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McQuitty EN, Black TA, Rousseau MA, Parvathaneni A, Gonna N, Farris DP, Nelson KC. Retrospective operationalization of allostatic load in patients with cancer: A systematic review. Psychoneuroendocrinology 2024; 167:107085. [PMID: 38833997 DOI: 10.1016/j.psyneuen.2024.107085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/05/2024] [Accepted: 05/21/2024] [Indexed: 06/06/2024]
Abstract
Allostatic load (AL) has been shown to impact cancer outcomes. At present, no gold standard exists surrounding AL computation. As such, a systematic review of the literature was performed to identify studies that retrospectively calculated AL in patients with cancer. The following variables were collected for each study: AL calculation method, including the biomarkers used and their cutoff values, number of biosystems represented, definition of high AL, and the use of proxy biomarkers. Thirteen articles were included for full-text review. The number of biomarkers used in the calculation of AL varied considerably, ranging from 6 to 16. Considerable variability was also observed in terms of utilized biomarkers and biosystem representation. This lack of standardization complicates retrospective AL calculation among patients with cancer. Nonetheless, determining AL in patients with cancer presents an important step in the optimization of patient care and outcomes.
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Affiliation(s)
- Emelie N McQuitty
- John P. and Kathrine G. McGovern Medical School at UTHealth Houston, Houston, TX, USA
| | - T Austin Black
- John P. and Kathrine G. McGovern Medical School at UTHealth Houston, Houston, TX, USA
| | - Morgan A Rousseau
- John P. and Kathrine G. McGovern Medical School at UTHealth Houston, Houston, TX, USA
| | - Aarthi Parvathaneni
- John P. and Kathrine G. McGovern Medical School at UTHealth Houston, Houston, TX, USA
| | - Nadeen Gonna
- John P. and Kathrine G. McGovern Medical School at UTHealth Houston, Houston, TX, USA
| | - David P Farris
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelly C Nelson
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Chen J, Elsaid MI, Handley D, Plascak JJ, Andersen BL, Carson WE, Pawlik TM, Fareed N, Obeng-Gyasi S. Association Between Neighborhood Opportunity, Allostatic Load, and All-Cause Mortality in Patients With Breast Cancer. J Clin Oncol 2024; 42:1788-1798. [PMID: 38364197 PMCID: PMC11095867 DOI: 10.1200/jco.23.00907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 12/06/2023] [Accepted: 12/18/2023] [Indexed: 02/18/2024] Open
Abstract
PURPOSE Adverse neighborhood contextual factors may affect breast cancer outcomes through environmental, psychosocial, and biological pathways. The objective of this study is to examine the relationship between allostatic load (AL), neighborhood opportunity, and all-cause mortality among patients with breast cancer. METHODS Women age 18 years and older with newly diagnosed stage I-III breast cancer who received surgical treatment between January 1, 2012, and December 31, 2020, at a National Cancer Institute Comprehensive Cancer Center were identified. Neighborhood opportunity was operationalized using the 2014-2018 Ohio Opportunity Index (OOI), a composite measure derived from neighborhood level transportation, education, employment, health, housing, crime, and environment. Logistic and Cox regression models tested associations between the OOI, AL, and all-cause mortality. RESULTS The study cohort included 4,089 patients. Residence in neighborhoods with low OOI was associated with high AL (adjusted odds ratio, 1.21 [95% CI, 1.05 to 1.40]). On adjusted analysis, low OOI was associated with greater risk of all-cause mortality (adjusted hazard ratio [aHR], 1.45 [95% CI, 1.11 to 1.89]). Relative to the highest (99th percentile) level of opportunity, risk of all-cause mortality steeply increased up to the 70th percentile, at which point the rate of increase plateaued. There was no interaction between the composite OOI and AL on all-cause mortality (P = .12). However, there was a higher mortality risk among patients with high AL residing in lower-opportunity environments (aHR, 1.96), but not in higher-opportunity environments (aHR, 1.02; P interaction = .02). CONCLUSION Lower neighborhood opportunity was associated with higher AL and greater risk of all-cause mortality among patients with breast cancer. Additionally, environmental factors and AL interacted to influence all-cause mortality. Future studies should focus on interventions at the neighborhood and individual level to address socioeconomically based disparities in breast cancer.
