The turn of the gradient? Educational differences in breast cancer mortality in 18 European populations during the 2000s

Educational Attainment and Cancer Incidence in a Large Nationwide Prospective Cohort

BACKGROUND

Educational attainment is a social determinant of health and frequently used as an indicator of socioeconomic status. Educational attainment is a predictor of cancer mortality, but associations with site-specific cancer incidence are variable. The aim of this study was to evaluate the association of educational attainment and site-specific cancer incidence adjusting for known risk factors in a large prospective cohort.

METHODS

Men and women enrolled in the American Cancer Society's Cancer Prevention Study-II Nutrition Cohort who were cancer free at baseline were included in this study (n = 148,965). Between 1992 and 2017, 22,810 men and 17,556 women were diagnosed with incident cancer. Cox proportional hazards regression models were used to estimate age- and multivariable-adjusted risk and 95% confidence intervals of total and site-specific cancer incidence in persons with lower versus higher educational attainment.

RESULTS

Educational attainment was inversely associated with age-adjusted cancer incidence among men but not women. For specific cancer sites, the multivariable-adjusted risk of cancer in the least versus most educated individuals remained significant for colon, rectum, and lung cancer among men and lung and breast cancer among women.

CONCLUSIONS

Educational attainment is associated with overall and site-specific cancer risk though adjusting for cancer risk factors attenuates the association for most cancer sites.

IMPACT

This study provides further evidence that educational attainment is an important social determinant of cancer but that its effects are driven by associated behavioral risk factors suggesting that targeting interventions toward those with lower educational attainment is an important policy consideration.

Spatial Analysis of Breast Cancer Mortality Rates in a Rural State

Introduction

Breast cancer affects 1 in 8 women in the US and is the most frequently diagnosed cancer in women. In South Dakota, 102 women die from breast cancer each year. We assessed which sociodemographic factors contributed to mortality rates in South Dakota and used spatial analysis to investigate how counties’ observed age-adjusted mortality rates compared with expected rates.

Methods

We computed standardized incidence ratios (SIRs) of all counties in South Dakota by using the age-adjusted mortality rates, the 2000 US standard population, and the South Dakota estimated population. We used a linear regression model to identify sociodemographic factors associated with breast cancer mortality rates and to compute a new SIR value, after controlling for relevant factors.

Results

Educational level and breast cancer incidence rates were significantly associated with breast cancer mortality rates at the county level. The SIR values based on age-adjusted counts showed which counties had more deaths due to breast cancer than what might be expected using South Dakota as the reference population. After controlling for sociodemographic factors, the range of SIR values decreased and had lower variability.

Conclusion

The regression model helped identify factors associated with mortality and provided insights into which risk factors are at play in South Dakota. This information, in combination with the spatial distribution of mortality by county, can be used to help allocate resources to the counties in South Dakota that need them most.

Social network change after new-onset pain among middle-aged and old European adults

OBJECTIVE

This study examines how onset of chronic pain affects characteristics of personal social networks among adults aged 51+ across Europe.

METHODS

We used population-based data from the Survey of Health, Ageing and Retirement in Europe (SHARE; 2011-2015; n = 12,647). Using a change score analysis approach, we tracked changes in personal social networks of respondents experiencing new-onset chronic pain (n = 3803) compared to pain-free counterparts (n = 8844) in 11 European countries over four years.

RESULTS

Overall, consistent with network activation theory, respondents with new-onset mild-to-moderate chronic pain reported increases in sizes and diversity of their personal social networks, compared to their pain-free counterparts. However, consistent with the "pain as threat to the social self" theory, respondents with new-onset moderate pain or mild-to-moderate pain reported a decrease over time in perceived satisfaction and closeness with networks, respectively. Estimates from interactions between new-onset pain severity and sex show that men with new-onset pain experienced greater decreases in network satisfaction (mild pain) and closeness (severe pain) than did women.

DISCUSSION

This study highlights the complex social consequences of chronic pain, which may vary based on pain severity, gender, and type of social outcome considered.

