Redlining’s Lasting Impact: Worse Breast Cancer Survival for Women in Historically Disadvantaged Areas

The legacy of redlining, a discriminatory housing policy outlawed nearly six decades ago, continues to cast a long shadow over breast cancer survival rates, according to a recent study published in Cancer. Researchers found that women who resided in historically redlined neighborhoods experienced significantly worse five-year survival rates compared to those living in areas graded as more desirable by the Home Owners’ Loan Corporation (HOLC) in the 1930s.

The HOLC, established during the Great Depression, created maps rating neighborhoods based on their perceived investment risk, factoring in racial, economic, and social makeup. Areas with predominantly minority populations were routinely “redlined,” deemed high-risk for home loans, and effectively denied access to resources and investment. While the 1968 Fair Housing Act prohibited redlining, the systemic disadvantages it created have proven remarkably persistent.

Neighborhoods Matter, Even Decades Later

The study, led by Sarah M. Lima, PhD, MPH, of Georgetown University’s Lombardi Comprehensive Cancer Center, analyzed data from over 135,000 women diagnosed with breast cancer in New York State between 1995 and 2019. Researchers linked patient addresses to historical HOLC maps to assess the impact of neighborhood grading on survival outcomes. The findings revealed that women living in D-graded (redlined) neighborhoods consistently had poorer survival rates throughout the study period.

“It is disappointing,” Lima told Healio. “Regardless of what the explanation is…it still doesn’t change the fundamental fact that we have differences in health care, in treatment of diseases based on place.”

The largest survival disparity was observed between 1995 and 1999, with women in redlined neighborhoods facing a 75% increased risk of mortality compared to those in A-graded areas. While disparities narrowed somewhat in the early 2000s, they widened again between 2015 and 2019, suggesting that recent advancements in breast cancer treatment may not be equitably distributed.

Unpacking the Disparities: More Than Just Access to Care

The reasons behind these persistent disparities are complex and multifaceted. While limited access to quality healthcare is undoubtedly a contributing factor, the study suggests that neighborhood-level factors play a significant role, even after accounting for individual characteristics like race, ethnicity, insurance status, and cancer stage.

Redlined neighborhoods often experience a confluence of disadvantages, including poorer air and environmental quality, limited access to healthy food options, fewer green spaces, and higher levels of stress and social disadvantage. These factors can all contribute to poorer health outcomes, independent of access to medical care. Previous research has linked historical redlining to health disparities in children with asthma, further illustrating the long-term consequences of this discriminatory policy.

Lima and her team likewise observed that disparities in mortality risk were particularly pronounced for women diagnosed with regional-stage disease and those with estrogen receptor/progesterone receptor (ER/PR)-positive breast cancer. This suggests that the impact of redlining may vary depending on the specific characteristics of the cancer and the stage at diagnosis.

The Role of Innovation and the Affordable Care Act

Interestingly, the study found that survival disparities increased again between 2015 and 2019, coinciding with the introduction of new breast cancer treatments like CDK4/6 inhibitors and PARP inhibitors. This suggests that while medical advancements can improve outcomes they may not benefit all populations equally. Underutilization of these newer therapies in underserved communities could be exacerbating existing disparities.

The researchers also noted that this period overlapped with the full implementation of the Affordable Care Act (ACA). While the ACA aimed to expand access to health insurance, its impact on reducing disparities appears to have been offset by other factors. “We believe that likely helped, but whatever these other extenuating circumstances are, they are blowing that out of proportion,” Lima explained.

What Does This Indicate for the Future?

The findings underscore the importance of addressing the root causes of health inequities, including the lasting effects of discriminatory policies like redlining. Simply improving access to healthcare is not enough; systemic changes are needed to create healthier and more equitable communities.

Lima suggests several potential interventions, including investing in environmental remediation in redlined neighborhoods, improving access to healthy food options, and implementing policies that promote economic opportunity. She also points to the example of Buffalo, New York, which is considering burying highways that bisect historically redlined neighborhoods to create more green space and improve air quality.

“You can intervene,” Lima emphasized. “We’ve done a decent job of identifying that this old policy…has a persistent effect. How can we change that? If redlining was a policy that shaped what neighborhoods look like, then how should we design them now to remediate that mortality risk?”

Further research is needed to identify the most effective strategies for mitigating the impact of redlining on breast cancer outcomes. Understanding the complex interplay between neighborhood-level factors, access to care, and individual characteristics will be crucial for developing targeted interventions that can improve health equity for all women. Historical structural racism’s impact on modern-day breast cancer outcomes is a growing area of study.

For more information:

Sarah M. Lima, PhD, MPH, can be reached at [email protected].