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      Impact of a programme of mass mammography screening for breast cancer on socio-economic variation in survival: a population-based study

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          Abstract

          Background

          After a systematic mass mammography breast cancer screening programme was implemented between 1991 and 1996 (attendance 80%), we evaluated its impact on survival according to socioeconomic status (SES).

          Methods

          We studied survival rates up to 1-1-2005 for all consecutive breast cancer patients aged 50–69 and diagnosed in the period 1983–2002 in the area of the Eindhoven Cancer Registry ( n = 4939). Multivariate analyses were performed using Cox regression analysis.

          Results

          The proportion of breast cancer patients with a low SES decreased from 22% in 1983–1990 to 14% in 1997–2002 when attendance was 85%. The proportion of newly diagnosed patients with stage III or IV disease in 1997–2002 was only 10% compared to 14% in 1991–1996 and 26% in 1983–1989 ( P < 0.0001). Stage distribution improved for all socio-economic groups ( P = 0.01). Survival was similar for all socio-economic groups in 1983–1990, but after the introduction of the screening programme women with low SES had lower age- and stage-adjusted survival rates (HR 2.0, 95%CI: 1.3–3.0). Survival was better for patients diagnosed in 1997–2002 compared to 1983–1990 for all socioeconomic strata; it was substantially better for the high SES group (HR 0.36, 0.2–0.5) compared to the lowest SES (HR 0.77, 0.6–1.1).

          Conclusion

          Although survival improved for women from each of the socio-economic strata, related to the high participation rate of the screening programme, women from lower socio-economic strata clearly benefited less from the breast cancer screening programme. That is also related to the higher prevalence of comorbidity and possibly suboptimal treatment.

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          Most cited references36

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          Socio-economic status, dietary intake and 10 y trends: the Dutch National Food Consumption Survey.

          To study differences in dietary intake between adults with different socioeconomic status (SES) and trends over time. Cross-sectional study based on data of three Dutch National Food Consumption Surveys (DNFCS-1 1987/88; DNFCS-2 1992; DNFCS-3 1997/98), obtained from a panel by a stratified probability sample of the non-institutionalized Dutch population. A total of 6008 men and 6957 women aged 19 y and over. Dietary intake was assessed with a 2 day dietary record. Background information was obtained by structured questionnaire. Sociodemographic variables were available from panel information. SES, based on educational level, occupation and occupational position was categorized into (very) low, middle and high. Analysis of variance with age as covariable was used to explore the effects of SES on dietary intake and anthropometry. Statistical tests for trend were carried out with models in which week-weekend-day effects and an interaction term of time with SES were also included. The prevalence of obesity and skipping of breakfast was higher among people with a low SES. In all three surveys, subjects in the (very) low SES group reported having a higher consumption of potatoes, meat and meat products, visible fats, coffee and soft drinks (men only). Subjects with a high SES reported consuming more vegetables, cheese and alcohol. As regards nutrients, in all surveys a higher SES was associated with higher intake of vegetable protein, dietary fibre and most micronutrients. A higher SES was also associated with a lower fat intake but the differences between social classes were rather small and not consistent when the contribution of alcohol to energy intake was taken into account. In general, dietary intake among subjects in higher SES groups tended to be closer to the recommendations of the Netherlands Food and Nutrition Council and this phenomenon was quite stable over a period of 10 y.
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            Widening socioeconomic inequalities in mortality in six Western European countries.

