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

Social Determinants of Health Framework to Identify and Reduce Barriers to Imaging in Marginalized Communities

Social determinants of health (SDOH) are conditions influencing individuals' health based on their environment of birth, living, working, and aging. Addressing SDOH is crucial for promoting health equity and reducing health outcome disparities. For conditions such as stroke and cancer screening where imaging is central to diagnosis and management, access to high-quality medical imaging is necessary. This article applies a previously described structural framework characterizing the impact of SDOH on patients who require imaging for their clinical indications. SDOH factors can be broadly categorized into five sectors: economic stability, education access and quality, neighborhood and built environment, social and community context, and health care access and quality. As patients navigate the health care system, they experience barriers at each step, which are significantly influenced by SDOH factors. Marginalized communities are prone to disparities due to the inability to complete the required diagnostic or screening imaging work-up. This article highlights SDOH that disproportionately affect marginalized communities, using stroke and cancer as examples of disease processes where imaging is needed for care. Potential strategies to mitigate these disparities include dedicating resources for clinical care coordinators, transportation, language assistance, and financial hardship subsidies. Last, various national and international health initiatives are tackling SDOH and fostering health equity.

Breast cancer is associated with coronary heart disease: a cross-sectional survey of NHANES 1999-2018

Background

Understanding the correlation between female breast cancer (BC) and the prevalence of coronary heart disease (CHD) is important for developing prevention strategies and reducing the burden of female social disease. This study aimed to evaluate the relationship between BC and CHD using data from the National Health and Nutrition Examination Survey (NHANES) database from 1999 to 2018.

Methods

The study cohort included 16,149 eligible non-pregnant female participants aged 20 years or older. Logistic regression was used to analyze the relationship between BC and CHD, excluding the interaction between covariates and BC through hierarchical subgroup analysis.

Results

The study found that participants with BC had a 2.30 times greater risk of developing CHD compared to those without BC [95% confidence interval (CI): 2.29-2.31]. After adjusting for all included covariates, BC was still significantly associated with CHD risk (odds ratio: 1.11, 95% CI: 1.10-1.12). When participants were stratified by age, education level, and prevalence of hypertension, it was evident that participants with BC had a higher risk of developing CHD compared to those without BC, although the effect of BC on CHD varied across stratification.

Conclusions

Our study demonstrates the close relationship between CHD and female BC. Therefore, it is necessary to screen patients with CHD for BC and monitor BC survivors for the long-term risk of developing CHD.

Trends in cancer incidence by socioeconomic deprivation in Germany in 2007 to 2018: An ecological registry-based study

Age-standardized cancer incidence has decreased over the last years for many cancer sites in developed countries. Whether these trends led to narrowing or widening socioeconomic inequalities in cancer incidence is unknown. Using cancer registry data covering 48 million inhabitants in Germany, the ecological association between age-standardized total and site specific (colorectal, lung, prostate and breast) cancer incidence in 2007 to 2018 and a deprivation index on district level (aggregated to quintiles) was investigated. Incidence in the most and least deprived districts were compared using Poisson models. Average annual percentage changes (AAPCs) and differences in AAPCs between deprivation quintiles were assessed using Joinpoint regression analyses. Age-standardized incidence decreased strongly between 2007 and 2018 for total cancer and all cancer sites (except female lung cancer), irrespective of the level of deprivation. However, differences in the magnitude of trends across deprivation quintiles resulted in increasing inequalities over time for total cancer, colorectal and lung cancer. For total cancer, the incidence rate ratio between the most and least deprived quintile increased from 1.07 (95% confidence interval: 1.01-1.12) to 1.23 (1.12-1.32) in men and from 1.07 (1.01-1.13) to 1.20 (1.14-1.26) in women. Largest inequalities were observed for lung cancer with 82% (men) and 88% (women) higher incidence in the most vs the least deprived regions in 2018. The observed increase in inequalities in cancer incidence is in alignment with trends in inequalities in risk factor prevalence and partly utilization of screening. Intervention programs targeted at socioeconomically deprived and urban regions are highly needed.

