Change in mammography screening attendance after removing the out-of-pocket fee: a population-based study in Sweden (2014-2018).

PURPOSE: To assess the change in mammography screening attendance in Sweden-overall and in sociodemographic groups at risk of low attendance-after removal of the out-of-pocket fee in 2016. METHODS: Individual-level data on all screening invitations and attendance between 2014 and 2018 were linked to sociodemographic data from Statistics Sweden. Odds ratios and 95% confidence intervals (CIs) for attendance by time period and sociodemographic factor were computed using mixed logistic regression to account for repeated measures within women. The study sample included 1.4 million women, aged 40-75, who had a mammography screening appointment in 2014-2015 and/or 2017-2018 in 14 of Sweden's 21 health care regions. RESULTS: Overall screening attendance was 83.8% in 2014-2015 and 84.1% in 2017-2018 (+ 0.3 percentage points, 95% CI 0.2-0.4). The greatest increase in attendance was observed in non-Nordic women with the lowest income, where attendance rose from 62.9 to 65.8% (+ 2.9 points, 95% CI 2.3-3.6), and among women with four or more risk factors for low attendance, where attendance rose from 59.2 to 62.0% (+ 2.8 points, 95% CI 2.2-3.4). CONCLUSION: Screening attendance did not undergo any important increase after implementing free screening, although attendance among some sociodemographic groups increased by almost three percentage points after the policy change.

Population-based mammography screening attendance in Sweden 2017-2018: A cross-sectional register study to assess the impact of sociodemographic factors.

Sweden has a population-based mammography screening programme for women aged 40-74. The objective of this study was to examine the association between mammography screening attendance and sociodemographic factors in 15 of Sweden's 21 health care regions. Register-based information was collected on all mammography screening invitations and attendance during 2017 and 2018, and linked to individual-level sociodemographic data from Statistics Sweden. Odds ratios (ORs) and 95% confidence intervals (CIs) for attendance were computed by sociodemographic factor. The study sample included 1.5 million women, aged 40-75, with an overall screening attendance of 81.3%. The lowest odds of attending were found for women living without a partner (OR = 0.52, 95% CI: 0.52-0.53), low-income women (OR = 0.57, 95% CI: 0.56-0.57), and non-Nordic women born in Europe (OR = 0.60, 95% CI: 0.59-0.61). Other groups with lower odds of attending were women whose main source of income was social assistance or benefits (OR = 0.62, 95% CI: 0.62-0.63), those not owning their home (OR = 0.66, 95% CI: 0.66-0.67), and those with low level of education (OR = 0.72, 95% CI: 0.71-0.73). Having multiple of these sociodemographic characteristics further lowered the odds of attending. Although overall mammography screening attendance in Sweden is high, sociodemographic inequalities exist, and efforts should be made to address these. Particular attention should be given to low-income women who live without a partner.

Negative cancer beliefs, recognition of cancer symptoms and anticipated time to help-seeking: an international cancer benchmarking partnership (ICBP) study.

BACKGROUND: Understanding what influences people to seek help can inform interventions to promote earlier diagnosis of cancer, and ultimately better cancer survival. We aimed to examine relationships between negative cancer beliefs, recognition of cancer symptoms and how long people think they would take to go to the doctor with possible cancer symptoms (anticipated patient intervals). METHODS: Telephone interviews of 20,814 individuals (50+) in the United Kingdom, Australia, Canada, Denmark, Norway and Sweden were carried out using the Awareness and Beliefs about Cancer Measure (ABC). ABC included items on cancer beliefs, recognition of cancer symptoms and anticipated time to help-seeking for cough and rectal bleeding. The anticipated time to help-seeking was dichotomised as over one month for persistent cough and over one week for rectal bleeding. RESULTS: Not recognising persistent cough/hoarseness and unexplained bleeding as cancer symptoms increased the likelihood of a longer anticipated patient interval for persistent cough (OR = 1.66; 95%CI = 1.47-1.87) and rectal bleeding (OR = 1.90; 95%CI = 1.58-2.30), respectively. Endorsing four or more out of six negative beliefs about cancer increased the likelihood of longer anticipated patient intervals for persistent cough and rectal bleeding (OR = 2.18; 95%CI = 1.71-2.78 and OR = 1.97; 95%CI = 1.51-2.57). Many negative beliefs about cancer moderated the relationship between not recognising unexplained bleeding as a cancer symptom and longer anticipated patient interval for rectal bleeding (p = 0.005). CONCLUSIONS: Intervention studies should address both negative beliefs about cancer and knowledge of symptoms to optimise the effect.

