Socioeconomic disparity in survival after breast cancer in ireland: observational study

Equitable Access, Lasting Results: The Influence of Socioeconomic Environment on Bariatric Surgery Outcomes

PURPOSE

Low socioeconomic status (SES) correlates with higher obesity rates and challenges in accessing treatments like bariatric surgery (BS). This study aims to assess SES's influence on medium-term BS outcomes in a setting of universal healthcare, ensuring equitable treatment access.

MATERIAL AND METHODS

We conducted a retrospective analysis of 193 BS patients (1997-2018) at a tertiary care hospital. Weight loss was expressed as change in % total weight loss (%TWL) and excess body weight (EBW) loss. Successful BS was defined as > 50% EBW loss. SES was gauged using quartiles of the Spanish Deprivation Index. A multivariable Cox regression model evaluated SES impact on BS success over follow-up.

RESULTS

The mean follow-up was 6.9 ± 4.6 years; patients averaged 43.9 ± 11.8 years, with 29.7% men. Preoperative BMI was 48.2 ± 8.2 kg/m2. At follow-up, BMI was 33.9 ± 6.6 kg/m2, with 29.3 ± 12.02% of %TWL. No SES quartile differences in BS success were noted at follow-up (log rank p = 0.960). Cox regression revealed no SES disparities in BS outcomes post-adjustment. However, female sex (HR 1.903; p = 0.009) and diabetes mellitus (HR = 0.504; p = 0.010) correlated with weight-related outcomes.

CONCLUSION

In a universal healthcare system with equitable treatment access, medium-term BS outcomes remain consistent irrespective of patients' socioeconomic status.

Impact of organized and opportunistic screening on excess mortality and on social inequalities in breast cancer survival

In most developed countries, both organized screening (OrgS) and opportunistic screening (OppS) coexist. The literature has extensively covered the impact of organized screening on women's survival after breast cancer. However, the impact of opportunistic screening has been less frequently described due to the challenge of identifying the target population. The aim of this study was to describe the net survival and excess mortality hazard (EMH) in each screening group (OrgS, OppS, or No screening) and to determine whether there is an identical social gradient in each groups. Three data sources (cancer registry, screening coordination centers, and National Health Data System [NHDS]) were used to identify the three screening groups. The European Deprivation Index (EDI) defined the level of deprivation. We modeled excess breast cancer mortality hazard and net survival using penalized flexible models. We observed a higher EMH for "No screening" women compared with the other two groups, regardless of level of deprivation and age at diagnosis. A social gradient appeared for each group at different follow-up times and particularly between 2 and 3 years of follow-up for "OrgS" and "OppS" women. Net survival was higher for "OrgS" women than "OppS" women, especially for the oldest women, and regardless of the deprivation level. This study provides new evidence of the impact of OrgS on net survival and excess mortality hazard after breast cancer, compared with opportunistic screening or no screening, and tends to show that OrgS attenuates the social gradient effect.

Socioeconomic and geographic disparities of breast cancer incidence according to stage at diagnosis in France

PURPOSE

Low socioeconomic background (SB) has been associated with lower breast cancer (BC) incidence and higher BC mortality. One explanation of this paradox is the higher frequency of advanced BC observed in deprived women. However, it is still unclear if SB affects similarly BC incidence. This study investigated the link between SB and early/advanced BC incidence from Loire-Atlantique/Vendee Cancer registry data (France).

MATERIALS AND METHODS

Fourteen thousand three hundred fifty three women living in the geographic area covered by the registry and diagnosed with a primary BC in 2008-2015 were included. SB was approached by a combination of two ecological indexes (French European Deprivation Index and urban/rural residence place). Mixed effects logistic and Poisson regressions were used, respectively, to estimate the odds of advanced (stage ≥ II) BC and the ratio of incidence rates of early (stage 0-I) and advanced BC according to SB, overall and by age group (< 50, 50-74, ≥ 75).