Elevated breast cancer mortality among highly educated Asian American women

Background

Postmenopausal breast cancer (PMBC) is the most commonly diagnosed and the second leading cause of cancer death among women in the US. Research examining the association between PMBC and education level has been inconsistent; no study in the US has examined how educational level impacts PMBC mortality in Asian American women, a largely immigrant population with above-average educational attainment.

Methods

California Vital Statistics data from 2012–2017 were analyzed to derive age-adjusted mortality rate ratios (MRRs) by education level (associates degree or above referred to as “higher education”, high school, less than high school) and race [Non-Hispanic White (NHW), Asian/Pacific Islander (Asian), and its two largest subpopulations: Chinese and Filipino] from negative binomial regression models.

Results

PMBC mortality for both NHWs and Asians was greater among women with higher education compared to those who did not complete high school: NHWs had 22% higher PMBC mortality (MRR 1.22; 95% CI: 1.14–1.31) and Asians had 2.6 times greater PMBC mortality (MRR 2.64; 95% CI: 2.32–3.00) than their counterparts who did not complete high school. Asians in the lowest education level had 70% lower mortality than NHWs (MRR 0.30; 95% CI: 0.27–0.34). This mortality advantage among Asians was greatly reduced to only 27% lower among the highest educated (MRR 0.73; 95% CI: 0.68–0.78). For higher educated Filipina women, no mortality advantage was evident compared to NHWs (MRR 0.96; 95% CI: 0.88–1.05).

Conclusion

PMBC mortality for higher educated Asian women is elevated in comparison to their counterparts with less education. Given that PMBC survival is greater among those with higher education, our findings strongly suggest an excess in the incidence of PMBC (more than double) among higher educated Asian women; this warrants more research into potentially modifiable causes of PMBC in this burgeoning population.

Do Breast Cancer Patients Manage to Participate in an Outdoor, Tailored, Physical Activity Program during Adjuvant Breast Cancer Treatment, Independent of Health and Socio-Demographic Characteristics?

Exercise could reduce the side-effects of adjuvant breast cancer treatment; however, socio-demographic, health, and intervention conditions may affect patients’ adherence to interventions. This study aimed to examine adherence to a 12-month outdoor post-surgery exercise program among newly diagnosed breast cancer patients during adjuvant treatment, and to identify socio-demographic and health-related predictors. In total, 47 women with invasive breast cancer stage I–II or ductal/lobular carcinoma grade 3 were included pre-surgery and randomized two weeks post-surgery to exercise (2 × 60 min/week). Patient characteristics (body-mass index (BMI), socioeconomic status, comorbidity, physical activity, and maximal oxygen uptake (VO2max)) were recorded pre-surgery. Correlations between adherence and patient characteristics and statistics for between-group differences were performed. The mean age was 54.2 years, mean BMI 27.8 kg/m², and 54.2% received chemotherapy. Completers had a mean adherence of 81%, independent of season. Withdrawals (23%) occurred after a mean of 6.5 weeks (0–24 weeks), they were suggestively older, had lower socioeconomic status and pre-surgery VO2max, and higher BMI. Household income was significantly lower among withdrawals. There were insignificant correlations between adherence and health conditions. High adherence is achievable in a Nordic outdoor physical exercise program in breast cancer patients during adjuvant treatment, including chemotherapy. Additional studies are needed to clarify follow-up needs in some groups.

Mortality differences between migrants and Italians residing in Rome before, during, and in the aftermath of the great recession. A longitudinal cohort study from 2001 to 2015

Background

In Europe, one of the most consistent findings is that of migrant mortality advantage in high-income countries. Furthermore, the literature shows that economic shocks, which bring worse health outcomes, can severely affect the most disadvantaged individuals. We analyse differences and changes in all-cause mortality between Italians and migrants residing in Rome before, during, and in the aftermath of the Great Recession (2001–2015) by birth-cohort.

Methods

The analysis is a longitudinal open cohort study. Mortality data come from the Register of the Causes of Death (58,637 deaths) and the population denominator (n = 2,454,410) comes from the Municipal Register of Rome. By comparing three time-periods (2001–2005, 2006–2010, and 2011–2015), we analyse all-cause mortality of Rome residents born, respectively, in the intervals 1937–1976, 1942–1981, 1947–1986 (aged 25–64 years at entry into observation). Computing birth-cohort-specific death rates and applying parametric survival models with age as the time-scale, we compare mortality differences between migrants and Italians by gender, area of origin, and time-period.

