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Journal of Clinical Epidemiology 54 (2001) 719–727 Socio-demographic factors, health behavior and late-stage diagnosis

Journal of Clinical Epidemiology 54 (2001) 719–727

Journal of Clinical Epidemiology 54 (2001) 719–727 Socio-demographic factors, health behavior and late-stage diagnosis

Socio-demographic factors, health behavior and late-stage diagnosis of breast cancer in Germany: A population-based study

Volker Arndt a , Til Stürmer a,b, *, Christa Stegmaier c , Hartwig Ziegler c , Georg Dhom d , Hermann Brenner a,b

a Department of Epidemiology, University of Ulm, 89081 Ulm, Germany b Department of Epidemiology, German Centre for Research on Ageing, 69115 Heidelberg, Germany c Saarland Cancer Registry, Virchowstr. 7, 66119 Saarbrücken, Germany d Am Webersberg 20, 66424 Homburg, Germany Received 10 November 1999; received in revised form 20 July 2000; accepted 4 October 2000

Abstract

Late-stage diagnosis of breast cancer is associated with poor survival. Identification of individuals at high risk of late-stage diagnosis could be an effective step to reduce breast cancer mortality. We examined the association of socio-demographic factors and health behav- ior with breast cancer stage in a population-based sample of 380 female breast cancer patients in Saarland, Germany. Overall, 182 women (47.9%) were diagnosed with late-stage (regional or distant) breast cancer. After control for potential confounding by multivariate logis- tic regression, an increased risk of late-stage diagnosis was observed for older age (OR 1.8; 95% CI 1.0–3.2), foreign nationality (OR 3.9; 95% CI 0.7–20.8), living in large households (OR 1.7; 95% CI 1.0–2.9), non-participation in general health check-up (OR 1.5; 95% CI 0.9–2.4) and low interest in health care (OR 1.6; 95% CI 1.0–2.7). The proportion of late-stage cancer was clearly decreased when tumors were detected by screening (OR 0.4; 95% CI 0.2–0.8). Certain socio-demographic factors and characteristics of health be- havior seem to represent independent risk indicators of late-stage diagnosis. © 2001 Elsevier Science Inc. All rights reserved.

Keywords: Breast neoplasm; Neoplasm staging; Socio-demographic factors; Health behavior; Diagnostic delay

1. Introduction

Cancer of the breast is the most frequent malignant tu- mor in females in developed countries [1]. It is estimated that breast cancer will account for 500,000 deaths annually by the year 2000 worldwide [2]. Long-term prognosis of breast cancer patients strongly depends on stage of disease at diagnosis [3]. Mammography screening has been shown to be an effective tool in lowering breast cancer mortality by early detection among women aged 50–69 [4,5]. However, participation in screening programs is low [6,7], and most breast cancer cases are diagnosed in symptomatic patients [8,9]. Targeting efforts to increase participation of screen- ing individuals at high risk for late-stage diagnosis could be an effective step to reduce breast cancer mortality. Denial, lack of information and financial considerations are considered to represent major reasons for delaying care among tumor patients [10,11]. Epidemiologic evidence exists

* Corresponding author. Department of Epidemiology, German Centre

for Research on Ageing, Bergheimer Strasse 20, 69115 Heidelberg, Ger- many. Tel.: 49-6221-548145; fax: 49-6221-548142. E-mail address : sturmer@dzfa.uni-heidelberg.de (T. Stürmer)

that late-stage diagnosis for breast cancer is related to a num- ber of demographic and socioeconomic factors such as old age [12–15], ethnicity [12,15–18], low socioeconomic status (SES) [12,15,17–20], low education [21], unemployment [22], marital status [15,20,23,24] and health insurance [20,25]. Most pertinent studies were undertaken in the US and indicated that patients generally thought to be disadvan- taged are at especially high risk for delaying care. Inequalities in access to health care have been proposed as major reasons for these associations and might therefore be hypothesized to vary between countries with different health care systems. Little is known about how much of the association be- tween socio-demographic factors and stage of breast cancer is influenced by health behavior or health awareness. Re- cent reports have shown that screening behavior [26] and health awareness [27] seem to be stronger predictors than socio-demographic factors. The potential impact of other re- lated characteristics such as BMI [28,29], comorbidity [30– 32] or family history [33–35] on late-stage diagnosis and prognosis of breast cancer patients has also been discussed. The aim of this study was to assess the association be- tween socio-demographic factors and health behavior with

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V. Arndt et al. / Journal of Clinical Epidemiology 54 (2001) 719–727

stage at diagnosis in a population-based sample of breast cancer patients in Saarland, Germany, diagnosed between October 1996 and February 1998.

