I bring a multi-disciplinary research approach, setting forth a new path to explore how social factors shape life for survivors of chronic disease.

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Lorraine T. Dean, ScD
Assistant Professor
John Hopkins University



Featured Publications

Representative first-authored publications (ordered most recent to earliest)

The Affordability of Providing Sexually Transmitted Disease Services at a Safety-net Clinic

Dean LT, Montgomery MC, Raifman J, Nunn A, Bertrand T, Almonte A, Chan PA. The affordability of providing STD services at a safety-net clinic.

American Journal of Preventive Medicine.  pii: S0749-3797(17)30748-1, January 2018. PMID: 29397280 DOI: 10.1016/j.amepre.2017.12.016

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Sexually transmitted diseases continue to increase in the U.S. There is a growing need for financially viable models to ensure the longevity of safety-net sexually transmitted disease clinics, which provide testing and treatment to high-risk populations. This micro-costing analysis estimated the number of visits required to balance cost and revenue of a sexually transmitted disease clinic in a Medicaid expansion state.

In 2017, actual and projected cost and revenues were estimated from the Rhode Island sexually transmitted disease clinic in 2015. Projected revenues for a hypothetical clinic offering a standard set of sexually transmitted disease services were based on Medicaid; private (“commercial”) insurance; and institutional (“list price”) reimbursement rates. The number of visits needed to cover clinic costs at each rate was assessed.

Total operating cost for 2,153 clinic visits was estimated at $255,769, or $119 per visit. Laboratory testing and salaries each accounted for 44% of operating costs, medications for treatment 7%, supplies 5%, and 28% of visits used insurance. For a standard clinic offering a basic set of sexually transmitted disease services to break even, a projected 73% of visits need to be covered at the Medicaid rate, 38% at private rate, or 11% at institutional rate.

Sexually transmitted disease clinics may be financially viable when a majority of visits are billed at a Medicaid rate; however, mixed private/public models may be needed if not all visits are billed. In this manner, sexually transmitted disease clinics can be solvent even if not all visits are billed to insurance, thus ensuring access to uninsured or underinsured patients.

Lorraine T.DeanScDMadeline C.MontgomeryMPHJuliaRaifmanPhDAmyNunnScD4
ThomasBertrandMPHAlexiAlmonteBAPhilip A.ChanMD25


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Figure 2. Potential income for in-house STD clinic based on number of visits billed, including treatment costs.

Source: Author’s analysis of costs from Lifespan clinic, 2015; Medicaid Fee Schedule for 2015.  STD, sexually transmitted disease; tx, treatment.

Consumer credit as a novel marker for health and economic burden in a diverse population of breast cancer survivors

Dean LT, Schmitz KH, Frick K, Nicholas LH, Zhang Y, Subramanian SV, Visvanathan K. Consumer credit as a novel marker for health and economic burden in a diverse population of breast cancer survivors. Journal of Cancer Survivorship. 12(3):306-315, June 2018. PMID: 29372485 PMCID: PMC5955811 DOI: 10.1007/s11764-017-0669-1

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Consumer credit may reflect financial hardship that patients face due to cancer treatment, which in turn may impact ability to manage health after cancer; however, credit’s relationship to economic burden and health after cancer has not been evaluated.


From May to September 2015, 123 women with a history of breast cancer residing in Pennsylvania or New Jersey completed a cross-sectional survey of demographics, socioeconomic position, comorbidities, SF-12 self-rated health, economic burden since cancer diagnosis, psychosocial stress, and self-reported (poor to excellent) credit quality. Ordinal logistic regression evaluated credit’s contribution to economic burden and self-rated health.


Mean respondent age was 64 years. Mean year from diagnosis was 11.5. Forty percent of respondents were Black or Other and 60% were White. Twenty-four percent self-reported poor credit, and 76% reported good to excellent credit quality. In adjusted models, changing income, using savings, borrowing money, and being unable to purchase a health need since cancer were associated with poorer credit. Better credit was associated with 7.72 ([1.22, 14.20], p = 0.02) higher physical health t-score, and a - 2.00 ([- 3.92, - 0.09], p = 0.04) point change in psychosocial stress.


