Medicare Coverage Improves Mortality Outcomes in Regions of Poverty in United States

Objectives: Access to care and poverty have been associated with a higher risk of breast cancer, but their impact on breast cancer death has not been fully evaluated. We hypothesized that analysis of data from a large database would further elucidate the association between socioeconomic status and breast cancer mortality. Methods: The Surveillance, Epidemiology, and End Results (SEER) database was used to identify cases of invasive ductal carcinoma diagnosed between 2006-2011, as well as data reflecting the presence or absence of a breast cancer death within five years. Two age groups, 40-64 year old women, and 65+ year old women, were analyzed. From the American Community Survey were acquired annual county level hospital rates, ambulatory care facility rates, nursing/residential care facility rates, rural business rates, population densities, and counts of women in the age groups of interest. Results: With respect to poverty rates, incidence based mortality rates for 40-64 year old women were 13% (99% CI 3%, 25%) higher for counties in the third quartile and 19% (7%, 35%) higher for counties in the fourth quartile (p < 0.01) than for counties in the first quartile; counties in the second quartile did not show higher incidence mortality rates (p > 0.01). Mortality rates for 65+ year old women did not differ among poverty rate quartiles (p > 0.01 for each assessment). A 50% increase in hospitals per 100,000 persons was associated with 8% (5%, 11%) and 5% (1%, 8%) increases in mortality rates for 40-64 y and 65+ y women, respectively, likely reflecting better ascertainment of causes of death at hospitals. Impacts of differences in other rates and population density were not detected (p > 0.01 for each analysis). Conclusion: Counties with higher poverty rates have increased breast cancer mortality rates for 40-64 y women, but not for 65+ y women. Universal coverage associated with Medicare is associated with the absence of an apparent effect of poverty upon breast cancer mortality.

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Participation in Mammography Screening Accomplishes an Enduring and Significant Reduction in Breast Cancer Mortality in the Era of Modern Therapy: An Observational Study Spanning 52 Years

Journal of Global Oncology ◽

10.1200/jgo.18.73200 ◽

2018 ◽

Vol 4 (Supplement 2) ◽

pp. 56s-56s

Author(s):

R. Smith ◽

Keyword(s):

Breast Cancer ◽

Early Detection ◽

Cancer Mortality ◽

Mammography Screening ◽

Breast Cancer Mortality ◽

Mortality Rates ◽

Trial Period ◽

Breast Cancer Death ◽

Self Selection ◽

Screening Trial

Background: A significant decrease in breast cancer mortality has been demonstrated in populations invited to mammography screening. There have been questions regarding the value of mammography in the era of modern therapies, and the relative contribution of mammography screening and modern therapy on mortality reduction. Aim: We have sought to clarify the extent to which early detection through mammography screening contributes to the reduction of breast cancer death in the era of modern adjuvant therapies. We address this question by studying five decades of continuous data from a stable population spanning the pre- and postscreening and adjuvant therapy periods. Methods: We analyzed changes in breast cancer mortality in a stable population in Dalarna County, Sweden, among women aged 40-69 years during the 52 years from 1964 through 2015. Mortality data were obtained from the National Cause of Death Register in Sweden, and incidence data from the Swedish National Cancer Registry. Crude and incidence-based mortality rates were compared among four successive 13-year periods: the prescreening period from 1964 through 1976, the Swedish Two-County randomized screening trial period from 1977 through 1989, and two service screening periods from 1990-2002 and from 2003-2015. Furthermore, we measured the effect of early detection upon breast cancer mortality in women exposed to mammography screening by comparison with breast cancer death in women not exposed to mammography screening, within these three screening periods. Data were analyzed by Poisson regression, with corrections for lead time and self-selection bias. Results: There were 5844 incident cases and 1425 breast cancer deaths during the 52 years of observation. The relative breast cancer mortality rates associated with exposure to screening, adjusted for self-selection bias, were 0.46 (95% CI 0.30-0.69) in the trial period (1977-1989), 0.44 (95% CI 0.30-0.65) in the 1990-2002 period, and 0.37 (95% CI 0.24-0.56) in the 2003-2015 period. The significant reductions in incidence-based breast cancer mortality associated with exposure to screening were independent of contemporaneous changes in therapy. Conclusion: The combination of early detection of breast cancer through mammography screening and the resultant earlier treatment has significantly reduced breast cancer mortality in Dalarna County in the women exposed to screening, compared with the women not participating in screening, by a factor of 2.2 in the screening trial period, increasing to a factor of 2.7 in the most recent service screening period. These mortality benefits can be attributed to the far greater effectiveness of modern therapeutic methods upon cancers detected at screening compared with the poorer effectiveness of the same therapeutic methods in women not participating in screening.