2. Materials and methods

2.1. Study design

This study is based on data obtained from the VERDI- study (“Verlauf der diagnostischen Abklärung bei Krebs- erkrankungen”), a population-based study among patients with primary breast, gastric or colorectal cancer from Saar- land, Germany, to assess the course from the first symptoms to diagnosis and treatment. Saarland is a state in southwest Germany close to the French border, covering a population of 1.08 million inhabitants.

2.2. Study population

The target population comprised all female breast cancer patients from Saarland, aged 18–80 years, with histologi- cally confirmed invasive breast cancer diagnosed between October 1, 1996 and February 28, 1998. Patients with recur- rent disease at the time of the interview, who died before the interview, who were not fully informed about their breast cancer diagnosis, or with no or only little German language skills were excluded. Eligible patients were reported to the study center by their physicians after they had given in- formed consent. All hospitals from the Saarland and from all adjacent counties from the Rhineland-Pfalz participated in case identification and enrollment. Overall, 387 of 401 eligible women reported to the study center with breast can- cer could be recruited (reponse rate 96.5%), representing approximately 50% of all new incident cases during the re- cruitment period according to projections by the Saarland Cancer Registry. The study participants did not substan- tially differ from the source population in terms of basic so- cio-demographic characteristics with the exception of a slightly higher proportion of younger patients.

2.3. Data collection

Face-to-face interviews were administered mostly during the first hospitalization due to breast cancer or in some cases, in which the interview could not be scheduled during hospitalization, in respondent’s homes. The interviews were conducted by trained physicians and required 45–90 min- utes to complete. The structured interviews contained de- tailed questions about disease history from first complaint to definite diagnosis, general health status, health practices, availability of health services, social network and socio-de- mographic factors. Histopathological data were abstracted from the hospital records of each study participant.

2.4. Measures

2.4.1. Stage of disease Stage of disease was categorized as “localized,” “re- gional” or “distant” according to TNM staging scheme [36].

“Localized” disease included all cases with T1–T3 and N0 and M0, “regional” included all M0 and N1 or M0 and T4

and “distant” comprised all cases with M1. Although this is

a relatively simple staging scheme, it has clear prognostic

significance and is widely used in cancer epidemiology. For the present study the relatively small number of “distant” disease ( n 14) was combined with “regional” ( n 168)

to represent late-stage disease in contrast to early (localized)

disease.

2.4.2. Socio-demographic factors

Socio-demographic factors included age ( 50 years, 50–65 years, 65 years), nationality (German, foreign), place of residence (population 100,000, 100,000), edu- cation ( 10 years, 10 years), current employment status (employed, unemployed, housewife/retired), most recent occupation (blue collar, white collar, never worked), kind of health insurance (private, non private), living arrangements [lives alone, lives with spouse only, lives with spouse and others, lives with others (not spouse)].

2.4.3. Indicators of health behavior

Indicators of health behavior included regular monthly breast self- examination (yes, no), utilization of breast cancer

screening (clinical breast examination or mammography) and of general health check-up during past 5 years (yes, no) and interest in health issues (low, regular). The biennial general health check-up to screen for diabetes mellitus, renal and chronic vascular diseases is offered to all members of regular health insurance plans aged 36 years and older in Germany since 1989. A proxy measure of interest in health issues was defined by the number of sources reported by the respondent to inform herself about health issues before the current dis- ease became apparent. The list of sources included TV, radio, newspapers, books, information booklets provided by health insurances, friends or relatives, pharmacists, physicians and other sources. The lowest tertile ( 3 sources) was consid- ered to represent low interest in health issues.

