Abstract
BackgroundTo investigate how socioeconomic position (SEP) influences the effectiveness of cancer-directed treatment in premenopausal breast cancer patients in terms of breast cancer recurrence and mortality.MethodsWe conducted a cohort study nested in the ProBeCaRe (Predictors of Breast Cancer Recurrence) cohort (n = 5959). We identified all premenopausal women aged 18–55 years diagnosed with non-metastatic breast cancer and prescribed docetaxel-based chemotherapy in Denmark during 2007–2011. Population-based administrative registries provided data on SEP: marital status (married including registered partnership or single including divorced or widowed), cohabitation (cohabiting or living alone), education (low, intermediate, or high), income (low, medium, or high), and employment status (employed, unemployed, or health-related absenteeism). For each SEP measure, we computed incidence rates, cumulative incidence proportions (CIPs), and used Poisson regression to compute incidence rate ratios (IRRs) and 95% confidence intervals (CIs) of recurrence and death. We stratified on estrogen receptor (ER) status/tamoxifen to evaluate interaction.ResultsOur study cohort included 2616 women; 286 (CIP 13%) experienced recurrence and 223 (CIP 11%) died during follow-up (median 6.6 and 7.2 years, respectively). Single women had both increased 5-year risks of recurrence (IRR 1.45, 95% CI 1.11–1.89) and mortality (IRR 1.83, 95% CI 1.32–2.52). Furthermore, we observed increased 5-year mortality in women with low education (IRR 1.49, 95% CI 0.95–2.33), low income (IRR 1.37, 95% CI 0.83–2.28), unemployment (IRR 1.61, 95% CI 0.83–3.13), or health-related work absenteeism (IRR 1.80, 95% CI 1.14–2.82), but smaller or no increased risk of recurrence. These findings were especially evident among women with ER+ tumors prescribed tamoxifen. Overall analyses (follow-up max. 10 years) provided similar results.ConclusionsLow SEP in premenopausal women with non-metastatic breast cancer was associated with increased mortality, but not always recurrence. This suggests underdetection of recurrences in certain groups. Poor prognosis in women with low SEP, especially single women, may partly be explained by tamoxifen adherence.
Highlights
To investigate how socioeconomic position (SEP) influences the effectiveness of cancer-directed treatment in premenopausal breast cancer patients in terms of breast cancer recurrence and mortality
SEP has been associated with breast cancer recurrence, but most studies stem from settings of unequal healthcare access and non-uniform insurance coverage [2,3,4,5,6]
Some of our estimates were imprecise, but across SEP measures, the lower bound of the 95% Confidence interval (CI) had the same direction, supporting that the core dimension of SEP may be associated with prognosis
Summary
To investigate how socioeconomic position (SEP) influences the effectiveness of cancer-directed treatment in premenopausal breast cancer patients in terms of breast cancer recurrence and mortality. Advances in breast cancer screening and treatment have enlarged the pool of breast cancer survivors [1] These women are at risk of breast cancer recurrence and premature death, but data on how socioeconomic position (SEP) influences this risk are scarce. Studies set in Denmark, a country with tax-funded healthcare, report increased risks of breast cancer recurrence (and other cancer types) among patients with low education and in those living alone [8], and a higher 5-year mortality in women with lower education and income [9, 10], even after adjusting for tumor characteristics, treatment, and comorbidities [11, 12]. SEP-related disparities in breast cancer prognosis are evident even in populations with universal healthcare access
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