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PURPOSE The objective was to examine the relationship between contemporary redlining (mortgage lending bias on the basis of property location) and survival among older women with breast cancer in the United States. METHODS A redlining index using Home Mortgage Disclosure Act data (2007-2013) was linked by census tract with a SEER-Medicare cohort of 27,516 women age 66-90 years with an initial diagnosis of stage I-IV breast cancer in 2007-2009 and follow-up through 2015. Cox proportional hazards models were used to examine the relationship between redlining and both all-cause and breast cancer–specific mortality, accounting for covariates. RESULTS Overall, 34% of non-Hispanic White, 57% of Hispanic, and 79% of non-Hispanic Black individuals lived in redlined tracts. As the redlining index increased, women experienced poorer survival. This effect was strongest for women with no comorbid conditions, who comprised 54% of the sample. For redlining index values of 1 (low), 2 (moderate), and 3 (high), as compared with 0.5 (least), hazard ratios (HRs) (and 95% CIs) for all-cause mortality were HR = 1.10 (1.06 to 1.14), HR = 1.27 (1.17 to 1.38), and HR = 1.39 (1.25 to 1.55), respectively, among women with no comorbidities. A similar pattern was found for breast cancer–specific mortality. CONCLUSION Contemporary redlining is associated with poorer breast cancer survival. The impact of this bias is emphasized by the pronounced effect even among women with health insurance (Medicare) and no comorbid conditions. The magnitude of this neighborhood level effect demands an increased focus on upstream determinants of health to support comprehensive patient care. The housing sector actively reveals structural racism and economic disinvestment and is an actionable policy target to mitigate adverse upstream health determinants for the benefit of patients with cancer.

e18557 Background: The purpose of this study was to examine the association between measures of housing quality, stability, and access on breast cancer stage at diagnosis among older women living in the United States. Methods: This study included 67,588 women aged 66-90 with data from the SEER-Medicare linked database. The primary outcome was breast cancer stage at diagnosis. Multinomial regression models were performed using a three-category outcome (stage 0, early-stage (I-II), late-stage (III-IV)). The key independent variables were median housing value, percentage living in the same house as the previous year, percentage owner occupied homes, and an index of contemporary mortgage lending bias (redlining). Results: In adjusted models, higher contemporary mortgage lending bias was significantly associated with later-stage diagnosis (RR = 1.10 1.02-1.20; RR = 1.31, 95% CI 1.16-1.49; RR = 1.41, 95% CI 1.24-1.60 for Least to High, respectively). Median housing value was inversely associated with later-stage diagnosis, but to a lesser degree than mortgage lending bias (RR = 0.88, 95%CI 0.80-0.96; RR = 0.77, 95% CI 0.68-0.88 for second and third tertiles, respectively). Owner occupancy and tenure were not significantly associated with late-stage diagnosis in adjusted models. Conclusions: Contemporary mortgage lending bias demonstrated a significant dose-response relationship with later stage at diagnosis of breast cancer in this cohort of elderly women. Policy interventions aimed at reducing the effects of redlining with the goal of decreasing late-stage breast cancer diagnosis to improve prognosis should be considered. Table. Relative risk of late stage breast cancer diagnosis based on measures of housing quality and stability, as well as redlining. Risk is relative to the base outcome, stage 0. Values for the first tertile of housing quality and stability as well as the “least” category for redlining are not shown in this table as they are the base outcome which the other values are compared to. Standard error was adjusted for MSA clustering effects in all models.[Table: see text]

Purpose To investigate the role of out-of-pocket cost supports through the Medicare Part D Low-Income Subsidy on disparities in breast cancer hormonal therapy persistence and adherence by race or ethnicity. Methods A nationwide cohort of women age ≥ 65 years with a breast cancer operation between 2006 and 2007 and at least one prescription filled for oral breast cancer hormonal therapy was identified from all Medicare D enrollees. The association of race or ethnicity with nonpersistence (90 consecutive days with no claims for a hormonal therapy prescription) and nonadherence (medication possession rate < 80%) was examined. Survival analyses were used to account for potential differences in age, comorbidity, or intensity of other treatments. Results Among the 25,111 women in the study sample, 77% of the Hispanic and 70% of the black women received a subsidy compared with 21% of the white women. By 2 years, 69% of black and 70% of Hispanic patients were persistent compared with 61% of white patients. In adjusted analyses, patients in all three unsubsidized race or ethnicity groups had greater discontinuation than subsidized groups (white patients: hazard ratio [HR], 1.83; 95% CI, 1.70 to 1.95; black patients: HR, 2.09; 95% CI, 1.73 to 2.51; Hispanic patients: HR, 3.00; 95% CI, 2.37 to 3.89). Racial or ethnic persistence disparities that were present for unsubsidized patients were not present or reversed among subsidized patients. All three subsidized race or ethnicity groups also had higher adherence than all three unsubsidized groups, although with the smallest difference occurring in black women. Conclusion Receipt of a prescription subsidy was associated with substantially improved persistence to breast cancer hormonal therapy among white, black, and Hispanic women and lack of racial or ethnic disparities in persistence. Given high subsidy enrollment among black and Hispanic women, policies targeted at low-income patients have the potential to also substantially reduce racial and ethnic disparities.

