Disparities in Surgical Treatment of Early-Stage Breast Cancer Among Female Residents of Texas: The Role of Racial Residential Segregation

Published:October 19, 2016DOI:



      Early-stage breast cancer can be surgically treated by using mastectomy or breast-conserving surgery and adjuvant radiotherapy, also known as breast-conserving therapy (BCT). Little is known about the association between racial residential segregation, year of diagnosis, and surgical treatment of early-stage breast cancer, and whether racial residential segregation influences the association between other demographic characteristics and disparities in surgical treatment.


      This was a retrospective study using data from the Texas Cancer Registry composed of individuals diagnosed with breast cancer between 1995 and 2012. The dependent variable was treatment using mastectomy or BCT (M/BCT) and the independent variables of interest (IVs) were racial residential segregation and year of diagnosis. The covariates were race, residence, ethnicity, tumor grade, census tract (CT) poverty level, age at diagnosis, stage at diagnosis, and year of diagnosis. Bivariate and multivariable multilevel logistic regression models were estimated. The final sample size was 69,824 individuals nested within 4335 CTs.


      Adjusting for the IVs and all covariates, there were significantly decreased odds of treatment using M/BCT, as racial residential segregation increased from 0 to 1 (odds ratio [OR] 0.47; 95% confidence interval [CI], 0.41-0.54). There was also an increased likelihood of treatment using M/BCT with increasing year of diagnosis (OR 1.14; 95% CI, 1.13-1.16). A positive interaction effect between racial residential segregation and race was observed (OR 0.56; 95% CI, 0.36-0.88).


      Residents of areas with high indices of racial residential segregation were less likely to be treated with M/BCT. Racial disparities in treatment using M/BCT increased with increasing racial residential segregation.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Breast Cancer
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Siegel R.L.
        • Miller K.D.
        • Jemal A.
        Cancer statistics, 2016.
        CA Cancer J Clin. 2016; 66: 7-30
      1. Surveillance, Epidemiology, and End Results Program. n.d. SEER stat fact sheets: female breast cancer. Available at: Accessed: June 20, 2016.

        • Lee-Feldstein A.
        • Anton-Culver H.
        • Feldstein P.J.
        Treatment differences and other prognostic factors related to breast cancer survival. Delivery systems and medical outcomes.
        JAMA. 1994; 271: 1163-1168
      2. National Cancer Institute. Breast cancer—health professional version. Available at: Accessed: July 11, 2016.

        • Fisher B.
        • Anderson S.
        • Bryant J.
        • et al.
        Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer.
        N Engl J Med. 2002; 347: 1233-1241
        • Gold H.T.
        • Do H.T.
        • Dick A.W.
        Correlates and effect of suboptimal radiotherapy in women with ductal carcinoma in situ or early invasive breast cancer.
        Cancer. 2008; 113: 3108-3115
      3. Simsek FS. 2000. Five year survival analysis of patients with clinical stages I and IIA breast cancer who received initial treatment at North Carolina hospitals. Available at: Accessed: January 29, 2016.

