The relation between socioeconomic and demographic factors and tumour stage in women diagnosed with breast cancer in Denmark, 1983-1999

Diagnosis and treatment of breast cancer in Denmark during the COVID-19 pandemic: a nationwide population-based study

BACKGROUND

The COVID-19 pandemic was a global health crisis with population-wide behavioural restrictions imposed worldwide to reduce transmission of infection and to limit the potential burden on the healthcare systems. We examined whether there was any change in the diagnosis or treatment of breast cancer during the pandemic as compared to previous years.

MATERIAL AND METHODS

The study population comprised all women aged ≥18 years diagnosed with breast cancer in 2015-2021 with data obtained from the clinical quality registry of the Danish Breast Cancer Cooperative Group (DBCG). Data on socioeconomic factors were retrieved from Statistics Denmark. Prevalence ratios (PR) with 95% confidence intervals (CI) were estimated from a generalised linear model (GLM) with a log link for the Poisson family with robust standard errors (SE) of each outcome, using the COVID-19 pandemic period in Denmark as the exposure of interest.

RESULTS

In total, 30,598 breast cancers were diagnosed during the study period. There was a small decrease (4.5%) in the total number of breast cancer cases in 2020 compared with previous years. During the pandemic, a lower proportion of the patients diagnosed with breast cancer had a short educational level (28.5 vs. 26.9%; PR = 0.91; 95% CI: 0.88-0.95), a low income (20.5 vs. 19.0%; PR = 0.90; 0.85-0.95) and fewer than expected in the age group 60-69 years (27.8 vs. 25.3; PR = 0.90; 0.86-0.94) were diagnosed, as compared with the pre-pandemic period. No difference in type of surgery or tumour size was observed. A higher proportion of patients received neo-adjuvant chemotherapy (49.0 vs 55.0%; PR = 1.15; 1.06-1.24), whereas a lower proportion received adjuvant chemotherapy (93.5 vs 85.6%; PR = 0.92; 0.90-0.93) during the pandemic, compared with the pre-pandemic period.

CONCLUSIONS

During the pandemic, a small decrease in the number of breast cancer diagnoses was observed particularly among socially disadvantaged groups. Overall, the quality of breast cancer treatment was maintained.

Reproductive factors and the risk of breast cancer among Nigerian women by age and oestrogen receptor status

PURPOSE OF THE STUDY

The aim of the study was to investigate the association between reproductive factors and breast cancer risk in Nigeria. This has not been widely investigated in sub-Saharan Africa.

METHODS

We conducted a hospital-based case-control study involving participants from five hospitals in Lagos and Abuja. Women were interviewed in-person between October 2016 and May 2017 using a semi-structured questionnaire. We collected data on parity, breastfeeding, age at first and last birth, age at menarche, oral contraceptive use and history of abortion. The data were analysed using multivariable logistic regression adjusting for relevant confounders.

RESULTS

Every additional 6 months of breastfeeding over a lifetime reduced breast cancer odds by: 7% (95% CI: 1%, 12%) in all women, 15% (95% CI: 5%, 24%) in women < 50 years, and 8% (95% CI: 0%, 12%, p for trend = 0.043) in oestrogen receptor negative (ER-) cases. Each additional 1-year delay before the first full-term pregnancy increased oestrogen receptor positive breast cancer odds by 9% (95% CI: 2%, 17%). Each additional 1-year delay before the last full-term pregnancy increased breast cancer odds by: 7% (95% CI: 2%, 12%) in all women, 12% (95% CI: 4%, 21%) in ER- breast cancer patients, and 14% (95% CI: 4%, 25%) in triple negative breast cancer patients. Other reproductive factors did not significantly increased breast cancer odds.

CONCLUSION

While advanced age at first and last full-term pregnancies increased breast cancer odds, breastfeeding reduced it. These associations varied by age and oestrogen receptor status. Improved breastfeeding practices and timely births should be promoted in Nigeria.

Body weight changes and associated predictors in a prospective cohort of young breast cancer survivors

BACKGROUND

Weight gain after a breast cancer diagnosis is common and is associated with inferior outcomes. Young survivors may be especially susceptible to weight changes given the impact of treatment on menopausal status.

METHODS

The authors identified women who were diagnosed with stage 0 to III breast cancer at age 40 years or younger between 2006 and 2016 from a multicenter prospective cohort. Self-reported weight was collected at diagnosis and at 1 year and 3 years postdiagnosis. Tumor and treatment data were obtained from medical records and patient surveys. Multinomial logistic regression was used to identify the factors associated with weight gain (≥5%) or weight loss (≥5%) versus stable weight at 1 year and 3 years postdiagnosis.

RESULTS

The cohort included 956 women with a median age of 37 years at diagnosis. Mean weight significantly increased over time from 66.54 ± 14.85 kg at baseline to 67.33 ± 15.53 and 67.77 ± 14.65 kg at 1 year and 3 years, respectively (p ≤ .001 for both comparisons). The proportion of women experiencing ≥5% weight gain increased from 24.8% at 1 year to 33.9% at 3 years. At 1 year, less self-perceived financial comfort, Black race, and stage III disease were significantly associated with weight gain; at 3 years, only less self-perceived financial comfort remained significant. Baseline overweight or obesity was significantly associated with weight loss at both time points. Chemotherapy, endocrine therapy, and treatment-related menopause were not associated with weight change.

CONCLUSIONS

One third of young breast cancer survivors experienced clinically significant weight gain 3 years after diagnosis; however, treatment-related associations were not observed. Age-appropriate lifestyle interventions, including the reduction of financial barriers, are needed to prevent weight gain in this high-risk population.