RESULTS

Compared to women living in affluent-urban areas, women living in deprived-urban and deprived-rural areas had a higher proportion of advanced BC [respectively, OR = 1.11 (1.01-1.22), OR = 1.60 (1.25-2.06)] and lower overall (from - 6 to - 15%) and early (from - 9 to - 31%) BC incidences rates Advanced BC incidence rates were not influenced by SB. These patterns were similar in women under 75 years, especially in women living in deprived-rural areas. In the elderly, no association between SB and BC frequency/incidence rates by stage was found.

CONCLUSION

Although advanced BC was more frequent in women living in deprived and rural areas, SB did not influence advanced BC incidence. Therefore, differences observed in overall BC incidence according to SB were only due to higher incidence of early BC in affluent and urban areas. Future research should confirm these results in other French areas.

The contribution of prognostic factors to socio-demographic inequalities in breast cancer survival in Victoria, Australia

BACKGROUND

Breast cancer survival in Australia varies according to socio-economic status (SES) and between rural and urban places of residence. Part of this disparity may be due to differences in prognostic factors at the time of diagnosis.

METHODS

Women with invasive breast cancer diagnosed from 2008 until 2012 (n = 14,165) were identified from the Victorian Cancer Registry and followed up for 5 years, with death from breast cancer or other causes recorded. A prognostic score, based on stage at diagnosis, cancer grade, whether the cancer was detected via screening, reported comorbidities and age at diagnosis, was constructed for use in a mediation analysis.

RESULTS

Five-year breast cancer mortality for women with breast cancer who were in the lowest quintile of SES (10.3%) was almost double that of those in the highest quintile (5.7%). There was a small survival advantage (1.7% on average, within each socio-economic quintile) of living in inner-regional areas compared with major cities. About half of the socio-economic disparity was mediated by prognostic factors, particularly stage at diagnosis and the presence of comorbidities. The inner-regional survival advantage was not due to differences in prognostic factors.

CONCLUSIONS

Part of the socio-economic disparity in breast cancer survival could be addressed by earlier detection in, and improved general health for, more disadvantaged women. Further research is required to identify additional causes of socio-economic disparities as well as the observed inner-regional survival advantage.

Is survival rate lower after breast cancer in deprived women according to disease stage?

BACKGROUND

Socioeconomic deprivation has been associated with lower breast cancer (BC) survival, but the influence of stage at diagnosis on this association merits further study. Our aim was to investigate this association using the Loire-Atlantique/Vendee Cancer Registry (France).

METHODS

Twelve-thousand seven-hundred thirty-eight women living in the area covered by the registry and diagnosed with invasive breast carcinoma between 2008 and 2015 were included in the study. They were censored at maximal 6 years. Deprivation was measured by the French European Deprivation Index. Excess hazard and net survival were estimated for deprivation level, stage and age at diagnosis using a flexible excess mortality hazard model.

RESULTS

After adjustment by stage, women living in the most deprived areas had a borderline non-significant higher excess mortality hazard (+25% (95% CI: -3%; +62%)) compared to those living in the least deprived areas. Stage-adjusted 5-year net survival differed significantly between these two subgroups (respectively, 88.2% (95% CI:85.2%-90.5%) and 92.5% (95% CI:90.6%-93.9%)).

CONCLUSION

BC survival remained lower in deprived areas in France, despite universal access to cancer care. Intensification of prevention measures could help to reduce advanced BC, responsible for the majority of deaths from BC. A better understanding of remaining social disparities is crucial to implement specific interventions.