        • Dragun A.E.
        • Huang B.
        • Tucker T.C.
        • Spanos W.J.
        Disparities in the application of adjuvant radiotherapy after breast-conserving surgery for early stage breast cancer: impact on overall survival.
        Cancer. 2011; 117: 2590-2598
      4. Townsend Jr., C.M. Beauchamp R.D. Evers B.M. Mattox K.L. Sabiston Textbook of Surgery. The Biological Basis of Modern Surgical Practice. Elsevier, Philadelphia, PA2012
        • Markossian T.W.
        • Hines R.B.
        Disparities in late stage diagnosis, treatment, and breast cancer-related death by race, age, and rural residence among women in Georgia.
        Women Health. 2012; 52: 317-335
        • Coughlin S.S.
        • Richardson L.C.
        • Orelien J.
        • et al.
        Contextual analysis of breast cancer stage at diagnosis among women in the United States, 2004.
        Open Health Serv Policy J. 2009; 2: 45-46
        • Markossian T.W.
        • Hines R.B.
        • Bayakly R.
        Geographic and racial disparities in breast cancer-related outcomes in Georgia.
        Health Serv Res. 2014; 49: 481-501
        • Dehal A.
        • Abbas A.
        • Johna S.
        Racial disparities in clinical presentation, surgical treatment and in-hospital outcomes of women with breast cancer: analysis of nationwide inpatient sample database.
        Breast Cancer Res Treat. 2013; 139: 561-569
        • Nguyen B.C.
        • Alawadi Z.M.
        • Roife D.
        • Kao L.S.
        • Ko T.C.
        • Wray C.J.
        Do socioeconomic factors and race determine the likelihood of breast-conserving surgery?.
        Clin Breast Cancer. 2016; 16: e93-e97
        • Haas J.S.
        • Earle C.C.
        • Orav J.E.
        • et al.
        Racial segregation and disparities in breast cancer care and mortality.
        Cancer. 2008; 113: 2166-2172
        • Massey D.S.
        • Denton N.A.
        Hypersegregation in U.S. metropolitan areas: black and Hispanic segregation along five dimensions.
        Demography. 1989; 26: 373-391
        • Dai D.
        Black residential segregation, disparities in spatial access to health care facilities, and late-stage breast cancer diagnosis in metropolitan Detroit.
        Health Place. 2010; 16: 1038-1052
        • Pruitt S.L.
        • Lee S.J.
        • Tiro J.A.
        • Xuan L.
        • Ruiz J.M.
        • Inrig S.
        Residential racial segregation and mortality among black, white, and Hispanic urban breast cancer patients in Texas, 1995 to 2009.
        Cancer. 2015; 121: 1845-1855
        • Ye J.C.
        • Yan W.
        • Christos P.J.
        • Nori D.
        • Ravi A.
        Equivalent survival with mastectomy or breast-conserving surgery plus radiation in young women aged < 40 years with early-stage breast cancer: a national registry-based stage-by-stage comparison.
        Clin Breast Cancer. 2015; 15: 390-397
        • McGuire K.P.
        • Santillan A.A.
        • Kaur P.
        • et al.
        Are mastectomies on the rise? A 13-year trend analysis of the selection of mastectomy versus breast conservation therapy in 5865 patients.
        Ann Surg Oncol. 2009; 16: 2682-2690
        • Katipamula R.
        • Degnim A.C.
        • Hoskin T.
        • et al.
        Trends in mastectomy rates at the Mayo Clinic Rochester: effect of surgical year and preoperative magnetic resonance imaging.
        J Clin Oncol. 2009; 27: 4082-4088
        • Dragun A.E.
        • Pan J.
        • Riley E.C.
        • et al.
        Increasing use of elective mastectomy and contralateral prophylactic surgery among breast conservation candidates: a 14-year report from a comprehensive cancer center.
        Am J Clin Oncol. 2013; 36: 375-380
        • Mandelblatt J.S.
        • Yabroff K.R.
        • Kerner J.F.
        Equitable access to cancer services: a review of barriers to quality care.
        Cancer. 1999; 86: 2378-2390
        • Goel M.S.
        • Burns R.B.
        • Phillips R.S.
        • Davis R.B.
        • Ngo-Metzger Q.
        • McCarthy E.P.
        Trends in breast conserving surgery among Asian Americans and Pacific Islanders, 1992-2000.
        J Gen Intern Med. 2005; 20: 604-611
      5. Iceland J, Weinberg DH, Steinmetz E. Measurement of segregation by the U.S. Bureau of the Census in racial and ethnic residential segregation in the United States: 1980-2000. Available at: Accessed: January 13, 2016.

        • Massey D.S.
        • Gross A.B.
        • Eggers M.L.
        Segregation, the concentration of poverty, and the life chances of individuals.
        Soc Sci Res. 1991; 20: 397-420
        • Mobley L.R.
        • Kuo T.M.
        • Watson L.
        • Gordon Brown G.
        Geographic disparities in late-stage cancer diagnosis: multilevel factors and spatial interactions.
        Health Place. 2012; 18: 978-990
        • Bradley C.J.
        • Given C.W.
        • Roberts C.
        Race, socioeconomic status, and breast cancer treatment and survival.
        J Natl Cancer Inst. 2002; 94: 490-496
        • Esnaola N.F.
        • Knott K.
        • Finney C.
        • Gebregziabher M.
        • Ford M.E.
        Urban/rural residence moderates effect of race on receipt of surgery in patients with nonmetastatic breast cancer: a report from the South Carolina central cancer registry.
        Ann Surg Oncol. 2008; 15: 1828-1836
        • DeSantis C.E.
        • Siegel R.L.
        • Sauer A.G.
        • et al.
        Cancer statistics for African Americans, 2016: progress and opportunities in reducing racial disparities.
        CA Cancer J Clin. 2016; 66: 290-308