            During the past decades a widening of the relative gap in death rates between upper and lower socioeconomic groups has been reported for several European countries. Although differential mortality decline for cardiovascular diseases has been suggested as an important contributory factor, it is not known what its quantitative contribution was, and to what extent other causes of death have contributed to the widening gap in total mortality. We collected data on mortality by educational level and occupational class among men and women from national longitudinal studies in Finland, Sweden, Norway, Denmark, England/Wales, and Italy (Turin), and analysed age-standardized death rates in two recent time periods (1981-1985 and 1991-1995), both total mortality and by cause of death. For simplicity, we report on inequalities in mortality between two broad socioeconomic groups (high and low educational level, non-manual and manual occupations). Relative inequalities in total mortality have increased in all six countries, but absolute differences in total mortality were fairly stable, with the exception of Finland where an increase occurred. In most countries, mortality from cardiovascular diseases declined proportionally faster in the upper socioeconomic groups. The exception is Italy (Turin) where the reverse occurred. In all countries with the exception of Italy (Turin), changes in cardiovascular disease mortality contributed about half of the widening relative gap for total mortality. Other causes also made important contributions to the widening gap in total mortality. For these causes, widening inequalities were sometimes due to increasing mortality rates in the lower socioeconomic groups. We found rising rates of mortality from lung cancer, breast cancer, respiratory disease, gastrointestinal disease, and injuries among men and/or women in lower socioeconomic groups in several countries. Reducing socioeconomic inequalities in mortality in Western Europe critically depends upon speeding up mortality declines from cardiovascular diseases in lower socioeconomic groups, and countering mortality increases from several other causes of death in lower socioeconomic groups.
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              Effect of NHS breast screening programme on mortality from breast cancer in England and Wales, 1990-8: comparison of observed with predicted mortality.

              To assess the impact of the NHS breast screening programme on mortality from breast cancer in women aged 55-69 years over the period 1990-8. Age cohort model with data for 1971-89 used to predict mortality for 1990-8 with assumption of no major effect from screening or improvements in treatment until after 1989. Effect of screening and other factors on mortality estimated by comparing three year moving averages of observed mortality with those predicted (by five year age groups from 50-54 to 75-79), the effect of screening being restricted to certain age groups. England and Wales. Women aged 40 to 79 years. Compared with predicted mortality in the absence of screening or other effects the total reduction in mortality from breast cancer in 1998 in women aged 55-69 was estimated as 21.3%. Direct effect of screening was estimated as 6.4% (range of estimates from 5.4-11.8%). Effect of all other factors (improved treatment with tamoxifen and chemotherapy, and earlier presentation outside the screening programme) was estimated as 14.9% (range 12.2-14.9%). By 1998 both screening and other factors, including improvements in treatment, had resulted in substantial reductions in mortality from breast cancer. Many deaths in the 1990s will be of women diagnosed in the 1980s and early 1990s, before invitation to screening. Further major effects from screening and treatment are expected, which together with cohort effects should result in further substantial reductions in mortality from breast cancer, particularly for women aged 55-69, over the next 10 years.
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                Author and article information

                Contributors
                +31 40 297 1616 , +31 40 297 1610 , research@ikz.nl
                Journal
                Breast Cancer Res Treat
                Breast Cancer Research and Treatment
                Springer US (Boston )
                0167-6806
                1573-7217
                9 January 2007
                November 2007
                : 105
                : 3
                : 369-375
                Affiliations
                [1 ]Eindhoven Cancer Registry, Comprehensive Cancer Centre South (IKZ), Eindhoven, P.O. Box 231, 5600 AE Eindhoven, The Netherlands
                [2 ]Department of Public Health, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
                [3 ]Department of Surgery, St. Elisabeth Hospital, Tilburg, The Netherlands
                [4 ]Department of Psychology and Health, Tilburg University, Tilburg, The Netherlands
                Article
                9464
                10.1007/s10549-006-9464-9
                2190785
                17211536
                79f1afda-3f44-4f69-90a7-a48d4090593f
                © Springer Science+Business Media, LLC 2006
                History
                : 16 November 2006
                : 25 November 2006
                Categories
                Epidemiology
                Custom metadata
                © Springer Science+Business Media, LLC. 2007

                Oncology & Radiotherapy
                mass screening,breast cancer,socio-economic status,survival
                Oncology & Radiotherapy
                mass screening, breast cancer, socio-economic status, survival

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