Estimation of the Potentially Avoidable Excess Deaths Associated with Socioeconomic Inequalities in Cancer Survival in Germany

Many countries have reported survival inequalities due to regional socioeconomic deprivation. To quantify the potential gain from eliminating cancer survival disadvantages associated with area-based deprivation in Germany, we calculated the number of avoidable excess deaths. We used population-based cancer registry data from 11 of 16 German federal states. Patients aged ≥15 years diagnosed with an invasive malignant tumor between 2008 and 2017 were included. Area-based socioeconomic deprivation was assessed using the quintiles of the German Index of Multiple Deprivation (GIMD) 2010 on a municipality level nationwide. Five-year age-standardized relative survival for 25 most common cancer sites and for total cancer were calculated using period analysis. Incidence and number of avoidable excess deaths in Germany in 2013-2016 were estimated. Summed over the 25 cancer sites, 4100 annual excess deaths (3.0% of all excess deaths) could have been avoided each year in Germany during the period 2013-2016 if relative survival were in all regions comparable with the least deprived regions. Colorectal, oral and pharynx, prostate, and bladder cancer contributed the largest numbers of avoidable excess deaths. Our results provide a good basis to estimate the potential of intervention programs for reducing socioeconomic inequalities in cancer burden in Germany.

Factors Explaining Socio-Economic Inequalities in Cancer Survival: A Systematic Review

BACKGROUND

There is strong and well-documented evidence that socio-economic inequality in cancer survival exists within and between countries, but the underlying causes of these differences are not well understood.

METHODS

We systematically searched the Ovid Medline, EMBASE, and CINAHL databases up to 31 May 2020. Observational studies exploring pathways by which socio-economic position (SEP) might causally influence cancer survival were included.

RESULTS

We found 74 eligible articles published between 2005 and 2020. Cancer stage, other tumor characteristics, health-related lifestyle behaviors, co-morbidities and treatment were reported as key contributing factors, although the potential mediating effect of these factors varied across cancer sites. For common cancers such as breast and prostate cancer, stage of disease was generally cited as the primary explanatory factor, while co-morbid conditions and treatment were also reported to contribute to lower survival for more disadvantaged cases. In contrast, for colorectal cancer, most studies found that stage did not explain the observed differences in survival by SEP. For lung cancer, inequalities in survival appear to be partly explained by receipt of treatment and co-morbidities.

CONCLUSIONS

Most studies compared regression models with and without adjusting for potential mediators; this method has several limitations in the presence of multiple mediators that could result in biased estimates of mediating effects and invalid conclusions. It is therefore essential that future studies apply modern methods of causal mediation analysis to accurately estimate the contribution of potential explanatory factors for these inequalities, which may translate into effective interventions to improve survival for disadvantaged cancer patients.

Screening status, tumour subtype, and breast cancer survival: a national population-based analysis

PURPOSE

We examined whether demographic and tumour characteristics (including subtype) were different for women with breast cancer diagnosed via mammography screening compared with women with interval breast cancers, lapsed attenders of the screening programme and non-participants of the screening programme. In addition, we explored whether there were survival differences between the groups, taking into account lead time bias.

METHODS

We used linked data from National Cancer Registry Ireland and the national breast screening programme BreastCheck. Multinomial logistic regression was used to test the association of covariates with screening status. For survival analysis, we corrected the survival time for screen-detected cases for lead time bias, examined Kaplan-Meier curves and then used Cox regression to investigate differences in survival by screening status.

RESULTS

Subtype (HER2 over-expressing, triple negative), stage (III/IV), grade (poor), having co-morbidities, area of deprivation, smoking status and age were associated with having interval cancer or being a non-participant of the screening programme in the multivariable model. After correcting for lead time bias, and adjusting for variables associated with screening status, there was no evidence that risk of breast-cancer death for women with screen-detected cancer was different from women with interval cancer (HR = 0.76, 95% CI 0.56-1.03), non-participants (HR = 1.07, 95% CI 0.84-1.37) and lapsed attenders (HR = 0.97, 95% CI 0.65-1.45).

CONCLUSIONS

Screening status was strongly associated with subtype and this association persisted after adjustment for covariates including tumour stage and grade. After correcting for lead-time bias and adjusting for stage, subtype, grade and socio-demographic variables, no significant survival difference was demonstrated for women with screen-detected cancer in the 5-year period post-diagnosis. Since we are adjusting for stage, subtype and other variables, the lack of difference between these groups would be expected but has not been demonstrated in studies which do not correct for lead time bias.