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Affiliation(s)
- J.C. Chen
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
| | - Mohamed I. Elsaid
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH
- Secondary Data Core, Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, OH
| | - Demond Handley
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH
- Secondary Data Core, Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, OH
| | - Jesse J. Plascak
- Division of Cancer Prevention and Control, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | | | - William E. Carson
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
| | - Timothy M. Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
| | - Naleef Fareed
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH
| | - Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
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Pleasant V. A Public Health Emergency: Breast Cancer Among Black Communities in the United States. Obstet Gynecol Clin North Am 2024; 51:69-103. [PMID: 38267132 DOI: 10.1016/j.ogc.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
While Black people have a similar incidence of breast cancer compared to White people, they have a 40% increased death rate. Black people are more likely to be diagnosed with aggressive subtypes such as triple-negative breast cancer. However, despite biological factors, systemic racism and social determinants of health create delays in care and barriers to treatment. While genetic testing holds incredible promise for Black people, uptake remains low and results may be challenging to interpret. There is a need for more robust, multidisciplinary, and antiracist interventions to reverse breast cancer-related racial disparities.
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Affiliation(s)
- Versha Pleasant
- Department of Obstetrics and Gynecology, Cancer Genetics & Breast Health Clinic, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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Wang F, Skiba MB, Follis S, Liu N, Bidulescu A, Mitra AK, Mouton CP, Qi L, Luo J. Allostatic load and risk of invasive breast cancer among postmenopausal women in the U.S. Prev Med 2024; 178:107817. [PMID: 38097139 DOI: 10.1016/j.ypmed.2023.107817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE Allostatic load can reflect the body's response to chronic stress. However, little is known about the association between allostatic load and risk of breast cancer in postmenopausal women. This study used a large prospective cohort in the United States to examine the relationship between allostatic load and invasive breast cancer risk, and to evaluate the relationship by racial and ethnic identity and breast cancer subtypes. METHODS Among 161,808 postmenopausal participants in Women's Health Initiative, eligible were a subsample of 27,393 postmenopausal women aged 50-79 years old, who enrolled from 1993 to 1998, had serum test biomarkers, and were followed for breast cancer incidence through February 2022. Allostatic load at enrollment was computed based on eight biomarkers from lab serum tests and a questionnaire about participants' prescription drug use. The associations between allostatic scores and risk of breast cancer (overall and by subtypes) were assessed using Cox proportional hazards models. The race and ethnic differences were examined. RESULTS Over a median follow-up time of 17.24 years, 1722 invasive breast cancer cases were identified. High allostatic load was associated with an increased risk of breast cancer (HR = 1.36, 95%CI: 1.20, 1.54 for third tertile vs first tertile, Ptrend < 0.0001). Similar trends were found in White women and non-Hispanic women. Higher allostatic load was associated with hormone receptor-positive and HER2/Neu-negative breast cancer (HR = 1.54, 95%CI: 1.30, 1.80 for third tertile vs first tertile, Ptrend < 0.0001). CONCLUSION In this study, we found that higher allostatic load was significantly associated with an increased risk of breast cancer in postmenopausal women.
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Affiliation(s)
- Fengge Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Bloomington, IN, USA.
| | - Meghan B Skiba
- Advanced Nursing Practice and Science Division, College of Nursing, University of Arizona, Tucson, AZ, USA
| | - Shawna Follis
- Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Nianjun Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Aurelian Bidulescu
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Anirban K Mitra
- Indiana University School of Medicine-Bloomington, Bloomington, IN, USA
| | - Charles P Mouton
- Department of Family Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Lihong Qi
- Department of Public Health Sciences, School of Medicine, University of California, Davis, Davis, CA, USA
| | - Juhua Luo
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Bloomington, IN, USA
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Chen JC, Handley D, Elsaid MI, Plascak JJ, Andersen BL, Carson WE, Pawlik TM, Carlos RC, Obeng-Gyasi S. The Implications of Racialized Economic Segregation and Allostatic Load on Mortality in Patients with Breast Cancer. Ann Surg Oncol 2024; 31:365-375. [PMID: 37865937 DOI: 10.1245/s10434-023-14431-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/26/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND The objective of this study was to examine the association between racialized economic segregation, allostatic load (AL), and all-cause mortality in patients with breast cancer. PATIENTS AND METHODS Women aged 18+ years with stage I-III breast cancer diagnosed between 01/01/2012 and 31/12/2020 were identified in the Ohio State University cancer registry. Racialized economic segregation was measured at the census tract level using the index of concentration at the extremes (ICE). AL was calculated with biomarkers from the cardiac, metabolic, immune, and renal systems. High AL was defined as AL greater than the median. Univariable and multivariable regression analyses using restricted cubic splines examined the association between racialized economic segregation, AL, and all-cause mortality. RESULTS Among 4296 patients, patients residing in neighborhoods with the highest racialized economic segregation (Q1 versus Q4) were more likely to be Black (25% versus 2.1%, p < 0.001) and have triple-negative breast cancer (18.2% versus 11.6%, p < 0.001). High versus low racialized economic segregation was associated with high AL [adjusted odds ratio (aOR) 1.40, 95% confidence interval (CI) 1.21-1.61] and worse all-cause mortality [adjusted hazard ratio (aHR) 1.41, 95% CI 1.08-1.83]. In dose-response analyses, patients in lower segregated neighborhoods (relative to the 95th percentile) had lower odds of high AL, whereas patients in more segregated neighborhoods had a non-linear increase in the odds of high AL. DISCUSSION Racialized economic segregation is associated with high AL and a greater risk of all-cause mortality in patients with breast cancer. Additional studies are needed to elucidate the causal pathways and mechanisms linking AL, neighborhood factors, and patient outcomes.
