Functional forms of socio-territorial inequities in breast cancer screening – A French cross-sectional study using hierarchical generalised additive models

To reduce the breast cancer burden, the French National Organised Breast Cancer Screening Programme (FNOBCSP) was implemented in 2004. The recommended participation rate has never been achieved and socio-territorial inequities in participation have been reported on several occasions. We investigated the functional forms and consistency of the relationships between neighbourhood deprivation, travel time to the nearest accredited radiology centre and screening uptake. We used two-level hierarchical generalised additive models in 8 types of territories classified by socio-demographic and economic factors. The first level was 368,201 women aged 50–72 invited to the 2013–2014 screening campaign in metropolitan France. They were nested in 41 départements, the level of organisation of the FNOBCSP. The effect of travel time showed two main patterns: it was either linear (with participation decreasing as travel time increased) or participation first increased with increasing travel time to a peak around 5–15 min and decreased afterward. In nearly all types and départements, the probability of participation decreased linearly with increasing deprivation. Territorial inequities in participation were more context-dependent and complex than social inequities. Inequities in participation represent a loss of opportunity for individuals who already have the worst cancer outcomes. Evidence-based public health policies are needed to increase the effectiveness and equity of breast cancer screening

Persistent inequalities in 90-day colon cancer mortality: an English cohort study.

BACKGROUND: Variation in colon cancer mortality occurring shortly after diagnosis is widely reported between socio-economic status (SES) groups: we investigated the role of different prognostic factors in explaining variation in 90-day mortality. METHODS: National cancer registry data were linked with national clinical audit data and Hospital Episode Statistics records for 69 769 adults diagnosed with colon cancer in England between January 2010 and March 2013. By gender, logistic regression was used to estimate the effects of SES, age and stage at diagnosis, comorbidity and surgical treatment on probability of death within 90 days from diagnosis. Multiple imputations accounted for missing stage. We predicted conditional probabilities by prognostic factor patterns and estimated the effect of SES (deprivation) from the difference between deprivation-specific average predicted probabilities. RESULTS: Ninety-day probability of death rose with increasing deprivation, even after accounting for the main prognostic factors. When setting the deprivation level to the least deprived group for all patients and keeping all other prognostic factors as observed, the differences between deprivation-specific averaged predicted probabilities of death were greatly reduced but persisted. Additional analysis suggested stage and treatment as potential contributors towards some of these inequalities. CONCLUSIONS: Further examination of delayed diagnosis, access to treatment and post-operative care by deprivation group may provide additional insights into understanding deprivation disparities in mortality

Inequalities in cancer care in England: from diagnosis to treatment

Cancer is among the leading causes of death and morbidity worldwide. Although it is a disease that predominantly affects older people, cancer incidence is increasing among adolescents and young adults. In the UK, cancer outcomes have been historically lagging behind other comparable countries and wide geographical and socio-economic inequalities have been observed within the country. The aim of this PhD is 1) to explore the increasing incidence of cancer among young adults and 2) to describe socio-economic inequalities in cancer outcomes in England. The second aim also entails the estimation of the societal and economic impact of those inequalities and identifying what may be some of the contributing health-system components. The main data source for most analyses was the National Cancer Registration Dataset, enriched with information from Hospital Episode Statistics (HES) in some publications. Socio-economic deprivation of cancer patients was determined by the ecological English Index of Multiple Deprivation (IMD). A wide range of advanced statistical methods was used, including non parametric approaches in the estimation of cancer survival and of alternative measures of cancer survival, the pseudo-observation approach in the estimation of crude probabilities of death due to cancer, hierarchical modelling and penalised regression. For the first aim, I describe trends of colorectal cancer incidence rates in England, focusing on differences by anatomical sub-site and socio-demographic characteristics, particularly age (Research Paper 1). The findings pointed to a steep increase in colorectal cancer incidence among young adults aged 20-39 years in contrast to an overall stabilising trend in older adults. The reasons for these trends remain largely unknown, with most mechanisms pointing to a combination of genetic and lifestyle factors. For the second aim, I set out to assess the effectiveness of the 2000 NHS Cancer Plan and of subsequent strategies in reducing the difference in cancer survival between the most and the least deprived cancer patients in England (Research Paper 2). Despite an overall improvement in cancer survival over time, survival in the most deprived remained consistently lower than in the least deprived. I estimated the impact of these socio-economic inequalities on the Number of Life-Years Lost (NLYL) due to cancer (Research Paper 3). For the vast majority of cancers, the most deprived patients lost more life-time than the least deprived and the largest differences were seen mostly in young adults with poor prognosis cancers. Finally, I explored the role of health care system factors on socio economic inequalities in prompt diagnosis and receipt of treatment. More deprived colon cancer patients used the emergency services more often, presenting with non-specific symptoms or conditions (Research Paper 4). Further, there was wide variation in resection rates and survival from pancreatic cancer between the 23 specialist centres in England where all pancreatic cancer resections are centralised (Research Paper 5). Resection rates for pancreatic cancer remained low at national level. In summary, socio-economic inequalities in cancer outcomes have been persistent in England, costing in lives and resources. My PhD dissertation highlights that delays in diagnosis among more deprived cancer patients may be related to health-system barriers in accessing primary and secondary care. Substantial geographical variation in the resection rates for pancreatic cancer points to further barriers in access to treatment, potentially related to distance and travel time. Future cancer policies and interventions should prioritise inequalities and focus on building a health care system that remove barriers in access for all under-served populations

Menopausal symptoms are associated with subclinical atherosclerosis in healthy recently postmenopausal women

Objective:s To determine whether menopausal symptoms are associated with changes in arterial structure and function in healthy, recently postmenopausal women. Methods: One hundred and ten postmenopausal women aged 4555 years were included in the present cross-sectional study. Menopausal symptoms were recorded by the Greene Climacteric Scale. Anthropometric measures, blood pressure, serum lipids, glucose, insulin, sex and thyroid hormones were determined in each individual. Arterial structure, function and stiffness were assessed by intimamedia thickness (IMT), flow-mediated dilation and pulse-wave velocity, respectively. Results: Women with moderate to severe hot flushes had increased IMT compared to women with no or mild hot flushes (IMT in women with no hot flushes 0.61±0.08 mm, IMT in women with mild hot flushes 0.62±0.11 mm, IMT in women with moderate to severe hot flushes 0.67±0.11 mm; p = 0.034). This difference was independent of cardiovascular risk factors like age, menopausal age, smoking, blood pressure, adiposity, lipid levels, insulin resistance or hormone levels. No association was detected between psychological or psychosomatic symptoms and arterial indices. Furthermore, menopausal symptoms were not associated with serum sex steroids or thyroid hormone levels. Conclusions: Carotid IMT, a surrogate marker of subclinical atherosclerosis and cardiovascular risk, was found to be increased in women with vasomotor symptoms as compared to asymptomatic women. This association was independent of cardiovascular risk factors or endogenous hormone levels. It remains to be elucidated whether the presence of menopausal symptoms is an additional cardiovascular risk factor requiring preventive intervention. © 2012 International Menopause Society