Influence of socioeconomic factors on survival after breast cancer--a nationwide cohort study of women diagnosed with breast cancer in Denmark 1983-1999

Socioeconomic Deprivation and Invasive Breast Cancer Incidence by Stage at Diagnosis: A Possible Explanation to the Breast Cancer Social Paradox

In this study, we assessed the influence of area-based socioeconomic deprivation on the incidence of invasive breast cancer (BC) in France, according to stage at diagnosis. All women from six mainland French departments, aged 15+ years, and diagnosed with a primary invasive breast carcinoma between 2008 and 2015 were included (n = 33,298). Area-based socioeconomic deprivation was determined using the French version of the European Deprivation Index. Age-standardized incidence rates (ASIR) by socioeconomic deprivation and stage at diagnosis were compared estimating incidence rate ratios (IRRs) adjusted for age at diagnosis and rurality of residence. Compared to the most affluent areas, significantly lower IRRs were found in the most deprived areas for all-stages (0.85, 95% CI 0.81-0.89), stage I (0.77, 95% CI 0.72-0.82), and stage II (0.84, 95% CI 0.78-0.90). On the contrary, for stages III-IV, significantly higher IRRs (1.18, 95% CI 1.08-1.29) were found in the most deprived areas. These findings provide a possible explanation to similar or higher mortality rates, despite overall lower incidence rates, observed in women living in more deprived areas when compared to their affluent counterparts. Socioeconomic inequalities in access to healthcare services, including screening, could be plausible explanations for this phenomenon, underlying the need for further research.

The cancer survival index-A prognostic score integrating psychosocial and biological factors in patients diagnosed with cancer or haematologic malignancies

Objective

We aimed to investigate whether (1) psychological and social indicators influence survival in patients diagnosed with cancer or haematologic malignancies when important biological aspects are controlled for, (2) psychological, social and biological indicators can be utilised to design one collated index for survival, usable in clinical practice to identify patients at risk of shorter survival and to improve personalised healthcare provision.

Methods

In this cross‐sectional study, 2263 patients with cancer or haematologic malignancies participated. We analysed 15 biological, psychological and social indicators as risk factors for survival with a Cox proportional hazards model. Indicators significantly associated with survival were combined to compute models for the identification of patient groups with different risks of death. The training sample contained 1122 patients. Validation samples included the remaining 1141 patients, the total sample, as well as groups with different cancer entities.

Results

Five indicators were found to significantly impact survival: Cancer site (HR: 3.56), metastatic disease (HR: 1.88), symptoms of depression (HR: 1.34), female sex (HR: 0.73) and anaemia (HR: 0.48). Combining these indicators to a model, we developed the Cancer Survival Index, identifying three distinct groups of patients with estimated survival times of 47.2 months, 141 months and 198.2 months (p < 0.001). Post hoc analysis of the influence of depression on survival showed a mediating effect of the following four factors, related to both depression and survival: previous psychiatric conditions, employment status, metastatic disease and haemoglobin levels.

Conclusions

Psychosocial and biological factors impact survival in various malignancies and can be utilised jointly to compute an index for estimating the survival of each patient individually—the Cancer Survival Index.

How Does Patient Socioeconomic Position Affect Breast Cancer Surgical Treatment and Mortality?: A Rapid Review

Background

Breast cancer is the second leading cause of death in women across the world. Despite significant improvements in overall breast cancer survival, disparities still exist. Research shows that socioeconomic position (SEP) plays a strong role in disparities in breast cancer care. Lower SEP can be a predictor of poorer breast cancer health outcomes and treatment received. No recent review has focused on SEP and breast cancer surgery outcomes. We conducted a rapid review assessing how patient SEP affects breast cancer surgical outcomes.

Methods

We developed and ran the search strategy in Ovid MEDLINE in January 2021. We assessed study eligibility using an adapted version of PICOS criteria. We included observational studies that assessed the relationship between SEP and breast cancer surgery treatment, including outcomes like surgery choice, survival, and wait time to surgery. We independently reviewed each article and independently extracted data using a pre-designed form. One reviewer narratively synthesized the data extracted from the included articles.

Results

We found twelve articles that met inclusion criteria. Eight out of 12 articles showed a difference in breast cancer surgery outcomes based on at least one measure of SEP. Six out of eight articles that collected surgery choice data found that women with lower SEP had lower rates of breast conserving surgery. One out of three articles that collected survival data found that higher SEP had a positive effect on survival. Additionally, one article that collected wait time to surgery data found a significant correlation between lower SEP and longer delays to surgical treatment.

Conclusion

In conclusion, our rapid review of SEP and breast cancer surgery outcomes found that there is a relationship between SEP and breast cancer surgery choice. This rapid review did not find enough evidence to see a relationship with overall survival and wait time to surgery.

Socioeconomic position and prognosis in premenopausal breast cancer: a population-based cohort study in Denmark

BACKGROUND

To investigate how socioeconomic position (SEP) influences the effectiveness of cancer-directed treatment in premenopausal breast cancer patients in terms of breast cancer recurrence and mortality.

METHODS

We conducted a cohort study nested in the ProBeCaRe (Predictors of Breast Cancer Recurrence) cohort (n = 5959). We identified all premenopausal women aged 18-55 years diagnosed with non-metastatic breast cancer and prescribed docetaxel-based chemotherapy in Denmark during 2007-2011. Population-based administrative registries provided data on SEP: marital status (married including registered partnership or single including divorced or widowed), cohabitation (cohabiting or living alone), education (low, intermediate, or high), income (low, medium, or high), and employment status (employed, unemployed, or health-related absenteeism). For each SEP measure, we computed incidence rates, cumulative incidence proportions (CIPs), and used Poisson regression to compute incidence rate ratios (IRRs) and 95% confidence intervals (CIs) of recurrence and death. We stratified on estrogen receptor (ER) status/tamoxifen to evaluate interaction.

RESULTS

Our study cohort included 2616 women; 286 (CIP 13%) experienced recurrence and 223 (CIP 11%) died during follow-up (median 6.6 and 7.2 years, respectively). Single women had both increased 5-year risks of recurrence (IRR 1.45, 95% CI 1.11-1.89) and mortality (IRR 1.83, 95% CI 1.32-2.52). Furthermore, we observed increased 5-year mortality in women with low education (IRR 1.49, 95% CI 0.95-2.33), low income (IRR 1.37, 95% CI 0.83-2.28), unemployment (IRR 1.61, 95% CI 0.83-3.13), or health-related work absenteeism (IRR 1.80, 95% CI 1.14-2.82), but smaller or no increased risk of recurrence. These findings were especially evident among women with ER+ tumors prescribed tamoxifen. Overall analyses (follow-up max. 10 years) provided similar results.

CONCLUSIONS

Low SEP in premenopausal women with non-metastatic breast cancer was associated with increased mortality, but not always recurrence. This suggests underdetection of recurrences in certain groups. Poor prognosis in women with low SEP, especially single women, may partly be explained by tamoxifen adherence.

Association between preexisting mental illnesses and mortality among medicaid-insured women diagnosed with breast cancer

BACKGROUND

We investigated the impact of preexisting mental illnesses on all-cause and cause-specific mortality among Medicaid-insured women diagnosed with breast cancer.

METHODS

Data from the New York State Cancer Registry for 10,444 women diagnosed with breast cancer from 2004 to 2016 and aged <65 years at diagnosis were linked with Medicaid claims. Women were categorized as having depression or a severe mental illness (SMI) if they had at least three relevant diagnosis claims with at least one claim within three years prior to breast cancer diagnosis. SMI included schizophrenia, bipolar disorder, and other psychotic disorders. Estimated menopausal status was determined by age (premenopausal age <50; postmenopausal age ≥50). Hazard ratios (HR) and 95% confidence intervals (95%CI) were calculated with Cox proportional hazards regression, adjusting for potential confounders.