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Affiliation(s)
- J C Chen
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Demond Handley
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
- Secondary Data Core, Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, USA
| | - Mohamed I Elsaid
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
- Secondary Data Core, Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, USA
| | - Jesse J Plascak
- Division of Cancer Prevention and Control, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | | | - William E Carson
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Ruth C Carlos
- Division of Radiology, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA
| | - Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA.
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Guan Y, Shen J, Lu J, Fuemmeler BF, Shock LS, Zhao H. Association between allostatic load and breast cancer risk: a cohort study. Breast Cancer Res 2023; 25:155. [PMID: 38115125 PMCID: PMC10729373 DOI: 10.1186/s13058-023-01754-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/13/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Allostatic load (AL) reflects the collective load of chronic stress during lifetime. Previous studies have shown that higher AL is associated with poor clinical outcomes among breast cancer patients. However, the relationship between AL and breast cancer risk is still unclear. METHODS To fill the gap, we analyzed the association between AL and the development of breast cancer in 181,455 women identified from the UK Biobank. RESULTS During the follow-up from 2006 to 2020, 5,701 women were diagnosed with incident breast cancer. Significantly higher AL was observed among incident breast cancer cases than all study participants (mean: 2.77 vs. 2.63, P < 0.01). Univariate Cox regression analysis indicated the risk of breast cancer was increased by 5% per one AL unit increase (hazard ratio (HR) = 1.05, 95% confidence interval (CI) 1.04, 1.07). In multivariate analyses, after adjusting demographics, family history of breast cancer, reproductive factors, socioeconomic status, lifestyle factors, and breast cancer polygenic risk score (PRS), the significant association remained (HR = 1.05, 95%CI 1.03, 1.07). The significant relationship was further confirmed in the categorical analysis. Compared with women in the low AL group (AL: 0 ~ 2), those in the high AL group (AL: 3 ~ 11) had a 1.17-fold increased risk of breast cancer (HR = 1.17, 95%CI 1.11, 1.24). Finally, in the stratified analysis, joint effects on the risk of breast cancer were observed between the AL and selected known breast cancer risk factors, including age, family history of breast cancer, PRS, income, physical activity, and alcohol consumption. CONCLUSION In summary, those findings have demonstrated that higher AL was associated with an increased breast cancer risk in women. This association is likely independent of known breast cancer risk factors. Thus, the AL could be a valuable biomarker to help breast cancer risk prediction and stratification.
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Affiliation(s)
- Yufan Guan
- Departments of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - Jie Shen
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, 22903, USA
| | - Juan Lu
- Departments of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - Bernard F Fuemmeler
- Departments of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - Lisa S Shock
- Departments of Microbiology and Immunology, School of Medicine, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - Hua Zhao
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, 22903, USA.
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Yap YS. Outcomes in breast cancer-does ethnicity matter? ESMO Open 2023; 8:101564. [PMID: 37290358 DOI: 10.1016/j.esmoop.2023.101564] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 06/10/2023] Open
Abstract
Ethnic or racial differences in breast cancer (BC) survival outcomes have been reported, but current data are largely restricted to comparisons between African Americans and non-Hispanic whites. Most analyses have traditionally been based on self-reported race which may not always be accurate, or are oversimplified in their classification. With increasing globalization, quantification of the genetic ancestry from genomic data may offer a solution to infer the complex makeup from admixture of races. Focusing on the larger and the latest studies, we will discuss recent findings on the differing host and tumor biology that may be driving these disparities, in addition to the extrinsic environmental or lifestyle factors. Socioeconomic disparities with lower cancer literacy may lead to late presentation, poorer adherence to treatment, and other lifestyle factors such as unhealthy diet, obesity, and inadequate physical activity. These hardships may also result in greater allostatic load, which is in turn associated with aggressive BC features in disadvantaged populations. Epigenetic reprogramming may mediate the effects of the environment or lifestyle factors on gene expression, with ensuing differences in BC characteristics and outcome. There is increasing evidence that germline genetics can influence somatic gene alterations or expression, as well as modulate the tumor or immune microenvironment. Although the precise mechanisms remain elusive, this may account for the varying distribution of different BC subtypes across ethnicities. These gaps in our knowledge highlight the need to interrogate the multiomics landscape of BC in diverse populations, ideally in large-scale collaborative settings with standardized methodology for the comparisons to be statistically robust. Together with improving BC awareness and access to good quality health care, a holistic approach with insights of the biological underpinnings is much needed to eradicate ethnic disparities in BC outcomes.