2.4.4. Further covariates

Further covariates describing health characteristics or family history included body mass index (BMI 25 kg/m 2 , 25–30 kg/m 2 , 30 kg/m 2 ), comorbidity (defined as being treated for cardiovascular disease, diabetes mellitus, asthma, chronic obstructive pulmonary disease, other can- cers or arthritis during past year), history of benign mastop- athy, use of hormones (contraceptives or hormone replace- ment therapy) during the year before diagnosis and history of breast cancer among a first-degree relative. The detection of a breast tumor is known to be impeded among obese women and obesity is associated with socio-demographic factors. Comorbidity, history of benign mastopathy and uti- lization of hormones are considered as potential covariates since these conditions lead to more frequent physician visits and thereby, may facilitate early-stage diagnosis [32,37]. In- formation concerning comorbidity was obtained by asking the patients whether they had been treated for one or more

V. Arndt et al. / Journal of Clinical Epidemiology 54 (2001) 719–727

 

721

Table 1 Description of study population ( n 380)

 

Table 1

Continued

 

n

%

n

%

Socio-demographic characteristics Age (years) 50

 

Duration of symptoms and diagnostics a 0–1 months 1–3 months 3 months

189

49.7

101

26.6

92

24.2

50–65

168

44.2

99

26.1

65 Nationality German Foreign Size of town (number of citizens) Small ( 100.000) Large ( 100.000) Education 10 years 10 years Current employment status Housewife/retired Employed Unemployed Last occupational class White collar Blue collar Never worked Health insurance Non private Private Living arrangements Single With spouse only With spouse and others With others (not spouse) Health behavior Regular monthly breast self examination Yes No Breast cancer screening during past 5 years Yes No General health check-up during past 5 years Yes No Interest in health issues Regular Low Health characteristics, family history Body mass index 25 kg/m 2 25–30 kg/m 2 30 kg/m 2 Comorbidity Yes No History of benign mastopathy Yes No Family history of breast cancer Yes No Hormones (OC, HRT) during past year Yes No Tumor detected by Symptoms Screening Incidental finding

111

29.2

370

97.4

a Defined as “interval between first symptom or screening examination and definite diagnosis.”

10

2.6

of the above- mentioned conditions during the last year be- fore onset of breast cancer symptoms. The list of medical conditions was constructed according to Moritz and Satari- ano [32] and comprises medical conditions where an exami- nation of the chest is likely to occur.

337

88.9

42

11.1

285

75.2

94

24.8

239

63.2

2.4.5. Mode of detection of tumor Mode of detection of tumor (symptoms, incidental find- ing, screening) and duration of symptoms and diagnostics (interval between first symptom or screening examination and definite diagnosis, categorized as 1 month, 1–3 months, 3 months) were obtained from the patient. Both variables might be considered as potential intermediate variables in the association between socio-demographic fac- tors and stage of disease at diagnosis.

121

32.0

18

4.8

215

57.6

67

18.0

91

24.4

336

88.7

43

11.3

99

26.1

2.5.

Statistical methods

136

35.9

Bivariate associations between stage of disease and each of the socio-demographic, health, social and potential inter- mediate variables were examined using contingency tables and chi-square statistics. Crude odds ratios (OR) including 95% confidence intervals (CI) were calculated with logistic regression. Next, logistic regression models were developed to examine the simultaneous influence of all socio-demo- graphic and health behavior factors on the likelihood of be- ing diagnosed with late-stage breast cancer. The first model (model 1) assessed the joint effect of all listed socio-demo- graphic factors. Model 2 examined whether sociod-demo- graphic factors are associated with breast cancer stage inde- pendently from health behavior, health characteristics and family history. To check whether the observed association between socio-demographic factors, health behavior and breast cancer stage was attributable to a long symptomatic period, the third model further considered information re-

garding duration of symptoms and diagnostics. A final model containing only the most predictive variables was ob-

96

25.3

48

12.7

197

54.0

168

46.0

284

74.9

95

25.1

234

62.1

143

37.9

270

71.1

110

28.9

167

45.5

110

30.0

90

24.5

256

67.4

124

32.6

89

23.4

291

76.6

tained by stepwise selection processing (significance level for staying or entering in the model both equal 0.15).

51

13.4

3. Results

 

329

86.6

112

29.7

3.1.