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Breast cancer mortality rates trends by race in São Paulo, Brazil

European Journal of Public Health ◽

10.1093/eurpub/ckaa166.1162 ◽

2020 ◽

Vol 30 (Supplement_5) ◽

Author(s):

D B Vale ◽

B Gozzi ◽

A C Marcelino ◽

J F Oliveira ◽

C Cardoso-Filho ◽

...

Keyword(s):

Breast Cancer ◽

Cancer Mortality ◽

Access To Health Care ◽

White Women ◽

Breast Cancer Mortality ◽

Age Groups ◽

Mortality Rates ◽

Sao Paulo ◽

São Paulo ◽

Access To Health

Abstract Background Breast cancer is the main cause of female death by neoplasia in Brazil. Although half of the Brazilian population is black/brown (BB), socio-economic disparities translate in a vulnerable situation to those women. Access to health care is an important barrier to improve the health of BB women. This study aims to investigate trends in breast cancer mortality rates regarding race and age. Methods This is a population-based study of trends evaluation on breast cancer mortality in São Paulo state, Brazil, from 2000 to 2017. The absolute number of deaths and population figures (including race) by age-groups and years were available online from government data. Data on race were not available by ten-year age-groups, so the figures were projected according to the female age structure by year. Total rates by year and race were age-adjusted to the 'World Population (2000)'. For trend analysis, linear regression was used, with 5% level of significance. Results In the period were observed 60,940 breast cancer deaths, 76.7% in white and 17.5% in BB women. The absolute number of deaths in white and BB women was respectively 2,095 and 333 in 2000, and 3,076 and 999 in 2017. The total age-adjusted mortality rates per 100,000 women of white and BB in 2000 were respectively 16.4, 17.2 and 7.5. In 2017 rates were 14.6, 16.6 and 16.1. There was a trend towards reducing the mortality rates of white women (P = 0.002) and in their age-groups from 40 to 79 years (P < 0.03). There was a trend towards increasing the mortality rates of BB women (P < 0.001) and in all their age-groups (P < 0.02). Conclusions Although breast cancer figures of death and mortality rates in BB women have more than doubled in 18 years, rates reached almost the same figures of white women in the period. Changes in behaviour risk factors may explain this result. However, it is very likely that access to health care to these women has been improved, reducing the disparities in the health system. Key messages Breast cancer mortality rates in black/brown women have reached almost the same figures as white women from 2000 to 2017 in São Paulo, Brazil. Access to health care in black women may have improved in São Paulo, Brazil.

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Association of Occupation and Breast Cancer Mortality in the State of Vermont, 1989-1993

McGill Journal of Medicine ◽

10.26443/mjm.v5i2.747 ◽

2020 ◽

Vol 5 (2) ◽

Author(s):

Dominic F Geffken ◽

Melissa J Perry ◽

Peter Callas

Keyword(s):

Breast Cancer ◽

Relative Risk ◽

Cancer Mortality ◽

Death Rate ◽

Breast Cancer Mortality ◽

Occupational Group ◽

Control Analysis ◽

Cancer Death ◽

Breast Cancer Death ◽

Increased Risk

Vermont’s breast cancer death rate is among the highest in the U.S. This study analyzed the association between breast cancer mortality and occupation in Vermont women. Given that Vermont is a rural state, one initial hypothesis was that occupational exposure to pesticides might partly explain the high death rate. Death certificate data from 1989-1993 were analyzed to determine relative risk of breast cancer death according to occupation. Case-control analysis demonstrated increased relative risk of breast cancer death for women in two broad occupational groups: 1) Executive, Administrator and Managers and 2) Professionals. Decreased relative risk of breast cancer death was seen for the occupational group of Homemaker. Data indicated that women in the occupational group of Farming, Forestry, and Fishing were not at increased risk of dying from breast cancer. The associations of occupation and breast cancer mortality in Vermont women do not differ significantly from those seen in larger U.S. studies.