Associations between comorbidities and advanced stage diagnosis of lung, breast, colorectal, and prostate cancer: A systematic review and meta-analysis

Comorbidities and advanced stage diagnosis (ASD) are both associated with poorer cancer outcomes, but the association between comorbidities and ASD is poorly understood. We summarized epidemiological evidence on the association between comorbidities and ASD of selected cancers in a systematic review and meta-analysis. We searched PubMed and Web of Science databases up to June 3rd, 2021 for studies assessing the association between comorbidities and ASD of lung, breast, colorectal, or prostate cancer. Summary odds ratios (ORs) and 95% confidence intervals (95%CIs) were calculated using random-effects models. Also, potential variations in the associations between comorbidities and ASD by cancer type were investigated using random-effects meta-regression. Thirty-seven studies were included in this review, including 8,069,397 lung, breast, colorectal, and prostate cancer patients overall. The Charlson comorbidity index score was positively associated with ASD (stages III-IV) of breast cancer but was inversely associated with ASD of lung cancer (p_interaction = 0.004). Regarding specific comorbidities, diabetes was positively associated with ASD (OR = 1.17, 95%CI = 1.09-1.26), whereas myocardial infarction was inversely associated with ASD (OR = 0.84, 95%CI = 0.75-0.95). The association between renal disease and ASD differed by cancer type (p_interaction < 0.001). A positive association was found with prostate cancer (OR = 2.02, 95%CI = 1.58-2.59) and an inverse association with colorectal cancer (OR = 0.84, 95%CI = 0.70-1.00). In summary, certain comorbidities (e.g., diabetes) may be positively associated with ASD of several cancer types. It needs to be clarified whether closer monitoring for early cancer signs or screening in these patients is reasonable, considering the problem of over-diagnosis particularly relevant in patients with short remaining life expectancy such as those with comorbidities. Also, evaluation of the cost-benefit relationship of cancer screening according to the type and severity of comorbidity (rather than summary scores) may be beneficial for personalized cancer screening in populations with chronic diseases.

Socio-Territorial Inequities in the French National Breast Cancer Screening Programme-A Cross-Sectional Multilevel Study

Simple Summary

France implemented a national breast cancer screening programme in 2004, which, despite recommendations, still coexists with opportunistic screening practices. We aimed to study socio-territorial inequities in participation in the 2013–2014 screening campaign, using multilevel models. With a representative sample of 42% of the estimated eligible population, we found that the organized programme does not erase social or territorial inequities in participation. Social inequities, at multiple levels, were found in nearly all départements, whereas territorial inequities seemed more context dependent. The impact of the coexistence with opportunistic screening, beyond any control and evaluation, is adding more risks (over-diagnosis, over-treatment) and leads to underestimating the true coverage of the population, mainly in the wealthiest, therefore leading to an underestimation of the true social gradient in participation. The French breast cancer screening programme needs to evolve to be more efficient in coverage, notably through the reduction of the unfair inequities in participation.

Abstract

Background. France implemented in 2004 the French National Breast Cancer Screening Programme (FNBCSP). Despite national recommendations, this programme coexists with non-negligible opportunistic screening practices. Aim. Analyse socio-territorial inequities in the 2013–2014 FNBCSP campaign in a large sample of the eligible population. Method. Analyses were performed using three-level hierarchical generalized linear model. Level one was a 10% random sample of the eligible population in each département (n = 397,598). For each woman, age and travel time to the nearest accredited radiology centre were computed. These observations were nested within 22,250 residential areas called “Îlots Regroupés pour l’Information Statistique” (IRIS), for which the European Deprivation Index (EDI) is defined. IRIS were nested within 41 départements, for which opportunistic screening rates and gross domestic product based on purchasing power parity were available, deprivation and the number of radiology centres for 100,000 eligible women were computed. Results. Organized screening uptake increased with age (OR_1SD = 1.05 [1.04–1.06]) and decreased with travel time (OR_1SD = 0.94 [0.93–0.95]) and EDI (OR_1SD = 0.84 [0.83–0.85]). Between départements, organized screening uptake decreased with opportunistic screening rate (OR_1SD = 0.84 [0.79–0.87]) and départements deprivation (OR_1SD = 0.91 [0.88–0.96]). Association between EDI and organized screening uptake was weaker as opportunistic screening rates and as département deprivation increased. Heterogeneity in FNBCSP participation decreased between IRIS by 36% and between départements by 82%. Conclusion. FNBCSP does not erase socio-territorial inequities. The population the most at risk of dying from breast cancer is thus the less participating. More efforts are needed to improve equity.

Epidemiology of De Novo Metastatic Breast Cancer

Most cases of metastatic breast cancer (MBC) arise as a recurrence of a previously treated early breast cancer. Distinct from recurrent MBC is de novo MBC (dnMBC), which describes patients who present with distant sites of disease at initial diagnosis and is reviewed here. dnMBC represents approximately 3% to 6% of new breast cancer diagnoses in high-income countries. This incidence has not declined despite decades of widespread use of population-based mammography screening. Overrepresentation of both biologically aggressive tumors and patients negatively impacted by social determinants of health are characteristics of dnMBC. Survival has generally been superior for patients with dnMBC compared with those with recurrent MBC, although it is similar to that for patients with recurrent MBC with long disease-free intervals. Subgroups of patients with dnMBC who experience prolonged survival include those with human epidermal growth factor receptor-2-positive disease or hormone receptor-positive bone-only disease. Opportunities to decrease dnMBC presentation may include novel screening modalities suited for biologically aggressive breast tumors and improved access to health care. Recognizing that there will remain some women diagnosed with dnMBC, refining our ability to identify those likely to be long-term survivors could allow for appropriate escalation or de-escalation of care. Finally, evaluation of tumor genomics in robust sample sizes has the potential to advance our knowledge of the biology of dnMBC as an entity distinct from recurrent MBC.

Factors associated with being diagnosed with high severity of breast cancer: a population-based study in Queensland, Australia

PURPOSE

This study explores factors that are associated with the severity of breast cancer (BC) at diagnosis.

METHODS

Interviews were conducted among women (n = 3326) aged 20-79 diagnosed with BC between 2011 and 2013 in Queensland, Australia. High-severity cancers were defined as either Stage II-IV, Grade 3, or having negative hormone receptors at diagnosis. Logistic regression models were used to estimate odds ratios (ORs) of high severity BC for variables relating to screening, lifestyle, reproductive habits, family history, socioeconomic status, and area disadvantage.