RESULTS

Preexisting SMI was associated with greater all-cause (HR = 1.36; 95%CI 1.18, 1.57) and cancer-specific (HR = 1.21; 95%CI 1.03, 1.44) mortality compared to those with no mental illnesses. No association was observed between preexisting depression and mortality. Among racial/ethnic subgroups, the association between SMI and all-cause mortality was observed among non-Hispanic white (HR = 1.47; 95%CI 1.19, 1.83) and non-Hispanic Asian/Pacific Islander (HR = 2.59; 95% 1.15, 5.87) women. Additionally, mortality hazards were greatest among women with preexisting SMI that were postmenopausal (HR = 1.49; 95%CI 1.25, 1.78), obese (HR = 1.58; 95%CI 1.26, 1.98), and had documented tobacco use (HR = 1.42; 95%CI 1.13, 1.78).

CONCLUSION

Women with preexisting SMI prior to breast cancer diagnosis have an elevated mortality hazard and should be monitored and treated by a coordinated cross-functional clinical team.

The effect of post mastectomy radiation therapy on survival in breast cancer patients with N1mic disease

Background

The role of post mastectomy radiation therapy (PMRT) in patients with N1mic breast cancer has not been well defined. A retrospective analysis was performed using the SEER database to evaluate the impact of PMRT on survival in patients with N1mic breast cancer.

Materials and methods

Women with T1-T2, N1mic, M0 breast cancer who had undergone mastectomy were analyzed. Descriptive statistics were calculated for all variables. Univariate analysis to assess for differences in survival with respect to covariates was performed using the log rank test while multivariate analysis was performed with Cox proportional hazards regression. Sub-cohort analysis with propensity score matching was used to assess differences in survival among patients undergoing PMRT vs no PMRT. Comparisons were considered statistically significant at P < 0.05.

Results

Among 5878 patients, 1202 (20%) underwent PMRT. On univariate analysis, PMRT was a significant predictor of CSS, but not OS. There was no difference in either OS or CSS between the PMRT vs no PMRT groups on multivariate Cox regression analysis and after propensity score matching.

Conclusions

Among patients with T1-T2, N1mic, M0 breast IDC from the SEER database, there was no difference in either OS or CSS among patients who underwent PMRT vs no PMRT. These results suggest that PMRT does not impact survival among breast cancer patients with N1mic disease. However, additional prospective studies with longer follow up are necessary for further evaluation.

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In women with N1mic breast cancer, there was no difference in overall survival with or without adjuvant radiation.

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CSS was worse among women undergoing adjuvant radiation on univariate analysis, but not on multivariate analysis.

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After propensity score matching, no significant difference was observed in survival between women undergoing PMRT vs no PMRT.

Use of Healthcare Services Two Years before Diagnosis in Danish Sarcoma Patients, 2000-2013

Background

Sarcoma is a rare type of cancer with nonspecific symptoms and uncertain aetiology. Thus, timely diagnosis of sarcomas is a clinical challenge. The aim of this study was to investigate the use of healthcare services 24 months preceding a sarcoma diagnosis compared to a matched cohort.

Materials and Methods

The study was a retrospective, population-based, matched cohort registry-study. Patients with sarcoma in Denmark in 2000–2013 were identified in the Danish Sarcoma Registry (n = 2167) and matched 1 : 10 on gender, age, and listed general practice. Using a binomial regression model, incidence rate ratios were calculated for face-to-face contacts in general practice, inpatient and outpatient visits, surgery, paraclinical examinations, and diagnostic imaging. Analyses were stratified for sarcoma subtypes, grade, stage, gender, and presence of comorbidity.

Results

The sarcoma patients had significantly increased incidence rate ratios in use of healthcare services compared to the matched cohort a year before their diagnoses. An increase in consultation rates was seen 11 months before diagnosis for inpatient visits, 9 months before diagnosis in general practice and outpatient visits, 8 months before diagnosis for paraclinical examinations, and 4 and 3 months before diagnosis for diagnostic imaging and surgery, respectively. There were no clinical significant differences in length of increased consultation rates between sarcoma type, stage, and grade. Sarcoma patients with comorbidity had persistently higher consultation rates compared to patients without comorbidity.

Conclusions

The use of healthcare services among sarcoma patients increased several months before diagnosis in all healthcare sectors. The results reveal a diagnostic time window and a potential to refer, diagnose, and treat sarcoma patients in a timelier manner.

Socioeconomic inequality in cancer survival - changes over time. A population-based study, Denmark, 1987-2013

Background: Socioeconomic inequality in survival after cancer have been reported in several countries and also in Denmark. Changes in cancer diagnostics and treatment may have changed the gap in survival between affluent and deprived patients and we investigated if the differences in relative survival by income has changed in Danish cancer patients over the past 25 years. Methods: The 1- and 5-year relative survival by income quintile is computed by comparing survival among cancer patients diagnosed 1987-2009 to the survival of a cancer-free matched sample of the background population. The comparison is done within the 15 most common cancers and all cancers combined. The gap in relative survival due to socioeconomic inequality for the period 1987-1991 is compared the period 2005-2009. Results: The relative 5-year survival increased for all 15 cancer sites investigated in the study period. In general, low-income patients diagnosed in 1987-1991 had between 0% and 11% units lower 5-year relative survival compared with high-income patients; however, only four sites (breast, prostate, bladder and head & neck) were statistically different. In patients diagnosed 2005-2009, the gap in 5-year RS was ranging from 2% to 22% units and statistically significantly different for 9 out of 15 sites. The results for 1-year relative survival were similar to the 5-year survival gap. An estimated 22% of all deaths at five years after diagnosis could be avoided had patients in all income groups had same survival as the high-income group. Conclusion: In this nationwide population-based study, we observed that the large improvements in both short- and long-term cancer survival among patients diagnosed 1987-2009. The improvements have been most pronounced for high-income cancer patients, leading to stable or even increasing survival differences between richest and poorest patients. Improving survival among low-income patients would improve survival rates among Danish cancer patients overall and reduce differences in survival when compared to other Western European countries.

Comorbidity Index as a Predictor of Mortality in Pediatric Patients With Solid Tumors

Purpose: The objective of this study was to determine whether a comorbidity index could be used to predict mortality in pediatric patients with chemotherapy-treated solid tumors. Methods: Pediatric patients who underwent chemotherapy treatment for solid tumors were included, and demographic, clinical, and comorbidity data were obtained from patient electronic records. Results: A total of 196 pediatric patients with embryonic solid tumors were included. Metastatic tumors were the most frequently observed (n = 103, 52.6%). The most common comorbidities encountered for the Charlson comorbidity index (CCI) were cellulitis (n = 24, 12.2%) and acute renal failure (n = 15, 7.7%). For the Pediatric Comorbidity Index (PCI), the most frequent comorbidities were pneumonia and sepsis, with n = 64 (32.7%) for each. We evaluated established the prognostic values for both indexes using Kaplan-Meier curves, finding that the CCI and PCI could predict mortality with p < 0.0001. Conclusion: Using the PCI, we observed 100% survival in patients without comorbidities, 70% survival in patients with a low degree of comorbidity, and 20% survival in patients with a high degree of comorbidity. Greater discrimination of probability of survival could be achieved using degrees of comorbidity on the PCI than using degrees of comorbidity on the CCI. The application of the PCI for assessing the hospitalized pediatric population may be of importance for improving clinical evaluation.

The impact of comorbidity on mortality in Danish sarcoma patients from 2000-2013: A nationwide population-based multicentre study

INTRODUCTION

Sarcoma is a rare type of cancer. The incidence increases with age and elderly patients may have comorbidity that affects the prognosis. The aim of this study was to describe the type and prevalence of comorbidity in a nationwide population-based study in Denmark from 2000-2013 and to analyse the impact of the different comorbidities on mortality.

MATERIAL AND METHODS

The Danish Sarcoma Registry is a national clinical database containing all patients with sarcoma in the extremities or trunk wall from 2000 and onwards. By linking data to other registries, we were able to get patient information on an individual level including date and cause of death as well as the comorbidity type up to 10 years prior to the sarcoma diagnosis. Based on diseases in the Charlson Comorbidity Index, we pooled the patients into six categories: no comorbidity, cardiopulmonary disease, gastrointestinal disease, neurovascular disease, malignant neoplasms, and miscellaneous (diabetes, renal and connective tissue diseases). 2167 patients were included.

