Variation in the relationship between BMI and survival by socioeconomic status in Great Britain

We investigate the relationship between obesity and survival, and the extent to which this relationship varies by socioeconomic status (SES). The underlying model is based on the “Pathways to health” framework in which SES affects health by modifying the relationship between lifestyles and health. We use data from the British Health and Lifestyle Survey (1984–1985) and the longitudinal follow-up in June 2009, and run parametric Gompertz survival models to investigate the association between obesity and survival, also accounting for interactions between obesity and both age and SES. Generally we find that obesity is negatively associated with survival, and that SES is positively associated with survival, in both men and women. The interactions between obesity and SES predict survival among women but not among men. Obesity compared with normal weight is associated with a reduction in survival of 3.3, 3.2 and 2.8 years in men aged 40, 50 and 60 years, respectively. Corresponding numbers among women in the lowest SES group are 13.1, 9.7 and 6.1 years, respectively; in the highest SES group they are 6.2, 3.1 and 0.1 years, respectively, a difference of approximately 6 years between the highest and lowest SES groups.     

Disparities in survival of stomach cancer among different socioeconomic groups in North-East Netherlands

Background: Survival differences in stomach cancer are depended on patient, tumour and treatment factors. Some populations are more prone to develop stomach cancer, such as people with low socioeconomic status (SES). The aim of this population based study was to assess whether differences in socioeconomic status (SES) alone, after adjusting for confounding factors, also influence survival. Methods: From 1989 to 2007 all patients with stomach cancer were selected from the cancer registry of the Comprehensive Cancer Centre North-East. Postal code at diagnosis was used to determine SES, dividing patients in three groups; low, intermediate and high SES. Associations between age, localization, grade, stage, and treatment were determined using Chi-square analysis. Relative survival analysis was used to estimate relative excess risk (RER) of dying according to SES. Results: In low SES neighbourhoods diagnosis was established at older age. More distal tumours were detected in patients with low SES, whereas pathology showed more poorly differentiated tumours in patients with high SES. Overall, more resections were performed in, and more chemotherapy was administrated to patients in high SES neighbourhoods. After adjusting for confounding factors, the risk of dying was lower for patients with high SES (RER 0.89, 95% Confidence Interval 0.81–0.98) compared to patients with low SES. Conclusion: SES proved to be an independent prognostic factor for survival in patients with stomach cancer.     

Ethnic,racial and socioeconomic disparities in breast cancer survival in two Brazilian capitals between 1996 and 2012

ObjectiveTo study the impact of socio-economic status and ethno-racial strata on excess mortality hazard and net survival of women with breast cancer in two Brazilian state capitals.MethodWe conducted a survival analysis with individual data from population-based cancer registries including women with breast cancer diagnosed between 1996 and 2012 in Aracaju and Curitiba. The main outcomes were the excess mortality hazard (EMH) and net survival. The associations of age, year of diagnosis, disease stage, race/skin colour and socioeconomic status (SES) with the excess mortality hazard and net survival were analysed using multi-level spline regression models, modelled as cubic splines with knots at 1 and 5 years of follow-up.ResultsA total of 2045 women in Aracaju and 7872 in Curitiba were included in the analyses. The EMH was higher for women with lower SES and for black and brown women in both municipalities. The greatest difference in excess mortality was seen between the most deprived women and the most affluent women in Curitiba, hazard ratio (HR) 1.93 (95%CI 1.63–2.28). For race/skin colour, the greatest ratio was found in Curitiba (HR 1.35, 95%CI 1.09–1.66) for black women compared with white women. The most important socio-economic difference in net survival was seen in Aracaju. Age-standardised net survival at five years was 55.7% for the most deprived women and 67.2% for the most affluent. Net survival at eight years was 48.3% and 61.0%, respectively. Net survival in Curitiba was higher than in Aracaju in all SES groups.”ConclusionOur findings suggest the presence of contrasting breast cancer survival expectancy in Aracaju and Curitiba, highlighting regional inequalities in access to health care. Lower survival among brown and black women, and those in lower SES groups indicates that early detection, early diagnosis and timely access to treatment must be prioritized to reduce inequalities in outcome among Brazilian women.     

