Journal of Community Health

, Volume 35, Issue 4, pp 398–408 | Cite as

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

  • Erica T. WarnerEmail author
  • Scarlett Lin Gomez
Original Paper


We examined the impact of metropolitan racial residential segregation on stage at diagnosis and all-cause and breast cancer-specific survival between and within black and white women diagnosed with breast cancer in California between 1996 and 2004. We merged data from the California Cancer Registry with Census indices of five dimensions of racial residential segregation, quantifying segregation among Blacks relative to Whites; block group (“neighborhood”) measures of the percentage of Blacks and a composite measure of socioeconomic status. We also examined simultaneous segregation on at least two measures (“hypersegregation”). Using logistic regression we examined effects of these measures on stage at diagnosis and Cox proportional hazards regression for survival. For all-cause and breast-cancer specific mortality, living in neighborhoods with more Blacks was associated with lower mortality among black women, but higher mortality among Whites. However, neighborhood racial composition and metropolitan segregation did not explain differences in stage or survival between Black and White women. Future research should identify mechanisms by which these measures impact breast cancer diagnosis and outcomes among Black women.


Breast cancer Survival Stage at diagnosis Residential segregation Race 



This study was supported by National Cancer Institute grants R03 CA117324-01A1 and R25CA78583 and a SEER Rapid Response Surveillance Study under the National Cancer Institute contract N01-PC-35136. Additional support was provided by National Institutes of Health grant 5R25GMO55353-12. The collection of cancer incidence data used in this study was supported by the California Department of Health Services as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885; the National Cancer Institute’s Surveillance, Epidemiology and End Results Program under contract N01-PC-35136 awarded to the NCCC, contract N01-PC-35139 awarded to the University of Southern California, and contract N02-PC-15105 awarded to the Public Health Institute; and the Centers for Disease Control and Prevention’s National Program of Cancer Registries.