RESULTS

The prevalence of comorbidity was 20%. For patients with localized disease, comorbidity increased the disease-specific mortality significantly (HR 1.70 (95% CI 1.36-2.13)). For patients with metastatic disease at the time of diagnosis, comorbidity did not affect the disease-specific mortality (HR 1.05 (95% CI 0.78-1.42)). The presence of another cancer diagnosis within 10 years prior to the sarcoma diagnosis was the only significant independent prognostic factor of disease-specific mortality with an increase of 66% in mortality rate compared to patients with no comorbidity (HR 1,66 (95% CI 1.22-2.25)).

CONCLUSION

Comorbidity is a strong independent prognostic factor of mortality in patients with localized disease. This study emphasizes the need for optimizing the general health of comorbid patients in order to achieve a survival benefit from treatment of patients with localized disease, as this is potentially modifiable.

Changing patterns of breast cancer incidence and mortality by education level over four decades in Norway, 1971-2009

Background

In the last century, breast cancer incidence and mortality was higher among higher versus lower educated women in developed countries. Post-millennium, incidence rates have flattened off and mortality declined. We examined breast cancer trends by education level, to see whether recent improvements in incidence and mortality rates have occurred in all education groups.

Methods

We linked individual registry data on female Norwegian inhabitants aged 35 years and over during 1971–2009. Using Poisson models, we calculated absolute and relative educational differences in age-standardised breast cancer incidence and mortality over four decades. We estimated educational differences by Slope and Relative Index of Inequality, which correspond to rate difference and rate ratio, comparing the highest to lowest educated women.

Results

Pre-millennium, incidence and mortality of breast cancer were significantly higher in higher versus lower educated women. Post-millennium, educational differences in breast cancer incidence and mortality attenuated. During 2000–2009, breast cancer incidence was still 38% higher for higher versus lower educated women (Relative Index of Inequality: 1.38, 95% confidence interval: 1.31–1.44), but mortality no longer varied significantly by education level (Relative Index of Inequality: 1.09, 95% confidence interval: 0.99–1.19). Among women below 50 years, however, the education gradient for mortality reversed, and mortality was 28% lower for the highest versus lowest educated women during 2000–2009 (Relative Index of Inequality: 0.72, 95% confidence interval: 0.51–0.93).

Results

Post-millennium improvements in breast cancer incidence and mortality have primarily benefited higher educated women. Breast cancer mortality is now highest among the lowest educated women below 50 years.

Cancer, the mind and the person: what we know about the causes of cancer

At a time when patients are challenged to cope adaptively with both the diagnosis and treatment of cancer, clinicians need to respond appropriately to the many inevitable questions about the causes of cancer and contributing factors, including ‘Is this my fault?’. The evidence guiding answers to such questions has been confounded by many methodological challenges, but personality, stress and life events are no longer considered causes of cancer. However, social isolation, untreated depression and social deprivation continue to influence quality of life and reduce cancer survival times. Psychiatry might play a role in promoting lifestyle changes that reduce the risk of cancer, but more importantly it can influence disease progression by optimising patients' adaptation to the many challenges that cancer brings.

Understanding the effects of socioeconomic status along the breast cancer continuum in Australian women: a systematic review of evidence

Background

Globally, the provision of equitable outcomes for women with breast cancer is a priority for governments. However, there is growing evidence that a socioeconomic status (SES) gradient exists in outcomes across the breast cancer continuum – namely incidence, diagnosis, treatment, survival and mortality. This systematic review describes this evidence and, because of the importance of place in defining SES, findings are limited to the Australian experience.

Methods

An on-line search of PubMed and the Web of Science identified 44 studies published since 1995 which examined the influence of SES along the continuum. The critique of studies included the study design, the types and scales of SES variable measured, and the results in terms of direction and significance of the relationships found. To aid in the interpretation of results, the findings were discussed in the context of a systems dynamic feedback diagram.

Results

We found 67 findings which reported 107 relationships between SES within outcomes along the continuum. Results suggest no differences in the participation in screening by SES. Higher incidence was reported in women with higher SES whereas a negative association was reported between SES and diagnosis. Associations with treatment choice were specific to the treatment choice undertaken. Some evidence was found towards greater survival for women with higher SES, however, the evidence for a SES relationship with mortality was less conclusive.

Conclusions

In a universal health system such as that in Australia, evidence of an SES gradient exists, however, the strength and direction of this relationship varies along the continuum. This is a complex relationship and the heterogeneity in study design, the SES indicator selected and its representative scale further complicates our understanding of its influence. More complex multilevel studies are needed to better understand these relationships, the interactions between predictors and to reduce biases introduced by methodological issues.

Racial differences in the effects of comorbidity on breast cancer-specific survival

PURPOSE

In an effort to explain racial disparities in breast cancer survival, this study aimed to investigate how comorbidity affects breast cancer-specific mortality by race.

METHODS

A retrospective cohort study was conducted using the Surveillance, Epidemiology and End Results-Medicare linked data including 68,090 women 66+ years, who were diagnosed with stage I-III breast cancer in the United States from 1994 to 2004. Hospital and outpatient claims from the year prior to breast cancer diagnosis were used to identify comorbid conditions and patients were followed for survival through 2010.

RESULTS

Competing risk survival analysis failed to demonstrate any negative comorbidity effects on breast cancer-specific survival for black women. An increased breast cancer-specific mortality hazard was observed for white women who had diabetes without complication relative to white women without this condition after adjusting for age and year of diagnosis (hazard ratio: 1.22, 95% confidence interval 1.13, 1.30). The Cochran-Armitage Test showed diabetes was associated with a later stage of diagnosis (p < 0.01) and a more aggressive tumor grade (p < 0.01) among white women in the study population.

CONCLUSION

Race specific comorbidity effects do not explain breast cancer-specific survival disparities. However, the relationship between diabetes and breast cancer, including the role of aggressive tumor characteristics, warrants special attention.

Relationship of Social Determinants of Health with the Three-year Survival Rate of Breast Cancer

Background: Social determinants of health are among the key factors affecting the pathogenesis of diseases. Considering the increasingly high prevalence of breast cancer and the association of social determinants of health with its occurrence, related morbidity and mortality and survival rate, this study sought to assess the relationship of three-year survival rate of breast cancer with social determinants of health. Materials and Methods: This cohort study was conducted on males and females presenting to the Cancer Research Center of Shohada-E-Tajrish Hospital from 2006 to 2010 with definite diagnosis of breast cancer. Data were collected via phone interviews. Kaplan-Meier and Cox regression was fitted using SPSS (version 18) and PH assumption was tested by STATA (version 11) software. Results: The study was performed on 797 breast cancer patients, aged 25-93 years with mean age of 54.66 (SD=11.86) years. After 3 years from diagnosing cancer 700 (87.8%) patients were alive and 97 (12.2%) patients were dead. Using log rank test, there was relationship between 3-year survivals with age, education, childhood residence, sibling, treatment type, and district were significant (p<0.05). Using Cox PH regression, 3-year survival was related to age, level of education, municipal district of residence and childhood condition (p<0.05). Conclusion: Social determinants of health such as childhood condition, city region residency, level of education and age affect the three-year survival rate of breast cancer. Future studies must focus on the effect of childhood social class on the survival rates of cancers, which have been paid less attention to.

Adult children's socioeconomic resources and mothers' survival after a breast cancer diagnosis: a Swedish population-based cohort study

OBJECTIVES

Socioeconomic inequalities in survival after breast cancer persist worldwide. We aim to determine whether adult offspring's socioeconomic resources contribute to inequalities in mothers' survival after breast cancer.