Awareness of cancer symptoms and anticipated patient interval for healthcare seeking. A comparative study of Denmark and Sweden.

Background Recent epidemiologic data show that Denmark has considerably poorer survival from common cancers than Sweden. This may be related to a lower awareness of cancer symptoms and longer patient intervals in Denmark than in Sweden. The aims of this study were to: 1) compare population awareness of three possible symptoms of cancer (unexplained lump or swelling, unexplained bleeding and persistent cough or hoarseness); 2) compare anticipated patient interval when noticing any breast changes, rectal bleeding and persistent cough; and 3) examine whether potential differences were noticeable in particular age groups or at particular levels of education in a Danish and Swedish population sample. Method Data were derived from Module 2 of the International Cancer Benchmarking Partnership. Telephone interviews using the Awareness and Beliefs about Cancer measure were conducted in 2011 among 3000 adults in Denmark and 3070 adults in Sweden. Results Danish respondents reported a higher awareness of two of three symptoms (i.e. unexplained lump or swelling and persistent cough or hoarseness) and a shorter anticipated patient interval for two of three symptoms studied (i.e. any breast changes and rectal bleeding) than Swedish respondents. Differences in symptom awareness and anticipated patient interval between these countries were most pronounced in highly educated respondents. Conclusion Somewhat paradoxically, the highest awareness of symptoms of cancer and the shortest anticipated patient intervals were found in Denmark, where cancer survival is lower than in Sweden. Thus, it appears that these differences in symptom awareness and anticipated patient interval do not help explain the cancer survival disparity between Denmark and Sweden.

Awareness of sunburn in childhood, use of sunbeds and change of moles in Denmark, Northern Ireland, Norway and Sweden.

BACKGROUND: Malignant melanoma (MM) is increasing rapidly in Northern Europe. To reduce incidence and mortality through earlier diagnosis, public awareness of MM is important. Thus, we aim to examine awareness of risk factors and a symptom of MM, and how awareness varies by country and socio-demographic factors in Denmark, Northern Ireland (NI), Norway and Sweden. METHODS: Population-based telephone interviews using the 'Awareness and Beliefs about Cancer' measure were conducted in 2011 among 8355 adults ≥50 years as part of the International Cancer Benchmarking Partnership Module 2. Prevalence ratios (PRs) with 95% confidence intervals were calculated. RESULTS: In these four countries, lowest awareness was found for 'sunburn in childhood' (63%), whereas awareness was high for 'use of sunbeds' (91%) and 'mole change' (97%). Lack of awareness of 'sunburn in childhood' was more prevalent among respondents from Norway [PR = 1.38 (1.28-1.48)] but less prevalent among respondents from Northern Ireland (NI) [PR = 0.78 (0.72-0.85)] and Sweden [PR = 0.86 (0.79-0.93)] compared with respondents from Denmark. Lack of awareness of 'use of sunbeds' was more prevalent among respondents from Norway [PR = 2.99 (2.39-3.74)], Sweden [PR = 1.57 (1.22-2.00)], and NI [PR = 1.65 (1.30-2.10)] compared with respondents form Denmark. Being a man, age ≥70, living alone, and having lower education, were each independently associated with lack of MM-awareness. CONCLUSIONS: The results indicate relatively low awareness of 'sunburn in childhood' as a risk factor for MM, and important disparities in MM-awareness across countries and socio-demographic groups. Improved and more directed initiatives to enhance public MM-awareness, particularly about 'sunburn in childhood', are needed.

Awareness of risk factors for cancer: a comparative study of Sweden and Denmark.

