for the assessment of potential interactions between many measures and summarize those measures into a more practical number of inter-relationships, apart from their impact on any given health outcome. Like principal component analysis for continuous variables and cluster analysis for categorical variables, LCA is a data reduction technique, but it has the additional benefits (shared by other latent variable methods for continuous measures like factor analysis and structural equation modeling) that it also addresses uncertainty, bias, and potential attenuation due to systematic and stochastic error in the measurement of variables.39 Nevertheless, the majority of studies that have used latent variable models to characterize neighborhoods utilized multiple measures of a single neighborhood domain (e.g., built environment attributes to describe neighborhood physical activity) and so were not designed to observe important interactions among social and built environment domains.[41], [42], [43], [44], [45], [46], [47], [48], [49] A study from Weden et al. identified 6 neighborhood archetypes with measures across multiple neighborhood domains for 1990 and 2000 census tracts across the U.S., but these archetypes were not used to study a health behavior or outcome.39

In this study, we used an analogous approach to Weden et al. with a broad set of social and built environment attributes across several neighborhood domains to define neighborhood archetypes in California (CA) and to examine associations between neighborhood archetypes and breast cancer survival. Moreover, literature to date on the neighborhood environment and breast cancer survival stresses that the relative importance of neighborhoods may depend on resident characteristics, including race/ethnicity,33 so we examine interactions between archetypes and race/ethnicity in their associations with survival.

Section snippets

Neighborhood data

Neighborhood data were from the California Neighborhoods Data System (CNDS).50 The CNDS is a geospatial dataset that compiles data on the social and built environment attributes for small areas (i.e., block groups and census tracts) using multiple sources of data. Thirty-nine indicator variables characterizing several domains of neighborhood social and built environments (i.e., socioeconomic status, urbanicity, demographics, housing, land use, commuting and traffic, residential mobility, and

Results

Labels and descriptions for the 9 different classes, or types, of neighborhoods characterized are in Table 1. Descriptions are based on the prevailing characteristics that the LCA model identified for each class. For example, suburban pioneer and city pioneer neighborhoods are both located in cities, but not right in downtown, have racially/ethnically diverse populations, and lots of mixed land use, but contrast in that suburban pioneer neighborhoods have more families and home owners and city

Discussion

Neighborhood archetypes provide a novel approach to assess the impact of multiple neighborhood factors on breast cancer survival. We present 9 neighborhood archetypes for census tracts in CA for the year 2000 developed with a broad suite of variables representing several domains of neighborhood social and built environments. These archetypes can be interpreted as (1) the most likely combinations of neighborhood characteristics observed in CA and (2) the most common forms of potential

Acknowledgments

(Andrew Hertz) We thank Mr. Andrew Hertz from the Cancer Prevention Institute of California for his contributions to this study.

This work was supported by the National Cancer Institute at the National Institutes of Health (1R21CA174469 to S.S.M.) The collection of cancer incidence data used in this study was supported by the California Department of Public Health pursuant to California Health and Safety Code Section 103,885; Centers for Disease Control and Prevention's (CDC) National Program of

References (82)

  • M.C. DeRouen et al.

    Impact of individual and neighborhood factors on disparities in prostate cancer survival

    Cancer Epidemiol

    (2018)
  • S. Warren Andersen et al.

    Associations between neighborhood environment, health behaviors, and mortality

    Am J Prev Med

    (2018)
  • B. Appleyard

    The meaning of livable streets to schoolchildren: an image mapping study of the effects of traffic on children's cognitive development of spatial knowledge

    J Transport Health

    (2017)
  • Cancer facts and figures 2018

    (2018)
  • A.V. Diez Roux et al.

    Neighborhoods and health

    Ann N Y Acad Sci

    (2010)
  • I. Kawachi et al.

    Neighborhoods and health

    (2003)
  • R.B. Warnecke et al.

    Approaching health disparities from a population perspective: the National Institutes of Health Centers for Population Health and Health Disparities

    Am J Public Health

    (2008)
  • S.L. Gomez et al.

    The impact of neighborhood social and built environment factors across the cancer continuum: current research, methodological considerations, and future directions

    Cancer

    (2015)
  • R.L. Siegel et al.