The impact of sociodemographic factors on the utilization of radiation therapy in breast cancer patients in Estonia: a register-based study

Background

Radiation therapy is an important part of multimodal breast cancer treatment. The aim was to examine the impact of sociodemographic factors on radiation therapy use in breast cancer (BC) patients in Estonia, linking cancer registry data to administrative databases.

Methods

Estonian Cancer Registry provided data on women diagnosed with BC in Estonia in 2007–2018, including TNM stage at diagnosis. Use of radiation therapy within 12 months of diagnosis was determined from Estonian Health Insurance Funds claims, and sociodemographic characteristics from population registry. Receipt of radiation therapy was evaluated over time and by clinical and sociodemographic factors. Poisson regression with robust variance was used to calculate univariate and multivariate prevalence rate ratios (PRR) with 95 % confidence intervals (CI) for receipt of radiation therapy among stage I–III BC patients age < 70 years who underwent primary surgery.

Results

Overall, of 8637 women included in the study, 4310 (50 %) received radiation therapy within 12 months of diagnosis. This proportion increased from 39 to 58 % from 2007 to 2009 to 2016–2018 (p < 0.001). Multivariate regression analysis showed that compared to women with stage I BC, those with more advanced stage were less likely to receive radiation therapy. Receipt of radiation therapy increased significantly over time and was nearly 40 % higher in 2016–2018 than in 2007–2009. Use of radiation therapy was significantly lower for women with the lowest level of education compared to those with a university degree (PRR 0.88, 95 % CI 0.80–0.97), and for divorced/widowed women (PRR 0.95, 95 % CI 0.91–0.99) and single women (PRR 0.92, 95 % CI 0.86–0.99), compared to married women. Age at diagnosis, nationality and place of residence were not associated with receipt of radiation therapy.

Conclusions

The study showed considerable increase in the use of radiation therapy in Estonia over the study period, which is in line with increases in available equipment. The lack of geographic variations suggests equal access to therapy for patients living in remote regions. However, educational level and marital status were significantly associated with receipt of radiation therapy, highlighting the importance of psychosocial support in ensuring equal access to care.

Socio-Economic Position, Cancer Incidence and Stage at Diagnosis: A Nationwide Cohort Study in Belgium

Background: Socio-economic position is associated with cancer incidence, but the direction and magnitude of this relationship differs across cancer types, geographical regions, and socio-economic parameters. In this nationwide cohort study, we evaluated the association between different individual-level socio-economic and -demographic factors, cancer incidence, and stage at diagnosis in Belgium. Methods: The 2001 census was linked to the nationwide Belgian Cancer Registry for cancer diagnoses between 2004 and 2013. Socio-economic parameters included education level, household composition, and housing conditions. Incidence rate ratios were assessed through Poisson regression models. Stage-specific analyses were conducted through logistic regression models. Results: Deprived groups showed higher risks for lung cancer and head and neck cancers, whereas an inverse relation was observed for malignant melanoma and female breast cancer. Typically, associations were more pronounced in men than in women. A lower socio-economic position was associated with reduced chances of being diagnosed with known or early stage at diagnosis; the strongest disparities were found for male lung cancer and female breast cancer. Conclusions: This study identified population groups at increased risk of cancer and unknown or advanced stage at diagnosis in Belgium. Further investigation is needed to build a comprehensive picture of socio-economic inequality in cancer incidence.

Social policies and change in education-related disparities in mortality in Japan, 2000-2010