Impact of geographic area level on measuring socioeconomic disparities in cancer survival in New South Wales,Australia: A period analysis

BackgroundArea-based socioeconomic measures are widely used in health research. In theory, the larger the area used the more individual misclassification is introduced, thus biasing the association between such area level measures and health outcomes. In this study, we examined the socioeconomic disparities in cancer survival using two geographic area-based measures to see if the size of the area matters.MethodsWe used population-based cancer registry data for patients diagnosed with one of 10 major cancers in New South Wales (NSW), Australia during 2004–2008. Patients were assigned index measures of socioeconomic status (SES) based on two area-level units, census Collection District (CD) and Local Government Area (LGA) of their address at diagnosis. Five-year relative survival was estimated using the period approach for patients alive during 2004–2008, for each socioeconomic quintile at each area-level for each cancer. Poisson-regression modelling was used to adjust for socioeconomic quintile, sex, age-group at diagnosis and disease stage at diagnosis. The relative excess risk of death (RER) by socioeconomic quintile derived from this modelling was compared between area-units.ResultsWe found extensive disagreement in SES classification between CD and LGA levels across all socioeconomic quintiles, particularly for more disadvantaged groups. In general, more disadvantaged patients had significantly lower survival than the least disadvantaged group for both CD and LGA classifications. The socioeconomic survival disparities detected by CD classification were larger than those detected by LGA. Adjusted RER estimates by SES were similar for most cancers when measured at both area levels.ConclusionsWe found that classifying patient SES by the widely used Australian geographic unit LGA results in underestimation of survival disparities for several cancers compared to when SES is classified at the geographically smaller CD level. Despite this, our RER of death estimates derived from these survival estimates were generally similar for both CD and LGA level analyses, suggesting that LGAs remain a valuable spatial unit for use in Australian health and social research, though the potential for misclassification must be considered when interpreting research. While data confidentiality concerns increase with the level of geographical precision, the use of smaller area-level health and census data in the future, with appropriate allowance for confidentiality     

Multiple mediation analysis of racial disparity in breast cancer survival

BackgroundRacial (Black vs. White) disparities in breast cancer survival have proven difficult to mitigate. Targeted strategies aimed at the primary factors driving the disparity offer the greatest potential for success. The purpose of this study was to use multiple mediation analysis to identify the most important mediators of the racial disparity in breast cancer survival.MethodsThis was a retrospective cohort study of non-Hispanic Black and non-Hispanic White women diagnosed with invasive breast cancer in Florida between 2004 and 2015. Cox regression was used to obtain unadjusted and adjusted hazard ratios (HR) with 95% confidence intervals (CI) for the association of race with 5- and 10-year breast cancer death. Multiple mediation analysis of tumor (advanced disease stage, tumor grade, hormone receptor status) and treatment-related factors (receipt of surgery, chemotherapy, radiotherapy, and hormone therapy) was used to determine the most important mediators of the survival disparity.ResultsThe study population consisted of 101,872 women of whom 87.0% (n = 88,617) were White and 13.0% were Black (n = 13,255). Black women experienced 2.3 times (HR, 2.27; 95% CI, 2.16–2.38) the rate of 5-year breast cancer death over the follow-up period, which decreased to a 38% increased rate (HR, 1.38; 95% CI, 1.31–1.45) after adjustment for age and the mediators of interest. Combined, all examined mediators explained 73% of the racial disparity in 5-year breast cancer survival. The most important mediators were: (1) advanced disease stage (44.8%), (2) nonreceipt of surgery (34.2%), and (3) tumor grade (18.2%) and hormone receptor status (17.6%). Similar results were obtained for 10-year breast cancer death.ConclusionThese results suggest that additional efforts to increase uptake of screening mammography in hard-to-reach women, and, following diagnosis, access to and receipt of surgery may offer the greatest potential to reduce racial disparities in breast cancer survival for women in Florida.     