Study population

265

70.3

From 387 women with primary breast cancer, seven had to be excluded due to missing data on stage, leading to a final study population of 380 women. Characteristics of the study

287

75.5

67

17.6

26

6.8

sample are shown in Table 1. The mean age of the study pop- ulation was 58.0 years. Most study participants were of Ger-

 

(

Continued )

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V. Arndt et al. / Journal of Clinical Epidemiology 54 (2001) 719–727

Table 2 Percentages of cases with late stage

Table 2

Continued

 

Late

Chi-

 

Total

stage

 

square

test

n

n

%

P

Total Socio-demographic characteristics Age (years) 50

380

182

47.9

101

45

44.6

0.73

50–65

168

82

48.8

0.46

a

65 Nationality German Foreign Size of town (number of citizens) Small ( 100.000) Large ( 100.000) Education 10 years 10 years Employment status Housewife/retired Employed Unemployed Last occupational class White collar Blue collar Never worked Health insurance Private Non private Living arrangements Single With spouse only With spouse and others With others (not spouse) Health behavior Regular monthly breast self examination Yes No Breast cancer screening during past 5 years Yes No General health check-up during past 5 years Yes No Interest in health issues Regular Low Health characteristics, family history Body mass index 25 kg/m 2 25–30 kg/m 2 30 kg/m 2 Comorbidity Yes No History of benign mastopathy Yes No Family history of breast cancer Yes No

111

55

49.6

370

175

47.3

0.16

10

7

70.0

337

158

46.9

0.21

42

24

57.1

285

135

47.4

0.66

94

47

50.0

239

112

46.9

0.50

121

59

48.8

18

11

61.1

215

97

45.1

0.34

67

34

50.8

91

49

53.9

43

19

44.2

0.59

336

163

48.5

99

48

48.5

0.31

136

58

42.7

96

53

55.2

48

23

47.9

197

94

47.7

0.90

168

79

47.0

284

133

46.8

0.42

95

49

51.6

234

104

44.4

0.08

143

77

53.9

270

118

43.7

0.01

110

64

58.2

167

71

42.5

0.11

110

56

50.9

0.04

a

90

50

55.6

256

116

45.3

0.15

124

66

53.2

89

46

51.7

0.41

291

136

46.7

51

20

39.2

0.18

329

162

49.2

( Continued )

 

Late

Chi-

 

Total

stage

square

test

n

n

%

P

Hormones (OC, HRT) during past year Yes No Tumor detected by Symptoms Screening Incidental finding Duration of symptoms and diagnostics 0–1 months 1–3 months 3 months

112

53

47.3

0.86

265

128

48.3

287

148

51.6

0.005

67

20

29.9

26

14

53.9

189

83

43.9

0.27

92

46

50.0

0.12 a

99

53

53.4

a P-value derived from test for trend.

man nationality and the majority lived in communities with less than 100,000 citizens. The educational level was gener- ally low, only a quarter of all women completed 10 years or more of formal schooling. With respect to occupational sta- tus, most women were either housewife or already retired at the time of the interview. Most women lived together with a spouse or others, whereas a quarter was living alone. Fifty-four percent of all women reported to have checked their breasts for palpable masses regularly by self-examina- tion. Almost three quarters reported to have seen a physi- cian for breast cancer screening during the past 5 years be- fore onset of current disease. About two thirds of all study participants had seen a doctor for treatment of some other chronic disease during the year before diagnosis. A history of benign mastopathy was reported by 23% of all women. Almost 30% of all women took hormones during the year before diagnosis. A history of breast cancer among first-de- gree relatives was found among 51 women (13%). Over 75% of all tumors were diagnosed following symp- toms detected by the patient. Abnormal findings during reg- ular breast cancer screening examination or during the work- up of some other disease were the trigger for further diagnos- tics in 17.6% and in 6.8% of all cases. Despite the observa- tion that definitive diagnosis could be obtained within 1 month after onset of symptoms or first abnormal finding in almost half of all cases, definitive diagnosis took more than 3 months in over 25% of all patients.

3.2. Percentages of late-stage diagnosis

Overall, 182 women (47.9%) were diagnosed with re- gional ( n 168) or distant ( n 14) breast cancer (Table 2). None of the assessed socio-demographic variables was sta- tistically associated with late-stage diagnosis of breast can- cer in bivariate analysis, although the prevalence of late- stage was higher in patients with foreign nationality

(70.0%), unemployed (61.1%), patients living in large cities (57.1%) or in large households together with a spouse and others (55.2%) and those who had never worked (53.9%).