This exploratory analysis establishes the premise for consumer credit as a marker of economic burden and health for breast cancer survivors. Future work should validate these findings in larger samples and for other health conditions.


Stabilizing and monitoring consumer credit may be a potential intervention point for mitigating economic burden after breast cancer.


Breast cancer; Credit; Economic burden; Lymphedema; Socioeconomic position; Survivorship; USA

Dean LT1,2,3Schmitz KH4Frick KD5,6Nicholas LH5Zhang Y7Subramanian SV8Visvanathan K9,10.


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Economically Burdensome Events among Long-Term Breast Cancer Survivors (n=123)

Healthcare system distrust, physician trust, and patient discordance with adjuvant breast cancer treatment recommendations

Dean LT & Moss SL, McCarthy AM, Armstrong KA. Healthcare system distrust, physician trust, and patient discordance with adjuvant breast cancer treatment recommendations. Cancer, Epidemiology, Biomarkers and Prevention. [Online first] September 2017. PMID: 28971987 DOI: 10.1158/1055-9965.EPI-17-0479


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Background: Adjuvant therapy after breast cancer surgery decreases recurrence and increases survival, yet not all women receive and complete it. Previous research has suggested that distrust in medical institutions plays a role in who initiates adjuvant treatment, but has not assessed treatment completion, nor the potential mediating role of physician distrust. Methods: Women listed in Pennsylvania and Florida cancer registries, who were under the age of 65 when diagnosed with localized invasive breast cancer between 2005 and 2007, were surveyed by mail in 2007 to 2009. Survey participants self-reported demographics, cancer stage and treatments, treatment discordance (as defined by not following their surgeon or oncologist treatment recommendation), healthcare system distrust, and physician trust. Age and cancer stage were verified against cancer registry records. Logistic regression assessed the relationship between highest and lowest tertiles of healthcare system distrust and the dichotomous outcome of treatment discordance, controlling for demographics and clinical treatment factors, and testing for mediation by physician trust. Results: Of the 2,754 participants, 30.2% (n = 832) reported not pursing at least one recommended treatment. The mean age was 52. Patients in the highest tertile of healthcare system distrust were 22% more likely to report treatment discordance than the lowest tertile; physician trust did not mediate the association between healthcare system distrust and treatment discordance. Conclusions: Healthcare system distrust is positively associated with treatment discordance, defined as failure to initiate or complete physician-recommended adjuvant treatment after breast cancer. Impact: Interventions should test whether or not resolving institutional distrust reduces treatment discordance. Cancer Epidemiol Biomarkers Prev; 26(12); 1745-52. ©2017 AACR.

Dean LT1,2Moss SL3McCarthy AM4,5Armstrong K4,5.


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Race or Resource? BMI, Race and Other Social Factors as Risk Factors for Inter-Limb Differences among Overweight Breast Cancer Survivors with Lymphedema

Dean LT, Kumar A, Kim T, Herling M, Brown J, Zhang Z, Evangelisti M, Hackley R, Kim J, Cheville A, Troxel A, Schwartz S, Schmitz KH. Race or Resource? BMI, Race and Other Social Factors as Risk Factors for Inter-Limb Differences among Overweight Breast Cancer Survivors with Lymphedema. Journal of Obesity: Obesity Associated Cancers. 8241710, June 2016. PMID: 27433356 PMCID: PMC4940553 DOI:10.1155/2016/8241710


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Introduction: High BMI is a risk factor for upper body breast cancer-related lymphedema (BCRL) onset. Black cancer survivors are more likely to have high BMI than White cancer survivors. While observational analyses suggest up to 2.2 times increased risk of BCRL onset for Black breast cancer survivors, no studies have explored race or other social factors that may affect BCRL severity, operationalized by interlimb volume difference (ILD). Materials and Methods. ILD was measured by perometry for 296 overweight (25 > BMI < 50) Black () or White () breast cancer survivors (>6 months from treatment) in the WISER Survivor trial. Multivariable linear regression examined associations between social and physical factors and ILD.

Results: Neither Black race (−0.26, ) nor BMI (0.22, ) was associated with ILD. Attending college (−4.89, ) was the strongest factor associated with ILD, followed by having more lymph nodes removed (4.75, ), >25% BCRL care adherence (4.10, ), and years since treatment (0.55, ).

