Original Research Article| Volume 224, ISSUE 6, P1403-1408, December 2022

Color or money?: The impact of socioeconomic status and race/ethnicity on breast cancer mortality


      • Mortality is worst in Black females regardless of socioeconomic or insurance status.
      • Only in the richest quartile did Blacks have survival like Whites in the poorest.
      • Outcome disparities improved with higher socioeconomic status.



      Although the incidence of breast cancer is highest in White women, Black women die at a higher rate. Our aim was to compare the relative association between race/ethnicity and socioeconomic status on breast cancer mortality.


      We identified female breast cancer patients diagnosed between 2007 - 2011 and followed through 2016 in the SEER database. Patients were grouped into socioeconomic quartiles by a prosperity index. The primary outcome of interest was 5-year cancer-specific survival.


      A total of 286,520 patients were included. Five-year survival was worst for Black women compared to other races/ethnicities in each socioeconomic quartile. When compared to White women in the lowest quartile, Black women in the lowest quartile, 2nd quartile, and 3rd quartile experienced the lowest 5-year survival rates (Hazard ratio 1.33, 1.23, 1.20; P < 0.01).


      Regarding cancer mortality, only in the most prosperous quartile do Black women achieve a similar outcome to the poorest quartile White women.


      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 The American Journal of Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • American Cancer Society
        Cancer Facts and Figures 2021.
        American Cancer Society, Atlanta, Ga2021
        • DeSantis C.E.
        • Ma J.
        • Gaudet M.M.
        • et al.
        Breast cancer statistics, 2019.
        Ca - Cancer J Clin. 2019 Nov; 69 (Epub 2019 Oct 2. PMID: 31577379): 438-451
        • Narod S.A.
        • Iqbal J.
        • Miller A.B.
        Why have breast cancer mortality rates declined?.
        J Cancer Policy. 2015; 5: 8-17
        • Coughlin S.S.
        Epidemiology of breast cancer in women.
        Adv Exp Med Biol. 2019; 1152: 9-29
      1. Female breast cancer — cancer stat facts.
        ([Internet]. [cited 2021 Sep 17]. Available from:)
        • Wheeler S.B.
        • Reeder-Hayes K.E.
        • Carey L.A.
        Disparities in breast cancer treatment and outcomes: biological, social, and health system determinants and opportunities for research.
        Oncol. 2013 Sep; 18: 986
        • Coughlin S.S.
        Social determinants of breast cancer risk, stage, and survival.
        Breast Cancer Res Treat. 2019; 177: 537-548
        • Bradley C.J.
        • Given C.W.
        • Roberts C.
        Race, socioeconomic status, and breast cancer treatment and survival.
        J Natl Cancer Inst. 2002 Apr 3; 94 (PMID: 11929949): 490-496
        • Semega J.L.
        • Fontenot K.R.
        • Kollar M.A.
        U.S. Census bureau, current population Survey, annual social and economic supplement. 2005.
        in: Income and Poverty in the United States: 2016. Current Population Reports, P60-259. U.S. Government Printing Office, Washington, DC2017 (Available from) (See Appendix I, Current Population Survey (CPS))
      2. Howlader N, Noone AM, Krapcho M, Garshell J, Neyman N, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2010, National Cancer Institute. Bethesda, MD,, based on November 2012 SEER data submission, posted to the SEER web site, April 2013.

        • Robert S.A.
        • Strombom I.
        • Trentham-Dietz A.
        • et al.
        Socioeconomic risk factors for breast cancer: distinguishing individual- and community-level effects.
        Epidemiology. 2004 Jul; 15: 442-450
        • Du X.L.
        • Fang S.
        • Coker A.L.
        • et al.
        Racial disparity and socioeconomic status in association with survival in older men with local/regional stage prostate carcinoma: findings from a large community-based cohort.
        Cancer. 2006 Mar 15; 106: 1276-1285
        • Sun M.
        • Abdollah F.
        • Liberman D.
        • et al.
        Racial disparities and socioeconomic status in men diagnosed with testicular germ cell tumors: a survival analysis.
        Cancer. 2011 Sep 15; 117: 4277-4285
        • Miller B.J.
        • Cram P.
        • Lynch C.F.
        • Buckwalter J.A.
        Risk factors for metastatic disease at presentation with osteosarcoma: an analysis of the SEER database.
        J Bone Joint Surg Am. 2013 Jul 3; 95: e89
        • Zhou H.
        • Zhang Y.
        • Wei X.
        • et al.
        Racial disparities in pancreatic neuroendocrine tumors survival: a SEER study.
        Cancer Med. 2017 Nov; 6: 2745-2756
        • Yamashita H.
        • YAndo Y.
        • Nishio M.
        • et al.
        Immunohistochemical evaluation of hormone receptor status for predicting response to endocrine therapy in metastatic breast cancer.
        Breast Cancer. 2006; 13 (PMID: 16518065): 74-83
        • Early Breast Cancer Trialists' Collaborative Group
        Effects of radiotherapy and surgery in early breast cancer. An overview of the randomized trials.
        N Engl J Med. 1995 Nov 30; 333 (Erratum in: N Engl J Med 1996 Apr 11;334(15):1003. PMID: 7477144): 1444-1455
        • Agarwal S.
        • Ying J.
        • Boucher K.M.
        • Agarwal J.P.
        The association between socioeconomic factors and breast cancer-specific survival varies by race.
        PLoS One. 2017 Dec 6; 12e0187018
        • Coughlin S.S.
        Social determinants of breast cancer risk, stage, and survival.
        Breast Cancer Res Treat. 2019 Oct; 177: 537-548
        • Silber J.H.
        • Rosenbaum P.R.
        • Clark A.S.
        • et al.
        Characteristics associated with differences in survival among black and white women with breast cancer.
        JAMA. 2013 Jul 24; 310: 389-397
        • Hill D.A.
        • Prossnitz E.R.
        • Royce M.
        • Nibbe A.
        Temporal trends in breast cancer survival by race and ethnicity: a population-based cohort study.
        PLoS One. 2019 Oct 24; 14e0224064
        • Ruiz J.M.
        • Hamann H.A.
        • Mehl M.R.
        • O'Connor M.F.
        The Hispanic health paradox: from epidemiological phenomenon to contribution opportunities for psychological science.
        Group Process Intergr Relat. 2016 Jul; 19: 462-476
        • Dietze E.C.
        • Sistrunk C.
        • Miranda-Carboni G.
        • O'regan R.
        • Seewaldt V.L.
        Triple-negative breast cancer in African-American women: disparities versus biology.
        Nat Rev Cancer. 2015 Apr; 15: 248-254