METHODS

14 231 women, aged 65-79 years, with a child aged ≥30 years and a first primary diagnosis of breast cancer in the National Cancer Register between 2001 and 2010 were followed until death, 10 years after diagnosis, or end of study (December 2015). Relative survival proportions and excess mortality within 10 years of diagnosis by strata of offspring's education level and disposable income were estimated using flexible parametric models accounting for measures of mothers' socioeconomic position and expected mortality in the general population.

RESULTS

4292 women died during 102 236 person-years of follow-up. Crude 10-year relative survival proportions for mothers of children with >14, 12-14 and <12 years of education were 0.89 (0.87 to 0.91), 0.87 (0.85 to 0.89) and 0.79 (0.76 to 0.81), respectively. Compared with mothers of children with >14 years of education, mothers of children with <12 or 12-14 years of education had substantially higher excess mortality (excess HR 1.69 (1.38 to 2.07) and 1.22 (1.00 to 1.48), respectively). Higher mortality did not differ between tertiles of offspring's disposable income.

CONCLUSIONS

Adult offspring's education level may contribute to inequalities in mothers' survival after breast cancer. Clinicians should be aware of the educational context beyond the individual and women with less educated offsprings may require extra support. This should be considered in future research, policy frameworks and interventions aimed at reducing survival inequalities.

Sociodemographic Factors and Late-stage Diagnosis of Breast Cancer in India: A Hospital-based Study

Context:

Breast cancer (BC) is one of the major causes of cancer mortality in India. Late-stage diagnosis of BC is associated with poor survival. Identification of factors affecting late presentation of the disease could be an effective step to reduce BC mortality.

Aims:

To study the association of sociodemographic factors with BC stage at diagnosis.

Settings and Design:

The study is a retrospective analysis from the case records from a single institution.

Subjects and Methods:

Data for the year 2008 was collected from the hospital records. A total of 1210 cases were included for the analysis. Sociodemographic factors included were age, place of residence, religion, marital status, level of education, and occupation. Other study variables were family history, presence of comorbidity, and stage at diagnosis.

Statistical Analysis:

Association between sociodemographic factors by stage at diagnosis was tested using Chi-square statistics, with odds ratios (ORs) estimated through logistic regression modeling.

Results:

In the study cohort, 46% patients had reported at early stages and 54% at advanced stages. All factors were evaluated for being predictors of disease stage at presentation using univariate and multivariate logistic regression model. Women from urban background were less likely to present with advanced stage disease (OR = 0.64; 95% confidence interval [CI]: 0.49–0.84) as compared to rural women. Similarly, illiterate women were also more likely to present with advanced-stage disease (OR = 1.55; 95% CI: 1.16–2.09).

Conclusions:

This data clearly indicate that the patients of rural background and of low education status are more likely than their respective counterparts to have an advanced stage of BC diagnosis. Our results may be considered the keys to determining how stage variation may be related to patients and community characteristics and where limited resources need to be invested to ensure early diagnosis of BC.

What might explain deprivation-specific differences in the excess hazard of breast cancer death amongst screen-detected women? Analysis of patients diagnosed in the West Midlands region of England from 1989 to 2011

BACKGROUND

Breast cancer survival is higher in less deprived women, even amongst women whose tumor was screen-detected, but reasons behind this have not been comprehensively investigated.

METHODS

The excess hazard of breast cancer death in 20,265 women diagnosed with breast cancer, followed up to 2012, was estimated for screen-detected and non-screen-detected women, comparing more deprived to less deprived women using flexible parametric models. Models were adjusted for individual and tumor factors, treatment received and comorbidity. For screen-detected women, estimates were also corrected for lead-time and overdiagnosis.

RESULTS

The excess hazard ratio (EHR) of breast cancer death in the most deprived group, adjusted only for age and year of diagnosis, was twice that of the least deprived among screen-detected women (EHR=2.12, 95%CI 1.48-2.76) and 64% higher among non-screen-detected women (EHR=1.64, 95%CI 1.41-1.87). Adjustment for stage at diagnosis lowered these estimates by 25%. Further adjustment had little extra impact. In the final models, the excess hazard for the most deprived women was 54% higher (EHR=1.54, 95%CI 1.10-1.98) among screen-detected women and 39% higher (EHR=1.39, 95%CI 1.20-1.59) among non-screen-detected women.

CONCLUSION

A persistent socio-economic gradient in breast cancer-related death exists in this cohort, even for screen-detected women. The impact of differential lifestyles, management and treatment warrant further investigation.

Ten-Year Mortality after a Breast Cancer Diagnosis in Women with Severe Mental Illness: A Danish Population-Based Cohort Study

BACKGROUND

Breast cancer is the leading cause of cancer death in women worldwide. Nevertheless, it is unknown whether higher mortality after breast cancer contributes to the life-expectancy gap of 15 years in women with severe mental illness (SMI).

METHODS

We estimated all-cause mortality rate ratios (MRRs) of women with SMI, women with breast cancer and women with both disorders compared to women with neither disorder using data from nationwide registers in Denmark for 1980-2012.

RESULTS

The cohort included 2.7 million women, hereof 31,421 women with SMI (12,852 deaths), 104,342 with breast cancer (52,732 deaths), and 1,106 with SMI and breast cancer (656 deaths). Compared to women with neither disorder, the mortality was 118% higher for women with SMI (MRR: 2.18, 95% confidence interval (CI): 2.14-2.22), 144% higher for women with breast cancer (MRR: 2.44, 95% CI: 2.42-2.47) and 327% higher for women with SMI and breast cancer (MRR: 4.27, 95% CI: 3.98-4.57). Among women with both disorders, 15% of deaths could be attributed to interaction. In a sub-cohort of women with breast cancer, the ten-year all-cause-mortality was 59% higher after taking tumor stage into account (MRR: 1.59, 95% CI: 1.47-1.72) for women with versus without SMI.

CONCLUSIONS

The mortality among women with SMI and breast cancer was markedly increased. More information is needed to determine which factors might explain this excess mortality, such as differences between women with and without SMI in access to diagnostics, provision of care for breast cancer or physical comorbidity, health-seeking-behavior, and adherence to treatment.

Socioeconomic inequalities in breast cancer incidence and mortality in Europe-a systematic review and meta-analysis

Background: Breast cancer is the leading cause of female cancer in Europe and is estimated to affect more than one in 10 women. Higher socioeconomic status has been linked to higher incidence but lower case fatality, while the impact on mortality is ambiguous. Methods: We performed a systematic literature review and meta-analysis on studies on association between socioeconomic status and breast cancer outcomes in Europe, with a focus on effects of confounding factors. Summary relative risks (SRRs) were calculated. Results: The systematic review included 25 articles of which 8 studied incidence, 10 case fatality and 8 mortality. The meta-analysis showed a significantly increased incidence (SRR 1.25, 1.17–1.32), a significantly decreased case fatality (SRR 0.72, 0.63–0.81) and a significantly increased mortality (SRR 1.16, 1.10–1.23) for women with higher socioeconomic status. The association for incidence became insignificant when reproductive factors were included. Case fatality remained significant after controlling for tumour characteristics, treatment factors, comorbidity and lifestyle factors. Mortality remained significant after controlling for reproductive factors. Conclusion: Women with higher socioeconomic status show significantly higher breast cancer incidence, which may be explained by reproductive factors, mammography screening, hormone replacement therapy and lifestyle factors. Lower case fatality for women with higher socioeconomic status may be partly explained by differences in tumour characteristics, treatment factors, comorbidity and lifestyle factors. Several factors linked to breast cancer risk and outcome, such as lower screening attendance for women with lower socioeconomic status, are suitable targets for policy intervention aimed at reducing socioeconomic-related inequalities in health outcomes.

Influence of metabolic indicators, smoking, alcohol and socioeconomic position on mortality after breast cancer

BACKGROUND

Factors differently distributed among social groups like obesity, metabolic syndrome, diabetes, smoking, and alcohol intake predict survival after breast cancer diagnosis and therefore might mediate part of the observed social inequality in survival.