Discussion: Neither race nor BMI was associated with ILD among overweight cancer survivors. Education, a proxy for resource level, was the strongest factor associated with greater ILD. Tailoring physical activity and weight loss interventions designed to address BCRL severity by resource rather than race should be considered.

Dean LT1,2Moss SL3McCarthy AM4,5Armstrong K4,5.


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Black Cancer Survivors Experience Greater Upper Extremity Disability

Dean LT, DeMichele A, Lee SQ, Colameco C, Stephens A, LeBlanc M, Coursey M, Mao JJ. Black Cancer Survivors Experience Greater Upper Extremity Disability. Breast Cancer Research and Treatment. 154(1):117-125, November 2015. doi: 10.1007/s10549-015-3580-3. PMCID: PMC4623964 PMID: 26420404


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Over one-third of breast cancer survivors experience upper extremity disability. Black women present with factors associated with greater upper extremity disability, including: increased body mass index (BMI), more advanced disease stage at diagnosis, and varying treatment type compared with Whites. No prior research has evaluated the relationship between race and upper extremity disability using validated tools and controlling for these factors. Data were drawn from a survey study among 610 women with stage I-III hormone receptor positive breast cancer. The disabilities of the arm, shoulder and hand (QuickDASH) is an 11-item self-administered questionnaire that has been validated for breast cancer survivors to assess global upper extremity function over the past 7 days. Linear regression and mediation analysis estimated the relationships between race, BMI and QuickDASH score, adjusting for demographics and treatment types. Black women (n = 98) had 7.3 points higher average QuickDASH scores than White (n = 512) women (p < 0.001). After adjusting for BMI, age, education, cancer treatment, months since diagnosis, and aromatase inhibitor status, Black women had an average 4-point (95% confidence interval 0.18-8.01) higher QuickDASH score (p = 0.04) than White women. Mediation analysis suggested that BMI attenuated the association between race and disability by 40%. Even several years post-treatment, Black breast cancer survivors had greater upper extremity disability, which was partially mediated by higher BMIs. Close monitoring of high BMI Black women may be an important step in reducing disparities in cancer survivorship. More research is needed on the relationship between race, BMI, and upper extremity disability.


Dean LT1DeMichele A2,3LeBlanc M3,4Stephens-Shields A2Li SQ5Colameco C3Coursey M2Mao JJ2,3,5.


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Can you party your way to better health?

Dean LT, Hillier A, Chau H, Subramanian SV, Williams DR, Kawachi, I. Can you party your way to better health? A Propensity Score Analysis of Block Parties and Health. Social Science & Medicine. Elsevier, 138: 201-209, August 2015. doi:10.1016/j.socscimed.2015.06.019. PMCID: PMC4500646 PMID: 26117555


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While other indicators of social capital have been linked to health, the role of block parties on health in Black neighborhoods and on Black residents is understudied. Block parties exhibit several features of bonding social capital and are present in nearly 90% of Philadelphia’s predominantly Black neighborhoods. This analysis investigated: (1) whether or not block parties are an indicator of bonding social capital in Black neighborhoods; (2) the degree to which block parties might be related to self-rated health in the ways that other bonding social indicators are related to health; and (3) whether or not block parties are associated with average self-rated health for Black residents particularly. Using census tract-level indicators of bonding social capital and records of block parties from 2003 to 2008 for 381 Philadelphia neighborhoods (defined by census tracts), an ecological-level propensity score was generated to assess the propensity for a block party, adjusting for population demographics, neighborhood characteristics, neighborhood resources and violent crime. Results indicate that in multivariable regression, block parties were associated with increased bonding social capital in Black neighborhoods; however, the calculation of the average effect of the treatment on the treated (ATT) within each propensity score strata showed no effect of block parties on average self-rated health for Black residents. Block parties may be an indicator of bonding social capital in Philadelphia’s predominantly Black neighborhoods, but this analysis did not show a direct association between block parties and self-rated health for Black residents. Further research should consider what other health outcomes or behaviors block parties may be related to and how interventionists can leverage block parties for health promotion.


Dean LT1Hillier A2Chau-Glendinning H3Subramanian SV4Williams DR5Kawachi I6.



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