e13615 Background: Although racism and racial residential segregation are widely considered to contribute to health disparities, including in breast cancer, studies examining the impact of mortgage discrimination, a factor contributing to residential racial segregation, and breast cancer survival are limited. The objective of this study is to examine the relationship between redlining (mortgage discrimination based on property location) and survival among older women with breast cancer. Methods: Using the Home Mortgage Disclosure Act (HMDA) database, we estimated redlining for all census tracts in the Metropolitan Statistical Areas (MSAs) within 15 Surveillance Epidemiology and End Results (SEER) areas. This measure was linked by tract with a SEER-Medicare cohort of 27,516 women aged 66-90 years with an incident stage I-IV breast cancer in 2007-2009 and claims information through 2014. We used cox proportional hazards regression models with survival time as the outcome variable and a 4-level categorical logged redlining variable as the key predictor. We also modeled the hazard ratio using redlining as a continuous variable. Models were stratified by stage, ER/PR status, and age group and adjusted for comorbidity and MSA-level standard error. Results: At a median follow-up of 72 months, one-third of the cohort was deceased. The majority of the cohort had no comorbidities and had hormone receptor-positive, early stage (I/II) cancers. Redlining was associated with poorer survival. When redlining is discretized into four groups with approximate equal-sized intervals, the first and second highest redlining groups are significantly associated with all-cause mortality (HR = 1.226 [1.108, 1.355] for the highest group; HR = 1.159 [1.095, 1.228] for the second highest group). When redlining and its quadratic terms are included in the model, the original and square terms are significantly associated with all-cause mortality (HR = 1.177 [1.111, 1.248] for redlining; HR = 0.982 [0.973, 0.991] for squared redlining). Conclusions: The study suggests that redlining could negatively contribute to breast cancer survival. Persistent place-based mortgage discrimination, as a manifestation of institutional racism, could have long-term effects on people’s health, possibly by impacting health care access or exposing residents to harmful neighborhood conditions. Housing policies that seek to reduce or eliminate place-based mortgage discrimination could contribute to reducing breast cancer survival disparities.

533 Background: Over 50% of breast cancer patients prescribed adjuvant endocrine therapy (ET) are nonadherent during the recommended 5-year course of therapy. We investigated the role of cancer medication delivery on adherence, including mail order pharmacy use, number of pharmacies and copays. Methods: We conducted a retrospective cohort study of 15,769 commercially insured breast cancer patients age 18-64 with newly diagnosed breast cancer in 2007-2015 that initiated ET. Incident breast cancer was identified by a validated algorithm which identifies mainly non-metastatic breast cancer. We examined the association between 12-month AET adherence (proportion of days covered by fills ≥0.80) and mail order pharmacy use, number of pharmacies, and AET copays. We used Poisson regression to estimate nonadherence risk ratios and adjusted for demographics (age, income, race, urbanicity), comorbidities, total medications, primary cancer treatments (surgery, radiation, chemo, and ET initiated), and generic AI availability. Sensitivity analyses were conducted using alternate specifications for independent variables. To test whether any observed differences were due to self-selection, we also conducted a negative control analysis. Results: Most patients were white (74.4%) and age 55-64 (43.3%). Only 16% of patients used a mail order pharmacy for ET fills, most patients only used one pharmacy (58.8%) and 25.2% had a co-pay of $20 or more. In the primary analysis, mail order patients were more likely to be adherent to their ET (aRR 1.21; 95% CI 1.18-1.24), patients using one pharmacy were more likely to be adherent (1 vs 3+: aRR 1.09; 95% CI 1.06-1.13), and patients with lower copays were more likely to be adherent (quartile 1 vs 4: aRR 1.04; 95% CI 1.01-1.08). Results were consistent across sensitivity analyses, and there was no association between mail order and copays and the negative control outcome of any pneumonia diagnoses. Conclusions: Medication delivery factors are associated with adherence to breast cancer AET. Future work should investigate whether interventions to streamline medication delivery could improve adherence for this population.