BACKGROUND: Sweden and Denmark are neighbouring countries with similarities in culture, healthcare, and economics, yet notable differences in cancer statistics. A crucial component of primary prevention is high awareness of risk factors in the general public. We aimed to determine and compare awareness of risk factors for cancer between a Danish and a Swedish population sample, and to examine whether there are differences in awareness across age groups. METHODS: Data derive from Module 2 of the International Cancer Benchmarking Partnership. Telephone interviews were conducted with 3000 adults in Denmark and 3070 in Sweden using the Awareness and Beliefs about Cancer measure. Data reported here relate to awareness of 13 prompted risk factors for cancer. Prevalence ratios with 95 % confidence intervals were calculated to examine associations between country, age, and awareness of risk factors. RESULTS: Over 90 % of respondents in both countries recognized smoking, use of sunbeds and ionizing radiation as risk factors for cancer. Lowest awareness (<50 %) was found for HPV-infection, low fruit and vegetable intake and alcohol intake. Swedish respondents reported higher awareness than Danish respondents for ten of the 13 risk factors studied. Respondents from Denmark reported higher awareness only regarding low fruit and vegetable intake and use of sunbeds. Low physical activity was the only risk factor for which there was no difference in awareness between the countries. A decline in awareness was generally seen with increasing age in both countries, but deviating patterns were seen for alcohol intake, red/processed meat, obesity and age 70+. CONCLUSIONS: This study supports findings from other European studies that generally demonstrate modest public awareness of many established cancer risk factors. Efforts should be made to improve awareness of the cancer risk factors HPV-infection, low fruit and vegetable intake and alcohol intake, which showed particularly low awareness in both countries. Previous studies indicate that repeated, broad campaigns are successful, and suggest that a multimedia approach is used.

Does the Neighborhood Area of Residence Influence Non-Attendance in an Urban Mammography Screening Program? A Multilevel Study in a Swedish City.

BACKGROUND AND AIM: The public health impact of population-based mammography screening programs depends on high participation rates. Thus, monitoring participation rates, as well as understanding and considering the factors influencing attendance, is important. With the goal to acquire information on the appropriate level of intervention for increasing screening participation our study aimed to (1) examine whether, over and above individual factors, the neighborhood of residence influences a woman's mammography non-attendance, and (2) evaluate, whether knowing a woman's neighborhood of residence would be sufficient to predict non-attendance. METHODS: We analyze all women invited to mammography screening in 2005-09, residing in the city of Malmö, Sweden. Information regarding mammography screening attendance was linked to data on area of residence, demographic and socioeconomic characteristics available from Statistics Sweden. The influence of individual and neighborhood factors was assessed by multilevel logistic regression analysis with 29,901 women nested within 212 neighborhoods. RESULTS: The prevalence of non-attendance among women was 18.3%. After adjusting for individual characteristics, the prevalence in the 212 neighborhoods was 3.6%. Neighborhood of residence had little influence on non-attendance. The multilevel analysis indicates that 8.4% of the total individual differences in the propensity of non-attendance were at the neighborhood level. However, when adjusting for specific individual characteristics this general contextual effect decreased to 1.8%. This minor effect was explained by the sociodemographic characteristic of the neighborhoods. The discriminatory accuracy of classifying women according to their non-attendance was 0.747 when considering only individual level variables, and 0.760 after including neighborhood level as a random effect. CONCLUSION: Our results suggest that neighborhoods of residence in Malmö, Sweden (as defined by small-area market statistics (SAMS) areas) do not condition women's participation in population based mammography screening. Thus, interventions should be directed to the whole city and target women with a higher risk of non-attendance.

Intention to leave the workplace among nurses working with cancer patients in acute care hospitals in Sweden.

