Journal of Clinical Epidemiology 54 (2001) 719–727

Socio-demographic factors, health behavior and late-stage diagnosis

of breast cancer in Germany: A population-based study
Volker Arndta, Til Stürmera,b,*, Christa Stegmaierc, Hartwig Zieglerc,
Georg Dhomd, Hermann Brennera,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 that late-stage diagnosis for breast cancer is related to a num-

ber of demographic and socioeconomic factors such as old
Cancer of the breast is the most frequent malignant tu-
age [12–15], ethnicity [12,15–18], low socioeconomic status
mor in females in developed countries [1]. It is estimated
(SES) [12,15,17–20], low education [21], unemployment
that breast cancer will account for 500,000 deaths annually
[22], marital status [15,20,23,24] and health insurance
by the year 2000 worldwide [2]. Long-term prognosis of
[20,25]. Most pertinent studies were undertaken in the US
breast cancer patients strongly depends on stage of disease
and indicated that patients generally thought to be disadvan-
at diagnosis [3]. Mammography screening has been shown
taged are at especially high risk for delaying care. Inequalities
to be an effective tool in lowering breast cancer mortality by
in access to health care have been proposed as major reasons
early detection among women aged 50–69 [4,5]. However,
for these associations and might therefore be hypothesized to
participation in screening programs is low [6,7], and most
vary between countries with different health care systems.
breast cancer cases are diagnosed in symptomatic patients
Little is known about how much of the association be-
[8,9]. Targeting efforts to increase participation of screen-
tween socio-demographic factors and stage of breast cancer
ing individuals at high risk for late-stage diagnosis could be
is influenced by health behavior or health awareness. Re-
an effective step to reduce breast cancer mortality.
cent reports have shown that screening behavior [26] and
Denial, lack of information and financial considerations
health awareness [27] seem to be stronger predictors than
are considered to represent major reasons for delaying care
socio-demographic factors. The potential impact of other re-
among tumor patients [10,11]. Epidemiologic evidence exists
lated characteristics such as BMI [28,29], comorbidity [30–
32] or family history [33–35] on late-stage diagnosis and
* Corresponding author. Department of Epidemiology, German Centre
for Research on Ageing, Bergheimer Strasse 20, 69115 Heidelberg, Ger-
prognosis of breast cancer patients has also been discussed.
many. Tel.: 49-6221-548145; fax: 49-6221-548142. The aim of this study was to assess the association be-
E-mail address: sturmer@dzfa.uni-heidelberg.de (T. Stürmer) tween socio-demographic factors and health behavior with
0895-4356/01/$ – see front matter © 2001 Elsevier Science Inc. All rights reserved.
PII: S0895-4356(00)00 3 5 1 - 6
720 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/m2,
25–30 kg/m2,  30 kg/m2), 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 Table 1
Description of study population (n  380) Continued
n % n %
a
Socio-demographic characteristics Duration of symptoms and diagnostics
Age (years) 0–1 months 189 49.7
50 101 26.6 1–3 months 92 24.2
50–65 168 44.2 3 months 99 26.1
65 111 29.2 a
Nationality Defined as “interval between first symptom or screening examination
German 370 97.4 and definite diagnosis.”
Foreign 10 2.6
Size of town (number of citizens) of the above- mentioned conditions during the last year be-
Small (100.000) 337 88.9 fore onset of breast cancer symptoms. The list of medical
Large (100.000) 42 11.1
conditions was constructed according to Moritz and Satari-
Education
10 years 285 75.2 ano [32] and comprises medical conditions where an exami-
10 years 94 24.8 nation of the chest is likely to occur.
Current employment status
Housewife/retired 239 63.2 2.4.5. Mode of detection of tumor
Employed 121 32.0 Mode of detection of tumor (symptoms, incidental find-
Unemployed 18 4.8 ing, screening) and duration of symptoms and diagnostics
Last occupational class
(interval between first symptom or screening examination
White collar 215 57.6
Blue collar 67 18.0 and definite diagnosis, categorized as 1 month, 1–3
Never worked 91 24.4 months, 3 months) were obtained from the patient. Both
Health insurance variables might be considered as potential intermediate
Non private 336 88.7 variables in the association between socio-demographic fac-
Private 43 11.3
Living arrangements
tors and stage of disease at diagnosis.