Novel artificial intelligence machine learning approaches to precisely predict survival and site-specific recurrence in cervical cancer: A multi-institutional study

BackgroundMachine learning (ML) has been gradually integrated into oncologic research but seldom applied to predict cervical cancer (CC), and no model has been reported to predict survival and site-specific recurrence simultaneously. Thus, we aimed to develop ML models to predict survival and site-specific recurrence in CC and to guide individual surveillance.MethodsWe retrospectively collected data on CC patients from 2006 to 2017 in four hospitals. The survival or recurrence predictive value of the variables was analyzed using multivariate Cox, principal component, and K-means clustering analyses. The predictive performances of eight ML models were compared with logistic or Cox models. A novel web-based predictive calculator was developed based on the ML algorithms.ResultsThis study included 5112 women for analysis (268 deaths, 343 recurrences): (1) For site-specific recurrence, larger tumor size was associated with local recurrence, while positive lymph nodes were associated with distant recurrence. (2) The ML models exhibited better prognostic predictive performance than traditional models. (3) The ML models were superior to traditional models when multiple variables were used. (4) A novel predictive web-based calculator was developed and externally validated to predict survival and site-specific recurrence.ConclusionML models might be a better analytic approach in CC prognostic prediction than traditional models as they can predict survival and site-specific recurrence simultaneously, especially when using multiple variables. Moreover, our novel web-based calculator may provide clinicians with useful information and help them make individual postoperative follow-up plans and further treatment strategies.     

Socioeconomic status,human papillomavirus,and overall survival in head and neck squamous cell carcinomas in Toronto,Canada

BackgroundDespite universal healthcare in some countries, lower socioeconomic status (SES) has been associated with worse cancer survival. The influence of SES on head and neck cancer (HNC) survival is of immense interest, since SES is associated with the risk and prognostic factors associated with this disease.Patients and methodsNewly diagnosed HNC patients from 2003 to 2010 (n = 2124) were identified at Toronto’s Princess Margaret Cancer Centre. Principal component analysis was used to calculate a composite score using neighbourhood-level SES variables obtained from the 2006 Canada Census. Associations of SES with overall survival were evaluated in HNC subsets and by p16 status (surrogate for human papillomavirus).ResultsSES score was higher for oral cavity (n = 423) and p16-positive oropharyngeal cancer (OPC, n = 404) patients compared with other disease sites. Lower SES was associated with worse survival [HR 1.14 (1.06–1.22), p = 0.0002], larger tumor staging (p < 0.001), current smoking (p < 0.0001), heavier alcohol consumption (p < 0.0001), and greater comorbidity (p < 0.0002), but not with treatment regimen (p > 0.20). After adjusting for age, sex, and stage, the lowest SES quintile was associated with the worst survival only for OPC patients [HR 1.66 (1.09–2.53), n = 832], primarily in the p16-negative subset [HR 1.63 (0.96–2.79)]. The predictive ability of the prognostic models improved when smoking/alcohol was added to the model (c-index 0.71 vs. 0.69), but addition of SES did not (c-index 0.69).ConclusionSES was associated with survival, but this effect was lost after accounting for other factors (age, sex, TNM stage, smoking/alcohol). Lower SES was associated with greater smoking, alcohol consumption, comorbidity, and stage.     

Impact of universal health care and screening on incidence and survival of Thai women with cervical cancer: A population-based study of the Chiang Mai Province

Universal Health Coverage (UHC) was implemented in Thailand in 2002. This study aims to compare cervical cancer incidence and survival before and after the implementation of UHC, including the national screening program, in the Chiang Mai population in Northern Thailand. Data of women diagnosed with in situ or malignant cervical cancer in Chiang Mai during 1998–2012 were used in our analysis. Annual age-standardized incidence rates (ASR) and age-adjusted relative survival (RS) were estimated for the following three diagnosis periods: period I: 1998–2002 (before UHC), period II: 2003–2007 (UHC implementation) and period III: 2008–2012 (after UHC). The ASR peaked in 2001 at 38 per 100,000, and then subsequently declined to 23 per 100,000 in 2012. The proportion of in situ and localized tumors increased in all age groups, while regional tumors declined. In all women (aged 15–89) with malignant cervical cancer or in situ, the 5-year RS in Period I, Period II and Period III was 73%, 74% and 77%, respectively; when only malignant cases were considered, the RS was 63%, 61% and 62%, respectively. In the screening target women (aged 30–59) with malignant or in situ tumors, the 5-year RS was 84%, 88% and 90%, respectively, in the three periods, while the RS was 71%, 74% and 75%, respectively, in only those with malignant cancers. The introduction of UHC including national cervical cancer screening program has likely reduced the magnitude and severity of cervical cancer and improved the survival of cervical cancer in the screening target age group.     