V. Arndt et al. / Journal of Clinical Epidemiology 54 (2001) 719–727

723

Health insurance and education were not related to stage of disease. Older patients (age 50 years) tended to present at later stage, but the differences were marginal. A stronger association with breast cancer stage was seen among variables describing health behavior. Low interest in health issues was clearly related with late-stage diagnosis of breast cancer. Attending a general health check-up during the past 5 years was associated with a higher proportion of localized tumors. Although breast cancer stage was less ad- vanced among patients who attended breast cancer screen- ing in the past, the association between history of profes- sional breast cancer screening and actual stage of disease was weak and statistically non-significant. No difference in stage of breast cancer was seen between women who re- ported to check their breasts regularly compared to others. There was a tendency that breast cancer stage was less often advanced in lean women (BMI 25 kg/m 2 ), women who have seen a doctor for treatment of some other chronic disease during the last year before diagnosis and among women with a first-degree relative with breast cancer. The association between comorbidity and stage of breast cancer diagnosis was not uniform for all underlying conditions. The proportion of women with advanced-stage breast can- cer was lower than average among women with ischemic heart disease (44.9%), stroke (38.5%), asthma (44.4%), ob- structive lung disease (42.9%), arthritis (41.9%) or other cancer (41.7%) but higher for women with diabetes (48.7%) or hypertension (50.8%, data not shown). The use of hor- mones (OC, HRT) was not associated with stage of disease. The type of detection was strongly associated with stage of breast cancer at diagnosis. In general, stage of breast can- cer was much more favorable among those women whose tumors were detected during the course of a regular screen- ing examination. No difference in tumor stage was noticed between tumors detected by symptoms and those detected incidentally. The duration of symptoms and diagnostic work-up was positively associated with tumor stage, how- ever the differences were of limited magnitude and not sta- tistically significant.

but did not substantially change the risk estimates for late- stage diagnosis of the socio-demographic variables. Among the variables describing health behavior, low in- terest in health issues (OR 1.7, 95% CI 1.0–2.9) and lack of general health check-ups during the past 5 years (OR 1.6, 95% CI 1.0–2.7) were independently associated with late-stage breast cancer. A previous history of clinical or self-conducted breast cancer screening was not associated with favorable breast cancer stage in multivariate analysis. Obesity (BMI 30 kg/m 2 ) was associated with late-stage breast cancer independently from socio-demographic char- acteristics and health behavior. Further adjustment for type of detection and total diag- nostic delay had only little impact on the risk estimates re- ferring to socio-demographic and health behavior variables. Although the association between tumor detection by screening and tumor stage is slightly attenuated in the multi- variate regression model, screening was the strongest pre- dictor of early-stage even after adjusting for all socio-demo- graphic and health behavior variables. In contrast, no significant association between tumor stage and duration of symptoms and/or diagnostic work-up was seen in the multi- variate regression model. Education, place of residence, marital status, health insurance and recent use of hormones were not associated with stage of disease in any model. Results of multivariate analysis when restricted to the most predictive variables of late-stage diagnosis are shown in Table 4. Besides screening as the most influential predic- tor of stage of diagnosis, older age, foreign nationality, liv- ing in large households, lack of general health check-ups during the past 5 years, low interest in health issues, BMI 30 kg/m 2 , history of benign mastopathy and family his- tory of breast cancer were strongly associated with late- stage disease. Both age and living arrangements could be di- chotomized without loss of information since the risk esti- mates of the referring subcategories did not differ (P 0.90). With an area under the receiver operating characteris- tic (ROC) curve of 0.68 the explanatory capacity of this par- simonious model was quite high.

3.3. Independent risk indicators for late-stage breast cancer

The results from bi- and multivariate logistic regression analyses are shown in Table 3. The presented crude odds ra- tios correspond to the associations shown in Table 2. As- sessing the joint effect of all socio-demographic factors (Model 1) strengthened the association between old age and living in large households with late-stage disease. Also for- eign nationality, employment status and occupational class were associated with late-stage. However, the joint explana- tory capacity of the model containing only socio-demo- graphic variables was not statistically significant (P 0.28). Further inclusion of health behavior factors, health characteristics and family history (Model 2) significantly improved the explanatory capacity of the logistic model predicting late-stage diagnosis of breast cancer (P 0.09)