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Affiliation(s)
- Y-S Yap
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore; Oncology Academic Clinical Programme, Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore.
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Obeng-Gyasi S, Elsaid MI, Lu Y, Chen JC, Carson WE, Ballinger TJ, Andersen BL. Association of Allostatic Load With All-Cause Mortality in Patients With Breast Cancer. JAMA Netw Open 2023; 6:e2313989. [PMID: 37200034 PMCID: PMC10196875 DOI: 10.1001/jamanetworkopen.2023.13989] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 04/04/2023] [Indexed: 05/19/2023] Open
Abstract
Importance Elevated allostatic load (AL) has been associated with adverse socioenvironmental stressors and tumor characteristics that convey poor prognosis in patients with breast cancer. Currently, the association between AL and all-cause mortality in patients with breast cancer is unknown. Objective To examine the association between AL and all-cause mortality in patients with breast cancer. Design, Setting, and Participants This cohort study used data from an institutional electronic medical record and cancer registry at the National Cancer Institute Comprehensive Cancer Center. Participants were patients with breast cancer diagnoses (stage I-III) between January 1, 2012, through December 31, 2020. Data were analyzed from April 2022 through November 2022. Exposure AL was expressed as a summary score calculated by assigning 1 point for biomarkers in the worst sample quartile. High AL was defined as AL greater than the median. Main Outcomes and Measures The main outcome was all-cause mortality. A Cox proportional hazard models with robust variance tested the association between AL and all-cause mortality. Results There were 4459 patients (median [IQR] age, 59 [49-67] years) with an ethnoracial distribution of 3 Hispanic Black patients (0.1%), 381 non-Hispanic Black patients (8.5%), 23 Hispanic White patients (0.5%), 3861 non-Hispanic White patients (86.6%), 27 Hispanic patients with other race (0.6%), and 164 non-Hispanic patients with other race (3.7%). The mean (SD) AL was 2.6 (1.7). Black patients (adjusted relative ratio [aRR], those with 1.11; 95% CI, 1.04-1.18), single marital status (aRR, 1.06; 95% CI, 1.00-1.12), and those with government-supplied insured (Medicaid aRR, 1.14; 95% CI, 1.07-1.21; Medicare aRR, 1.11; 95% CI, 1.03-1.19) had a higher adjusted mean AL than those who were White, married/living as married, or privately insured, respectively. Adjusting for sociodemographic, clinical, and treatment factors, high AL was associated with a 46% increase in mortality risk (hazard ratio [HR], 1.46; 95% CI, 1.11-1.93) over low AL. Similarly, compared with patients in the first AL quartile, those in the third quartile (HR, 1.53; 95% CI, 1.07-2.18) and the fourth quartile (HR, 1.79; 95% CI, 1.16-2.75) had significantly increased risks of mortality. There was a significant dose-dependent association between increased AL and a higher risk of all-cause mortality. Furthermore, AL remained significantly associated with higher all-cause mortality after adjusting for the Charlson Comorbidity Index. Conclusions and Relevance These findings suggest increased AL is reflective of socioeconomic marginalization and associated with all-cause mortality in patients with breast cancer.