The current status of immunotherapy for cervical cancer

BackgroundImmunotherapy has been proven effective in several tumours, hence diverse immune checkpoint inhibitors are currently licensed for the treatment of melanoma, kidney cancer, lung cancer and most recently, tumours with microsatellite instability. There is much enthusiasm for investigating this approach in gynaecological cancers and the possibility that immunotherapy might become part of the therapeutic landscape for gynaecological malignancies.Cervical cancer is the fourth most frequent cancer in women worldwide and represents 7.9% of all female cancers with a higher burden of the disease and mortality in low- and middle-income countries. Cervical cancer is largely a preventable disease, since the introduction of screening tests, the recognition of the human papillomavirus (HPV) as an etiological agent, and the subsequent development of primary prophylaxis against high risk HPV subtypes. Treatment for relapsed/advanced disease has improved over the last 5 years, since the introduction of antiangiogenic therapy. However, despite advances, the median overall survival for advanced cervical cancer is 16.8 months and the 5-year overall survival for all stages is 68%. There is a need to improve outcomes and immunotherapy could offer this possibility. Clinical trials aim to understand the best timing for immunotherapy, either in the adjuvant setting or recurrent disease and whether immunotherapy, alone or in combination with other agents, improves outcomes.     

Contextual determinants of participation in cervical cancer screening in France, 2010

BackgroundSome contextual factors associated with participation in cervical cancer screening are reported in the literature, but few studies have examined their combined effect. Our objective was to assess the role of contextual characteristics, separately and in combination, in participation in cervical cancer screening in France.MethodsMarginal Poisson regression models – taking into account the correlation between women in a given commune – were conducted using data from the Baromètre Santé 2010 survey. The characteristics of the commune of residence of the women studied were the potential spatial accessibility to general practitioners (GP) and gynecologists, the agglomeration category, and the socioeconomic level.ResultsThe analyses were performed in 3380 women, 88.2% of whom were up to date with their cervical cancer screening. Once the individual characteristics were taken into account, the screening participation rate was similar in all the communes, with the exception of those with poor access to a gynecologist and good access to a GP, where the rate was 6% lower (95%CI: 0.5–11%) than in the communes with good access to both GP and gynecologist. The same association with accessibility was observed in small agglomerations. Compared to women living in the more advantaged communes, the screening participation rate was 8% (2–12%) lower in those living in the more disadvantaged ones, except when accessibility to both types of physician was high.DiscussionWe observed an association between potential spatial accessibility to care in women’s residential communities and their cervical cancer screening practices, in particular in small agglomerations, rural communes, and more disadvantaged communes.     

The impact of civil conflict on child health: Evidence from Colombia

Internal armed conflicts have become more common and more physically destructive since the mid-20th century, with devastating consequences for health and development in low- and middle-income countries. This paper investigates the causal impacts of the long-term internal conflict on child health in Colombia, following an identification strategy based on the temporal and geographic variation of conflict intensity. We estimate the effect of different levels of conflict intensity on height-for-age (HAZ), weight-for-age (WAZ), and weight-for-height z-scores among children under five years old, and explore the underlying potential mechanisms, through maternal health behavior and health care utilization. We find a harmful effect of exposure to conflict violence in utero and in early childhood for HAZ and WAZ, in the full sample and even more strongly in the rural sample, yet these estimates are smaller than those found for shorter term conflicts. The underlying pathways appear to operate around the time of the pregnancy and birth (in the form of maternal alcohol use, use of antenatal care and skilled birth attendance), rather than during the post-birth period (via breastfeeding or vaccination), and the impacts accumulate over the childhood. The most adverse impacts of conflict violence on child health and utilization of maternal healthcare were observed in municipalities which suffered from intermittent presence of armed groups.     