Results

Overall, we find a lower risk of dying for migrants than Italians regardless of gender (Women: HR = 0.61, 95% CI 0.56–0.66; Men: HR = 0.49, 95% CI 0.45–0.53), and a lower death risk over time for the total population. Nevertheless, such a pattern changes according to gender and migrants’ area of origin.

Conclusion

Given the relevance of international migrations in Europe, studying migrants’ health has proved increasingly important. The deterioration in migrant health and the gradual weakening of migrants’ mortality advantage is likely to become a public health issue with important consequences for the healthcare system of all European countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12176-8.

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.

Educational level, ethnicity and mortality rates in Israel: national data linkage study

Background

Many studies have shown significant gaps in mortality, and cause specific mortality by educational status. This study investigated these measures in Israel by educational and ethnic status in recent decades.

Method

A mortality follow-up till 2017 was done of a cohort of Israeli residents aged 25–64 in 2000 who remained in Israel and had available educational data, grouped into under 8, 9–11, 12, 13–15 and 16 and above years of education. Indirect age adjustment was used to calculate Standard Mortality Ratios (SMRs) by sex and educational group, and a Cox regression model to assess relative risk of total and cause specific mortality controlling for age and ethnic group (Jews and Others and Arabs).The analysis was repeated for each ethnic group separately.

Results

2,776,422 persons were included of whom 174,792 (6.3%) died till 2017. SMR’s for total mortality of males and females with less than 8 years of education compared to 16 and over were 2.2 and 1.8, respectively. Corresponding HR were 2.13 (95% CI 2.08–2.18) and 1.77 (95% CI 1.72–1.82), respectively.

The highest cause specific hazard ratios in males were for homicide, 4.40 (95% CI 3.19–6.07), respiratory diseases, 4.01 (95% CI 3.61–4.44), infectious diseases, 3.55 (95% CI 3.15–3.19) and diabetes 3.41 (95% CI 3.06–3.79) and in females for diabetes, 4.41 (95% CI 3.76–5.16), infectious diseases, 4.16 (95% CI 3.52–4.91), respiratory diseases, 4.13 (95% CI 3.55–4.81), and heart disease, 2.96 (95% CI 2.66–3.29).

Education-adjusted risk of all-cause mortality for Arab males was 1.07 (1.05–1.09) times that of Jews and Others and non-significant in females. High mortality risk was found for Arab males and females compared to Jews and Others for homicide, diabetes, heart and cerebrovascular disease and for respiratory disease in males. Lower risk was found for suicide and infectious diseases in both sexes and

cancer in females.

Conclusion

We found significant effect of educational level on all-cause and cause specific mortality, particularly respiratory diseases, infectious diseases, diabetes and homicide. Our results highlight the importance of increasing the educational level of all groups in the population and of encouraging healthy behavior in the lower educated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13584-021-00483-9.

Literature Review: Social Determinant of Health in Breast Cancer Patients Survival

BACKGROUND: Social determinants have an important role in the survival of breast cancer patients. AIM: This article aims to reviews the social determinants that affect the survival of breast cancer patient. METHODS: We searched PubMed and Google Scholar for identifying studies related to this review using free-text terms and Medical Subject Headings terms. Both experimental and observational studies on social determinants of breast cancer patient survival which were published in the English language have been included in this review except expert opinions, commentaries, editorials, and review articles. Ten studies were eligible to be included in review. RESULTS: Social health determinants that play a role in the survival of breast cancer patients are education level, place of residence, socioeconomic status, social environment, racial discrimination, and access to health services. CONCLUSION: Social determinants have an influence on the survival of breast cancer patients, so it is important to pay attention to these factors.

Socioeconomic inequalities in stage-specific breast cancer incidence: a nationwide registry study of 1.1 million young women in Norway, 2000-2015

BACKGROUND

Women with high socioeconomic status (SES) have the highest incidence rates of breast cancer. We wanted to determine if high SES women only have higher rates of localized disease, or whether they also have higher rates of non-localized disease. To study this, we used data on a young population with universal health care, but not offered screening.