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Affiliation(s)
- Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus
| | - Mohamed I. Elsaid
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus
- Secondary Data Core, Center for Biostatistics, College of Medicine, The Ohio State University, Columbus
| | - Yurong Lu
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus
| | - JC Chen
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus
| | - William E. Carson
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus
| | - Tarah J. Ballinger
- Department of Medicine, Indiana University School of Medicine, Indianapolis
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Neighborhood deprivation, racial segregation and associations with cancer risk and outcomes across the cancer-control continuum. Mol Psychiatry 2023; 28:1494-1501. [PMID: 36869227 DOI: 10.1038/s41380-023-02006-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/10/2023] [Accepted: 02/16/2023] [Indexed: 03/05/2023]
Abstract
The racial/ethnic disparities in cancer incidence and outcome are partially due to the inequities in neighborhood advantage. Mounting evidences supported a link between neighborhood deprivation and cancer outcomes including higher mortality. In this review, we discuss some of the findings related to work on area-level neighborhood variables and cancer outcomes, and the potential biological and built/natural environmental mechanisms that might explain this link. Studies have also shown that residents of deprived neighborhoods or of racially or economically segregated neighborhoods have worse health outcomes than residents of more affluent neighborhoods and/or less racially or economically segregated neighborhoods, even after adjusting for the individual-level socioeconomic status. To date, little research has been conducted investigating the biological mediators that may play roles in the associations of neighborhood deprivation and segregation with cancer outcomes. The psychophysiological stress induced by neighborhood disadvantage among people living in these neighborhoods could be a potential underlying biological mechanism. We examined a number of chronic stress-related pathways that may potentially mediate the relationship between area-level neighborhood factors and cancer outcomes, including higher allostatic load, stress hormones, altered epigenome and telomere maintenance and biological aging. In conclusion, the extant evidence supports the notion that neighborhood deprivation and racial segregation have unfavorable impacts on cancer. Understanding how neighborhood factors influence the biological stress response has the potential to inform where and what types of resources are needed within the community to improve cancer outcomes and reduce disparities. More studies are warranted to directly assess the role of biological and social mechanisms in mediating the relationship between neighborhood factors and cancer outcomes.
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10
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Owusu-Brackett N, Chen JC, Li Y, Fisher JL, Bhattacharyya O, Obeng-Gyasi S. Examining racial differences in treatment and survival among patients with Paget's disease of the breast. Surgery 2023; 173:619-625. [PMID: 36273972 DOI: 10.1016/j.surg.2022.07.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 07/25/2022] [Accepted: 07/30/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The objective of this study was to evaluate racial differences in treatment (ie, surgery, chemotherapy, and radiation) and survival among patients with Paget's disease of the breast in the Surveillance, Epidemiology and End Result program. METHODS Women >18 years old diagnosed with localized or regional Paget's disease between January 1, 2010 to December 31, 2016 in the Surveillance, Epidemiology and End Result program were included. The cohort was divided into Black and White patients. Univariable analysis compared the groups. Using propensity score matching, Black and White patients were nearest matched (1:2) on age at diagnosis; Surveillance, Epidemiology and End Result summary stage; surgery; chemotherapy; and year of diagnosis. The log-rank test evaluated the matched sample's overall survival and disease-specific survival. RESULTS Of the 1,181 patients, the racial distribution was 1,049 (88.8%) White and 132 (11.2%) Black. A higher percentage of Black women were Medicaid insured (Black 25.8% vs White 11.1%), lived in neighborhoods with low socioeconomic status (Black 53.0% vs White 25.4%), and had regional disease than White women (Black 41.7% vs White 29%). There were no racial differences in receipt of radiation therapy (P = .90), breast surgery (P = .23), or axillary surgery (P = .25). Black patients were more likely to receive chemotherapy (Black 34.8% vs White 26.3% P = .038). In the propensity matched cohort, Black patients had a worse overall survival (P < .005) and disease-specific survival (P = .05) than White patients. CONCLUSION In this cohort of patients with Paget's disease, despite differences in sociodemographic factors, there were no disparities in locoregional treatment. However, on matched analysis, Black patients had a worse overall survival and disease-specific survival than their White counterparts.
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Affiliation(s)
- Nicci Owusu-Brackett
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH
| | - J C Chen
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH. https://twitter.com/JCChenMD
| | - Yaming Li
- Department of Biomedical Informatics, University of Pittsburg, PA
| | - James L Fisher
- James Cancer Hospital and Solove Research Institute, Columbus, OH
| | | | - Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH.
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Lord BD, Harris AR, Ambs S. The impact of social and environmental factors on cancer biology in Black Americans. Cancer Causes Control 2023; 34:191-203. [PMID: 36562901 DOI: 10.1007/s10552-022-01664-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
Low socioeconomic status (SES) is associated with early onset of chronic diseases and reduced life expectancy. The involvement of neighborhood-level factors in defining cancer risk and outcomes for marginalized communities has been an active area of research for decades. Yet, the biological processes that underlie the impact of SES on chronic health conditions, such as cancer, remain poorly understood. To date, limited studies have shown that chronic life stress is more prevalent in low SES communities and can affect important molecular processes implicated in tumor biology such as DNA methylation, inflammation, and immune response. Further efforts to elucidate how neighborhood-level factors function physiologically to worsen cancer outcomes for disadvantaged communities are underway. This review provides an overview of the current literature on how socioenvironmental factors within neighborhoods contribute to more aggressive tumor biology, specifically in Black U.S. women and men, including the impact of environmental pollutants, neighborhood deprivation, social isolation, structural racism, and discrimination. We also summarize commonly used methods to measure deprivation, discrimination, and structural racism at the neighborhood-level in cancer health disparities research. Finally, we offer recommendations to adopt a multi-faceted intersectional approach to reduce cancer health disparities and develop effective interventions to promote health equity.