The socioeconomic gradient in child health and noncognitive skills: Evidence from the Czech Republic

We investigate the presence of a socioeconomic status (SES) gradient in children’s health and noncognitive skill development, and its evolution with child age using cohort data from the Czech Republic. We show that family SES are positively associated with better child health. These effects start to emerge at age 3 and are persistent for all subsequent ages. We find a modest strengthening of the gradient as the children grow older. Similarly, at the lowest distribution of average family income, children lag in their noncognitive skills. We find evidence that children enter school with substantial differences in noncognitive skill endowments based on family SES. This correlation persists when controlling for poor health at birth, the roles of specific and chronic health problems, housing conditions, and partner characteristics. Maternal health status explains some of the association between family income and child noncognitive skills. We account for the endogeniety of SES and non-linearities in measures.     

Overall and recurrence-free survival among black and white bladder cancer patients in an equal-access health system

BackgroundWhile the incidence of bladder cancer is twice as high among whites than among blacks, mortality is higher among blacks than whites. Unequal access to medical care may be an important factor. Insufficient access to care could delay cancer detection and treatment, which can result in worse survival. The purpose of this study was to evaluate whether survival differed between black and white bladder cancer patients in the Department of Defense (DoD), which provides universal healthcare to all beneficiaries regardless of racial background.MethodsThis study was based on data from the U.S. DoD Automated Central Tumor Registry (ACTUR). White and black patients histologically diagnosed with bladder cancer between 1990 and 2004 were included in the study and followed to the end of 2007. The outcomes were all-cause mortality and recurrence. We assessed the relationship between race and outcomes of interest using Cox proportional hazard ratios (HRs) for all, non-muscle invasive (NMIBC), and muscle invasive (MIBC) bladder cancers, separately.ResultsThe survival of black and white individuals did not differ statistically. No significant racial differences in survival (HR: 0.96, 95% CI: 0.76–1.22) or recurrence-free survival (HR: 0.94, 95% CI: 0.69–1.30) were observed after adjustment for demographic variables, tumor characteristics, and treatment. Similar findings were observed for NMIBC and MIBC patients, respectively.ConclusionBlack patients were more likely to present with MIBC than white patients. However, white and black patients with bladder cancer were not significantly different in overall and recurrence-free survival regardless of muscle invasion. Our study suggests the importance of equal access to healthcare in reducing racial disparities in bladder cancer survival.     

Completeness of cervical cancer staging information in Brazil: A national hospital-based study

BackgroundCancer staging information in Hospital Cancer Registries (HCR) is essential for cancer care quality evaluations. This study aimed to analyze the completeness of cervical cancer staging in Brazilian HCR and identify individual and contextual factors associated with unknown staging.MethodsThe outcome analyzed was missing or unknown staging (Malignant Tumor Classification System and/or International Federation of Gynecology and Obstetrics) in 2006–2015. Individual data on cancer cases were collected from the HCR Integrator. Contextual variables were collected from the Atlas of Human Development in Brazil, the National Registry of Health Facilities, and the Outpatient Information System. The random intercept multilevel Poisson regression model was performed to identify the factors associated with the outcome.ResultsThe prevalence of unknown staging data was 32.4% (95% confidence interval [CI], 32.1–32.7). Women aged 18–29 years (prevalence ratio [PR], 1.48; 95% CI, 1.42–1.54), referred by the public health system (PR, 1.16; 95% CI, 1.11–1.21), living in states with a low density of oncologists (PR, 1.70; 95% CI, 1.62–1.79), and with a low cytopathological testing rate (PR, 1.69; 95% CI, 1.57–1.82) showed a higher prevalence of unknown tumor staging data. A lower level of education (PR, 0.91; 95% CI, 0.84–0.98) was associated with complete staging data.ConclusionsIndividual and contextual factors were associated with missing staging data. It is necessary to improve information on cancer in the HCRs by improving the awareness and training of Brazilian cancer care professionals.     