Single 99 26.1
2.5. Statistical methods
With spouse only 136 35.9
With spouse and others 96 25.3 Bivariate associations between stage of disease and each
With others (not spouse) 48 12.7 of the socio-demographic, health, social and potential inter-
Health behavior mediate variables were examined using contingency tables
Regular monthly breast self examination and chi-square statistics. Crude odds ratios (OR) including
Yes 197 54.0
No 168 46.0
95% confidence intervals (CI) were calculated with logistic
Breast cancer screening during past 5 years regression. Next, logistic regression models were developed
Yes 284 74.9 to examine the simultaneous influence of all socio-demo-
No 95 25.1 graphic and health behavior factors on the likelihood of be-
General health check-up during past 5 years
Yes 234 62.1
ing diagnosed with late-stage breast cancer. The first model
No 143 37.9 (model 1) assessed the joint effect of all listed socio-demo-
Interest in health issues graphic factors. Model 2 examined whether sociod-demo-
Regular 270 71.1 graphic factors are associated with breast cancer stage inde-
Low 110 28.9
pendently from health behavior, health characteristics and
Health characteristics, family history
Body mass index family history. To check whether the observed association
25 kg/m2 167 45.5 between socio-demographic factors, health behavior and
25–30 kg/m2 110 30.0 breast cancer stage was attributable to a long symptomatic
30 kg/m2 90 24.5 period, the third model further considered information re-
Comorbidity
Yes 256 67.4
garding duration of symptoms and diagnostics. A final
No 124 32.6 model containing only the most predictive variables was ob-
History of benign mastopathy tained by stepwise selection processing (significance level
Yes 89 23.4 for staying or entering in the model both equal 0.15).
No 291 76.6
Family history of breast cancer
Yes 51 13.4 3. Results
No 329 86.6
Hormones (OC, HRT) during past year 3.1. Study population
Yes 112 29.7
No 265 70.3 From 387 women with primary breast cancer, seven had to
Tumor detected by be excluded due to missing data on stage, leading to a final
Symptoms 287 75.5
Screening 67 17.6 study population of 380 women. Characteristics of the study
Incidental finding 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)
722 V. Arndt et al. / Journal of Clinical Epidemiology 54 (2001) 719–727

Table 2 Table 2
Percentages of cases with late stage Continued

Late Chi- Late Chi-

stage square stage square
Total test Total test
n n % P n n % P
Total 380 182 47.9 Hormones (OC, HRT) during past year
Socio-demographic characteristics Yes 112 53 47.3 0.86
Age (years) No 265 128 48.3
50 101 45 44.6 0.73 Tumor detected by
50–65 168 82 48.8 0.46a Symptoms 287 148 51.6 0.005
65 111 55 49.6 Screening 67 20 29.9
Nationality Incidental finding 26 14 53.9
German 370 175 47.3 0.16 Duration of symptoms and diagnostics
Foreign 10 7 70.0 0–1 months 189 83 43.9 0.27
Size of town (number of citizens) 1–3 months 92 46 50.0 0.12a
Small (100.000) 337 158 46.9 0.21 3 months 99 53 53.4
Large (100.000) 42 24 57.1 a
Education P-value derived from test for trend.
10 years 285 135 47.4 0.66
10 years 94 47 50.0
Employment status man nationality and the majority lived in communities with
Housewife/retired 239 112 46.9 0.50
less than 100,000 citizens. The educational level was gener-
Employed 121 59 48.8
Unemployed 18 11 61.1 ally low, only a quarter of all women completed 10 years or
Last occupational class more of formal schooling. With respect to occupational sta-
White collar 215 97 45.1 0.34 tus, most women were either housewife or already retired at
Blue collar 67 34 50.8 the time of the interview. Most women lived together with a
Never worked 91 49 53.9
Health insurance spouse or others, whereas a quarter was living alone.
