Individual and Neighborhood Socioeconomic Status in Relation to Breast
Cancer Incidence in African-American Women
Julie R. Palmer*, Deborah A. Boggs, Lauren A. Wise, Lucile L. Adams-Campbell, and
* Correspondence to Dr. Julie R. Palmer, Slone Epidemiology Center at Boston University, 1010 Commonwealth Avenue, Boston, MA 02215
Initially submitted January 5, 2012; accepted for publication April 11, 2012.
Socioeconomic status (SES) for both individuals and neighborhoods has been positively associated with inci-
dence of breast cancer, although not consistently. The authors conducted an assessment of these factors
among African-American women, based on data from the Black Women’s Health Study, a prospective cohort
study of 59,000 African-American women from all regions of the United States. Individual SES was defined as
the participant’s self-reported level of education, and neighborhood SES was measured by a score based on
census block group data for 6 indicators of income and education. Analyses included 1,343 incident breast
cancer cases identified during follow-up from 1995 through 2009. In age-adjusted analyses, SES for both indi-
viduals and neighborhoods was associated with an increased incidence of estrogen receptor-positive breast
cancer. The associations were attenuated by control for parity and age at first birth, and there was no association
after further control for other breast cancer risk factors. These findings suggest that the observed associations of
breast cancer with SES may be largely mediated by reproductive factors that are associated with both estrogen
receptor-positive breast cancer and SES.
African Americans; breast neoplasms; female; residence characteristics; social class
Abbreviations: CI, confidence interval; ER+, estrogen receptor positive; ER−, estrogen receptor negative; SES, socioeconomic
Breast cancer incidence rates have been shown to be
higher in areas of high socioeconomic status (SES) than in
more disadvantaged areas (1–6). A number of observational
studies have also found breast cancer incidence to be greater
among women with higher individual-level SES (7–9), and
this relation appears to be due in part to the distribution of
predisposing factors such as late age at first birth, low parity,
and menopausal female hormone use (8). It is unclear
whether the increased incidence of breast cancer in higher
SES neighborhoods is due to characteristics of the neigh-
borhoods themselves or to the fact that greater proportions
of women in those areas have high personal-level SES.
Only 2 studies, both of white women, have considered
individual-level and neighborhood-level SES simultane-
ously. In a Wisconsin case-control study of 7,179 cases of
breast cancer and 7,488 controls (10), the odds of having
breast cancer were 20% greater in the highest quintile of
neighborhood SES relative to the lowest after control for
individual-level SES and breast cancer risk factors. In a
Massachusetts case-control study of 548 cases and 490 con-
trols, the odds of breast cancer were 30% greater for those
living in the wealthiest areas relative to the poorest areas
and about 20% greater for those with the highest level of
education relative to those with the lowest (11).
At the same levels of education and income, African-
American women are more likely than their white counter-
parts to live in neighborhoods of low SES (12–14). Thus, it
may be more feasible to disentangle the individual effects
of personal and neighborhood-level SES on breast cancer
incidence by studying African-American women. We have
Am J Epidemiol. 2012;176(12):1141–1146
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a marker of individual SES in our study; previous research
indicates that level of education is a strong correlate of indi-
vidual level of SES in African Americans (24). Neverthe-
less, it is possible that different findings could result if
individual SES were better characterized.
In sum, in the present study of African-American women,
individual educational level and neighborhood SES were
positively associated with incidence of ER+ breast cancer
but not ER− breast cancer. Parity and age at first birth were
the primary factors mediating the association.
Author affiliations: Slone Epidemiology Center at
Boston University, Boston, Massachusetts (Julie R. Palmer,
Deborah A. Boggs, Lauren A. Wise, Lynn Rosenberg);
and Lombardi Cancer Center, Georgetown University,
Washington, DC (Lucile L. Adams-Campbell).
This work was supported by grant R01 CA058420 from
the National Cancer Institute, National Institutes of Health,
and by a grant from the Susan G. Komen for the Cure
The content is solely the responsibility of the authors
and does not necessarily represent the official views of the
National Cancer Institute or the National Institutes of
Health. Data on breast cancer pathology were obtained
from several state cancer registries (Arizona, California,
Colorado, Connecticut, Delaware, District of Columbia,
Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana,
North Carolina, Oklahoma, Pennsylvania, South Carolina,
Tennessee, Texas, Virginia), and the results reported do not
necessarily represent their views.
Conflict of interest: none declared.
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