RESULTS

Symptom-detected women had greater odds (OR 3.38, 2.86-4.00) of being diagnosed with high-severity cancer than screen-detected women. Women who did not have regular mammograms had greater odds (OR 1.78, 1.40-2.28) of being diagnosed with high-severity cancer than those who had mammograms biennially. This trend was significant in both screen-detected and symptom-detected women. Screen-detected women who were non-smokers (OR 1.77, 1.16-2.71), postmenopausal (OR 2.01, 1.42-2.84), or employed (OR 1.46, 1.15-1.85) had greater odds of being diagnosed with high-severity cancer than those who were current smokers, premenopausal, or unemployed. Symptom-detected women being overweight (OR 1.67, 1.31-2.14), postmenopausal (OR 2.01, 1.43-2.82), had hormone replacement therapy (HRT) < 2 years (OR 1.60, 1.02-2.51) had greater odds of being diagnosed with high-severity cancer than those of healthy weight, premenopausal, had HRT > 10 years.

CONCLUSION

Screen-detected women and women who had mammograms biennially had lower odds of being diagnosed with high-severity breast cancer, which highlighted the benefit of regular breast cancer screening. Women in subgroups who are more likely to have more severe cancers should be particularly encouraged to participate in regular mammography screening.

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.

Addressing Potential Health Disparities in the Adoption of Advanced Breast Imaging Technologies

With the advent of new screening technologies, including digital breast tomosynthesis, screening ultrasound, and breast magnetic resonance imaging, there is growing concern that existing disparities among traditionally underserved populations will worsen. These newer screening modalities purport improved cancer detection over mammography alone but are not offered at all screening facilities and often require a larger co-pay or out-of-pocket expense. Thus, the potential for worsening disparities with regard to access and appropriate utilization of supplemental screening technologies exists. Currently, there is a dearth of literature on the topic of health disparities related to access and the use of supplemental breast cancer screening and their impact on outcomes. Identifying and addressing explanatory factors for persistent and potentially worsening disparities remain a central focus of efforts to improve equity in breast cancer care. Therefore, this paper provides an overview of factors that may contribute to present and future disparities in breast cancer screening and outcomes, and explores specific relevant topics requiring greater research efforts as more personalized, multimodality breast cancer screening approaches are adopted into clinical practice.

Geographical differences in risk of advanced breast cancer: Limited evidence for reductions over time, Queensland, Australia 1997-2014

BACKGROUND

Reducing geographical inequalities in breast cancer stage remains a key focus of public health policy. We explored whether patterns of advanced breast cancer by residential accessibility and disadvantage in Queensland, Australia, have changed over time.

METHODS

Population-based cancer registry study of 38,706 women aged at least 30 years diagnosed with a first primary invasive breast cancer of known stage between 1997 and 2014. Multilevel logistic regression was used to examine temporal changes in associations of area-level factors with odds of advanced disease after adjustment for individual-level factors.

RESULTS

Overall 19,401 (50%) women had advanced breast cancer. Women from the most disadvantaged areas had higher adjusted odds (OR = 1.23 [95%CI 1.13, 1.32]) of advanced disease than those from least disadvantaged areas, with no evidence this association had changed over time (interaction p = 0.197). Living in less accessible areas independently increased the adjusted odds (OR = 1.18 [1.09, 1.28]) of advanced disease, with some evidence that the geographical inequality had reduced over time (p = 0.045). Sensitivity analyses for un-staged cases showed that the original associations remained, regardless of assumptions made about the true stage distribution.

CONCLUSIONS

Both geographical and residential socioeconomic inequalities in advanced stage diagnoses persist, potentially reflecting barriers in accessing diagnostic services. Given the role of screening mammography in early detection of breast cancer, the lack of population-based data on private screening limits our ability to determine overall participation rates by residential characteristics. Without such data, the efficacy of strategies to reduce inequalities in breast cancer stage will remain compromised.

Education Level Is a Strong Prognosticator in the Subgroup Aged More Than 50 Years Regardless of the Molecular Subtype of Breast Cancer: A Study Based on the Nationwide Korean Breast Cancer Registry Database

Purpose

This study investigated the role of the education level (EL) as a prognostic factor for breast cancer and analyzed the relationship between the EL and various confounding factors.

Materials and Methods

The data for 64,129 primary breast cancer patients from the Korean Breast Cancer Registry were analyzed. The EL was classified into two groups according to the education period; the high EL group (≥ 12 years) and low EL group (< 12 years). Survival analyses were performed with respect to the overall survival between the two groups.

Results

A high EL conferred a superior prognosis compared to a low EL in the subgroup aged > 50 years (hazard ratio, 0.626; 95% confidence interval [CI], 0.577 to 0.678) but not in the subgroup aged ≤ 50 years (hazard ratio, 0.941; 95% CI, 0.865 to 1.024). The EL was a significant independent factor in the subgroup aged > 50 years according to multivariate analyses. The high EL group showed more favorable clinicopathologic features and a higher proportion of patients in this group received lumpectomy, radiation therapy, and endocrine therapy. In the high EL group, a higher proportion of patients received chemotherapy in the subgroups with unfavorable clinicopathologic features. The EL was a significant prognosticator across all molecular subtypes of breast cancer.

Conclusion

The EL is a strong independent prognostic factor for breast cancer in the subgroup aged > 50 years regardless of the molecular subtype, but not in the subgroup aged ≤ 50 years. Favorable clinicopathologic features and active treatments can explain the main causality of the superior prognosis in the high EL group.

Does stage of cancer, comorbidity or lifestyle factors explain educational differences in survival after endometrial cancer? A cohort study among Danish women diagnosed 2005-2009

BACKGROUND

Several studies have documented an association between socioeconomic position and survival from gynaecological cancer, but the mechanisms are unclear.