4. Discussion

Although all necessary diagnostic procedures and treat- ments are covered for 98% of the German population by regular and private health insurance plans [38], high-risk groups for late-stage diagnosis of breast cancer could also be identified in Germany. This is even more striking as there should be no financial barriers in order to obtain health care since obligatory health insurance or subsidary social security plans also cover migrants, unemployed, homeless and their dependents. In our study, women of older ages or from ethnic minori- ties are more prone to procrastinate early detection of breast cancer. Similar findings have been reported from other countries [12–15,39–41]. One explanation for the delayed diagnosis among elderly could be that early cancer symp-

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V. Arndt et al. / Journal of Clinical Epidemiology 54 (2001) 719–727

Table 3 Crude and adjusted odds ratios (including 95% confidence intervals) of late-stage breast cancer (distant/regional versus localized)

 

Crude OR

Model 1

Model 2

Model 3

Socio-demographic characteristics Age 50–65 years 65 years Foreign nationality Size of town 100,000 Education 10 years Employment status Employed Unemployed Occupational class Blue collar Never worked No private health insurance Living arrangements Single With spouse and others With others (not spouse) Health behavior No regular monthly breast self examination During past 5 years No breast cancer screening No general check-up Low interest in health issues Health characteristics, family history Body mass index 25–30 kg/m 2 30 kg/m 2 Comorbidity History of benign mastopathy Hormones during past year Family history of breast cancer Tumor detected by Screening Incidental finding Duration of symptoms and diagnostics 1–3 months 3 months Model Fitting (likelihood ratio)

Association of predicted probabilities and observed responses

1.2 (0.7-1.9)

1.7 (0.9-3.1)

1.8 (0.9-3.5)

1.9 (1.0-3.8)

1.2 (0.7-2.1)

2.2 (1.0-4.8)

1.9 (0.8-4.5)

2.0 (0.8-4.9)

2.6 (0.7-10.2)

2.2 (0.5-9.4)

3.3 (0.6-18.1)

3.2 (0.6-18.1)

1.5 (0.8-2.9)

1.4 (0.7-2.8)

1.1 (0.5-2.5)

1.1 (0.5-2.5)

0.9 (0.6-1.4)

1.0 (0.6-1.7)

1.0 (0.5-1.8)

0.9 (0.5-1.7)

1.1 (0.7-1.7)

1.6 (0.9-2.8)

1.4 (0.8-2.6)

1.4 (0.8-2.7)

1.8 (0.7-4.8)

2.3 (0.8-7.1)

1.7 (0.5-5.4)

1.6 (0.5-5.4)

1.3 (0.7-2.2)

1.4 (0.8-2.4)

1.3 (0.7-2.4)

1.2 (0.6-2.3)

1.4 (0.9-2.3)

1.6 (0.9-2.9)

1.9 (1.0-3.6)

1.9 (1.0-3.6)

1.2 (0.6-2.3)

1.2 (0.6-2.5)

1.5 (0.7-3.1)

1.4 (0.7-3.1)

1.3 (0.8-2.1)

1.1 (0.6-2.0)

1.1 (0.6-2.1)

1.1 (0.6-2.1)

1.7 (1.0-2.4)

2.0 (1.1-3.6)

1.9 (1.0-3.5)

1.9 (1.0-3.5)

1.2 (0.6-2.4)

1.2 (0.6-2.4)

1.2 (0.6-2.7)

1.2 (0.6-2.7)

1.0 (0.6–1.5)

1.1 (0.7–1.7)

1.0 (0.6–1.7)

1.2 (0.8–1.9)

1.0 (0.6–1.8)

0.9 (0.5–1.7)

1.5 (1.1–2.8)

1.6 (1.0–2.7)

1.5 (0.9–2.6)

1.8 (1.1–2.8)

1.7 (1.0–2.9)

1.7 (1.0–2.8)

1.4 (0.9-2.3)

1.3 (0.7-2.3)

1.4 (0.8-2.5)

1.7 (1.0-2.8)

1.7 (0.9-3.2)

1.8 (0.9-3.3)

0.7 (0.5-1.1)

0.9 (0.5-1.5)

0.9 (0.5-1.6)

1.2 (0.8-2.0)

1.6 (0.9-2.7)

1.5 (0.8-2.7)

1.0 (0.6-1.5)

1.1 (0.6-1.9)

1.2 (0.7-2.2)

0.7 (0.4-1.2)

0.6 (0.3-1.1)

0.6 (0.3-1.2)

0.4 (0.2-0.7)

0.4 (0.2-0.9)

1.1 (0.5-2.5)

