Are there socioeconomic gradients in stage and grade of breast cancer at diagnosis? Cross sectional analysis of UK cancer registry data
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《英国医生杂志》
1 School of Population and Health Science, Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH, 2 University of Leeds, Leeds LS2 9JT
Correspondence to: J Adams j.m.adams@ncl.ac.uk
Introduction
We have found strong socioeconomic trends in the chance of both advanced stage and high grade of breast cancer at diagnosis. Women living in more materially deprived areas tended to have more advanced disease at diagnosis than those living in less deprived areas.
Socioeconomic variations in the use of hormone replacement therapy may have confounded our results in relation to grade at diagnosis. Furthermore, tumour grade may not be an accurate marker of breast cancer progression. However, the direction of effect seen here is consistent in terms of both stage and grade, with a stronger magnitude of effect in relation to stage. This is the first work in this area to use data from NYCRIS, and, although it is unlikely, our results might reflect geographical, rather than temporal, variations in breast cancer progression by socioeconomic position.
Clear socioeconomic gradients in the uptake of breast screening have been reported,1 and breast cancer screening increases the detection of breast cancers early in their clinical course. The socioeconomic gradients in disease progression at diagnosis may thus be due in part to socioeconomic gradients in uptake of breast cancer screening. The finding that no such gradients were present in data collected before the implementation of the national breast cancer screening programme supports this explanation, although such data are from other parts of the United Kingdom and rarely have complete stage data. Other factors must explain the gradient in women who were not screened.
The national breast cancer screening programme may have led to socioeconomic inequalities in disease progression at diagnosis in the United Kingdom. Further consideration of the possible impact of interventions on socioeconomic inequalities in health is needed.
What is already known on this topic
Socioeconomic gradients exist in uptake of breast cancer screening in the United Kingdom
What this study adds
Significant socioeconomic trends exist in the likelihood of breast cancer being diagnosed at high grade or advanced stage
These trends are stronger in women potentially exposed to the breast cancer screening programme
Further information and an extra table are on bmj.com
We thank Caroline Brook and Cheryl Craigs at NYCRIS for help in abstracting the data used in this analysis.
Contributors: JA conceived the study, did the analysis, and drafted the paper. MW supervised the analysis and critically appraised an earlier draft of the manuscript. DF facilitated data extraction and critically appraised an earlier draft of the manuscript. JA will act as guarantor.
Funding: This analysis was funded by the Faculty of Public Health/BUPA joint research fellowship (2001-4) awarded to JA. All of the authors are independent from this funding source.
Competing interests: DF is director of information and research at NYCRIS.
Ethical approval: Not needed.
References
Sutton S, Bickler G, Sancho-Aldridge J, Siadi G. Prospective study of predictors of attendance for breast screening in inner London. J Epidemiol Community Health 1994;48: 65-73.
Thomson C, Hole D, Twelves C, Brewster D, Black R. Prognostic factors in women with breast cancer: distribution by socioeconomic status and effect on difference in survival. J Epidemiol Community Health 2001;55: 308-15.
Macleod U, Ross S, Gillis C, McConnachie A, Twelves C, Watt G. Socio-economic deprivation and stage of disease at presentation in women with breast cancer. Ann Oncol 2000;11: 105-7.
Brewster D, Thomson C, Hole D, Black R, Stroner P, Gillis C. Relation between socioeconomic status and tumour stage in patients with breast, colorectal, ovarian, and lung cancer: results from four national, population based studies. BMJ 2001;322: 830-1.
Carnon A, Ssemwogerere A, Lamont D, Hole D, Mallon E, George W, et al. Relation between socioeconomic deprivation and pathological prognostic factors in women with breast cancer. BMJ 1994;309: 1054-7.(Jean Adams, research fell)
Correspondence to: J Adams j.m.adams@ncl.ac.uk
Introduction
We have found strong socioeconomic trends in the chance of both advanced stage and high grade of breast cancer at diagnosis. Women living in more materially deprived areas tended to have more advanced disease at diagnosis than those living in less deprived areas.
Socioeconomic variations in the use of hormone replacement therapy may have confounded our results in relation to grade at diagnosis. Furthermore, tumour grade may not be an accurate marker of breast cancer progression. However, the direction of effect seen here is consistent in terms of both stage and grade, with a stronger magnitude of effect in relation to stage. This is the first work in this area to use data from NYCRIS, and, although it is unlikely, our results might reflect geographical, rather than temporal, variations in breast cancer progression by socioeconomic position.
Clear socioeconomic gradients in the uptake of breast screening have been reported,1 and breast cancer screening increases the detection of breast cancers early in their clinical course. The socioeconomic gradients in disease progression at diagnosis may thus be due in part to socioeconomic gradients in uptake of breast cancer screening. The finding that no such gradients were present in data collected before the implementation of the national breast cancer screening programme supports this explanation, although such data are from other parts of the United Kingdom and rarely have complete stage data. Other factors must explain the gradient in women who were not screened.
The national breast cancer screening programme may have led to socioeconomic inequalities in disease progression at diagnosis in the United Kingdom. Further consideration of the possible impact of interventions on socioeconomic inequalities in health is needed.
What is already known on this topic
Socioeconomic gradients exist in uptake of breast cancer screening in the United Kingdom
What this study adds
Significant socioeconomic trends exist in the likelihood of breast cancer being diagnosed at high grade or advanced stage
These trends are stronger in women potentially exposed to the breast cancer screening programme
Further information and an extra table are on bmj.com
We thank Caroline Brook and Cheryl Craigs at NYCRIS for help in abstracting the data used in this analysis.
Contributors: JA conceived the study, did the analysis, and drafted the paper. MW supervised the analysis and critically appraised an earlier draft of the manuscript. DF facilitated data extraction and critically appraised an earlier draft of the manuscript. JA will act as guarantor.
Funding: This analysis was funded by the Faculty of Public Health/BUPA joint research fellowship (2001-4) awarded to JA. All of the authors are independent from this funding source.
Competing interests: DF is director of information and research at NYCRIS.
Ethical approval: Not needed.
References
Sutton S, Bickler G, Sancho-Aldridge J, Siadi G. Prospective study of predictors of attendance for breast screening in inner London. J Epidemiol Community Health 1994;48: 65-73.
Thomson C, Hole D, Twelves C, Brewster D, Black R. Prognostic factors in women with breast cancer: distribution by socioeconomic status and effect on difference in survival. J Epidemiol Community Health 2001;55: 308-15.
Macleod U, Ross S, Gillis C, McConnachie A, Twelves C, Watt G. Socio-economic deprivation and stage of disease at presentation in women with breast cancer. Ann Oncol 2000;11: 105-7.
Brewster D, Thomson C, Hole D, Black R, Stroner P, Gillis C. Relation between socioeconomic status and tumour stage in patients with breast, colorectal, ovarian, and lung cancer: results from four national, population based studies. BMJ 2001;322: 830-1.
Carnon A, Ssemwogerere A, Lamont D, Hole D, Mallon E, George W, et al. Relation between socioeconomic deprivation and pathological prognostic factors in women with breast cancer. BMJ 1994;309: 1054-7.(Jean Adams, research fell)