OBJECTIVE

The aim of this study was to examine the association between level of education and survival after endometrial cancer among Danish women; and whether differences in stage at diagnosis and comorbidity contribute to the educational differences in survival.

METHODS

Women with endometrial cancer diagnosed between 2005 and 2009 were identified in the Danish Gynaecological Cancer Database, with information on clinical characteristics, surgery, body mass index (BMI) and smoking status. Information on highest attained education, cohabitation and comorbidity was obtained from nationwide administrative registries. Logistic regression models were used to determine the association between level of education and cancer stage and Cox proportional hazards model for analyses of overall survival.

RESULTS

Of the 3638 patients identified during the study period, 787 had died by the end of 2011. The group of patients with short education had a higher odds ratio (OR) for advanced stage at diagnosis, but this was not statistically significant (adjusted OR 1.20; 95% CI 0.97-1.49). The age-adjusted hazard ratio (HR) for dying of patients with short education was 1.47 (CI 95% 1.17-1.80). Adjustment for cohabitation status, BMI, smoking and comorbidity did not change HRs, but further adjustment for cancer stage yielded a HR of 1.36 (1.11-1.67).

CONCLUSION

Early detection in all educational groups might reduce social inequalities in survival, however, the unexplained increased risk for death after adjustment for prognostic factors, warrants increased attention to patients with short education in all age groups throughout treatment and rehabilitation.

Long-term subjective cognitive functioning following adjuvant systemic treatment: 7-9 years follow-up of a nationwide cohort of women treated for primary breast cancer

Background:

There is growing concern among breast cancer (BC) patients and survivors about cognitive impairment following systemic treatments. The aim of the present study was to investigate the long-term effects of standard systemic adjuvant therapies on subjective cognitive impairment (SCI) in a large nationwide cohort of BC survivors 7–9 years after primary surgery.

Methods:

Participants were recruited from the nationwide Psychosocial Factors and Breast Cancer inception cohort of Danish women treated for primary BC. SCI was assessed with the Cognitive Failures Questionnaire and women allocated to systemic treatment according to nationwide standard protocols were compared with women who had not received any systemic treatments.

Results:

A total of 1889 recurrence-free survivors were eligible for analysis. No difference in SCI was found between survivors across standardized systemic treatment protocols when analyses were stratified by menopausal status and adjusted for possible sociodemographic and treatment-related confounders. The frequency of significant SCI in a subgroup of survivors in the age range 65–74 years was ∼7%.

Conclusions:

No differences in long-term SCI at 7–9 years post surgery were found between women who had received systemic therapies and those who had not. Furthermore, the observed proportion of survivors with significant SCI was comparable to normative data. These results are important to communicate to patients, survivors, and clinicians alike, especially in the light of increasing concern about cognitive impairment following systemic therapies.

Disparity in Breast Cancer Late Stage at Diagnosis in Missouri: Does Rural Versus Urban Residence Matter?

INTRODUCTION

Despite the fact that black women have a lower incidence of breast cancer compared to white women, black women experience higher death rates than any other group. We examined the stage of breast cancer presentation by race and geographic region using population-based breast cancer incidence in all 115 counties in the state of Missouri.

METHODS

We used 2003-2008 breast cancer incidence data from Missouri Cancer Registry and Research Center. County of residence was categorized as urban or rural using the rural-urban continuum code. We computed the conditional proportion of stage at diagnosis by race and metropolitan status and also used Pearson's chi-squared test with Yates' continuity correction to determine statistical significance of association.

RESULTS

Results of the study indicate that a greater proportion of black women (38.8 %) compared to white women (30.2 %) were diagnosed with more advanced breast metastasis. Our results further suggest that stage at diagnosis depended on county of residence or metropolitan status (p = .04). Women living in non-metropolitan counties were slightly more likely to have late-stage breast cancer than their metropolitan counterparts (32.0 vs 30.7 %). Overall, black women had 1.5-fold increased odds of late-stage breast cancer diagnosis compared to their white counterparts (OR = 1.50; 95 % CI, 1.39, 1.63; p < 0.0001). While the odds of late diagnosis among women living in non-metropolitan or rural counties was over 11 % higher compared with their metropolitan or urban counterpart.

CONCLUSION

The current study corroborates previous findings that the risk of late-stage breast cancer diagnosis was higher among women residing in non-metropolitan rural counties.

Cancer stage, comorbidity, and socioeconomic differences in the effect of cancer on labour market participation: a danish register-based follow-up study

Purpose

Socioeconomic inequality in return to work after cancer treatment and rehabilitation have been documented, but less is known about its causes. This paper investigates the role played by breast cancer stage at diagnosis and comorbidity.

Methods

We used the comprehensive Danish Cancer Registry to follow 7372 women aged 30-60, who were in the labour force when diagnosed with breast cancer in 2000-06 and survived at least three years. Controls were 213,276 women without breast cancer. Inequalities in employment outlook were estimated as interaction effects in linear regression between educational attainment and disease on employment.

Results

There is significant interaction between education and breast cancer, but it is only marginally affected by including stage and comorbidity in the regression models. Education, breast cancer stage, and comorbidity all have strong effects on later employment, and a considerable amount of the educational effect is mediated by comorbidity and pre-cancer labour market participation and income.

Conclusion

The result of the study is negative in the sense that the stronger effect of breast cancer on employment among low-educated compared to highly educated individuals is not explained by cancer stage or comorbidity. The fact that comorbidity has little impact on inequality may be due to a different social patterning of most comorbidity compared to breast cancer.

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.

Socioeconomic position and stage at diagnosis of head and neck cancer - a nationwide study from DAHANCA

BACKGROUND

Socioeconomic differences in survival after head and neck squamous cell carcinoma (HNSCC) are among the greatest for any malignancy. To improve our understanding of the mechanisms by which socioeconomic position influences HNSCC survival, we investigated the association between socioeconomic position and advanced stage HNSCC at diagnosis.