Influence of patient,physician, and hospital characteristics on the receipt of guideline-concordant care for inflammatory breast cancer

PurposeInflammatory breast cancer (IBC) is an aggressive subtype of breast cancer for which treatments vary, so we sought to identify factors that affect the receipt of guideline-concordant care.MethodsPatients diagnosed with IBC in 2004 were identified from the Breast and Prostate Cancer Data Quality and Patterns of Care Study, containing information from cancer registries in seven states. Variation in guideline-concordant care for IBC, based on National Comprehensive Cancer Network (NCCN) guidelines, was assessed according to patient, physician, and hospital characteristics.ResultsOf the 107 IBC patients in the study without distant metastasis at the time of diagnosis, only 25.8% received treatment concordant with guidelines. Predictors of non-concordance included patient age (≥70 years), non-white race, normal body mass index (BMI 18.5–25 kg/m²), patients with physicians graduating from medical school >15 years prior, and smaller hospital size (<200 beds). IBC patients survived longer if they received guideline-concordant treatment based on either 2003 (p = 0.06) or 2013 (p = 0.06) NCCN guidelines.ConclusionsTargeting factors associated with receipt of care that is not guideline-concordant may reduce survival disparities in IBC patients. Prompt referral for neoadjuvant chemotherapy and post-operative radiation therapy is also crucial.     

The possible impact of socioeconomic,income, and educational status on adverse effects of drug and their therapeutic episodes in patients targeted with a combination of tuberculosis interventions

First-line antituberculosis (anti-TB) compounds have been considered as proven components of the Directly Observed Treatment-Short course (DOTS). Drug therapy against tuberculosis has been categorized as I, II, or III following the Revised National Tuberculosis Control Program guidelines. Anti-TB are drugs are quite common and show limited adverse effects. However, first-line anti-TB compounds mediated DOTS therapy and were found with several complications. Thus, those drugs have been discontinued. Therefore, the present study was designed to find out the possible impact of socioeconomic, income, and educational status on the adverse effects of drugs and their therapeutic episodes in patients targeted with a combination of tuberculosis intervention. This study found that an increased incidence of tuberculosis was found in patients who have finished high school, contributing to a high percentage of adverse effects. Notably, adverse events were shown maximally in poor patients compared with rich- or high-income patients. On the contrary, a high prevalence of adverse events was shown to be increased in partially skilled workers compared with full-skilled workers. Consequently, adversely considerable events were implicated to be raised in patients associated with minimal socioeconomic class. Such interesting factors would help in monitoring such events in experimental patients.     

The combined effect of individual and neighborhood socioeconomic status on cancer survival rates

Background

This population-based study investigated the relationship between individual and neighborhood socioeconomic status (SES) and mortality rates for major cancers in Taiwan.

Methods

A population-based follow-up study was conducted with 20,488 cancer patients diagnosed in 2002. Each patient was traced to death or for 5 years. The individual income-related insurance payment amount was used as a proxy measure of individual SES for patients. Neighborhood SES was defined by income, and neighborhoods were grouped as living in advantaged or disadvantaged areas. The Cox proportional hazards model was used to compare the death-free survival rates between the different SES groups after adjusting for possible confounding and risk factors.

Results

After adjusting for patient characteristics (age, gender, Charlson Comorbidity Index Score, urbanization, and area of residence), tumor extent, treatment modalities (operation and adjuvant therapy), and hospital characteristics (ownership and teaching level), colorectal cancer, and head and neck cancer patients under 65 years old with low individual SES in disadvantaged neighborhoods conferred a 1.5 to 2-fold higher risk of mortality, compared with patients with high individual SES in advantaged neighborhoods. A cross-level interaction effect was found in lung cancer and breast cancer. Lung cancer and breast cancer patients less than 65 years old with low SES in advantaged neighborhoods carried the highest risk of mortality. Prostate cancer patients aged 65 and above with low SES in disadvantaged neighborhoods incurred the highest risk of mortality. There was no association between SES and mortality for cervical cancer and pancreatic cancer.

Conclusions

Our findings indicate that cancer patients with low individual SES have the highest risk of mortality even under a universal health-care system. Public health strategies and welfare policies must continue to focus on this vulnerable group.     

