The Community-Level Impact of Poverty on Late-Stage Breast Cancer

Poverty is a pervasive health challenge in many communities. Take Roxbury, Massachusetts, a historically underserved Boston neighborhood with a predominantly Black and Hispanic population. This is the neighborhood where I lived while earning my graduate degree. Just two miles away, Back Bay, a wealthy neighborhood and tourist hub, has a life expectancy more than 22 years longer than Roxbury’s. Not only do incomes differ by more than $100,000, but resources also differ. While I frequented Back Bay for groceries and medical appointments, and the commercial buzz of Newbury Street, many of my Roxbury neighbors relied on corner stores and emergency medical care.

Regardless of their individual circumstances, many Roxbury residents simply do not have adequate resources readily available to them. People’s environments, rather than personal health choices, affect their ability to live healthy lives.

The aforementioned health challenges can heighten the risk of chronic illnesses, including cancer. Residents of low-income neighborhoods face barriers to early diagnosis, which is critical for many cancers, including breast cancer. Early-stage breast cancer has a five-year survival rate of 99%, while late-stage breast cancer survival drops to just 32%. Counties with higher poverty rates show a higher proportion of late-stage breast cancer diagnoses. Individuals in these areas are less likely to be screened and more likely to be diagnosed with advanced-stage breast cancer.

Noting the contrast between the neighborhoods I frequented, I wanted to understand the effects of community-level, sustained poverty on breast cancer diagnosis. My team’s research focused on persistently poor counties, which have had a poverty rate higher than 20% since 1990. While previous research has examined the role of poverty in late-stage cancer diagnosis, most research analyzes recent poverty and has not considered the modulating roles of other related factors, including county-level rural-urban location and racial and ethnic composition. These factors are relevant, as rural communities show lower rates of breast cancer overall, but higher rates of cancer mortality, indicating late-stage diagnosis. Additionally, one of the most aggressive tumor subtypes, triple-negative breast cancer, is usually caught in late stages and is most prevalent among non-Hispanic Black women.

Although late-stage breast cancer diagnoses have decreased overall since 2004, regions with persistent poverty and rural communities have experienced minimal progress.

Our team modeled differences in late-stage breast cancer diagnosis rates between counties facing persistent poverty and those with adequate income between 2017 and 2021 using data from the Surveillance, Epidemiology, and End Results (SEER) program. We also compared differences in diagnosis rates across rural and urban counties based on county-level Rural-Urban Continuum Codes, as well as between counties with small (5% or fewer) and large (over 5%) non-Hispanic Black populations based on American Community Survey data. Lastly, we evaluated trends in breast cancer diagnosis between 2004 and 2021, comparing trends across persistent poverty and rural-urban levels.

Late-stage breast cancer rates were higher in counties facing persistent poverty, which showed an average increase of 5.78 cases per 100,000 individuals. Counties with a prominent non-Hispanic Black population showed an even larger increase, meaning that structural racism exacerbates the relationship between poverty and timely breast cancer diagnosis.

While overall late-stage breast cancer diagnoses have declined since 2004, areas experiencing persistent poverty and rural communities have seen little progress. In fact, since 2017, late-stage diagnoses have increased in these regions. This could be linked to policy changes, like cuts to the Affordable Care Act and the National Breast and Cervical Cancer Early Detection Program, which reduced access to screenings.

The impact of socioeconomic and geographic factors, as well as systemic racism, is visible on the two-mile bus ride from Roxbury to Back Bay and is evident in our research. Since these barriers to health are often interconnected, future research should focus on understanding how systemic, environmental, and lifestyle factors contribute to late-stage diagnoses in different areas. Tailored solutions, such as expanding health insurance access and targeted education on the importance of regular screenings, are key to improving outcomes.