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Affiliation(s)
- Brittany D Lord
- Laboratory of Human Carcinogenesis, Center for Cancer Research, National Cancer Institute (NCI), National Institutes of Health (NIH), Bldg. 37/Room 3050, Bethesda, MD, 20892-4258, USA.
| | - Alexandra R Harris
- Laboratory of Human Carcinogenesis, Center for Cancer Research, National Cancer Institute (NCI), National Institutes of Health (NIH), Bldg. 37/Room 3050, Bethesda, MD, 20892-4258, USA
| | - Stefan Ambs
- Laboratory of Human Carcinogenesis, Center for Cancer Research, National Cancer Institute (NCI), National Institutes of Health (NIH), Bldg. 37/Room 3050, Bethesda, MD, 20892-4258, USA
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Barrett M, Wilcox NS, Huang A, Levy R, Demissei B, Narayan V, Ky B. Bearing allostatic load: insights into a more equitable future within cardio-oncology. Trends Mol Med 2022; 28:1040-1049. [PMID: 36207229 DOI: 10.1016/j.molmed.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/23/2022] [Accepted: 09/08/2022] [Indexed: 11/09/2022]
Abstract
Chronic stress is often regarded as a significant cause of morbidity and mortality; however, the mechanistic link between stress and various disease states has not yet been fully characterized. We explore the concept of allostatic load, a measurement of the physiological burden of chronic stress, as well as its potential role in disease pathogenesis as it relates to cardiovascular disease, cancer, and health-related disparities. Building from this framework, we then posit the potential implications of allostatic load on patient care and research in cardio-oncology. We identify allostatic load as a potential clinically actionable tool to improve health equity in cardio-oncology.
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Affiliation(s)
- Matthew Barrett
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nicholas S Wilcox
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anran Huang
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Richard Levy
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Biniyam Demissei
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Vivek Narayan
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Bonnie Ky
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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13
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Allostatic Load and Breast Cancer: a Systematic Review of the Literature. CURRENT BREAST CANCER REPORTS 2022. [DOI: 10.1007/s12609-022-00455-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Shen J, Fuemmeler BF, Sheppard VB, Bear HD, Song R, Chow WH, Zhao H. Neighborhood disadvantage and biological aging biomarkers among breast cancer patients. Sci Rep 2022; 12:11006. [PMID: 35773311 PMCID: PMC9246873 DOI: 10.1038/s41598-022-15260-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/21/2022] [Indexed: 11/09/2022] Open
Abstract
Living in a disadvantaged neighborhood is associated with adverse clinical outcomes among breast cancer patients, but the underlying pathway is still unclear. Limited evidence has suggested that accelerated biological aging may play an important role. In this study, using a sub-sample of 906 women with newly diagnosed breast cancer at M.D. Anderson, we examined whether levels of selected markers of biological aging (e.g., allostatic load, telomere length, and global DNA methylation) were affected by neighborhood disadvantage. The Area Deprivation Index was used to determine the neighborhood disadvantage. Based on the median ADI at the national level, the study population was divided into low and high ADI groups. Overall, breast cancer patients from the high ADI group were more likely to be younger and non-Hispanic Black than those from the low ADI group (P < 0.001, respectively). They were also more likely to have higher grade and poorly differentiated breast tumors (P = 0.029 and 0.019, respectively). For the relationship with markers, compared to the low ADI group, high ADI group had higher median levels of allostatic load (P = 0.046) and lower median levels of global DNA methylation (P < 0.001). Compared to their counterparts, those from the high ADI group were 20% more likely to have increased allostatic load and 51% less likely to have increased levels of global DNA methylation. In summary, we observed that levels of allostatic load and global DNA methylation are influenced by neighborhood disadvantage among breast cancer patients.
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Affiliation(s)
- Jie Shen
- Departments of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - Bernard F Fuemmeler
- Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - Vanessa B Sheppard
- Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - Harry D Bear
- Department of Surgery, School of Medicine, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - Renduo Song
- Departments of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Wong-Ho Chow
- Departments of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Hua Zhao
- Departments of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, VA, 23284, USA.