Socioeconomic status and its relation with breast cancer recurrence and survival in young women in the Netherlands

BackgroundAssociations between socioeconomic status (SES) and breast cancer survival are most pronounced in young patients. We further investigated the relation between SES, subsequent recurrent events and mortality in breast cancer patients < 40 years. Using detailed data on all recurrences that occur between date of diagnosis of the primary tumor and last observation, we provide a unique insight in the prognosis of young breast cancer patients according to SES.MethodsAll women < 40 years diagnosed with primary operated stage I-III breast cancer in 2005 were selected from the nationwide population-based Netherlands Cancer Registry. Data on all recurrences within 10 years from primary tumor diagnosis were collected directly from patient files. Recurrence patterns and absolute risks of recurrence, contralateral breast cancer (CBC) and mortality – accounting for competing risks – were analysed according to SES. Relationships between SES, recurrence patterns and excess mortality were estimated using a multivariable joint model, wherein the association between recurrent events and excess mortality (expected mortality derived from the general population) was included.ResultsWe included 525 patients. The 10-year recurrence risk was lowest in high SES (18.1%), highest in low SES (29.8%). Death and CBC as first events were rare. In high, medium and low SES 13.2%, 15.3% and 19.1% died following a recurrence. Low SES patients had shorter median time intervals between diagnosis, first recurrence and 10-year mortality (2.6 and 2.7 years, respectively) compared to high SES (3.5 and 3.3 years, respectively). In multivariable joint modeling, high SES was significantly related to lower recurrence rates over 10-year follow-up, compared to low SES. A strong association between the recurrent event process and excess mortality was found.ConclusionsHigh SES is associated with lower recurrence risks, less subsequent events and better prognosis after recurrence over 10 years than low SES. Breast cancer risk factors, adjuvant treatment adherence and treatment of recurrence may possibly play a role in this association.     

Self-efficacy difference among patients with cancer with different socioeconomic status: Application of latent class analysis and standardization and decomposition analysis

IntroductionAlthough the relationship between partial socioeconomic status (SES) and self-efficacy has been studied in previous studies, few research have examined self-efficacy difference among patients with cancer with different SES.MethodsA cross-sectional survey involving 764 patients with cancer was completed. Latent class analysis (LCA) was applied to identify distinct groups of patients with cancer using four SES indicators (education, income, employment status and health insurance status). Standardization and decomposition analysis (SDA) was then used to examine differences in patients’ self-efficacy among SES groups and the components of the differences attributed to confounding factors, such as gender, age, anxiety, depression and social support.ResultsParticipants were classified into four distinctive SES groups via using LCA method, and the observed self-efficacy level significantly varied by SES groups; as theorized, higher self-efficacy was associated with higher SES. The self-efficacy differences by SES groups were decomposed into “real” group differences and factor component effects that are attributed to group differences in confounding factor compositions.ConclusionSelf-efficacy significantly varies by SES. Social support significantly confounded the observed differences in self-efficacy between different SES groups among Chinese patients with cancer.     

The effect of health on socioeconomic status: Using instrumental variables to revisit a successful randomized controlled trial

Poor health is widely recognized as a consequence of social disadvantage, but health problems may also help transmit social disadvantage over time and generations. Experimentally assigned health exposures, namely those tested in randomized controlled trials, may provide opportunities to estimate the causal effects of health on socioeconomic status (SES). We revisit data from the Diabetes Control and Complications Trial, a randomized controlled trial of glucose control therapy in Type 1 diabetic patients, and use treatment assignment as an instrument for health status to test the causal effect of treatment-related health improvement on subsequent SES measured during the trial's follow-up study, the Epidemiology of Diabetes Interventions and Complications study. We used the Two-Factor Hollingshead Index of Social Position, which comprises education and occupation, to measure SES. Glycated hemoglobin (HbA1c) served as a proxy for health status. Ordinary least squares (OLS) regression models showed that lower HbA1c at the trial's end was associated with higher SES at both the start of the follow-up and 17 years later. However, instrumental variable analyses showed no causal effect of HbA1c on SES, suggesting that OLS estimates are biased by endogeneity. Sensitivity analyses showed robustness to several alternate specifications. While the HbA1c advantage conferred by random assignment to treatment within the trial did not produce higher Hollingshead Index scores, we note that occupation and education categories may be harder to affect than are outcomes such as income. This analysis offers evidence that clinical trial data may be a rich and unrecognized resource for estimating health effects on SES.