MATERIAL AND METHODS

Men and women with HNSCC diagnosed between 1992 and 2008 were identified in the Danish Head and Neck Cancer Group (DAHANCA) database, which contains detailed information on all cases of HNSCC treated in Denmark. Individual information on the following four socioeconomic indicators: highest attained educational level, cohabitation status, disposable income and degree of urbanisation were obtained from Statistics Denmark. For the 9683 cases on which there was full information, we estimated odds ratios (ORs) for a diagnosis of advanced stage (TNM III-IV) HNSCC in multivariate logistic regression models by site (glottic, non-glottic larynx, oropharynx, hypopharynx and oral cancer), with adjustment for age, gender, period of diagnosis, education, income, cohabitation status, degree of urbanisation and comorbidity in accordance with a causal diagram.

RESULTS

For all HNSCC sites, the ORs for advanced stage at diagnosis were increased for patients with low income and for men living alone. For glottic and oral cancers, the ORs for advanced stage HNSCC increased systematically by decreasing length of education. Increased ORs were found for hypopharynx cancer patients living in rural areas or provincial cities. Having one or more comorbid conditions was associated with an increased OR for advanced stage oral cancer but with a decreased OR for oropharynx cancer.

CONCLUSION

In this nationwide population-based study, socioeconomic differences in stage at diagnosis were found for all HNSCC subsites. Focus on the high risk for advanced stage HNSCC among vulnerable patients may be beneficial during referral and diagnosis in order to improve HNSCC outcomes.

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.

Association between body mass index and risk of breast cancer among females of north India

Background:

Worldwide, breast cancer is most common cancer among women. In India and other developing countries, breast carcinoma ranks second only to cervical carcinoma among women. Although studies have been done globally, to find association between BMI and breast cancer, very few studies in India document any such association.

Purpose:

To find out the association between BMI and breast cancer.

Materials and Methods:

A Case-control study was done from August 2009 - July 2010 in the wards of General Surgery and Oncosurgery at Pt.B.D.Sharma, PGIMS Rohtak, Haryana. A total of 128 histopathologically confirmed new cases of breast cancer during the study period were taken as cases. Equal number of controls was selected by simple random sampling. Controls were matched for age with range of ±2 years. Subjects were interviewed using a pretested questionnaire after obtaining written informed consent. Data were analyzed by applying appropriate statistical tests using SPSS version 17.

Results:

Age group of the cases was 25 - 78 years, while that of the controls was 24 - 79 years. Proportion of cases and controls living in rural areas were more than those living in urban areas. A significant association of breast cancer cases was found with high BMI and high fat intake

Conclusion:

Obesity and high fat intake are the significant risk factors, which are modifiable. So women should be encouraged to take care of all these factors. Maximum cases presented in late stages so public awareness of this fatal disease must be developed.

Disparities in breast cancer stage at diagnosis in urban and rural adult women: a systematic review and meta-analysis

PURPOSE

Survival from breast cancer is dependent on stage at diagnosis and some evidence suggests that rural women are more likely than urban women to be diagnosed with advanced stage disease. This systematic review and meta-analysis compared the stage of breast cancer at diagnosis between women residing in urban and rural areas.

METHODS

PubMed (1951-2012), EMBASE (1966-2012), CINAHL (1982-2012), RURAL (1966-2012), and Sociological abstracts (1952-2012) were systematically searched in November 2012 for relevant peer reviewed studies. Studies on adult women were included if they reported quantitative comparisons of rural and urban differences in staging of breast cancer at diagnosis.

RESULTS

Twenty-four studies were included in the systematic review and 21 studies had sufficient information for inclusion in the meta-analysis (N = 879,660). Evidence indicated that patients residing in rural areas were more likely to be diagnosed with more advanced breast cancer. Using a random effects model, the results of the meta-analysis showed that rural breast cancer patients had 1.19 higher odds (95% confidence interval, 1.12-1.27) of late stage breast cancer compared with urban breast cancer patients.

CONCLUSIONS

Rural women were more likely than urban women to be diagnosed at a later stage. Preventive measures may need to target the rural population.

Timeliness of abnormal screening and diagnostic mammography follow-up at facilities serving vulnerable women

BACKGROUND

Whether timeliness of follow-up after abnormal mammography differs at facilities serving vulnerable populations, such as women with limited education or income, in rural areas, and racial/ethnic minorities is unknown.

METHODS

We examined receipt of diagnostic evaluation after abnormal mammography using 1998-2006 Breast Cancer Surveillance Consortium-linked Medicare claims. We compared whether time to recommended breast imaging or biopsy depended on whether women attended facilities serving vulnerable populations. We characterized a facility by the proportion of mammograms performed on women with limited education or income, in rural areas, or racial/ethnic minorities.

RESULTS

We analyzed 30,874 abnormal screening examinations recommended for follow-up imaging across 142 facilities and 10,049 abnormal diagnostic examinations recommended for biopsy across 114 facilities. Women at facilities serving populations with less education or more racial/ethnic minorities had lower rates of follow-up imaging (4%-5% difference, P<0.05), and women at facilities serving more rural and low-income populations had lower rates of biopsy (4%-5% difference, P<0.05). Women undergoing biopsy at facilities serving vulnerable populations had longer times until biopsy than those at facilities serving nonvulnerable populations (21.6 vs. 15.6 d; 95% confidence interval for mean difference 4.1-7.7). The proportion of women receiving recommended imaging within 11 months and biopsy within 3 months varied across facilities (interquartile range, 85.5%-96.5% for imaging and 79.4%-87.3% for biopsy).

CONCLUSIONS

Among Medicare recipients, follow-up rates were slightly lower at facilities serving vulnerable populations, and among those women who returned for diagnostic evaluation, time to follow-up was slightly longer at facilities that served vulnerable population. Interventions should target variability in follow-up rates across facilities, and evaluate effectiveness particularly at facilities serving vulnerable populations.

Socioeconomic position and surgery for early-stage non-small-cell lung cancer: A population-based study in Denmark

AIM

To examine possible associations between socioeconomic position and surgical treatment of patients with early-stage non-small-cell lung cancer (NSCLC).