MATERIAL AND METHODS

We conducted a cohort study among 1250 postmenopausal breast cancer patients identified among 29 875 women in the Danish Diet, Cancer and Health Study. Participants completed questionnaires and anthropometric measurements were made at enrollment. Information on survival, socioeconomic position, and comorbidity was obtained by linkage to national Danish registries. Clinical information was obtained from the nationwide Danish Breast Cancer Database. Selected information was obtained from hospital records at time of diagnosis. All analyses were based on Cox proportional hazard models, using death from all causes as outcome.

RESULTS

Median follow-up was 9.6 years [interquartile range (IQR), 2.2-17.0 years]. The hazard ratio (HR) for death from all causes increased with lower education (p for trend, 0.01). Adjustment for disease-related prognostic factors, comorbidity and metabolic indicators measured as BMI, waist circumference and diabetes, and smoking and alcohol affected but did not explain the social gradient.

CONCLUSION

The findings indicate that these factors explain some but not all the social inequality in survival after breast cancer and that improvement of lifestyle to some extent would improve survival among women with low socioeconomic position.

Rural-urban disparities in incidence and outcomes of neuroendocrine tumors: A population-based analysis of 6271 cases

BACKGROUND

Despite their rising incidence, neuroendocrine tumors (NETs) remain a poorly understood disease. Living in a rural area (RA) affects the incidence and outcomes of other types of cancer. This study compared the incidence and outcomes of NETs for patients in RAs and patients in urban areas (UAs).

METHODS

A population-based cohort study of patients with NETs in Ontario, Canada from 1994 to 2011 was conducted. An RA was defined as any community with a population < 10,000 and outside the commuting zone of a metropolitan area. Incidence, advanced stage at presentation, distant recurrence-free survival (dRFS), and overall survival (OS) were compared between patients who lived in RAs and patients who lived in UAs with univariate and multivariate regression analyses.

RESULTS

The cohort included 6271 patients diagnosed with NETs, of whom 13.5% (n = 846) resided in RAs. The incidence of NETs was higher in RAs at 3.01 per 100,000 per year versus UAs at 2.82 per 100,000 per year (relative rate, 1.10; P = .04). RA living was not associated with an advanced stage at presentation (odds ratio, 1.15; 95% confidence interval, 0.96-1.38). Patients who lived in RAs had worse 10-year dRFS (62.8% vs 65.9%, P = .03) and OS (44.6% vs 48.8%, P = .004). RAs were independently associated with decreased OS (hazard ratio, 1.16; 95% confidence interval, 1.04-1.30).

CONCLUSIONS

Patients are more commonly diagnosed with NETs in RAs, but they do not present at more advanced stages in comparison with patients diagnosed in UAs. Patients living in RAs experience worse cancer recurrence and OS, and this is possibly related to variations in socioeconomic status, rural environmental factors, and access to specialized health care.

Socioeconomic inequalities in cancer survival: a population-based study of adult patients diagnosed in Osaka, Japan, during the period 1993-2004

BACKGROUND

Long-term recession of the Japanese economy during the 1990s led to growing social inequalities whilst health inequalities also appeared. The 2007 National Cancer Control Program of Japan targeted "equalisation of cancer medical services", but the system to monitor health inequalities was still inadequate. We aimed to measure socioeconomic inequalities in cancer survival in Japan.

MATERIAL AND METHODS

We analysed 13 common invasive, primary, malignant tumours diagnosed from 1993 to 2004 and registered by the population-based Cancer Registry of Osaka Prefecture. An ecological socioeconomic deprivation index based on small area statistics, divided into quintile groups, was linked to patients according to their area of residence at the time of diagnosis. We estimated one-, five-year and conditional five-year net survival by sex, period of diagnosis (1993-1996/1997-2000/2001-2004) and deprivation group. Changes in survival over time, deprivation gap in survival, and change in deprivation gap were estimated at one and five years after diagnosis using variance-weighted least square regression.

RESULTS

The deprivation gap in one-year net survival was narrower than in five-year net survival and conditional five-year survival. During the study period, there was no change in deprivation gap, except for reductions for pancreas (men) and stomach (women), and an increase for lung (men) in one-year survival. We observed a linear association between level of survival and deprivation gap at five years and conditional five years, but no association at one-year survival.

CONCLUSION

A wide deprivation gap in survival was observed in most of the adult, solid, malignant tumours, within the universal healthcare system in Japan. Overall, cancer survival improved in Osaka without any widening of inequalities in cancer survival in 1993-2004, shortly after the long-term economic recession and deep modifications in the social and work environments in Japan. The longer term impact of the recession on inequalities in cancer survival needs to be monitored using population-based cancer registry data.

Space-time clusters of breast cancer using residential histories: a Danish case-control study

BACKGROUND

A large proportion of breast cancer cases are thought related to environmental factors. Identification of specific geographical areas with high risk (clusters) may give clues to potential environmental risk factors. The aim of this study was to investigate whether clusters of breast cancer existed in space and time in Denmark, using 33 years of residential histories.

METHODS

We conducted a population-based case-control study of 3138 female cases from the Danish Cancer Registry, diagnosed with breast cancer in 2003 and two independent control groups of 3138 women each, randomly selected from the Civil Registration System. Residential addresses of cases and controls from 1971 to 2003 were collected from the Civil Registration System and geo-coded. Q-statistics were used to identify space-time clusters of breast cancer. All analyses were carried out with both control groups, and for 66% of the study population we also conducted analyses adjusted for individual reproductive factors and area-level socioeconomic indicators.

RESULTS

In the crude analyses a cluster in the northern suburbs of Copenhagen was consistently found throughout the study period (1971-2003) with both control groups. When analyses were adjusted for individual reproductive factors and area-level socioeconomic indicators, the cluster area became smaller and less evident.

CONCLUSIONS

The breast cancer cluster area that persisted after adjustment might be explained by factors that were not accounted for such as alcohol consumption and use of hormone replacement therapy. However, we cannot exclude environmental pollutants as a contributing cause, but no pollutants specific to this area seem obvious.

Effects of breast and colorectal cancer on labour market outcomes-average effects and educational gradients

We estimate causal effects of breast and colorectal cancer on labour market outcomes 1-3 years after the diagnosis. Based on Danish administrative data we estimate average treatment effects on the treated by propensity score weighting methods using persons with no cancer diagnosis as control group. We conduct robustness checks using matching, difference-in-differences methods and an alternative control group of later cancer patients. The different methods give approximately the same results. Cancer increases the risks of leaving the labour force and receiving disability pension, and the effects are larger for the less educated. Effects on income are small and mostly insignificant. We investigate some of the mechanisms which may be important in explaining the educational gradient in effects of cancer on labour market attachment.

The impact of comorbidity on cancer survival: a review

Background

A number of studies have shown poorer survival among cancer patients with comorbidity. Several mechanisms may underlie this finding. In this review we summarize the current literature on the association between patient comorbidity and cancer prognosis. Prognostic factors examined include tumor biology, diagnosis, treatment, clinical quality, and adherence.

Methods

All English-language articles published during 2002–2012 on the association between comorbidity and survival among patients with colon cancer, breast cancer, and lung cancer were identified from PubMed, MEDLINE and Embase. Titles and abstracts were reviewed to identify eligible studies and their main results were then extracted.

Results

Our search yielded more than 2,500 articles related to comorbidity and cancer, but few investigated the prognostic impact of comorbidity as a primary aim. Most studies found that cancer patients with comorbidity had poorer survival than those without comorbidity, with 5-year mortality hazard ratios ranging from 1.1 to 5.8. Few studies examined the influence of specific chronic conditions. In general, comorbidity does not appear to be associated with more aggressive types of cancer or other differences in tumor biology. Presence of specific severe comorbidities or psychiatric disorders were found to be associated with delayed cancer diagnosis in some studies, while chronic diseases requiring regular medical visits were associated with earlier cancer detection in others. Another finding was that patients with comorbidity do not receive standard cancer treatments such as surgery, chemotherapy, and radiation therapy as often as patients without comorbidity, and their chance of completing a course of cancer treatment is lower. Postoperative complications and mortality are higher in patients with comorbidity. It is unclear from the literature whether the apparent undertreatment reflects appropriate consideration of greater toxicity risk, poorer clinical quality, patient preferences, or poor adherence among patients with comorbidity.