MATERIAL AND METHODS

Using individually linked registry data, we compared stage-specific breast cancer incidence, by education level and income quintile, in a Norwegian cohort of 1,106,863 women aged 30-48 years during 2000-2015 (N = 7531 breast cancer cases). We calculated stage-specific age-standardized rates and incidence rate ratios and rate differences using Poisson models adjusted for age, period and immigration history.

RESULTS

Incidence of localized and regional disease increased significantly with increasing education and income level. Incidence of distant stage disease did not vary significantly by education level but was significantly reduced in the four highest compared to the lowest income quintile. The age-standardized rates for tertiary versus compulsory educated women were: localized 28.2 vs 19.8, regional 50.8 vs 40.4 and distant 2.3 vs 2.6 per 100,000 person-years. The adjusted incidence rate ratios (tertiary versus compulsory) were: localized 1.40 (95% CI 1.25-1.56), regional 1.25 (1.15-1.35), distant 0.90 (0.64-1.26). The age-standardized rates for women in the highest versus lowest income quintile were: localized 28.9 vs 17.7, regional 52.8 vs 41.5 and distant 2.3 vs 3.2 per 100,000 person-years. The adjusted incidence rate ratios (highest versus lowest quintile) were: localized 1.63 (1.42-1.87), regional 1.27 (1.09-1.32), distant 0.64 (0.43-0.94).

CONCLUSION

Increased breast cancer rates among young high SES women is not just increased detection of small localized tumors, but also increased incidence of tumors with regional spread. The higher incidence of young high SES women is therefore real and not only because of excessive screening.

Education, income and risk of cancer: results from a Norwegian registry-based study

INTRODUCTION

Several studies have shown an association between socioeconomic status and incidence of cancer. In this study, we have examined the association between socioeconomic factors, using income and education as proxies, and cancer incidence in Norway, a country known to be egalitarian, with universal access to health care and scoring high on the human development index.

METHODS

We linked individual data for the total Norwegian population with information on all cancer patients registered in the Cancer Registry of Norway (CRN) with any cancer diagnosed between 2012 and 2016. Data on education, and individual income, were provided from Statistics Norway. We used Poisson regression to obtain incidence rate ratios (IRR) across education and income levels for 23 cancer sites.

RESULTS

A total of 9 cancers among men and 13 cancers among women were observed to have significantly higher incidence rates in cases with the lowest level of education. Melanoma for both sexes, testis and prostate cancer in men, and breast cancer in women were found to have a higher incidence rate among those with the highest level of education. The largest differences in IRR were found for lung cancer, where men and women with college or university education as their highest completed education had a two- to threefold decreased risk, compared to those with primary school (IRR men; 0.40 [0.37-0.43], women 0.34 [0.31-0.37]). The results for income mirrored the results for education among men, while for women we did not observe many differences in cancer risk across income groups.

CONCLUSION

Our findings were consistent with findings from other studies showing that the incidence rate of cancer differs across levels of socioeconomic status. We may need behavioral change campaigns focused on lifestyle changes that lower the risk of cancer and target perhaps to those with lower socioeconomic status.

Socioeconomic inequalities in cancer incidence in Europe: a comprehensive review of population-based epidemiological studies

Background

Since the end of the previous century, there has not been a comprehensive review of European studies on socioeconomic inequality in cancer incidence. In view of recent advances in data source linkage and analytical methods, we aimed to update the knowledge base on associations between location-specific cancer incidence and individual or area-level measures of socio-economic status (SES) among European adults.

Materials and methods

We systematically searched three databases (PubMed, Scopus and Web of Science) for articles on cancer incidence and SES. Qualitative synthesis was performed on the 91 included English language studies, published between 2000 and 2019 in Europe, which focused on adults, relied on cancer registry data and reported on relative risk (RR) estimates.