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Balancing the benefits and detriments among women targeted by the Norwegian Breast Cancer Screening Program

Journal of Medical Screening ◽

10.1177/0969141315625088 ◽

2016 ◽

Vol 23 (4) ◽

pp. 203-209 ◽

Cited By ~ 4

Author(s):

Solveig Hofvind ◽

Marta Román ◽

Sofie Sebuødegård ◽

Ragnhild S Falk

Keyword(s):

Breast Cancer ◽

Cancer Screening ◽

Breast Cancer Screening ◽

Cancer Mortality ◽

Screening Program ◽

Breast Cancer Mortality ◽

Cancer Death ◽

Breast Cancer Death ◽

Breast Cancer Screening Program ◽

Cancer Screening Program

Objective To compute a ratio between the estimated numbers of lives saved from breast cancer death and the number of women diagnosed with a breast cancer that never would have been diagnosed during the woman’s lifetime had she not attended screening (epidemiologic over-diagnosis) in the Norwegian Breast Cancer Screening Program. Methods The Norwegian Breast Cancer Screening Program invites women aged 50–69 to biennial mammographic screening. Results from published studies using individual level data from the programme for estimating breast cancer mortality and epidemiologic over-diagnosis comprised the basis for the ratio. The mortality reduction varied from 36.8% to 43% among screened women, while estimates on epidemiologic over-diagnosis ranged from 7% to 19.6%. We computed the average estimates for both values. The benefit–detriment ratio, number of lives saved, and number of women over-diagnosed were computed for different scenarios of reduction in breast cancer mortality and epidemiologic over-diagnosis. Results For every 10,000 biennially screened women, followed until age 79, we estimated that 53–61 (average 57) women were saved from breast cancer death, and 45–126 (average 82) were over-diagnosed. The benefit–detriment ratio using average estimates was 1:1.4, indicating that the programme saved about one life per 1–2 women with epidemiologic over-diagnosis. Conclusion The benefit–detriment ratio estimates of the Norwegian Breast Cancer Screening Program, expressed as lives saved from breast cancer death and epidemiologic over-diagnosis, should be interpreted with care due to substantial uncertainties in the estimates, and the differences in the scale of values of the events compared.

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Evaluating the Effect of Medicaid Expansion on Black/White Breast Cancer Mortality Disparities: A Difference-in-Difference Analysis

JCO Global Oncology ◽

10.1200/go.20.00068 ◽

2020 ◽

pp. 1178-1183

Author(s):

Jason Semprini ◽

Olufunmilayo Olopade

Keyword(s):

Breast Cancer ◽

Health Care ◽

Cancer Mortality ◽

Breast Cancer Mortality ◽

Age Groups ◽

Mortality Rates ◽

Cost Of Care ◽

Medicaid Expansion ◽

Difference In Difference ◽

Black And White

PURPOSE Medicaid expansion was designed to increase access to health care. Evidence is mixed, but theory and empirical data suggest that lower cost of care through greater access to insurance increases health care utilization and possibly improves the health of poor and sick populations. However, this major health policy has yet to be thoroughly investigated for its effect on health disparities. The current study is motivated by one of today’s most stark inequalities: the disparity in breast cancer mortality rates between Black and White women. METHODS This analysis used a difference-in-difference fixed effects regression model to evaluate the impact of Medicaid expansion on the disparity between Black and White breast cancer mortality rates. State-level breast cancer mortality data were obtained from the Centers for Disease Control and Prevention. Each state’s Medicaid expansion status was provided by a Kaiser Family Foundation white paper. Two tests were conducted, one compared all expanding states with all nonexpanding states, and the second compared all expanding states with nonexpanding states that voted to expand—but did not by 2014. The difference-in-difference regression models considered the year 2014 a washout period and compared 2012 and 2013 (pretreatment) with 2015 and 2016 (posttreatment). RESULTS Medicaid expansion did not lower the disparity in breast cancer mortality. In contrast to expectations, the Black/White mortality ratio increased in states expanding Medicaid for all Medicaid-eligible age groups, with significant effects in younger age groups ( P = .01 to .15). CONCLUSION These results suggest that states cannot solely rely on access to insurance to alleviate disparities in cancer or other chronic conditions. More exploration of the impacts of low-quality health systems is warranted.

