Association Between Neighborhood Opportunity, Allostatic Load, and All-Cause Mortality in Patients With Breast Cancer

Author(s): J.C. Chen, MD1; Mohamed I. Elsaid, PhD, MPH2,3; Demond Handley, MS2,3; Jesse J. Plascak, PhD4; Barbara L. Andersen, PhD5; William E. Carson, MD1; Timothy M. Pawlik, MD, PhD, MPH, MTS, MBA1; Naleef Fareed, PhD2; Samilia Obeng-Gyasi, MD, MPH1
Anjan J Patel MD

Dr. Anjan Patel's Thoughts

Noteworthy NCCI database study showing zip code has a negative influence on tumor burden and outcomes. I wonder if the presence of community oncology practices in similar geographical zones reduces this interaction of environmental opportunity and outcomes.


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.


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.


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).


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.

Author Affiliations

1Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH; 2Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH; 3Secondary Data Core, Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, OH; 4Division of Cancer Prevention and Control, Department of Internal Medicine, The Ohio State University, Columbus, OH; 5Department of Psychology, The Ohio State University, Columbus, OH

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