Results

Adults with low SES have increased risk of head and neck, oesophagogastric, liver and gallbladder, pancreatic, lung, kidney, bladder, penile and cervical cancers (highest RRs for lung, head and neck, stomach and cervix). Conversely, high SES is linked with increased risk of thyroid, breast, prostate and skin cancers. Central nervous system and haematological cancers are not associated with SES. The positive gap in testicular cancer has narrowed, while colorectal cancer shows a varying pattern in different countries. Negative associations are generally stronger for men compared to women.

Conclusions

In Europe, cancers in almost all common locations are associated with SES and the inequalities can be explained to a varying degree by known life-style related factors, most notably smoking. Independent effects of many individual and area SES measures which capture different aspects of SES can also be observed.

Social determinants of adult mortality from non-communicable diseases in northern Ethiopia, 2009-2015: Evidence from health and demographic surveillance site

INTRODUCTION

In developing countries, mortality and disability from non-communicable diseases (NCDs) is rising considerably. The effect of social determinants of NCDs-attributed mortality, from the context of developing countries, is poorly understood. This study examines the burden and socio-economic determinants of adult mortality attributed to NCDs in eastern Tigray, Ethiopia.

METHODS

We followed 45,982 adults implementing a community based dynamic cohort design recording mortality events from September 2009 to April 2015. A physician review based Verbal autopsy was used to identify the most probable causes of death. Multivariable Cox proportional hazards regression was performed to identify social determinants of NCD mortality.

RESULTS

Across the 193,758.7 person-years, we recorded 1,091 adult deaths. Compared to communicable diseases, NCDs accounted for a slightly higher proportion of adult deaths; 33% vs 34.5% respectively. The incidence density rate (IDR) of NCD attributed mortality was 194.1 deaths (IDR = 194.1; 95% CI = 175.4, 214.7) per 100,000 person-years. One hundred fifty-seven (41.8%), 68 (18.1%) and 34 (9%) of the 376 NCD deaths were due to cardiovascular disease, cancer and renal failure, respectively. In the multivariable analysis, age per 5-year increase (HR = 1.35; 95% CI: 1.30, 1.41), and extended family and non-family household members (HR = 2.86; 95% CI: 2.05, 3.98) compared to household heads were associated with a significantly increased hazard of NCD mortality. Although the difference was not statistically significant, compared to poor adults, those who were wealthy had a 15% (HR = 0.85; 95% CI: 0.65, 1.11) lower hazard of mortality from NCDs. On the other hand, literate adults (HR = 0.35; 95% CI: 0.13, 0.9) had a significantly decreased hazard of NCD attributed mortality compared to those adults who were unable to read and write. The effect of literacy was modified by age and its effect reduced by 18% for every 5-year increase of age among literate adults.

CONCLUSION

In summary, the study indicates that double mortality burden from both NCDs and communicable diseases was evident in northern rural Ethiopia. Public health intervention measures that prioritise disadvantaged NCD patients such as those who are unable to read and write, the elders, the extended family and non-family household co-residents could significantly reduce NCD mortality among the adult population.

Lower attendance rates in immigrant versus non-immigrant women in the Norwegian Breast Cancer Screening Programme

Objective

The Norwegian Breast Cancer Screening Programme invites women aged 50–69 to biennial mammographic screening. Although 84% of invited women have attended at least once, attendance rates vary across the country. We investigated attendance rates among various immigrant groups compared with non-immigrants in the programme.

Methods

There were 4,053,691 invitations sent to 885,979 women between 1996 and 2015. Using individual level population-based data from the Cancer Registry and Statistics Norway, we examined percent attendance and calculated incidence rate ratios, comparing immigrants with non-immigrants, using Poisson regression, following women's first invitation to the programme and for ever having attended.

Results

Immigrant women had lower attendance rates than the rest of the population, both following the first invitation (53.1% versus 76.1%) and for ever having attended (66.9% versus 86.4%). Differences in attendance rates between non-immigrant and immigrant women were less pronounced, but still present, when adjusted for sociodemographic factors. We also identified differences in attendance between immigrant groups. Attendance increased with duration of residency in Norway. A subgroup analysis of migrants' daughters showed that 70.0% attended following the first invitation, while 82.3% had ever attended.

Conclusions

Immigrant women had lower breast cancer screening attendance rates. The rationale for immigrant women's non-attendance needs to be explored through further studies targeting women from various birth countries and regions.