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Negative controls to detect uncontrolled confounding in observational studies of mammographic screening comparing participants and non-participants

International Journal of Epidemiology ◽

10.1093/ije/dyaa029 ◽

2020 ◽

Vol 49 (3) ◽

pp. 1032-1042 ◽

Cited By ~ 3

Author(s):

Mette Lise Lousdal ◽

Timothy L Lash ◽

W Dana Flanders ◽

M Alan Brookhart ◽

Ivar Sønbø Kristiansen ◽

...

Keyword(s):

Breast Cancer ◽

Dental Care ◽

Cancer Mortality ◽

Mammography Screening ◽

Breast Cancer Mortality ◽

Cancer Death ◽

Breast Cancer Death ◽

External Causes ◽

Negative Controls ◽

Lower Hazard

Abstract Background When comparing mammography-screening participants and non-participants, estimates of reduction in breast-cancer mortality may be biased by poor baseline comparability. We used negative controls to detect uncontrolled confounding. Methods We designed a closed cohort of Danish women invited to a mammography-screening programme at age 50–52 years in Copenhagen or Funen from 1991 through 2001. We included women with a normal screening result in their first-invitation round. Based on their second-invitation round, women were divided into participants and non-participants and followed until death, emigration or 31 December 2014, whichever came first. We estimated hazard ratios (HRs) of death from breast cancer, causes other than breast cancer and external causes. We added dental-care participation as an exposure to test for an independent association with breast-cancer mortality. We adjusted for civil status, parity, age at first birth, educational attainment, income and hormone use. Results Screening participants had a lower hazard of breast-cancer death [HR 0.47, 95% confidence interval (CI) 0.32, 0.69] compared with non-participants. Participants also had a lower hazard of death from other causes (HR 0.43, 95% CI 0.39, 0.46) and external causes (HR 0.35, 95% CI 0.23, 0.54). Reductions persisted after covariate adjustment. Dental-care participants had a lower hazard of breast-cancer death (HR 0.75, 95% CI 0.56, 1.01), irrespective of screening participation. Conclusions Negative-control associations indicated residual uncontrolled confounding when comparing breast-cancer mortality among screening participants and non-participants.

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Flexible Bayesian P-splines for smoothing age-specific spatio-temporal mortality patterns

Statistical Methods in Medical Research ◽

10.1177/0962280217726802 ◽

2017 ◽

Vol 28 (2) ◽

pp. 384-403 ◽

Cited By ~ 4

Author(s):

T Goicoa ◽

A Adin ◽

J Etxeberria ◽

AF Militino ◽

MD Ugarte

Keyword(s):

Breast Cancer ◽

Cancer Mortality ◽

Breast Cancer Mortality ◽

Age Groups ◽

Mortality Rates ◽

Mcmc Methods ◽

Mortality Data ◽

Two Dimensional ◽

Scale Invariant ◽

General Decline

In this paper age–space–time models based on one and two-dimensional P-splines with B-spline bases are proposed for smoothing mortality rates, where both fixed relative scale and scale invariant two-dimensional penalties are examined. Model fitting and inference are carried out using integrated nested Laplace approximations, a recent Bayesian technique that speeds up computations compared to McMC methods. The models will be illustrated with Spanish breast cancer mortality data during the period 1985–2010, where a general decline in breast cancer mortality has been observed in Spanish provinces in the last decades. The results reveal that mortality rates for the oldest age groups do not decrease in all provinces.

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