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15
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Association of Allostatic Load and All Cancer Risk in the SWAN Cohort. Cancers (Basel) 2022; 14:cancers14133044. [PMID: 35804816 PMCID: PMC9264860 DOI: 10.3390/cancers14133044] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/13/2022] [Accepted: 06/16/2022] [Indexed: 11/23/2022] Open
Abstract
Elevated chronic stress is thought to increase cancer risk, though the results so far have been inconsistent. In this study, we assessed the relationship between allostatic load (AL), a biological indicator of chronic stress, and overall cancer risk in 3015 women who participated in the Study of Women’s Health Across the Nation (SWAN). Based on the distribution of AL, the study population was categorized into four groups, from the lowest (1st category) to the highest AL group (4th category). At baseline, African American and Hispanic women were more likely to be in the higher AL categories than White women (p < 0.001). In addition, women who smoked regularly, drank alcohol regularly, had no leisure physical activity, and had restless sleep were also more likely to be in the higher AL categories than their relative counterparts (p < 0.001). We also observed that women in the lower-income category with no health insurance were more likely to be in the higher AL category (p < 0.001). The study then found that women in the 4th category of AL (the highest AL group) had a 1.64-fold increased risk of overall cancer (Hazard ratio (HR): 1.64, 95% confidence interval (CI): 1.04, 2.59). The risk association was further strengthened after adjusting demographics, healthy behaviors, and socioeconomic factors with an HR of 2.08. In further analysis of individual biomarkers of AL score, we found that higher levels of triglyceride and CRP were associated with increased risk of cancer, highlighting the role of metabolic dysfunction and inflammation in the etiology of cancer development. In summary, we report that higher AL is associated with increased cancer risk.
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Obeng-Gyasi S. Invited Commentary: It Is Time for Theoretically Informed Approaches to Surgical Disparities Research. J Am Coll Surg 2022; 234:772-773. [PMID: 35426389 PMCID: PMC9139040 DOI: 10.1097/xcs.0000000000000067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, Ohio, USA
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17
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Allostatic Load as an Insight into the Psychological Burden after Primary Treatment in Women with Breast Cancer: Influence of Physical Side Effects and Pain Perception. J Clin Med 2022; 11:jcm11082144. [PMID: 35456237 PMCID: PMC9031666 DOI: 10.3390/jcm11082144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/04/2022] [Accepted: 04/11/2022] [Indexed: 12/12/2022] Open
Abstract
Breast cancer (BC) diagnosis and treatment have become a cumulative long-standing chronic disease impairment, causing stress and turning into an allostatic load (AL) framework. This study aimed to investigate the relationship between physical issues and mental health in patients with BC after medical treatment. We conducted an observational study of 61 female patients with BC, and clinical and psychological markers have been detected. We conducted descriptive statistics, ANOVA analyses, correlations, and mediation analyses to verify the effect of the comorbidity index on psychological dimensions. The findings showed high levels of distress and moderate pain, and 32.8% of the patients showed moderate physical impairment. Significant effects of “age” and “physical issues” were found. The adult group reported a higher incidence of physical issues, and the group of patients reporting moderate physical impairment seemed more depressed than patients with mild physical issues. Finally, the comorbidity condition mediated the presence of signs of depression. Patients with BC seemed to experience negative emotions related to comorbidities associated with compromised activities of daily living. Our findings highlighted allostatic overload as a predictive framework to better understand the mental health of women with BC diagnoses to tailor effective psychological treatments for enhanced recovery.