Conclusion

Despite increasing recognition of the importance of comorbid illnesses among cancer patients, major challenges remain. Both treatment effectiveness and compliance appear compromised among cancer patients with comorbidity. Data on clinical quality is limited.

Comorbidities and breast cancer survival: a report from the Shanghai Breast Cancer Survival Study

We investigated the association of major comorbidities with breast cancer outcomes using the Shanghai Breast Cancer Survival Study, a population-based, prospective cohort study of Chinese women diagnosed with breast cancer. Analyses included 4,664 women diagnosed with stage I-III incident breast cancer aged 20-75 years (median age = 51) during 2002-2006. Women were interviewed at 3-11 months post-diagnosis (median = 6.4) and followed up by in-person interviews and linkage with the vital statistics registry. Multivariable hazard ratios (HRs) and (95 % confidence intervals (CIs)) for the associations of comorbidities with breast cancer outcomes were estimated using Cox regression models. After a median follow-up of 5.3 years (range: 0.64-8.9), 647 women died (516 from breast cancer) and 632 recurrence/metastases were documented. The main comorbidities reported included: hypertension (22.4 %), chronic gastritis (14.3 %), diabetes mellitus (6.2 %), chronic bronchitis/asthma (5.8 %), coronary heart disease (5.0 %), and stroke (2.2 %). Diabetes was associated with increased risk of total mortality (adjusted HR: 1.40 (1.06-1.85)) and non-breast cancer mortality (adjusted HR: 2.64 (1.63-4.27)), but not breast cancer-specific mortality (adjusted HR: 0.98 (0.68-1.41)), adjusting for socio-demographics, clinical characteristics, selected lifestyle factors, and other comorbidities. Women with a history of stroke had a non-significant increased risk of total mortality (adjusted HR: 1.42 (0.91-2.22)) and a significant increased risk of non-breast cancer mortality (adjusted HR: 2.52 (1.33-4.78)), but not breast cancer-specific mortality (adjusted HR: 0.78 (0.38-1.62)). Overall, none of the comorbidities investigated were significantly associated with recurrence. In this large prospective cohort of breast cancer survivors, diabetes was significantly associated with increased risk of total and non-breast cancer mortality, and history of stroke was associated with increased risk of non-breast cancer mortality.

Changes in body mass index and alcohol and tobacco consumption among breast cancer survivors and cancer-free women: a prospective study in the Danish Diet, Cancer and Health Cohort

BACKGROUND

A breast cancer diagnosis has been suggested as a teachable moment when a woman is more open to making healthier lifestyle changes. Little is known about the health behaviour changes women with breast cancer initiate compared to those made by other women.

MATERIAL AND METHODS

We examined changes in body mass index (BMI) and tobacco and alcohol consumption among women with a diagnosis of breast cancer and among cancer-free women. We used data from 23 420 women aged 50-64 years who participated in the Diet, Cancer and Health cohort, of whom 449 were diagnosed with breast cancer between baseline (1993-1997) and follow-up (2000-2002), and 22 971 remained cancer-free. We used multiple linear regression analysis to examine differences in BMI and alcohol and tobacco consumption between the two groups and to examine whether demographic and prognostic factors were associated with behavioural changes in women with breast cancer.

RESULTS

There were no significant differences in changes in BMI, alcohol and tobacco consumption between the two groups. Only in sub-analyses among women who lost weight between baseline and follow-up, women with breast cancer lost more weight than cancer-free women (β = 0.2; CI 0.1; 0.4), but residual confounding from stage cannot be excluded. Among the women with breast cancer we found no significant changes in BMI, alcohol and tobacco consumption by level of education, marital status, chemotherapy, hormone therapy or radiation.

CONCLUSION

Women with breast cancer did not reduce their BMI, or modify their alcohol use or tobacco consumption compared with cancer-free women. This study indicates that guidelines and interventions to change health behaviour are needed after a cancer diagnosis.

Survival from breast cancer in relation to access to tertiary healthcare, body mass index, tumor characteristics and treatment: a Hellenic Cooperative Oncology Group (HeCOG) study

Apart from tumour, treatment and patient characteristics at diagnosis, access to healthcare delivery may as well play a significant role in breast cancer prognosis. This study aimed to assess the additional impact exerted on survival by travel burden-a surrogate indicator of limited access to healthcare- expressed as geographical distance and/or time needed to reach the tertiary healthcare center from the patient's residence. Between 1997 and 2005, 2,789 women participated in therapeutic clinical trials conducted by the Hellenic Cooperative Oncology Group. The effect of geographical distance and travel time between patient's residence and treating hospital on survival was estimated using Cox proportional hazards regression adjusting for age, menopausal status, tumour size/grade, positive nodes (number), hormonal receptor status, HER2 overexpression, surgery type/treatment protocol as well as for body mass index>30 kg/m2. More aggressive tumour features, older treatment protocols and modifiable patient characteristics, such as obesity (HR: 1.27) adversely impacted on breast cancer survival. In addition, less studied indicators of access to healthcare, such as geographic distance>350 km and travel time>4 h were independently and significantly associated with worse outcomes (HR=1.43 and 1.34 respectively). In conclusion, to address inequalities in breast cancer survival, improvements in access to healthcare services related to increased travel burden especially for patients of lower socioeconomic status should be considered, more than ever at times of financial crisis and independently of already known modifiable patient characteristics.

Socio-economic inequalities: a review of methodological issues and the relationships with cancer survival

During the past few decades, many studies on socio-economic factors and health outcomes have been developed using various methodologies with differing approaches. A bibliographic research in MEDLINE/PubMed and SCOPUS was carried out for the period 2000-2011 to describe the influence of socio-economic status (SES) on cancer survival, in particular with reference to the outcome of European research results and the results of some cases of other Western studies. This review is divided into two sections: the first describing the different approaches of the study on individuals and populations of the concept of "social class" as well as methods used to measure the association between deprivation and health (i.e. ecological level studies, deprivation indexes, etc.); and the second discussing the association between socio-economic factors and cancer survival, describing the roles of various determinants of differences in survival, such as clinical and pathological prognostic factors, together with consideration of diagnosis and treatment and some patients' characteristics.

For patients with breast cancer, geographic and social disparities are independent determinants of access to specialized surgeons. A eleven-year population-based multilevel analysis

Background

It has been shown in several studies that survival in cancer patients who were operated on by a high-volume surgeon was better. Why then do all patients not benefit from treatment by these experienced surgeons? The aim of our work was to study the hypothesis that in breast cancer, geographical isolation and the socio-economic level have an impact on the likelihood of being treated by a specialized breast-cancer surgeon.

Methods

All cases of primary invasive breast cancer diagnosed in the Côte d’Or from 1998 to 2008 were included. Individual clinical data and distance to the nearest reference care centre were collected. The Townsend Index of each residence area was calculated. A Log Rank test and a Cox model were used for survival analysis, and a multilevel logistic regression model was used to determine predictive factors of being treated or not by a specialized breast cancer surgeon.

Results

Among our 3928 patients, the ten-year survival of the 2931 (74.6 %) patients operated on by a high-volume breast cancer surgeon was significantly better (LogRank p < 0.001), independently of age at diagnosis, the presence of at least one comorbidity, circumstances of diagnosis (screening or not) and TNM status (Cox HR = 0.81 [0.67-0.98]; p = 0.027). In multivariate logistic regression analysis, patients who lived 20 to 35 minutes, and more than 35 minutes away from the nearest reference care centre were less likely to be operated on by a specialized surgeon than were patients living less than 10 minutes away (OR = 0.56 [0.43; 0.73] and 0.38 [0.29; 0.50], respectively). This was also the case for patients living in rural areas compared with those living in urban areas (OR = 0.68 [0.53; 0.87]), and for patients living in the two most deprived areas (OR = 0.69 [0.48; 0.97] and 0.61 [0.44; 0.85] respectively) compared with those who lived in the most affluent area.