  1. 1.
    Curtis, E., Quale, C., Haggstrom, D., & Smith-Bindman, R. (2008). Racial and ethnic differences in breast cancer survival: How much is explained by screening, tumor severity, biology, treatment, comorbidities, and demographics? Cancer, 112, 171–180.CrossRefPubMedGoogle Scholar
  2. 2.
    Li, C. I. (2005). Racial and ethnic disparities in breast cancer stage, treatment, and survival in the United States. Ethnicity and Disease, 15, S5–S9.PubMedGoogle Scholar
  3. 3.
    Li, C. I., Malone, K. E., & Daling, J. R. (2003). Differences in breast cancer stage, treatment, and survival by race and ethnicity. Archives of Internal Medicine, 163, 49–56.CrossRefPubMedGoogle Scholar
  4. 4.
    Smigal, C., Jemal, A., Ward, E., et al. (2006). Trends in breast cancer by race and ethnicity: Update 2006. CA: A Cancer Journal for Clinicians, 56, 168–183.CrossRefGoogle Scholar
  5. 5.
    American Hospital Association. (1996). AHA Guide to the Health Care Field, 1995–96. Chicago, IL: American Hospital Association.Google Scholar
  6. 6.
    Eley, J. W., Hill, H. A., Chen, V. W., et al. (1994). Racial differences in survival from breast cancer. Results of the National Cancer Institute Black/White Cancer Survival Study. Journal of the American Medical Association, 272, 947–954.CrossRefPubMedGoogle Scholar
  7. 7.
    Ansell, D., Whitman, S., Lipton, R., & Cooper, R. (1993). Race, income, and survival from breast cancer at two public hospitals. Cancer, 72, 2974–2978.CrossRefPubMedGoogle Scholar
  8. 8.
    Bassett, M. T., & Krieger, N. (1986). Social class and black-white differences in breast cancer survival. American Journal of Public Health, 76, 1400–1403.CrossRefPubMedGoogle Scholar
  9. 9.
    Boyer-Chammard, A., Taylor, T. H., & Anton-Culver, H. (1999). Survival differences in breast cancer among racial/ethnic groups: A population-based study. Cancer Detection and Prevention, 23, 463–473.CrossRefPubMedGoogle Scholar
  10. 10.
    Williams, D. R., & Rucker, T. D. (2000). Understanding and addressing racial disparities in health care. Health Care Financing Review, 21, 75–90.PubMedGoogle Scholar
  11. 11.
    Lantz, P. M., Mujahid, M., Schwartz, K., et al. (2006). The influence of race, ethnicity, and individual socioeconomic factors on breast cancer stage at diagnosis. American Journal of Public Health, 96, 2173–2178.CrossRefPubMedGoogle Scholar
  12. 12.
    Jones, C. (2002). The impact of racism on health. Ethnicity and Disease, 12: S2-10–13.Google Scholar
  13. 13.
    Williams, D. R., & Collins, C. (2001). Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Reports, 116, 404–416.PubMedGoogle Scholar
  14. 14.
    Wen, M., Browning, C. R., & Cagney, K. A. (2003). Poverty, affluence, and income inequality: neighborhood economic structure and its implications for health. Social Science Medicine, 57, 843–860.CrossRefPubMedGoogle Scholar
  15. 15.
    Acevedo-Garcia, D., Lochner, K. A., Osypuk, T. L., & Subramanian, S. V. (2003). Future directions in residential segregation and health research: A multilevel approach. American Journal of Public Health, 93, 215–221.CrossRefPubMedGoogle Scholar
  16. 16.
    Krivo, L. J., & Kaufman, R. L. (2004). Housing and wealth inequality: Racial-ethnic differences in home equity in the United States. Demography, 41, 585–605.CrossRefPubMedGoogle Scholar
  17. 17.
    Schulz, A., Israel, B., Williams, D., Parker, E., Becker, A., & James, S. (2000). Social inequalities, stressors and self reported health status among African American and white women in the Detroit metropolitan area. Social Science Medicine, 51, 1639–1653.CrossRefPubMedGoogle Scholar
  18. 18.
    Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener’s tale. American Journal of Public Health, 90, 1212–1215.CrossRefPubMedGoogle Scholar
  19. 19.
    Fischer, M. J. (2003). The relative importance of income, race in determining residential outcomes in U.S. urban areas, 1970–2000. Urban Affairs Review, 38, 669–696.CrossRefGoogle Scholar
  20. 20.
    Acevedo-Garcia, D. (2000). Residential segregation and the epidemiology of infectious diseases. Social Science Medicine, 51, 1143–1161.CrossRefPubMedGoogle Scholar
  21. 21.
    Massey, D. S. (2000). How segregation concentrates poverty. Ethnic and Racial Studies, 23, 670–691.CrossRefGoogle Scholar
  22. 22.
    Polednak, A. P. (1996). Segregation, discrimination and mortality in U.S. blacks. Ethnicity and Disease, 6, 99–108.PubMedGoogle Scholar
  23. 23.
    Massey, D. S., & Denton, N. A. (1989). Hypersegregation in U.S. metropolitan areas: Black and Hispanic segregation along five dimensions. Demography, 26, 373–391.CrossRefPubMedGoogle Scholar
  24. 24.
    Wilkes, R., & Iceland, J. (2004). Hypersegregation in the twenty-first century. Demography, 41, 23–36.CrossRefPubMedGoogle Scholar
  25. 25.
    Kawachi, I. (2002). Income inequality and economic residential segregation. Journal of Epidemiology and Community Health, 56, 165–166.CrossRefPubMedGoogle Scholar
  26. 26.
    Din-Dzietham, R., Nembhard, W. N., Collins, R., & Davis, S. K. (2004). Perceived stress following race-based discrimination at work is associated with hypertension in African-Americans. The metro Atlanta heart disease study, 1999–2001. Social Science Medicine, 58, 449–461.CrossRefPubMedGoogle Scholar
