Abstract
BackgroundPatients living in more deprived localities have lower cancer survival in England, but the role of individual health status at diagnosis and the utilisation of primary health care in explaining these differentials has not been widely considered. We set out to evaluate whether pre-existing individual health status at diagnosis and primary care consultation history (peri-diagnostic factors) could explain socio-economic differentials in survival amongst women diagnosed with breast cancer.MethodsWe conducted a retrospective cohort study of women aged 15–99 years diagnosed in England using linked routine data. Ecologically-derived measures of income deprivation were combined with individually-linked data from the English National Cancer Registry, Clinical Practice Research Datalink (CPRD) and Hospital Episodes Statistics (HES) databases. Smoking status, alcohol consumption, BMI, comorbidity, and consultation histories were derived for all patients. Time to breast surgery was derived for women diagnosed after 2005. We estimated net survival and modelled the excess hazard ratio of breast cancer death using flexible parametric models. We accounted for missing data using multiple imputation.ResultsNet survival was lower amongst more deprived women, with a single unit increase in deprivation quintile inferring a 4.4% (95% CI 1.4–8.8) increase in excess mortality. Peri-diagnostic co-variables varied by deprivation but did not explain the differentials in multivariable analyses.ConclusionsThese data show that socio-economic inequalities in survival cannot be explained by consultation history or by pre-existing individual health status, as measured in primary care. Differentials in the effectiveness of treatment, beyond those measuring the inclusion of breast surgery and the timing of surgery, should be considered as part of the wider effort to reduce inequalities in premature mortality.
Highlights
Patients living in more deprived localities have lower cancer survival in England, but the role of individual health status at diagnosis and the utilisation of primary health care in explaining these differentials has not been widely considered
Cohort & data linkage Out of the 733,809 persons aged 16–99 years in England recorded in the National Cancer Registry as having being diagnosed with invasive breast cancer between 1 January 1988 and 31 December 2010, we analysed 21,802 women for whom follow-up was complete up to 31 December 2014 (Fig. 1)
Women living in deprived areas were on average 2 years older at diagnosis and less likely to be diagnosed in the screening age range 50–69 (p-value < 0.001)
Summary
Patients living in more deprived localities have lower cancer survival in England, but the role of individual health status at diagnosis and the utilisation of primary health care in explaining these differentials has not been widely considered. The relative contribution of these mechanisms in explaining the persistence of socio-economic differences in England has focussed on a variety of factors These include the examination of patterns of survival by screening status [8,9,10], analyses of routine data from secondary care [11,12,13,14,15,16] and the equalisation of treatment [17,18,19]. The presence of factors measured in primary health care, such as the presence of other diseases, obesity, smoking history, alcohol consumption, as well as the total number of consultations attended by the patient may be associated with these inequalities Their role in explaining survival differentials has not been considered outside our own analysis of screening-eligible women diagnosed with breast cancer [20, 21]
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