Private 43 19 44.2 0.59 Fifty-four percent of all women reported to have checked
Non private 336 163 48.5 their breasts for palpable masses regularly by self-examina-
Living arrangements tion. Almost three quarters reported to have seen a physi-
Single 99 48 48.5 0.31
With spouse only 136 58 42.7
cian for breast cancer screening during the past 5 years be-
With spouse and others 96 53 55.2 fore onset of current disease. About two thirds of all study
With others (not spouse) 48 23 47.9 participants had seen a doctor for treatment of some other
Health behavior chronic disease during the year before diagnosis. A history
Regular monthly breast self examination
of benign mastopathy was reported by 23% of all women.
Yes 197 94 47.7 0.90
No 168 79 47.0 Almost 30% of all women took hormones during the year
Breast cancer screening during past 5 years before diagnosis. A history of breast cancer among first-de-
Yes 284 133 46.8 0.42 gree relatives was found among 51 women (13%).
No 95 49 51.6 Over 75% of all tumors were diagnosed following symp-
General health check-up during past 5 years
Yes 234 104 44.4 0.08 toms detected by the patient. Abnormal findings during reg-
No 143 77 53.9 ular breast cancer screening examination or during the work-
Interest in health issues up of some other disease were the trigger for further diagnos-
Regular 270 118 43.7 0.01 tics in 17.6% and in 6.8% of all cases. Despite the observa-
Low 110 64 58.2
Health characteristics, family history
tion that definitive diagnosis could be obtained within 1
Body mass index month after onset of symptoms or first abnormal finding in
25 kg/m2 167 71 42.5 0.11 almost half of all cases, definitive diagnosis took more than
25–30 kg/m2 110 56 50.9 0.04a 3 months in over 25% of all patients.
30 kg/m2 90 50 55.6
Comorbidity 3.2. Percentages of late-stage diagnosis
Yes 256 116 45.3 0.15
No 124 66 53.2 Overall, 182 women (47.9%) were diagnosed with re-
History of benign mastopathy gional (n  168) or distant (n  14) breast cancer (Table 2).
Yes 89 46 51.7 0.41
No 291 136 46.7
None of the assessed socio-demographic variables was sta-
Family history of breast cancer tistically associated with late-stage diagnosis of breast can-
Yes 51 20 39.2 0.18 cer in bivariate analysis, although the prevalence of late-
No 329 162 49.2 stage was higher in patients with foreign nationality
(Continued) (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
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/m2), 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.
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)
723
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/m2) 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/m2, 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.
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-
724 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 1.2 (0.7-1.9) 1.7 (0.9-3.1) 1.8 (0.9-3.5) 1.9 (1.0-3.8)
65 years 1.2 (0.7-2.1) 2.2 (1.0-4.8) 1.9 (0.8-4.5) 2.0 (0.8-4.9)
Foreign nationality 2.6 (0.7-10.2) 2.2 (0.5-9.4) 3.3 (0.6-18.1) 3.2 (0.6-18.1)
Size of town 100,000 1.5 (0.8-2.9) 1.4 (0.7-2.8) 1.1 (0.5-2.5) 1.1 (0.5-2.5)
Education 10 years 0.9 (0.6-1.4) 1.0 (0.6-1.7) 1.0 (0.5-1.8) 0.9 (0.5-1.7)
Employment status
Employed 1.1 (0.7-1.7) 1.6 (0.9-2.8) 1.4 (0.8-2.6) 1.4 (0.8-2.7)
Unemployed 1.8 (0.7-4.8) 2.3 (0.8-7.1) 1.7 (0.5-5.4) 1.6 (0.5-5.4)
Occupational class
Blue collar 1.3 (0.7-2.2) 1.4 (0.8-2.4) 1.3 (0.7-2.4) 1.2 (0.6-2.3)
Never worked 1.4 (0.9-2.3) 1.6 (0.9-2.9) 1.9 (1.0-3.6) 1.9 (1.0-3.6)