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Sadigh G, Gray RJ, Sparano JA, Yanez B, Garcia SF, Timsina LR, Obeng-Gyasi S, Gareen I, Sledge GW, Whelan TJ, Cella D, Wagner LI, Carlos RC. Assessment of Racial Disparity in Survival Outcomes for Early Hormone Receptor-Positive Breast Cancer After Adjusting for Insurance Status and Neighborhood Deprivation: A Post Hoc Analysis of a Randomized Clinical Trial. JAMA Oncol 2022; 8:579-586. [PMID: 35175284 PMCID: PMC8855314 DOI: 10.1001/jamaoncol.2021.7656] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Racial disparities in survival outcomes among Black women with hormone receptor-positive breast cancer have been reported. However, the association between individual-level and neighborhood-level social determinants of health on such disparities has not been well studied. OBJECTIVE To evaluate the association between race and clinical outcomes (ie, relapse-free interval and overall survival) adjusting for individual insurance coverage and neighborhood deprivation index (NDI), measured using zip code of residence, in women with breast cancer. DESIGN, SETTING, AND PARTICIPANTS This was a post hoc analysis of 9719 women with breast cancer in the Trial Assigning Individualized Options for Treatment, a randomized clinical trial conducted from April 7, 2006, to October 6, 2010. All participants received a diagnosis of hormone receptor-positive, ERBB2-negative, axillary node-negative breast cancer. The present data analysis was conducted from April 1 to October 22, 2021. MAIN OUTCOMES AND MEASURES A multivariate model was developed to evaluate the association between race and relapse-free interval and overall survival adjusting for insurance and NDI level at study entry, early discontinuation of endocrine therapy 4 years after initiation, and clinicopathologic characteristics of cancer. Median follow-up for clinical outcomes was 96 months. RESULTS A total of 9719 women (4.2% [n = 405] Asian; 7.1% [n = 693] Black; 84.3% [n = 8189] White; 4.4% [n = 403] others/not specified) were included; 9.1% of included women [n = 889] were Hispanic or Latino. Median (SD) age was 56 (9.2) years. In multivariate models, Black race compared with White race was associated with statistically significant shorter relapse-free interval (hazard ratio [HR], 1.39; 95% CI, 1.05-1.84; P = .02) and overall survival (HR, 1.49; 95% CI, 1.10-2.99; P = .009), adjusting for insurance and NDI level at study entry and other factors. Although uninsured status was not associated with clinical outcomes, patients with Medicare (HR, 1.30; 95% CI, 1.01-1.68; P = .04) and Medicaid (HR, 1.44; 95% CI, 1.01-2.05; P = .05) had shorter overall survival compared with those with private insurance. Participants living in neighborhoods in the highest NDI quartile experienced shorter overall survival compared with those in the lowest quartile (HR, 1.34; 95% CI, 1.01-1.77; P = .04), regardless of self-identified race. CONCLUSIONS AND RELEVANCE The findings of this post hoc analysis of a randomized clinical trial suggest that Black women with breast cancer have significantly shorter relapse-free interval and overall survival compared with White women. Early discontinuation of endocrine therapy, clinicopathologic characteristics, insurance coverage, and NDI do not fully explain the observed disparity. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00310180.
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Affiliation(s)
- Gelareh Sadigh
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Robert J. Gray
- Dana Farber Cancer Institute, ECOG-ACRIN Biostatistics Center, Boston, Massachusetts
| | - Joseph A. Sparano
- Department of Hematology and Oncology, The Mount Sinai Hospital, New York, New York
| | - Betina Yanez
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sofia F. Garcia
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lava R. Timsina
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus
| | - Ilana Gareen
- Center for Statistical Sciences, Brown University, Providence, Rhode Island
| | | | - Timothy J. Whelan
- Canadian Cancer Trials Group, McMaster University, Hamilton, Ontario, Canada
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lynne I. Wagner
- Wake Forest University Health Sciences, Winston Salem, North Carolina
| | - Ruth C. Carlos
- University of Michigan Comprehensive Cancer Center, Ann Arbor
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Interrogating Patterns of Cancer Disparities by Expanding the Social Determinants of Health Framework to Include Biological Pathways of Social Experiences. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042455. [PMID: 35206642 PMCID: PMC8872134 DOI: 10.3390/ijerph19042455] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 02/01/2023]
Abstract
The objective of this article is to call for integrating biological pathways of social experiences in the concept model of cancer disparities and social determinants of health (SDH) fields. Black, Indigenous, and People of Color (BIPOC) populations experience more negative outcomes across the cancer continuum. Social conditions are instrumental in better understanding the contemporary and historical constructs that create these patterns of disparities. There is an equally important body of evidence that points to the ways that social conditions shape biological pathways. To date, these areas of research are, for the most part, separate. This paper calls for a bridging of these two areas of research to create new directions for the field of cancer disparities. We discuss inflammation, epigenetic changes, co-morbidities, and early onset as examples of the biological consequences of social conditions that BIPOC populations experience throughout their lifespan that may contribute to disproportionate tumorigenesis and tumor progression.
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20
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Obeng-Gyasi S, Tarver W, Carlos RC, Andersen BL. Allostatic load: a framework to understand breast cancer outcomes in Black women. NPJ Breast Cancer 2021; 7:100. [PMID: 34330927 PMCID: PMC8324921 DOI: 10.1038/s41523-021-00309-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 07/01/2021] [Indexed: 02/06/2023] Open
Affiliation(s)
- Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA.
| | - Willi Tarver
- Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Ruth C Carlos
- Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI, USA
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