    Cancer statistics, 2019

    CA Cancer J Clin

    (2019)
  • J. Alvidrez et al.

    The national institute on minority health and health disparities research framework

    Am J Public Health

    (2019)
  • N.L. Jones et al.

    Cross-cutting themes to advance the science of minority health and health disparities

    (2019)
  • R.C. Palmer et al.

    Social determinants of health: future directions for health disparities research

    (2019)
  • M.P. Banegas et al.

    Heterogeneity of breast cancer subtypes and survival among Hispanic women with invasive breast cancer in California

    Breast Cancer Res Tr

    (2014)
  • M.T. Bassett et al.

    Social class and black-white differences in breast cancer survival

    Am J Public Health

    (1986)
  • T.E. Byers et al.

    The impact of socioeconomic status on survival after cancer in the United States : findings from the National Program of Cancer Registries Patterns of Care Study

    Cancer.

    (2008)
  • C.M. Chang et al.

    The combined effect of individual and neighborhood socioeconomic status on cancer survival rates

    PLoS ONE

    (2012)
  • S. Harper et al.

    Trends in area-socioeconomic and race-ethnic disparities in breast cancer incidence, stage at diagnosis, screening, mortality, and survival among women ages 50 years and over (1987-2005)

    Cancer Epidem Biomar

    (2009)
  • M. Lian et al.

    Neighborhood socioeconomic deprivation, tumor subtypes, and causes of death after non-metastatic invasive breast cancer diagnosis: a multilevel competing-risk analysis

    Breast Cancer Res Treat

    (2014)
  • S. Shariff-Marco et al.

    Impact of neighborhood and individual socioeconomic status on survival after breast cancer varies by race/ethnicity: the Neighborhood and Breast Cancer Study

    Cancer Epidemiol Biomarkers Prev

    (2014)
  • B.L. Sprague et al.

    Socioeconomic status and survival after an invasive breast cancer diagnosis

    Cancer

    (2011)
  • E.T. Warner et al.

    Impact of neighborhood racial composition and metropolitan residential segregation on disparities in breast cancer stage at diagnosis and survival between black and white women in California

    J Community Health

    (2010)
  • A. Seow et al.

    Reproductive variables, soy intake, and lung cancer risk among nonsmoking women in the Singapore Chinese Health Study

    Cancer Epidemiol Biomarkers Prev

    (2009)
  • L. Lipworth et al.

    Socio-economic factors in the prognosis of cancer patients

    J Chronic Dis

    (1970)
  • S. Shariff-Marco et al.

    Intersection of race/ethnicity and socioeconomic status in mortality after breast cancer

    J Community Health

    (2015)
  • P. Dasgupta et al.

    Multilevel determinants of breast cancer survival: association with geographic remoteness and area-level socioeconomic disadvantage

    Breast Cancer Res Treat

    (2012)
  • E. Russell et al.

    Residential Racial Composition, Spatial Access to Care, and Breast Cancer Mortality among Women in Georgia

    J Urban Health

    (2011)
  • E.F. Russell et al.

    Metropolitan area racial residential segregation, neighborhood racial composition, and breast cancer mortality

    Cancer Causes Control

    (2012)
  • C.Y. Fang et al.

    Ethnic density and cancer: a review of the evidence

    Cancer

    (2018)
  • T.H. Keegan et al.

    Neighborhood influences on recreational physical activity and survival after breast cancer

    Cancer Causes & Control

    (2014)
  • T.H.M. Keegan et al.

    The influence of nativity and neighborhoods on breast cancer stage at diagnosis and survival among California Hispanic women

    BMC Cancer

    (2010)
  • S.L. Gomez et al.

    Disparities in breast cancer survival among Asian women by ethnicity and immigrant status: a population-based study

    Am J Public Health

    (2010)
  • Cited by (10)

    • Breast Cancer Disparities and the Impact of Geography

      2022, Surgical Oncology Clinics of North America
      Citation Excerpt :

      The study results suggest that overall and breast cancer-specific survival are associated with neighborhood archetype. Specifically, patients in upper middle class neighborhoods with a high socioeconomic status had the highest survival rates.37 The legacy of redlining has been implicated in increasing breast cancer mortality.38

    View all citing articles on Scopus

    Competing Interests: Authors have no conflicts of interest to declare.

    View full text