71 Background: No population-based effectiveness studies have been performed to determine to what extent breast cancer patients are benefiting from sentinel lymph node biopsy (SLNB). This study investigates the extent of unnecessary axillary lymph node dissection (ALND) by surgeon volume and specialty, and estimates the resultant rates of excess lymphedema (LE). Methods: Women with Stage I-III pathologically node-negative (pN0) breast cancer diagnosed in 2008-2009 were identified from the SEER-Medicare linked database. Patients who received neoadjuvant chemotherapy were excluded. Type of axillary surgery was defined by claims. Unnecessary ALND was defined as a patient who underwent either an initial ALND or SLNB followed by ALND. Surgeon volume tertiles were created with roughly a third of cases in each volume group (low, medium, high). Surgical specialty (surgical oncologist, general, other) was determined by the specialty code listed on the claim. A logistic regression model, adjusting for patient and tumor characteristics, was performed to predict the likelihood of receiving an unnecessary ALND. Estimates of LE rates were determined based on the number of nodes removed. Results: 7,946 pN0 patients underwent surgery by 2,101 surgeons. Half underwent SLNB only; 50% had unnecessary ALND (39% converted from SLNB to ALND, 11% ALND only). There was an interaction between surgeon volume and specialty (p < 0.01); surgical oncologists, compared to non-surgical oncologists, were less likely to perform unnecessary ALND in all three volume groups. This effect was largest in the medium volume group (OR 0.37; 95% CI: 0.26-0.51). The LE probability was 14% with an excess LE rate of 4.5%. Unnecessary ALNDs accounted for 84% of the estimated excess LE patients and represented 27% of all potentially avoidable LE cases. Conclusions: Half of pN0 patients underwent unnecessary ALNDs, which accounts for 27% of all potentially avoidable LE cases. The likelihood of undergoing an unnecessary ALND was lower in all three surgeon volume groups if patients were operated on by surgical oncologists. Policies to assess surgeon proficiency in SLNB and/or regionalization of care should be considered to decrease rates of unnecessary ALND and ultimately LE.

6532 Background: Evidence suggests that drug utilization under Medicare Part D has been uneven, varying significantly by geographic region. We sought to examine the extent to which geographic varia...

e17602 Background: A major goal of the Medicare Part D program was to enhance access to oral medications thereby reducing medication cost-related disparities in health outcomes. We examined whether...

2 Background: Breast cancer outcomes are worse among black than white women, but the role of income and out-of-pocket costs (OOPCs) in these disparities is understudied. The Medicare D program provided medication insurance for older women and also included a low-income subsidy (LIS) which eliminated or reduced OOPCs among women with low assets and limited income (based on federal poverty level). We examined differences in adherence to HT by race/ethnicity among a Medicare D population, hypothesizing that LIS might reduce racial disparities in HT adherence. Methods: With data collected from a national sample of women enrolled in Medicare Parts A, B, and D, we identified Medicare Part D enrollees ≥65 years diagnosed with breast cancer who underwent mastectomy or breast conserving surgery in 2006-07 and received either tamoxifen or an AI (anastrozole, letrozole, or exemestane) within one year of surgery. Nonadherence rates (medication possession rate of >0.80) were calculated by race and LIS status for each year after first fill up through December 2011. The association of race with HT adherence was examined in unadjusted Chi-square analyses and in regression models adjusted for age, comorbidity, chemotherapy use, and zip code level- income and education. All models utilized GEE to account for within-patient clustering. Results: Among a sample of 23,299 women (50.6% age 65-74, 40.9% age 75-84), 27.2% received LIS. LIS (but not AI use) varied substantially by race, so that 20.6% of white women and 69.7% of black women received the subsidy. In the first year of therapy, differences in adherence by race were statistically significant, but small (64.2% for white, 63.2% for black and 66.7% for Hispanic). Adherence dropped during years 2-3 of the study, but reductions were much smaller among LIS recipients. Results were confirmed in adjusted models. Conclusions: Enrollment in the Medicare D LIS was high among black and Hispanic breast cancer patients, and disparities in adherence to breast cancer HT among these women were small and remained so over three years. Our study offers important information about the role of medication subsidies and SES in adherence, and suggests their potential to reduce the breast cancer outcomes gap by race.

6642 Background: Because of the adverse effects of AI’s on bone mineral density (BMD) and fracture risk, current guidelines recommend baseline BMD testing when initiating adjuvant AI’s. Methods: We used a validated breast cancer algorithm of Medicare claims to identify older US female breast cancer patients starting adjuvant AI therapy and to examine baseline BMD testing rates. The cohort included all US non-HMO Medicare D-enrolled women age ≥67 years who initiated AI therapy within one year after a 2006-2007 initial breast cancer surgery. Women receiving IV bisphosphonates consistent with metastatic breast cancer treatment (interval