1.2 (0.5-2.9)

1.3 (0.8–2.1)

0.9 (0.5–1.7) 1.4 (0.8–2.5) 2 41.5 27 df P 0.04 c 0.692

1.5 (0.9–2.4)

— — 2 15.4 13 df P 0.28 c 0.609

— — 2 32.4 23 df P 0.09 c 0.675

Reference categories: age 50 years; nationality German; size of town 100,000; education 10 years; employment status housewife/retired; occu- pational class white collar; health insurance private; living arrangements lives with spouse only; monthly breast examination; breast cancer screening yes; general check-up yes; interest in health issues regular; body mass index 25.0 kg/m 2 ; comorbidity no; history of benign mastopathy no; hor- mones no; family history of breast cancer no; tumor detected by symptoms; duration of symptoms and diagnostics 1 month.

toms might be attributed to comorbid conditions, but our data indicate that old age is associated with late-stage diag- nosis of breast cancer independently from comorbidity. Language or cultural barriers may impede women from eth- nic minorities to seek medical advice. We also found that women who live in larger households and thus may have to care for children or other dependent per- sons are at higher risk to present with late-stage breast cancer. To our knowledge, the association between living arrange- ments and late-stage diagnosis has not been observed so far, but Moritz and Satariano [32] found that women who lived alone were least likely to be diagnosed with advanced disease.

It is noteworthy that these socio-demographic factors seem to represent independent risk indicators of late-stage diagnosis irrespective of health behavior and health aware- ness. The data also show that intention to seek evaluation of breast symptoms is not merely a matter of education and economics. According to Facione [42], it is dependent on a complex picture of personal and social factors, on the per- ceived amount of negative consequences of delaying diag- nosis and on previous habits of health care utilization. Besides socio-demographic characteristics, factors repre- senting health behavior and health awareness, such as inter- est in health issues or attending general check-up examina-

V. Arndt et al. / Journal of Clinical Epidemiology 54 (2001) 719–727

725

Table 4 Final model predicting late stage diagnosis of breast cancer

 

OR (95% CI)

Socio-demographic characteristics Age 50 years Foreign nationality Lives with spouse and others Health behavior During past 5 years no general check-up Low interest in health issues Health characteristics, family history Body mass index 25-30 kg/m 2 30 kg/m 2 History of benign mastopathy Family history of breast cancer Tumor detected by Screening Model Fitting likelihood ratio

1.8 (1.0–3.2)

3.9 (0.7–20.8)

1.7 (1.0–2.9)

1.5 (0.9–2.4)

1.6 (1.0–2.7)

1.4 (0.8–2.4)

1.8 (1.0–3.2)

1.6 (0.9–2.7)

0.6 (0.3–1.2)

0.4 (0.2–0.8)

2 33.8, 10 df

Association of predicted probabilities and observed responses

P 0.0002

c 0.682

Reference categories: age 50 years; nationality German; living ar- rangements: all others; interest in health issues regular; body mass in- dex 25.0 kg/m 2 ; tumor detected by symptoms or incidental finding.

tions, seem to be strong and independent predictors of tumor stage. Women who are interested in health issues and who volunteer for regular screening are more likely to be aware of their health and motivated to present promptly if they develop breast cancer symptoms [43]. Early diagnosis of breast cancer can either result from screening of asymptomatic patients or from patients with symptoms who present to a doctor in a timely manner. The favorable outcome with respect to stage at diagnosis among asymptomatic patients whose tumors have been discovered in the course of a screening examination is obvious. Our data furthermore indicate that a short duration of symptoms and a timely diagnostic work-up is also compatible with an early stage at diagnosis. The finding that obese women are at higher risk of late- stage diagnosis is in agreement with several studies which reported an association between increasing body mass index (BMI) or body weight and advanced stage [29,44,45]. De- tection of a tumor is more difficult among women with larger breasts and it is generally assumed that increased BMI is a proxy measure for increased breast size. The find- ing that women with a first-degree relative with breast can- cer are less likely to be diagnosed with late-stage cancer is likely to be due to higher breast cancer awareness, as sug- gested by Berman and Wandersman [46]. These women might be more susceptible to seek help if they discover signs of breast cancer [44]. The finding that neither previous history of breast self-ex- amination nor clinical breast cancer screening are associated with breast cancer stage is somewhat surprising. Although the proportion of late-stage breast cancer cases was lower in women who underwent breast cancer screening during the