  27. 27.
    Kwate, N. O., Valdimarsdottir, H. B., Guevarra, J. S., & Bovbjerg, D. H. (2003). Experiences of racist events are associated with negative health consequences for African American women. Journal of the National Medicine Association, 95, 450–460.Google Scholar
  28. 28.
    Jackson, S. A., Anderson, R. T., Johnson, N. J., & Sorlie, P. D. (2000). The relation of residential segregation to all-cause mortality: A study in black and white. American Journal of Public Health, 90, 615–617.CrossRefPubMedGoogle Scholar
  29. 29.
    Polednak, A. P. (1993). Poverty, residential segregation, and black/white mortality ratios in urban areas. Journal of Health Care for the Poor Underserved, 4, 363–373.PubMedGoogle Scholar
  30. 30.
    Laveist, T. A. (1993). Segregation, poverty, and empowerment: health consequences for African Americans. Milbank Quarterly, 71, 41–64.CrossRefPubMedGoogle Scholar
  31. 31.
    Polednak, A. P. (1996). Trends in US urban black infant mortality, by degree of residential segregation. American Journal of Public Health, 86, 723–726.CrossRefPubMedGoogle Scholar
  32. 32.
    Shihadeh, E. S., & Flynn, N. (1996). Segregation and crime: The effect of black social isolation on the rates of black urban violence. Social Forces, 74, 1325–1352.CrossRefGoogle Scholar
  33. 33.
    Sucoff, C. A., & Upchurch, D. M. (1998). Neighborhood context and the risk of childbearing among metropolitan-area black adolescents. American Sociological Review, 63, 571–585.CrossRefGoogle Scholar
  34. 34.
    Cooper, R. S. (2001). Social inequality, ethnicity and cardiovascular disease. International Journal of Epidemiology, 30(Suppl 1), S48–S52.PubMedGoogle Scholar
  35. 35.
    Acevedo-Garcia, D. (2001). Zip code-level risk factors for tuberculosis: neighborhood environment and residential segregation in New Jersey, 1985–1992. American Journal of Public Health, 91, 734–741.CrossRefPubMedGoogle Scholar
  36. 36.
    Subramanian, S. V., Acevedo-Garcia, D., & Osypuk, T. L. (2005). Racial residential segregation and geographic heterogeneity in black/white disparity in poor self-rated health in the US: A multilevel statistical analysis. Social Science Medicine, 60, 1667–1679.CrossRefPubMedGoogle Scholar
  37. 37.
    Lopez, R. (2002). Segregation and black/white differences in exposure to air toxics in 1990. Environmental Health Perspectives, 110, 289.PubMedGoogle Scholar
  38. 38.
    Morello-Frosch, R., & Jesdale, B. M. (2006). Separate and unequal: Residential segregation and estimated cancer risks associated with ambient air toxics in U.S. metropolitan areas. Environmental Health Perspectives, 114, 386–393.CrossRefPubMedGoogle Scholar
  39. 39.
    U.S. Census Bureau, Housing and Household Economic Statistics Division. (2006). Place Table Creation. Available at:
  40. 40.
    United States Census Bureau, Housing and Household Economic Statistics Division. (2006). Place MS Excel Files. Available at:
  41. 41.
    Iceland J., & Lake C. (2004). The effect of immigration on residential segregation in U.S. metropolitan areas. Available at:
  42. 42.
    Steinmetz E., & Iceland J. (2000). Racial and ethnic residential housing patterns in places: 2000. Available at:
  43. 43.
    Massey, D. S. (2001). Residential segregation and neighborhood conditions in US metropolitan areas. America Becoming: Racial Trends and their Consequences, 1, 391–434.Google Scholar
  44. 44.
    Massey, D. S., & Denton, N. A. (1988). The dimensions of residential segregation. Social Forces, 67, 281–315.CrossRefGoogle Scholar
  45. 45.
    Yost, K. N., Perkins, C. N., Cohen, R. N., Morris, C. N., & Wright, W. N. (2001). Socioeconomic status and breast cancer incidence in California for different race/ethnic groups. Cancer Causes and Control, 12, 703–711.CrossRefPubMedGoogle Scholar
  46. 46.
    Eschbach, K., Mahnken, J. D., & Goodwin, J. S. (2005). Neighborhood composition and incidence of cancer among Hispanics in the United States. Cancer, 103, 1036–1044.CrossRefPubMedGoogle Scholar
  47. 47.
    Barrett, R. E., Cho, Y. I., Weaver, K. E., et al. (2008). Neighborhood change and distant metastasis at diagnosis of breast cancer. Annals of Epidemiology, 18, 43–47.CrossRefPubMedGoogle Scholar
  48. 48.
    Barry, J., & Breen, N. (2005). The importance of place of residence in predicting late-stage diagnosis of breast or cervical cancer. Health and Place, 11, 15–29.CrossRefPubMedGoogle Scholar
  49. 49.
    Reyes-Ortiz, C. A., Eschbach, K., Zhang, D. D., & Goodwin, J. S. (2008). Neighborhood composition and cancer among Hispanics: Tumor stage and size at time of diagnosis. Cancer Epidemiology, Biomarkers and Prevention, 17, 2931–2936.CrossRefPubMedGoogle Scholar
  50. 50.
    Haas J. S., Earle, C. C., Orav J. E., et al. (2008). Racial segregation and disparities in breast cancer care and mortality. Cancer 113.Google Scholar
  51. 51.
    Haas, J. S., Earle, C. C., Orav, J. E., Brawarsky, P., Neville, B. A., & Williams, D. R. (2008). Racial segregation and disparities in cancer stage for seniors. Journal of General Internal Medicine, 23, 699–705.CrossRefPubMedGoogle Scholar