METHODS

In a register-based clinical cohort study, patients with early-stage (stages I-IIIa) NSCLC were identified in the Danish Lung Cancer Register 2001-2008 (date of diagnosis, histology, stage, and treatment), the Central Population Register (vital status), the Integrated Database for Labour Market Research (socioeconomic position), and the Danish Hospital Discharge Register (comorbidity). Logistic regression analyses were performed overall and separately for stages I, II and IIIa.

RESULTS

Of the 5538 eligible patients with stages I-IIIa NSCLC diagnosed 2001-2008, 53% underwent surgery. Higher stage, older age, being female and diagnosis early in the study period were associated with higher odds for not receiving surgery. Low disposable income was associated with greater odds for no surgery in stage I and stage II patients as was living alone for stage I patients. Comorbidity, a short diagnostic interval and small diagnostic volume were all associated with higher odds for not undergoing surgery; but these factors did not appear to explain the association with income or living alone for early-stage NSCLC patients.

CONCLUSION

Early-stage NSCLC patients with low income or who live alone are less likely to undergo surgery than those with a high income or who live with a partner, even after control for possible explanatory factors. Thus, even in a health care system with free, equal access to health services, disadvantaged groups are less likely to receive surgery for lung cancer.

Socioeconomic position, stage of lung cancer and time between referral and diagnosis in Denmark, 2001-2008

Introduction:

We investigated the association between socioeconomic position, stage at diagnosis, and length of period between referral and diagnosis in a nationwide cohort of lung cancer patients.

Methods:

Through the Danish Lung Cancer Register, we identified 18 103 persons diagnosed with lung cancer (small cell and non-small cell) in Denmark, 2001–2008, and obtained information on socioeconomic position and comorbidity from nationwide administrative registries. The odds ratio (OR) for a diagnosis of advanced-stage lung cancer (stages IIIB–IV) and for a diagnosis >28 days after referral were analysed by multivariate logistic regression models.

Results:

The adjusted OR for advanced-stage lung cancer was reduced among persons with higher education (OR, 0.92; 95% confidence interval (CI), 0.84–0.99), was increased in persons living alone (OR, 1.06; 95% CI, 1.01–1.13) and decreased stepwise with increasing comorbidity. Higher education was associated with a reduced OR for >28 days between referral and diagnosis as was high income in early-stage patients. Male gender, age and severe comorbidity were associated with increased ORs in advanced-stage patients.

Interpretation:

Differences by socioeconomic position in stage at diagnosis and in the period between referral and diagnosis indicate that vulnerable patients presenting with lung cancer symptoms require special attention.

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.

Accuracy of diagnostic mammography at facilities serving vulnerable women

BACKGROUND

Breast cancer missed on diagnostic mammography may contribute to delayed diagnoses, whereas false-positive results may lead to unnecessary invasive procedures. Whether accuracy of diagnostic mammography at facilities serving vulnerable women differs from other facilities is unknown.

OBJECTIVE

To compare the interpretive performance of diagnostic mammography at facilities serving vulnerable women to those serving nonvulnerable women.

DESIGN

We examined 168,251 diagnostic mammograms performed at Breast Cancer Surveillance Consortium facilities from 1999 to 2005. We used hierarchical logistic regression to compare sensitivity, false positive rates, and cancer detection rates.

SUBJECTS

Women aged between 40 and 80 years underwent diagnostic mammography to evaluate an abnormal screening mammogram or breast problem.

MEASURES

Facilities were assigned vulnerability indices according to the populations served based on the proportion of mammograms performed on women with lower educational attainment, racial/ethnic minority status, limited household income, or rural residences.

RESULTS

Sensitivity of diagnostic mammography did not vary significantly across vulnerability indices adjusted for patient-level characteristics, but false-positive rates for diagnostic mammography examinations to evaluate a breast problem were higher at facilities serving vulnerable women defined as those with lower educational attainment (odds ratio [OR], 1.39; 95% confidence interval [CI]: 1.08, 1.79); racial/ethnic minorities (OR, 1.32; 95% CI: 0.98, 1.76); limited income (OR, 1.34; 95% CI: 1.08, 1.66); and rural residence (OR, 1.55; 95% CI: 1.27, 1.88).

CONCLUSIONS

Diagnostic mammography to evaluate a breast problem at facilities serving vulnerable women had higher false positive rates than at facilities serving nonvulnerable women. This may reflect concerns that vulnerable populations may be less likely to follow-up after abnormal diagnostic mammography or concerns that such populations have higher cancer prevalence.

Factors affecting survival of women diagnosed with breast cancer in El-Minia Governorate, Egypt

OBJECTIVES

This study was conducted to determine breast cancer survival time and the association between breast cancer survival and socio-demographic and pathologic factors among women, in El-Minia, Egypt. While there has been much researches regarding prognostic factors for breast cancer but the majority of these studies were from developed countries. El-Minia has a population of approximately 4 million. To date, no research has been performed to determine breast cancer survival and the factors affecting it in El-minia.

METHODS

This retrospective study used data obtained from the cancer registry in the National Institute of Oncology in El-Minia and included 1207 women diagnosed with first primary breast cancer between 1(st) January 2005 and 31(st) December 2009 and followed to 30(th) June 2010. The association between survival and sociodemographic and pathological factors and distant metastasis at diagnosis, and treatment options was investigated using unifactorial chi-square test and multi-factorial (Cox regression) analyses. Kaplan-Meier analysis was used to compare survival time among different groups.

RESULTS

Median survival time was 83.8 ± 3.2. Cox regression showed that high vs low educational level (Hazard ratio (HR)= 0.35, 95% CI; 0.27-0.46), metastases to bone (HR = 3.22, 95% CI: 1.71-6.05), metastases to lung (HR= 2.314, 95% CI: 1.225-4.373), tumor size (≤ 2 cm vs ≥ 5 cm: HR = 1.4, 95% CI: 1.1-1.8) and number of involved nodes (1 vs > 10 HR = 5.21, 95%CI: 3.1-9.01) were significantly related to survival.