Conclusions

A disadvantageous socio-economic environment, a rural lifestyle and living far from large specialized treatment centres were significant independent predictors of not gaining access to surgeons specialized in breast cancer. Not being treated by a specialist surgeon implies a less favourable outcome in terms of survival.

Impact of comorbidity on management and mortality in women diagnosed with breast cancer

To investigate associations between comorbidity burden, management, and mortality in women with breast cancer. A total of 42,646 women diagnosed with breast cancer between 1992 and 2008 were identified in two Clinical Quality Registers in Central Sweden. Breast cancer-specific, conditional breast cancer, competing-cause and all-cause mortality were estimated in relation to comorbidity burden assessed by the Charlson comorbidity index. All analyses were stratified by stage at diagnosis using competing risk analyses, and all-cause mortality was estimated as a function of follow-up time. Following adjustment for age and calendar period, breast conserving surgery was significantly less likely to be offered to women with severe comorbidity (OR 0.63; 95 % CI 0.58-0.69). Similarly, the proportion treated with radiotherapy, tamoxifen, or chemotherapy was lower in women with severe compared to those with no comorbidity. In women with early stage disease, breast cancer-specific mortality was higher among patients with severe comorbidity (sHR 1.47; 95 % CI 1.11-1.94). In all stages of breast cancer, conditional breast cancer and competing-cause mortality were elevated in women with severe comorbidity. For all stages, the relative risk of all-cause mortality between women with severe versus no comorbidity varied by time since diagnosis, and was most pronounced at early follow-up. Comorbidity affects treatment decisions and mortality. In women with early stage breast cancer, severe comorbidity was associated not only with conditional breast cancer, competing-cause and all-cause mortality, but also breast cancer-specific mortality. The observed differences in breast cancer-specific mortality may be due to less extensive treatment, impaired tumor defense and differences in general health status and lifestyle factors.

Adjuvant Radiation and Outcomes After Breast Conserving Surgery in Publicly Insured Patients

OBJECTIVES: Epidemiologic studies report that lack of adjuvant radiation (RT) after breast conserving surgery (BCS) is associated with higher short-term mortality. It is generally accepted that adjuvant RT decreases risk of breast cancer recurrence and thereby lowers long-term mortality; here, we explore reasons for its relationship to short-term mortality. MATERIALS AND METHODS: We studied 1,583 publically insured women who had BCS between 1998 and 2002 (mean 71.8 years, range 27-101), of whom 1,346 (85%) received RT. Multivariate analyses with Cox Proportional Hazards and Logistic Regression models included: age; race; comorbidity; insurance status; tumor size; number of nodes positive; hormone receptor status; receipt of radiation; adjuvant chemotherapy; preventive care - including mammography, Pap smear and primary care visits; and hospitalization. RESULTS: At a mean follow-up of 52.8 months, overall mortality was significantly lower in those who received RT (HR 0.45, p<0.0001) and higher with older age (HR 1.05, p<0.0001) and greater comorbidity (HR 1.16, p=0.0007). Local recurrence was less with receipt of optimal radiation (HR 0.47; p=0.03). Breast cancer event, as determined by a clinically logical algorithm to detect breast cancer recurrence and death, however, was not significantly associated with receipt of RT (OR 1.32, p=0.2). CONCLUSION: These results imply that the higher short-term mortality in women not receiving RT after BCS is related to factors other than breast cancer recurrence.

Increased mortality among Hispanic testis cancer patients independent of neighborhood socioeconomic status: a SEER study

Testis cancer-specific survival (CSS) varies by Hispanic ethnicity. Our goal was to assess whether neighborhood socioeconomic status (SES) accounts for elevated testis CSS among Hispanic patients. We queried the Surveillance, Epidemiology, and End Results (SEER) database for Hispanic (HW) and Non-Hispanic white (NHW) patients. Multivariate Cox regression analyses evaluated Hispanic ethnicity's impact on tCSS while adjusting for neighborhood socioeconomic status (education and income levels). HWs constituted 14.3% of the 26,258 patients in the cohort. Neighborhood SES factors such as county income (P < 0.001) and education level (P < 0.001) were significant predictors of testis cancer-specific survival (tCSS). Controlling for SES and other variables, Hispanic ethnicity remained a significant predictor of tCSS. Compared to NHWs, HWs experienced a 41% greater cancer-specific mortality (HR: 1.406, 95% CI: 1.178-1.678, P < 0.001). The mechanism underlying the increased testis cancer mortality experienced by Hispanic patients remains unknown.

Effect of socioeconomic status as measured by education level on survival in breast cancer clinical trials

OBJECTIVES

This paper aims to investigate the effect of socioeconomic status, as measured by education, on the survival of breast cancer patients treated on 10 studies conducted by the Cancer and Leukemia Group B.

METHODS

Sociodemographic data, including education, were reported by the patient at trial enrollment. Cox proportional hazards model stratified by treatment arm/study was used to examine the effect of education on survival among patients with early stage and metastatic breast cancer, after adjustment for known prognostic factors.

RESULTS

The patient population included 1020 patients with metastatic disease and 5146 patients with early stage disease. Among metastatic patients, factors associated with poorer survival in the final multivariable model included African American race, never married, negative estrogen receptor status, prior hormonal therapy, visceral involvement, and bone involvement. Among early stage patients, significant factors associated with poorer survival included African American race, separated/widowed, post/perimenopausal, negative/unknown estrogen receptor status, negative progesterone receptor status, >4 positive nodes, tumor diameter >2 cm, and education. Having not completed high school was associated with poorer survival among early stage patients. Among metastatic patients, non-African American women who lacked a high school degree had poorer survival than other non-African American women, and African American women who lacked a high school education had better survival than educated African American women.

CONCLUSIONS

Having less than a high school education is a risk factor for death among patients with early stage breast cancer who participated in a clinical trial, with its impact among metastatic patients being less clear. Post-trial survivorship plans need to focus on women with low social status, as measured by education.

Impact of comorbidity on mortality: a cohort study of 62,591 Danish women diagnosed with early breast cancer, 1990-2008

The incidence of breast cancer, as well as other chronic disease, increases with age, older breast cancer patients being more likely than younger to suffer from other diseases at time of diagnosis. Our objective was to assess the effect of comorbidity on mortality after early breast cancer. 62,591 women diagnosed with early breast cancer 1990-2008 were identified using the Danish Breast Cancer Cooperative Group Registry. Data were linked to the Danish National Patient Register and the Danish Register of Causes of Death. Main outcome measures were mortality from all causes, breast cancer, and non-breast cancer causes in relation to Charlson comorbidity index (CCI). Compared with patients without comorbidity (CCI 0), the presence of comorbidity increased the risk of dying from breast cancer as well as other causes with adjusted hazard ratios (HRs) for all-cause mortality of 1.45 (CI 95% 1.40-1.51) for CCI 1, 1.52 (95% CI 1.45-1.60) for CCI 2, and 2.21 (95% CI 2.08-2.35) for CCI 3+. Equivalent HRs for breast cancer-specific mortality were 1.30 (95% CI, 1.24-1.36) for CCI 1, 1.31 (95% CI 1.23-1.39) for CCI 2, and 1.79 (95% CI, 1.66-1.93) for CCI 3+ (all P values < 0.0001). For patients with CCI 0, 5-year overall survival increased over time from 72.5% (95% CI, 71.7-73.3%) in 1990-1994 to 81.6% (95% CI, 80.9-82.2) in 2000-2004, whereas the 5-year overall survival remained stable around 43% among the patients with CCI 3+. This population-based cohort study shows that compared with patients without comorbidity, the risk of dying from breast cancer as well as other causes increased significantly with increasing CCI score. While survival improved over time for patients without comorbidity, no improvement was seen among patients with severe comorbidity (CCI 3+).