past 5 years prior to the onset of the current disease, this fa- vorable association did not persist in multivariate analysis. One explanation could be that women who had inconspicu- ous mammographies in the recent past might tend to neglect self-discovered symptoms which will delay early detection of the tumor. Another explanation could be that the staging scheme we used is too crude to detect differences in tumor size, especially among women where the tumor is confined to the breast. However, observational studies which exam- ined the association between previous mammography use and breast cancer stage are equivocal. Taplin et al. [47] re- ported a reduction in late-stage disease occurred among women 50 years of age and older, who underwent regular mammography, even when regular was not synonymous with annual. In contrast, a recent study from Italy has shown that previous mammographies are not uniformly related to stage and that health-aware women who did not undergo

regular mammography have a relatively short diagnostic de-

lay if they develop signs of breast cancer [27]. Monthly breast self-examination (BSE) to decrease mor- tality from breast cancer is frequently advocated. However, evidence for the value of BSE is limited. None of the major randomized screening studies has produced data on the ef- fectiveness of BSE in reducing mortality from breast cancer [48–51]. The results suggest that BSE as practiced by most women in our study population is of little or no benefit de- spite the observation that over 75% of all breast cancers were discovered by the women themselves. Neither education nor comorbidity were related to stage at diagnosis within our study population. Former reports in- dicated that women with low education tend to present at later stage [21,52], but the difference might be too small to be detected in our study. The association between comor- bidity and stage of diagnosis was not uniform for all condi- tions and its interaction with diagnostic decision making de- serves further study. Women with comorbid conditions may be more likely to see a physician but non-specific cancer symptoms like fatigue might also be attributed to comorbid conditions. Weak, statistically non-significant associations were found with respect to employment status or occupational class. Patient delay among low SES women has been ad- dressed in several studies [53–56] without finding sufficient evidence. Regular health insurance companies, who insure 89% of the population in Germany, promote and cover atten- dance of cancer screening measures. Despite this encourage- ment, our data suggest that privately insured patients tend to present at an earlier stage than members of regular health in- surances. Members of private health insurances tend to be wealthier, younger and better educated. Due to the lack of power our results do not allow firm conclusions about the as- sociation between type of health insurance and tumor stage. This study has examined a range of individual factors that might influence breast cancer stage at time of diagnosis. To our knowledge, this work is unique in looking simulta- neously at socio-demographic, health behavior and other re-

726

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lated factors in a population-based sample of breast cancer patients. Several limitations, however, must be considered when interpreting these results. We could only consider so- cio-demographic characteristics of the patients, information regarding occupational class or education of the spouse not being available. Despite extensive efforts to obtain high par- ticipation, only about 50% of patients expected from average incidence figures from the Saarland cancer registry could be recruited for the study. This proportion may appear low at first glance. However, the incidence figures include a sub- stantial proportion of patients, who were not eligible for re- cruitment in our study for various reasons (see above), in- cluding patients who were too sick to be interviewed, or who died before they could be enrolled in the study (those pa- tients were not notified to the study center due to confidenti- ality reasons). Thus, it might be speculated that patients with advanced breast cancer were under-represented in our study sample. Nevertheless, the distribution of tumor stage is simi- lar to those reported in other studies [17,23,25,26,32,57] limiting the extent of possible selection bias. One major lim- itation is that our study did not have the power to detect po- tential meaningful interactions or specific high-risk sub- groups. Compared to other studies, however, we could consider a wider range of potential covariates and thus better control potential confounding by socio-demographic vari- ables, comorbidity, BMI and other covariates.

5. Conclusions

Although the predictive power of socio-demographic factors remained limited, these data indicate that high-risk groups for late-stage diagnosis also exist in Germany. Both socio-demographic factors and health behavior/health awareness are related to tumor stage at diagnosis. Whether efforts to increase health awareness will result in lowering breast cancer mortality deserves further study. The data clearly confirm that screening results in earlier diagnosis. Thus, broader acceptance of regular screening measures should be encouraged.

Acknowledgments

This study was supported by the Deutsche Krebshilfe (Ger- man Cancer Aid Foundation, M24/95/BR I). The authors thank Drs. Corinna Hetke, Wiebke Michaels, Annelie Becker, and Marianne Schramm for conducting the interviews.

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