PURPOSE: To examine associations between perceived leadership and intention to leave the workplace due to job dissatisfaction among registered nurses (RNs) who care for patients with cancer. We also examine intention to leave in relation to proportion of cancer patients, length of time in practice, perceived adequacy of cancer care education, and burnout. METHODS AND SAMPLE: The data originated from the Swedish component of RN4CAST, based on a survey of RNs working with in-patient care in all acute care hospitals in Sweden. The 7412 RNs reporting ≥10% patients with cancer on their unit were included in this analysis. Data were collected on perceptions of work environment, burnout, future employment intentions, and demographic characteristics. Additional questions related to cancer care. KEY RESULTS: About 1/3 of all RNs intended to leave their workplace within the next year. Intention to leave was more prevalent among RNs reporting less favourable perceptions of leadership, who had worked ≤ two years as RN, who reported having inadequate cancer care education, and with higher burnout scores. Associations between leadership and intention to leave were stronger among RNs in the profession > two years, who reported having adequate cancer care education, and with lower burnout scores. CONCLUSIONS: Perception of leadership is strongly associated with intention to leave among RNs in both specialized and general cancer care. This suggests a crucial area for improvement in order to reduce turnover rates.

Health-related lifestyle factors and mammography screening attendance in a Swedish cohort study.

To determine whether health-related lifestyle factors are associated with attendance at a population-based invitational mammography screening program in southern Sweden, data on health-related lifestyle factors (smoking, alcohol use, physical activity, BMI, diet, self-rated health, and stress) were obtained from the Malmö Diet and Cancer Study and linked to the Malmö mammography register (Sweden, 1992-2009). Women (n=11 409) who were free from breast cancer at study entry were included in the cohort, and mammography attendance was followed from cohort entry to 31 December 2009. Generalized estimating equations were used to account for repeated measures within patients. Adjusted odds ratios (OR) and 95% confidence intervals (CI) are reported. Nonattendance occurred in 8% of the 69 746 screening opportunities that were observed. Nonattendance was more common among women who were current or former smokers [OR=1.60 (1.45-1.76) and OR=1.15 (1.05-1.28)], had not used alcohol in the past year [OR=1.55 (1.32-1.83)], were less physically active outside of work [OR=1.10 (1.00-1.20)], had high physical activity at work (OR=1.13, 95% CI: 1.00-1.28), were vegetarians or vegans [OR=1.49 (1.11-1.99)], had not used dietary supplements [OR=1.11 (1.01-1.21)], had poor self-rated health [OR=1.24 (1.14-1.36)], and were experiencing greater stress [OR=1.25 (1.14-1.36)]. In this cohort, nonattendance was associated with smoking, alcohol abstinence, physical activity, poor self-rated health, stress, and following a vegetarian/vegan diet. These findings generally support the notion that women with less healthy lifestyles are less likely to engage in mammography screening.

Psychosocial factors and attendance at a population-based mammography screening program in a cohort of Swedish women.

BACKGROUND: A better understanding of the factors that influence mammography screening attendance is needed to improve the effectiveness of these screening programs. The objective of the study was to examine whether psychosocial factors predicted attendance at a population-based invitational mammography screening program. METHODS: Data on cohabitation, social network/support, sense of control, and stress were obtained from the Malmö Diet and Cancer Cohort Study and linked to the Malmö mammography register in Sweden. We analyzed 11,409 women (age 44 to 72) who were free of breast cancer at study entry (1992 to 1996). Mammography attendance was followed from cohort entry to December 31, 2009. Generalized Estimating Equations were used to account for repeated measures within subjects. Adjusted odds ratios (OR) and 95% confidence intervals (CI) are reported. RESULTS: Among 69,746 screening opportunities there were 5,552 (8%) cases of non-attendance. Higher odds of non-attendance were found among women who lived alone (OR = 1.47 (1.33-1.63)) or with children only (OR = 1.52 (1.29-1.81)), had one childbirth (OR = 1.12 (1.01-1.24)) or three or more childbirths (OR = 1.34 (1.21-1.48)), had low social participation (OR= 1.21 (1.10-1.31)), low sense of control (OR = 1.12 (1.02-1.23)), and experienced greater stress (OR = 1.24 (1.13-1.36)). CONCLUSIONS: Public health campaigns designed to optimize mammography screening attendance may benefit from giving more consideration of how to engage with women who are less socially involved.