  52. 52.
    Rosenberg, L., Wise, L. A., Palmer, J. R., Horton, N. J., & Adams-Campbell, L. L. (2005). A multilevel study of socioeconomic predictors of regular mammography use among African-American women. Cancer Epidemiology, Biomarkers and Prevention, 14, 2628–2633.CrossRefPubMedGoogle Scholar
  53. 53.
    Datta, G. D., Colditz, G. A., Kawachi, I., Subramanian, S. V., Palmer, J. R., & Rosenberg, L. (2006). Individual-, neighborhood-, and state-level socioeconomic predictors of cervical carcinoma screening among U.S. black women: a multilevel analysis. Cancer, 106, 664–669.CrossRefPubMedGoogle Scholar
  54. 54.
    Reynolds, P. (1994). The relationship between social ties and survival among black and white breast cancer patients. National Cancer Institute Black/White Cancer Survival Study Group. Cancer Epidemiology, Biomarkers and Prevention, 3, 253–259.PubMedGoogle Scholar
  55. 55.
    Weihs, K. L., Enright, T. M., & Simmens, S. J. (2008). Close relationships and emotional processing predict decreased mortality in women with breast cancer: Preliminary evidence. Psychosomatic Medicine, 70, 117.CrossRefPubMedGoogle Scholar
  56. 56.
    Weihs, K. L., Simmens, S. J., Mizrahi, J., Enright, T. M., Hunt, M. E., & Siegel, R. S. (2005). Dependable social relationships predict overall survival in Stages II and III breast carcinoma patients. Journal of Psychosomatic Research, 59, 299–306.CrossRefPubMedGoogle Scholar
  57. 57.
    Kroenke, C. H., Kubzansky, L. D., Schernhammer, E. S., Holmes, M. D., & Kawachi, I. (2006). Social networks, social support, and survival after breast cancer diagnosis. Journal of Clinical Oncology, 24, 1105.CrossRefPubMedGoogle Scholar
  58. 58.
    Stainback, K., & Connotea, C. U. L. (2008). Social contacts and race/ethnic job matching. Social Forces, 87, 857.CrossRefGoogle Scholar
  59. 59.
    Echenique, F., & Fryer, R. G., Jr. (2007). A measure of segregation based on social interactions. The Quarterly Journal of Economics, 122, 441–485.CrossRefGoogle Scholar
  60. 60.
    Smith, K. P., & Christakis, N. A. (2008). Social networks and health. Annual Reviews of Sociology, 34, 405–429.CrossRefGoogle Scholar
  61. 61.
    Schulz, A. J., Israel, B. A., Zenk, S. N., et al. (2006). Psychosocial stress and social support as mediators of relationships between income, length of residence and depressive symptoms among African American women on Detroit’s eastside. Social Science Medicine, 62, 510–522.CrossRefPubMedGoogle Scholar
  62. 62.
    Uchino, B. N. (2006). Social support and health: A review of physiological processes potentially underlying links to disease outcomes. Journal of Behavioral Medicine, 29, 377–387.CrossRefPubMedGoogle Scholar
  63. 63.
    Chida, Y., Hamer, M., Wardle, J., & Steptoe, A. (2008). Do stress-related psychosocial factors contribute to cancer incidence and survival? Nature Clinical Practice Oncology, 5, 466–475.CrossRefPubMedGoogle Scholar
  64. 64.
    Marchick, J., & Henson, D. E. (2005). Correlations between access to mammography and breast cancer stage at diagnosis. Cancer, 103, 1571–1580.CrossRefPubMedGoogle Scholar
  65. 65.
    McCarthy, E. P., Burns, R. B., Coughlin, S. S., et al. (1998). Mammography use helps to explain differences in breast cancer stage at diagnosis between older black and white women. Annals of Internal Medicine, 128, 729–736.PubMedGoogle Scholar
  66. 66.
    Randolph, W. M., Goodwin, J. S., Mahnken, J. D., & Freeman, J. L. (2002). Regular mammography use is associated with elimination of age-related disparities in size and stage of breast cancer at diagnosis. Annals of Internal Medicine, 137, 783–790.PubMedGoogle Scholar
  67. 67.
    Smith-Bindman, R., Miglioretti, D. L., Lurie, N., et al. (2006). Does utilization of screening mammography explain racial and ethnic differences in breast cancer? Annals of Internal Medicine, 144, 541–553.PubMedGoogle Scholar
  68. 68.
    Tarlov, E., Zenk, S. N., Campbell, R. T., Warnecke, R. B., & Block, R. (2009). Characteristics of mammography facility locations and stage of breast cancer at diagnosis in Chicago. Journal of Urban Health, 86, 196–213.CrossRefPubMedGoogle Scholar
  69. 69.
    Zenk, S. N., Tarlov, E., & Sun, J. (2006). Spatial equity in facilities providing low- or no-fee screening mammography in Chicago neighborhoods. Journal of Urban Health, 83, 195–210.CrossRefPubMedGoogle Scholar
  70. 70.
    Babey, S. H., Ponce, N. A., Etzioni, D. A., Spencer, B. A., Brown, E. R., & Chawla, N. (2003). Cancer screening in California: Racial and ethnic disparities persist. UCLA Center for Health Policy Research Policy Brief. Available at:
  71. 71.
    MacKinnon, J. A., Duncan, R. C., Huang, Y., et al. (2007). Detecting an association between socioeconomic status and late stage breast cancer using spatial analysis and area-based measures. Cancer Epidemiology, Biomarkers and Prevention, 16, 756–762.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Department of EpidemiologyHarvard School of Public HealthBostonUSA
  2. 2.Northern California Cancer CenterFremontUSA

Personalised recommendations