The role of early-life socioeconomic status in breast cancer incidence and mortality: unraveling life course mechanisms

OBJECTIVES

We examine (a) how breast cancer onset and survival are affected by various dimensions of early-life socioeconomic status (SES) and (b) the extent to which women's characteristics in adulthood mediate the associations between early-life conditions and breast cancer.

METHOD

We apply Cox regression models and a decomposition analysis to the data from the 4,275 women in the Wisconsin Longitudinal Study.

RESULTS

Higher levels of mothers' education and early-life family income were associated with a greater risk of breast cancer incidence. The effect of mothers' education was mediated by women's adult SES and reproductive behaviors. Fathers' education was related negatively to breast cancer mortality, yet this effect was fully mediated by women's own education.

DISCUSSION

This study identifies mechanisms linking early-life social environment to breast cancer onset and mortality. The findings emphasize the role of social factors in breast cancer incidence and survival.

Comorbidity and survival after early breast cancer. A review

INTRODUCTION

Survival after breast cancer is determined by disease related factors such as stage at diagnosis, patient characteristics, e.g., age, and treatment.

AIM

To review evidence published during the last ten years on the effect of comorbidity on survival after early breast cancer.

METHODS

A search in Pubmed with keywords, breast neoplasm, comorbidity, and survival, was performed. A total of 18 studies published between 2000 and August 2010 was included in this review.

RESULTS

All 18 studies demonstrated that comorbidity had a significant impact on survival after breast cancer with poorer survival among patients with one or more comorbid conditions. The effect of comorbidity persisted after adjustment for age at diagnosis and stage of disease. Older patients with comorbidity were less likely to receive therapy according to guidelines.

CONCLUSION

Presence of comorbidity at diagnosis is an important prognostic factor in early breast cancer, irrespective of age and stage of disease.

Socioeconomic inequalities in attending the mass screening for breast cancer in the south of the Netherlands--associations with stage at diagnosis and survival

The associations of socioeconomic status (SES) and participation in the breast cancer screening program, as well as consequences for stage of disease and prognosis were studied in the Netherlands, where no financial barriers for participating or health care use exist. From 1998 to 2005, 1,067,952 invitations for biennial mammography were sent to women aged 50-75 in the region covered by the Eindhoven Cancer Registry. Screening attendance rates according to SES were calculated. Tumor stage and survival were studied according to SES group for patients diagnosed with breast cancer between 1998 and 2006, whether screen-detected, interval carcinoma or not attended screening at all. Attendance rates were rather high: 79, 85 and 87% in women with low, intermediate and high SES (p < 0.001), respectively. Compared to the low SES group, odds ratios for attendance were 1.5 (95%CI:1.5-1.6) for the intermediate SES group and 1.8 (95%CI:1.7-1.8) for the high SES group. Moreover, women with low SES had an unfavorable tumor-node-metastasis stage compared to those with high SES. This was seen in non-attendees, among women with interval cancers and with screen-detected cancers. Among non-attendees and interval cancers, the socioeconomic survival disparities were largely explained by stage distribution (48 and 35%) and to a lesser degree by therapy (16 and 16%). Comorbidity explained most survival inequalities among screen-detected patients (23%). Despite the absence of financial barriers for participation in the Dutch mass-screening program, socioeconomic inequalities in attendance rates exist, and women with low SES had a significantly worse tumor stage and lower survival rate.

Socioeconomic position and breast reconstruction in Danish women

Few studies have been conducted on the socioeconomic position of women undergoing breast reconstruction, and none have been conducted in the Danish population. We investigated the association between educational level and breast reconstruction in a nationwide cohort of Danish women with breast cancer.

MATERIAL AND METHODS

From nationwide registers, 13 379 women aged 30-80 years who had been treated by mastectomy for breast cancer in Denmark in 1999-2006 were identified and followed up through November 2009. Multivariate logistic regression models were used to investigate the simultaneous influence of educational level on the likelihood of having immediate or delayed (up to three years after mastectomy) breast reconstruction, with adjustment for age, breast cancer characteristics, comorbidity, socioeconomic variables and availability of plastic surgery services at each woman's affiliated hospital.

RESULTS

The odds ratios (ORs) for both immediate and delayed breast reconstruction increased significantly with level of education. Being affiliated to a hospital with a plastic surgery department increased the likelihood of both immediate (adjusted OR, 4.02; 95% confidence interval [CI], 2.81-5.75) and delayed breast reconstruction (adjusted OR, 1.41; 95% CI, 1.26-1.66). There was no association between education and breast reconstruction among 30-44 year old women, regardless of type of breast reconstruction; however, medium or higher education was significantly associated with a fourfold increase in the OR for immediate breast reconstruction in women aged 45-59 years and a more than twofold increase in the OR for delayed breast reconstruction in women aged 60-80 years compared to women with short education.

CONCLUSION

Increasing education was associated with increasing odds for having immediate or delayed breast reconstruction, but only in the older age groups. The offer of breast reconstruction appears to be unequally distributed in Denmark, and living in an area where the hospital has a plastic surgery department significantly increased the odds for having breast reconstruction.

Quality of life data as prognostic indicators of survival in cancer patients: an overview of the literature from 1982 to 2008

BACKGROUND

Health-related quality of life and survival are two important outcome measures in cancer research and practice. The aim of this paper is to examine the relationship between quality of life data and survival time in cancer patients.

METHODS

A review was undertaken of all the full publications in the English language biomedical journals between 1982 and 2008. The search was limited to cancer, and included the combination of keywords 'quality of life', 'patient reported-outcomes' 'prognostic', 'predictor', 'predictive' and 'survival' that appeared in the titles of the publications. In addition, each study was examined to ensure that it used multivariate analysis. Purely psychological studies were excluded. A manual search was also performed to include additional papers of potential interest.

RESULTS

A total of 451 citations were identified in this rapid and systematic review of the literature. Of these, 104 citations on the relationship between quality of life and survival were found to be relevant and were further examined. The findings are summarized under different headings: heterogeneous samples of cancer patients, lung cancer, breast cancer, gastro-oesophageal cancers, colorectal cancer, head and neck cancer, melanoma and other cancers. With few exceptions, the findings showed that quality of life data or some aspects of quality of life measures were significant independent predictors of survival duration. Global quality of life, functioning domains and symptom scores - such as appetite loss, fatigue and pain - were the most important indicators, individually or in combination, for predicting survival times in cancer patients after adjusting for one or more demographic and known clinical prognostic factors.

CONCLUSION

This review provides evidence for a positive relationship between quality of life data or some quality of life measures and the survival duration of cancer patients. Pre-treatment (baseline) quality of life data appeared to provide the most reliable information for helping clinicians to establish prognostic criteria for treating their cancer patients. It is recommended that future studies should use valid instruments, apply sound methodological approaches and adequate multivariate statistical analyses adjusted for socio-demographic characteristics and known clinical prognostic factors with a satisfactory validation strategy. This strategy is likely to yield more accurate and specific quality of life-related prognostic variables for specific cancers.

Social and psychological determinants of participation in internet-based cancer support groups

PURPOSE

In this study, we identified the social and psychological characteristics of Danish cancer patients that determine use of the internet for support.

MATERIALS AND METHODS

We invited 230 cancer patients taking part in a public rehabilitation program to participate in an internet module comprising training in the retrieval of cancer-related information from the internet and self-support groups. Persons who were motivated to join the internet groups (N = 100; 47%) were compared with persons who chose not to participate (N = 111) on the basis of self-reported baseline questionnaire data. Nineteen persons either did not return the questionnaire or had missing values in confounding variables.

RESULTS

Cancer patients who were motivated to participate in internet support groups belong to higher socioeconomic groups (based on household income and employment) compared to non-participants. We observed no difference between the two groups in quality of life or psychological well-being, while coping to some extent seemed related to participation in internet support groups.

CONCLUSION

This study adds to the discussion on social inequality in internet use by cancer patients, showing that patients who are not inclined to use internet-based interventions are characterized by social position and employ more passive coping strategies.