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    • Among patients diagnosed with breast cancer a poor

    2018-11-05

    Among patients diagnosed with breast cancer, a poor prognosis is more frequent among women with a lower SES (Byers et al., 2008; Halmin et al., 2008; Kravdal, 2000; Louwman, van de Poll-Franse, Fracheboud, Roukema, & Coebergh, 2007), and this substance p relationship has been shown to relate to differences in cancer stage at diagnosis. Indeed, this is a finding common among a wide array of cancer types (Lyratzopoulos et al., 2012; Woods, Rachet, & Coleman, 2006). In Norway, Kravdal (2000) used pre-screening program data from 1960 to 1991 to document the importance of SES (focusing on attained education) for mortality among cancer patients in general. Furthermore, for breast cancer, Kravdal found that differences in stage distribution had a mediating role, explaining a quarter of differences between education levels. Link, Northridge, Phelan, and Ganz (1998) discussed education as an important marker of SES in the context of breast cancer since a given education leads to particular working careers and associated incomes as well as knowledge and interpersonal power. In the setting of screening, Yabroff and Gordis (2003) investigated the relationship between breast cancer incidence, survival, and mortality. Yabroff and Gordis stressed that the relative importance of these aspects on the overall association between SES and breast cancer mortality depends on the stage distribution of new cases and the relation of stage distribution with SES as well as the strength of the relationship between SES and survival, all aspects that are susceptible to change under new cancer control programs. These authors further mentioned that other factors, such as adjuvant therapy, may also differ by SES. In Norwegian counties, organized mammography screening for breast cancer was introduced in phases starting in 1995/1996 and again in 2004. Following the objectives of the Norwegian Breast Cancer Screening Program (NBCSP), screening was introduced to reduce breast cancer mortality through earlier detection (Cancer Registry of Norway, 2000). It should be noted that, in Norway, higher education in public institutions is tuition-free, and universal access to health care is provided within a single-payer public system. Any mammography screening conducted prior to the introduction of the public program in Norway has been referred to as a setting of opportunistic screening. This describes a situation where the general practitioner or social network promoted, or the women themselves pursued, unsystematic mammography screening at some, often irregular, interval (Hofvind, Vacek, Skelly, Weaver, & Geller, 2008; Lynge et al., 2011). Lynge et al. estimated that some 40% of Norwegian women had a mammography examination prior to introduction of the program. However, with the introduction of organized screening in Norway, every female aged 50–69 was invited to be screened every 2 years resulting in an overall participation rate of 77% (Giordano et al., 2012). In addition, Link et al. (1998) point to the dynamics of changing inequalities, whereby higher SES groups are more adept to make use of technologies when introduced. Link et al. also discussed the diverging inequalities concerning mammography screening in an opportunistic screening setting. From a technology diffusion point of view, these authors did not comment on whether population-based screening programs could contribute to narrowing the gap in inequalities. Against this background, the aims of this article are twofold. The first aim is to explore changes in patient mortality rates associated with changes in cancer stage at the introduction of the screening program for each level of education (the within-education group changes). The second aim is to describe changes to the marginal importance of cancer stage for differences by education level before and after the introduction of the screening program (the between-education group differences). Motivated by the discussion of Yabroff and Gordis (2003), a small sensitivity analysis was conducted to determine the plausibility of the results. Thus, education-specific changes in the incidence of breast cancer at the introduction of the program were investigated and the results on mortality were compared after adjusting for the association between education and the risk of dying from causes other than breast cancer.