Persistent socioeconomic disparity in mortality is a widely observed phenomenon despite improvements in the economic standard of living and the prevailing universal healthcare coverage policy. In this study, we selected Japan as a case in which public universal coverage has maintained horizontal equity in healthcare access while demographic and economic challenges have affected the life chances of vulnerable subpopulations over the past decade. We assessed the changing trends in the education-related disparity in mortality over a decade across demographic subpopulations for different causes of death, with the goal of generating social policy lessons to contribute to closing the mortality gap. Using a deterministic data merge between nationwide census and death records, we estimated age- and sex-specific mortality rates for 14 causes and their education-related gradients with absolute and relative indices of inequality in 2000 and 2010 via Poisson regression. Estimation parameters were standardized to the age structure of the sub-population of high school graduates in 2000 as the reference. The results demonstrated that the relative gaps in all-cause mortality persisted despite a decrease in the average mortality rate over the study period. The absolute gaps in mortality increased for preventable causes of death associated with lifestyle behavior choices. The average mortality worsened among socioeconomically vulnerable populations such as youth and women, who were left behind in the existing social/economic policy. External causes of death such as suicide and traffic accidents showed decreasing absolute gaps in a subpopulation targeted by universal social and labor policy measures. These change patterns indicate that, compared with a high-risk approach, a universal policy approach to dealing with societal and fundamental causes of health inequality seems more effective in reducing the education-related mortality gap in both absolute and relative terms.

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Socioeconomic gaps in mortality persist despite extended healthcare coverage.

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Education-related mortality gaps were confirmed in 2000 and 2010 in Japan.

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Relative inequality in preventable diseases increased under checkup-for-all policy.

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Youth and women, left behind in the current social policy, faced worsened gaps.

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Mortality gaps decreased when a universal policy on societal causes was adopted.

Socio-economic inequalities on cancer mortality in nine European areas: The effect of the last economic recession

BACKGROUND

The effect of inequalities aggravated by economic recessions in the mortality rates of certain diseases has been previously described. In this study, we analyzed the relationship between socio-economic deprivation and cancer mortality. We focused on lung, colon, prostate, and breast cancers in nine European urban areas over three periods: two before (2000-2003 and 2004-2008) and one after (2009-2014) the onset of the 2008 financial crisis.

METHODS

This is an ecological study of trends. The units of analysis were small areas within nine European urban areas. We used a composite deprivation index as a socio-economic indicator. As a mortality indicator, we used the smoothed standardized mortality ratio, calculated using the hierarchical Bayesian model proposed by Besag, York and Mollié. To analyze the evolution of socio-economic inequalities, we fitted an ecological regression model that included the socio-economic indicator, the period of time, and the interaction between these terms.

RESULTS

In men, socio-economic inequalities in all-cancer and lung cancer mortality were observed in most of the cities studied, but did not increase after the onset of the economic crisis. In women, only two cities (Stockholm and London) showed socio-economic inequalities in all-cancer and lung cancer mortality; there was also no increase in inequalities.

CONCLUSIONS

Our results did not validate our hypothesis that inequalities increase in times of crisis. However, they emphasize the importance of socio-economic measurements for understanding mortality inequalities, and can be used to inform prevention strategies and help plan local health programs aimed at reducing health inequalities.

Educational inequalities in high- vs. low-preventable health conditions: Exploring the fundamental cause theory

AIM

To explore variations in educational gradients or gaps between high- and low-preventable health conditions.

BACKGROUND

This is one of the first European studies to test whether the association between socioeconomic status and morbidity is stronger for 10 high- than three low-preventable health conditions, by gender across 20 countries.

DATA AND METHODS

The 2014 European Social Survey included questions on 11 health conditions experienced over the last 12 months, cancer at any age, and symptoms of depression during the last week. We include respondents from 20 countries (N_men = 12,073; N_women = 13,488) aged 25 to 69. We estimated age-adjusted educational gradients on 13 conditions using logistic or OLS-regression stratified by country and gender, and high- and low-preventable pooled conditions variables on pooled country samples.

RESULTS

Both among men and women the proportion of educational gaps were larger for the high-preventable than the low-preventable conditions in most countries, supporting the Fundamental Cause Theory (FCT) hypothesis. However, there was large variations in the number of significant associations across countries and between genders. In the pooled conditions and countries analysis, no associations were significant among the low-preventable conditions. For the high-preventable conditions there was a weak significant educational gap among men, and a weak but nevertheless more distinctive and complete sigificant educational gradient among women.