Enculturation in The Life Pattern of Breast Cancer Patients: An Ethno-Nursing Study on Sundanese Women

Introduction: Death of breast cancer remains the highest position in the totem of incidents not only in Indonesia but also in the world. Its treatment process, which in fact brings huge impacts to the life quality of breast cancer patients in terms of physique, psychology, and social life, shapes a number of behavioral patterns throughout their life. The aim of this research is thus to explore patterns of breast cancer patients in sustaining their lifespan.Methods: This research is designed using ethno-nursing qualitative approach. The sampling technique is done purposively to 6 informants, all of whom are breast cancer patients in Garut District, West Java, Indonesia. Data collecting is done through interviews and participatory observation. Data transcription is analyzed using ethno-nursing analysis method.Results: The result of the research shows four domains occurring as a pattern of inculturation of breast cancer patients in Sundanese culture, namely 1) dedication as wife and mother of Sundanese breast cancer patients, 2) medicine seeking for the rest of their life, 3) factors affecting to breast cancer patients adaptation for daily routines, and 4) family gathering as a meaning for end of life.Discussion: The result of this research shows an interconnected cultural pattern in the life of these patients. It is thus advised that nurses provide service to breast cancer clients by applying nursing care inherent to their cultural values.

Temporal Trends in Geographical Variation in Breast Cancer Mortality in China, 1973-2005: An Analysis of Nationwide Surveys on Cause of Death

To describe geographical variation in breast cancer mortality over time, we analysed breast cancer mortality data from three retrospective national surveys on causes of death in recent decades in China. We first calculated the age-standardized mortality rate (ASMR) for each of the 31 provinces in mainland China stratified by survey period (1973-1975, 1990-1992 and 2004-2005). To test whether the geographical variation in breast cancer mortality changed over time, we then estimated the rate ratio (RR) for the aggregated data for seven regions and three economic zones using generalized linear models. Finally, we examined the correlation between mortality rate and several macro-economic measures at the provincial level. We found that the overall ASMR increased from 2.98 per 100,000 in 1973-1975 to 3.08 per 100,000 in 1990-1992, and to 3.85 per 100,000 in 2004-2005. Geographical variation in breast cancer mortality also increased significantly over time at the regional level (p = 0.002) but not at the economic zone (p = 0.089) level, with RR being generally lower for Western China (Northwest and Southwest) and higher in Northeast China over the three survey periods. These temporal and spatial trends in breast cancer mortality were found to be correlated with per capita gross domestic product, number of hospitals and health centres' beds per 10,000 population and number of practicing doctors per 10,000 population, and average number of live births for women aged 15-64. It may be necessary to target public health policies in China to address the widening geographic variation in breast cancer mortality, and to take steps to ensure that the ease of access and the quality of cancer care across the country is improved for all residents.

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

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

Survival analysis of geospatial factors in the Irish ALS cohort

Variations in environmental risk factors potentially influence incidence and progression in complex multifactorial diseases. Few studies have examined the association of survival in amyotrophic lateral sclerosis (ALS) with environmental geospatial variables. Here we use data from the Irish ALS cohort to perform such an analysis. Geographic data sources were used to generate small area values for four geospatial variables (population density, social deprivation, distance to coast, and distance to ALS multidisciplinary (MDT) clinic) for each ALS case on the Irish ALS register. These were combined with follow-up data and used as covariates in Royston-Parmar regression survival analysis including age of onset, site of onset, diagnostic delay, riluzole prescription and MDT clinic attendance as covariates. One thousand, two hundred and thirty-two patients with median survival of 2.31 years from disease onset were included. After addition of the individual geospatial variables in turn, none of the four variables was found to be associated with survival with a p-value <0.05. The results may reflect the public healthcare system that provides riluzole prescription and access to the MDT to all patients free of charge, and is also congruent with our recent finding that social deprivation is not associated with ALS incidence in Ireland.