CONCLUSIONS

The results showed the need to develop screening programs and standardized treatment regimens in a tax-funded health care system.

Socioeconomic inequalities in prognostic markers of non-Hodgkin lymphoma: analysis of a national clinical database

The survival of non-Hodgkin lymphoma patients strongly depends on a range of prognostic factors. This registry-based clinical cohort study investigates the relation between socioeconomic position and prognostic markers in 6234 persons included in a national clinical database in 2000-2008, Denmark. Several measures of individual socioeconomic position were achieved from Statistics Denmark. The risk of being diagnosed with advanced disease, as expressed by the six prognostic markers (Ann Arbor stage III or IV, more than one extranodal lesion, elevated serum lactate dehydrogenase (LDH), performance status of two or more, presence of B symptoms and International Prognostic Index (IPI) of two or more), increased with decreasing level of education, in patients living alone, and in men. For instance, a significant decrease in the odds of being diagnosed with elevated LDH (p=0.02), high performance status (p=0.004), high IPI score (p=0.004) and B symptoms (p=0.02) was seen with higher level of education, whereas high stage of disease was significantly less likely in the higher educated (odds ratio [OR]=0.85 (0.74-0.99)). The difference in risk seemed not to be mediated by differences in histological subgroups reflecting aggressiveness of disease among the social groups. One of the most likely mechanisms of the social difference is longer delay in those with low socioeconomic position. The findings of social inequality in prognostic markers in non-Hodgkin lymphoma (NHL) patients could already be implemented in the clinical practice if general practitioners (GP's) and physicians on hospitals paid special attention to patients with low educational level and unspecific symptoms.

Trends in the survival of patients diagnosed with breast cancer in the Nordic countries 1964-2003 followed up to the end of 2006

BACKGROUND

Breast cancer is the leading cancer among women worldwide in terms of both incidence and mortality. European patients have generally high 5-year relative survival ratios, and the Nordic countries, except for Denmark, have ratios among the highest.

MATERIAL AND METHODS

Based on the NORDCAN database we present trends in age-standardised incidence and mortality rates of invasive breast cancer in the Nordic countries, alongside 5- and 10-year relative survival for the period of diagnosis 1964-2003 followed up to the end of 2006. Excess mortality rates are also provided for varying follow-up intervals after diagnosis. The analysis is confined to invasive breast cancer in Nordic women.

RESULTS

Incidence increased rapidly in all five countries, whereas mortality remained almost unchanged. Both incidence and mortality rates were highest in Denmark. Between 1964 and 2003 both 5- and 10-year relative survival increased by 20-30 percentage points in all countries, and 10-year survival remained around 10 percentage points lower than 5-year survival. Relative survival was lowest in Denmark throughout the period, with a 5-year survival of 79% for years 1999-2003, but 83-87% in the other countries. From 1964 the youngest women had the highest survival ratios up until the introduction of screening, when a shift occurred towards higher survival among age groups 50-59 and 60-69 in each country, except for Denmark. Excess death rates during the first months after diagnosis were highest in Denmark.

CONCLUSION

Breast cancer survival is high and rising in the Nordic countries, and probably relates to the early implementation of organised mammography screening in each country except Denmark and a high and relatively uniform standard of living, diagnosis and treatment. Denmark stands out with higher mortality and poorer survival. The major determinants may include a failure to instigate national breast screening and a greater co-morbidity resulting from a higher prevalence of both tobacco smoking and alcohol consumption.

An exploratory study of associations between illness perceptions and adjustment and changes after psychosocial rehabilitation in survivors of breast cancer

BACKGROUND. Although psychosocial interventions have been found to be beneficial for cancer patients, the role of the patients' perceptions of illness in these interventions remains unclear. We examined illness perceptions and psychological adjustment (distress and QoL) among women who had survived breast cancer and attended a psychosocial rehabilitation course. MATERIAL AND METHODS. From an ongoing longitudinal study, we used data from two sub-studies with a total of 177 survivors (145 from the descriptive study and 32 from the randomised trial). The survivors from the descriptive study and the half of the randomised survivors attended a 1-week rehabilitation course, whereas the other half of the randomised survivors only received standard care (no intervention). All survivors filled out a questionnaire 2.5 weeks before and one and six months after the course. RESULTS AND DISCUSSION. No differences in the change of illness perceptions and the level of psychological adjustment were observed between the three groups of survivors between baseline and one and six months of follow-up. Baseline analyses showed that illness perceptions were associated with distress and QoL. This study indicates that illness perceptions are associated with adjustment; however, illness perceptions did not change after participation in a one-week multi-component rehabilitation course.

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.

Inequalities in breast cancer stage at diagnosis in the Trent region, and implications for the NHS Breast Screening Programme

BACKGROUND

This study investigates risk factors for diagnosis with late-stage breast cancer in order to identify inequalities and inform the understanding of barriers affecting access to mammography screening.

METHODS

Data from the Trent Cancer Registry were used to identify all women with invasive breast cancer, diagnosed in 1998-2006. Risk of diagnosis with late-stage breast cancer was calculated to quantify strength of association between exposure and outcome.

RESULTS

Women outside the age group for routine screening were approximately 30% [<50 years, relative risk (RR) = 1.34 (95% confidence interval, CI: 1.26-1.43) and >70 years, RR = 1.27 (95% CI: 1.19-1.36)] more likely to be diagnosed with late-stage breast cancer; the most deprived women were 37% [RR = 1.37 (95% CI: 1.01-2.56)] more likely to be diagnosed with Stage IV breast cancer; ethnic minority women were 15% [RR = 1.15 (95% CI: 1.09-1.22)] more likely to be diagnosed with late-stage breast cancer and women resident in 5 of 11 Trent Primary Care Trusts (PCT) had a greater than 30% increased risk of diagnosis with late-stage breast cancer than those in Nottingham City PCT.