CONCLUSION

In a first explorative comparative European analysis we found support for the FCT hypothesis. Thus, the FCT can be used on morbidity data classified as low- versus high-preventable. We recommend extending this framework with institutional theories to explain within- and between-country health inequalities.

Comparison of national cross-sectional breast-feeding surveys by maternal education in Europe (2006-2016)

OBJECTIVE

Breast-feeding is an important determinant of health of mothers and their offspring. The present study aimed to compare breast-feeding rates across Europe disaggregated by maternal education and establish what proportion achieves at least 50 % exclusive breast-feeding (EBF) at 6 months.Design/SettingSecondary analysis of national or sub-national studies' breast-feeding data for EU Member States plus Norway and Iceland, published in 2006-2016. Nineteen EU Member States plus Norway reported rates of EBF and any breast-feeding disaggregated by maternal education, of which only thirteen could be matched to the International Standard Classification of Education.ParticipantsMothers and their infants aged 0-12 months.

RESULTS

Data on EBF rates at 6 and 4 months were found in only four and six countries, respectively. At 6 months, EBF rates of 49 % in Slovakia and 44 % in Hungary were closest to WHO's target of at least 50 % EBF. At 4 months, mothers with high education level in Denmark, the Netherlands and Germany had the highest EBF rates (71, 52 and 50 %, respectively). Mothers with low education level were less likely to initiate breast-feeding and cessation occurred early. The inequality gap ranged from 63 % in Irish mothers to no gap or very low levels of inequality in Poland, Sweden and Norway.

CONCLUSIONS

More mothers with high, compared with low, education initiate breast-feeding and practise EBF for longer. More European policies should be targeted to protect, support and promote breast-feeding, especially among mothers with only mandatory education.

[Death is a respecter of persons : 30 years of research comparing European countries regarding social inequality in mortality]

BACKGROUND

In 1989 the first international comparisons of mortality differences according to educational level and occupational status were published. A few years later systematic comparisons between European countries were initiated at the Erasmus University in Rotterdam. This became a trigger for several European Union (EU)-funded collaboration programs scrutinizing social inequalities in health. The collaboration revealed substantial differences in mortality within and between European populations.

OBJECTIVE

This article provides a synthesis of the most important research results over the past 30 years and also identifies existing research gaps and potentials.

MATERIAL AND METHODS

Descriptive summary of research results comparing European countries regarding male and female all-cause and cause-specific mortality according to educational level and occupational status.

RESULTS

In all European populations analyzed there was a consistent gradient with substantial and in part increasing advantages for higher socioeconomic status groups. There is, however, substantial variation between individual countries. This also applies to trends and cause of death-specific analyses. While relative differences have increased in virtually all populations, absolute differences have often decreased in many populations. Among women and in higher ages the relative differences were smaller. Within Europe, the southern countries had the smallest and the eastern countries the largest gradients. Tobacco and alcohol-related diseases had an especially noteworthy impact on trends and gradients.

CONCLUSION

The evidence for social health inequalities and their determinants has substantially improved during the past 30 years; however, there remains substantial potential for future research questions, for example concerning the contribution of the different phases of life to healthy aging.

Health inequalities in Germany and in international comparison: trends and developments over time

Social epidemiological research has consistently demonstrated that people with a low socioeconomic status are particularly at risk of diseases, health complaints and functional limitations, and die at younger ages than those with a higher socioeconomic status. Greater stresses and strains in the workplace, family and living environment are under discussion as possible explanations. Health-related behaviours, psycho-social factors and personal resources, which are important in coping with everyday demands, certainly also play a role. From a public health and health policy perspective, reducing these health inequalities is an important goal. Insights into developments and trends in health inequalities over time can contribute towards highlighting new and emerging problems, and can thus help identify possible target groups and settings for relevant interventions. At the same time, these insights provide a basis upon which the success of policies and programmes that have already been implemented can be analysed and measured. Against this background, this review examines how health inequalities in Germany have developed over the last 20 to 30 years and places its findings within the context of the latest international research in this field.