Socioeconomic inequalities in breast cancer incidence and mortality in Europe-a systematic review and meta-analysis

Abstract

Background: Breast cancer is the leading cause of female cancer in Europe and is estimated to affect more than one in 10 women. Higher socioeconomic status has been linked to higher incidence but lower case fatality, while the impact on mortality is ambiguous.

Methods: We performed a systematic literature review and meta-analysis on studies on association between socioeconomic status and breast cancer outcomes in Europe, with a focus on effects of confounding factors. Summary relative risks (SRRs) were calculated.

Results: The systematic review included 25 articles of which 8 studied incidence, 10 case fatality and 8 mortality. The meta-analysis showed a significantly increased incidence (SRR 1.25, 1.17-1.32), a significantly decreased case fatality (SRR 0.72, 0.63-0.81) and a significantly increased mortality (SRR 1.16, 1.10-1.23) for women with higher socioeconomic status. The association for incidence became insignificant when reproductive factors were included. Case fatality remained significant after controlling for tumour characteristics, treatment factors, comorbidity and lifestyle factors. Mortality remained significant after controlling for reproductive factors.

Conclusion: Women with higher socioeconomic status show significantly higher breast cancer incidence, which may be explained by reproductive factors, mammography screening, hormone replacement therapy and lifestyle factors. Lower case fatality for women with higher socioeconomic status may be partly explained by differences in tumour characteristics, treatment factors, comorbidity and lifestyle factors. Several factors linked to breast cancer risk and outcome, such as lower screening attendance for women with lower socioeconomic status, are suitable targets for policy intervention aimed at reducing socioeconomic-related inequalities in health outcomes.

Figure 1

PRISMA flow diagram of the study selection process

Figure 2

Meta-analysis of studies with incidence as outcome in relation to SES. The studies are organised by included covariates. The black squares and horizontal lines correspond to the study-specific relative risks and 95% confidence intervals, while the diamonds represent the pooled relative risk and the 95% confidence interval

Figure 3

Meta-analysis of studies with case fatality as outcome measure in relation to SES. The studies are organised by included covariates. The black squares and horizontal lines correspond to the study-specific relative risks and 95% confidence intervals, while the diamonds represent the pooled relative risk and the 95% confidence interval

Figure 4

Meta-analysis of studies with mortality as outcome measure in relation to SES. The studies are organised by included covariates. The black squares and horizontal lines correspond to the study-specific relative risks and 95% confidence intervals, while the diamonds represent the pooled relative risk and the 95% confidence interval