CONCLUSION

These findings highlight the need for appropriate targeted interventions to address compositional and contextual inequalities that are evident in breast cancer stage at diagnosis.

Social differences in breast cancer survival in relation to patient management within a National Health Care System (Sweden)

Epidemiologic studies have shown that cancer survival is poorer in low compared with high socioeconomic groups. We investigated whether these differences were associated with disparities in tumour characteristics and management. This cohort study was based on 9,908 women aged 20-79 years at diagnosis with primary breast cancer identified in a Swedish population-based clinical register. Information on socioeconomic standing was obtained from a social database. The 5-year cause-specific survival (CSS) and mortality hazard ratios (HR) were estimated by Cox proportional hazard models to assess differences in survival between socioeconomic groups while adjusting for diagnostic intensity, tumour characteristics and treatment. Following adjustment for age, year and stage at diagnosis, the risk of dying of breast cancer was 35% lower among women with high education compared with that of low education (HR = 0.65, 95% CI 0.53-0.80). When compared with women with high education, a lower percentage of women with low education had been investigated for proliferation (84 vs. 76%) or hormone receptor status (89 vs. 81%), had tumours <or=20 mm (68 vs. 64%), were treated at a main hospital (75 vs. 68%) and had received radiation treatment (80 vs. 67%) or chemotherapy (31 vs. 18%). However, these proportional differences could not explain the observed social gradient in survival. To minimize social differences in breast cancer survival, further research should address not only factors leading to inequities in management but also focus on patient factors such as health awareness, comorbidity burden and compliance to adjuvant treatment.

Delayed breast reconstruction with implants after invasive breast cancer does not impair prognosis

We investigated if delayed breast implant reconstruction after breast cancer impairs prognosis. Using data from the Danish Breast Cancer Cooperative Group register, we identified all women <70 years who underwent breast reconstruction with implants after mastectomy after invasive breast cancer during 1978 to 1992, on average 2.2 years (range, 3 days-9.4 years) after mastectomy. The reconstructed women were closely matched to breast cancer patients without reconstruction on age and calendar time of diagnosis, tumor size, regional lymph node involvement, and adjuvant radiation therapy. Overall, 580 reconstructed women and 1158 individually matched controls were followed-up for disease-free survival within the first 10 years and for overall survival for an average of 20.1 year (range, 12.8-27.5 years). Disease-free survival was significantly improved hazard ratio 0.78; 95% confidence interval 0.64-0.95 and overall survival was nonsignificantly improved (hazard ratio, 0.90; 95% confidence interval 0.76-1.06) among the breast reconstructed women. This is likely because of differences in socioeconomic and health factors.

Social inequality in incidence of and survival from cancer in a population-based study in Denmark, 1994-2003: Summary of findings

The purpose of this nationwide, population register-based study was to describe variations in cancer incidence and survival by social position in a social welfare state, Denmark, on the basis of a range of socioeconomic, demographic and health-related indicators. Our study population comprised all 3.22 million Danish residents born in 1925-1973 and aged >or=30 years, who were followed up for cancer incidence in 1994-2003 and for survival in 1994-2006, yielding 147,973 cancers. The incidence increased with lower education and income, especially for tobacco- and other lifestyle-related cancers, although for cancers of the breast and prostate and malignant melanoma the association was inverse. Conversely there was a general increase in incidence among early retirement pensioners, persons living in rented housing and those living in the smallest dwellings. Also incidence rates were generally higher in persons living alone compared to those living with a partner and in the capital area compared to the rural areas. Social inequality in the prognosis of most cancers was observed, despite the equal access to health care in Denmark, with poorer relative survival related to fewer advantages, regardless of how they were measured, often most pronounced in the first year after diagnosis. Also living alone and having somatic or psychiatric comorbidity negatively impacted the relative survival after most cancers. Our study shows that inequalities in cancer incidence and survival must be addressed in all aspects of public health, with interventions both to reduce incidence and to prolong survival.

The influence of socio-economic and surveillance characteristics on breast cancer survival: a French population-based study

Survival data on female invasive breast cancer with 9-year follow-up from five French cancer registries were analysed by logistic regression for prognostic factors of cancer stage. The Kaplan–Meier method and log-rank test were used to estimate and compare the overall survival probability at 5 and 7 years, and at the endpoint. The Cox regression model was used for multivariate analysis. County of residence, age group, occupational status, mammographic surveillance, gynaecological prevention consultations and the diagnosis mammography, whether within a screening framework or not, were independent prognostic factors of survival. Moreover, for the same age group, and only for cancers T2 and/or N+ (whether 1, 2 or 3) and M0, the prognosis was significantly better when the diagnosis mammography was done within the framework of screening. Socio-economic and surveillance characteristics are independent prognostic factors of both breast cancer stage at diagnosis and of survival. Screening mammography is an independent prognostic factor of survival.

Low-Dose Aspirin May Prevent Growth and Later Surgical Repair of Medium-Sized Abdominal Aortic Aneurysms

Experimental data suggest that aspirin-induced platelet inhibition may retard growth of abdominal aortic aneurysms. In this article, whether low-dose aspirin use is associated with reduced aneurysm progression and subsequent need for surgery is examined. In this observational cohort study within a screening trial, 148 patients with small aneurysms (maximum diameter 30-48 mm) annually are followed. Patients were referred for surgery when the aneurysmal diameter exceeded 50 mm. Median follow-up time was 6.6 years. Among patients whose abdominal aortic aneurysms were initially 40 to 49 mm in size, the abdominal aortic aneurysm expansion rate for low-dose aspirin users compared with nonusers was 2.92 mm/y versus 5.18 mm/y (difference 2.27 mm/y, 95% CI, 0.42-4.11). No difference in expansion rates and risk ratios for operative repair was found for patients with abdominal aortic aneurysms <40 mm. For medium-sized abdominal aortic aneurysms, low-dose aspirin may prevent abdominal aortic aneurysm growth and need for subsequent repair, but residual confounding cannot be excluded.