No private health insurance 1.2 (0.6-2.3) 1.2 (0.6-2.5) 1.5 (0.7-3.1) 1.4 (0.7-3.1)
Living arrangements
Single 1.3 (0.8-2.1) 1.1 (0.6-2.0) 1.1 (0.6-2.1) 1.1 (0.6-2.1)
With spouse and others 1.7 (1.0-2.4) 2.0 (1.1-3.6) 1.9 (1.0-3.5) 1.9 (1.0-3.5)
With others (not spouse) 1.2 (0.6-2.4) 1.2 (0.6-2.4) 1.2 (0.6-2.7) 1.2 (0.6-2.7)
Health behavior
No regular monthly breast self examination 1.0 (0.6–1.5) — 1.1 (0.7–1.7) 1.0 (0.6–1.7)
During past 5 years
No breast cancer screening 1.2 (0.8–1.9) — 1.0 (0.6–1.8) 0.9 (0.5–1.7)
No general check-up 1.5 (1.1–2.8) — 1.6 (1.0–2.7) 1.5 (0.9–2.6)
Low interest in health issues 1.8 (1.1–2.8) — 1.7 (1.0–2.9) 1.7 (1.0–2.8)
Health characteristics, family history
Body mass index
25–30 kg/m2 1.4 (0.9-2.3) — 1.3 (0.7-2.3) 1.4 (0.8-2.5)
30 kg/m2 1.7 (1.0-2.8) — 1.7 (0.9-3.2) 1.8 (0.9-3.3)
Comorbidity 0.7 (0.5-1.1) — 0.9 (0.5-1.5) 0.9 (0.5-1.6)
History of benign mastopathy 1.2 (0.8-2.0) — 1.6 (0.9-2.7) 1.5 (0.8-2.7)
Hormones during past year 1.0 (0.6-1.5) — 1.1 (0.6-1.9) 1.2 (0.7-2.2)
Family history of breast cancer 0.7 (0.4-1.2) — 0.6 (0.3-1.1) 0.6 (0.3-1.2)
Tumor detected by
Screening 0.4 (0.2-0.7) — — 0.4 (0.2-0.9)
Incidental finding 1.1 (0.5-2.5) — — 1.2 (0.5-2.9)
Duration of symptoms and diagnostics
1–3 months 1.3 (0.8–2.1) — — 0.9 (0.5–1.7)
3 months 1.5 (0.9–2.4) — — 1.4 (0.8–2.5)
Model Fitting (likelihood ratio) 2  15.4 2  32.4 2  41.5
13 df 23 df 27 df
P  0.28 P  0.09 P  0.04
Association of predicted probabilities and observed responses c  0.609 c  0.675 c  0.692
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/m2; 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
Table 4
Final model predicting late stage diagnosis of breast cancer
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/m2
30 kg/m2
History of benign mastopathy
Family history of breast cancer
Tumor detected by
Screening
Model Fitting
likelihood ratio
Association of predicted probabilities
and observed responses
Reference categories: age 50 years; nationality  German; living ar-
rangements: all others; interest in health issues  regular; body mass in-
dex  25.0 kg/m2; 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
725
past 5 years prior to the onset of the current disease, this fa-
vorable association did not persist in multivariate analysis.
OR (95% CI) One explanation could be that women who had inconspicu-
ous mammographies in the recent past might tend to neglect
1.8 (1.0–3.2) self-discovered symptoms which will delay early detection
3.9 (0.7–20.8)
1.7 (1.0–2.9)
of the tumor. Another explanation could be that the staging
scheme we used is too crude to detect differences in tumor
1.5 (0.9–2.4) size, especially among women where the tumor is confined
1.6 (1.0–2.7) to the breast. However, observational studies which exam-
ined the association between previous mammography use
1.4 (0.8–2.4) and breast cancer stage are equivocal. Taplin et al. [47] re-
1.8 (1.0–3.2) ported a reduction in late-stage disease occurred among
1.6 (0.9–2.7) women 50 years of age and older, who underwent regular
0.6 (0.3–1.2) mammography, even when regular was not synonymous
0.4 (0.2–0.8)
with annual. In contrast, a recent study from Italy has shown
that previous mammographies are not uniformly related to
2  33.8, 10 df stage and that health-aware women who did not undergo
P  0.0002 regular mammography have a relatively short diagnostic de-
c  0.682
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 V. Arndt et al. / Journal of Clinical Epidemiology 54 (2001) 719–727
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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