Assessing population-wide behaviour change: concordance of 10-year trends in self-reported and observed sun protection.

OBJECTIVES: Increases in socially desirable responses in self-reports might occur in the context of ongoing public education. We examine concordance of trends in two long-term studies monitoring population impact for SunSmart. METHODS: One study employed telephone interviews of Melbourne residents; the other entailed observations at public recreation venues across Melbourne. The studies assessed people's sun protection on identical weekend dates (Nw = 33 dates). Data from five summers between 1992 and 2001 (n ~ 23,000 individuals) were analysed. A body cover index score was calculated for participants on each date. Outcomes were aggregated separately for Saturdays and Sundays by date and year. Regression analyses tested whether these trends differed by survey method. RESULTS: The pattern of change in body cover over time was similar for both surveys. Self-reported body cover was consistently higher than observed body cover, suggesting that social desirability bias may be present. Regression analyses showed no divergence between self-reported and observed trends in mean body cover, suggesting no evidence of significant increased social desirability bias in self-reporting over time. CONCLUSION: Findings suggest that self-report offers a valid means of assessing change in a population's sun protection compliance over time, at least when self-reports are precisely focussed for time and activity context.

Do reproductive and hormonal risk factors for breast cancer associate with attendance at mammography screening?

PURPOSE: To determine whether reproductive and hormonal risk factors for breast cancer associate with mammography attendance. METHODS: We linked data from the Malmö Diet and Cancer Study to the Malmö mammography register (Sweden, 1992-2009). We analyzed 11,409 women (age 44-72) who were free of breast cancer at study entry and a total of 69,746 screening invitations. Generalized Estimating Equations were used to account for repeated measures within subjects. Models were adjusted for age and other sociodemographic factors. RESULTS: In this study cohort, mammography screening attendance ranged from 87.6 to 94.5% between calendar years, with an average attendance of 92%. Higher attendance was found among women who had given birth to fewer than three children (ORs ranging between 1.15 and 1.37) and had used oral contraceptives (OC) within the last decade (OR = 1.22, 95% CI 1.07-1.38) and for a longer period (OR = 1.13, 95% CI 1.01-1.27). A lower odds of attendance was found among post-menopausal women (OR = 0.86, 95% CI 0.77-0.96). Age < 13 at menarche, age ≥ 30 at first childbirth, age ≥ 55 at menopause, age < 20 at first OC use, nulliparity, breastfeeding, and hormone replacement therapy were not associated with mammography attendance. CONCLUSION: Reproductive and hormonal risk factors for breast cancer have little effect on mammography screening attendance. This may indicate a potential for under-screening of some women at higher risk.

An international measure of awareness and beliefs about cancer: development and testing of the ABC.

OBJECTIVES: To develop an internationally validated measure of cancer awareness and beliefs; the awareness and beliefs about cancer (ABC) measure. DESIGN AND SETTING: Items modified from existing measures were assessed by a working group in six countries (Australia, Canada, Denmark, Norway, Sweden and the UK). Validation studies were completed in the UK, and cross-sectional surveys of the general population were carried out in the six participating countries. PARTICIPANTS: Testing in UK English included cognitive interviewing for face validity (N=10), calculation of content validity indexes (six assessors), and assessment of test-retest reliability (N=97). Conceptual and cultural equivalence of modified (Canadian and Australian) and translated (Danish, Norwegian, Swedish and Canadian French) ABC versions were tested quantitatively for equivalence of meaning (≥4 assessors per country) and in bilingual cognitive interviews (three interviews per translation). Response patterns were assessed in surveys of adults aged 50+ years (N≥2000) in each country. MAIN OUTCOMES: Psychometric properties were evaluated through tests of validity and reliability, conceptual and cultural equivalence and systematic item analysis. Test-retest reliability used weighted-κ and intraclass correlations. Construction and validation of aggregate scores was by factor analysis for (1) beliefs about cancer outcomes, (2) beliefs about barriers to symptomatic presentation, and item summation for (3) awareness of cancer symptoms and (4) awareness of cancer risk factors. RESULTS: The English ABC had acceptable test-retest reliability and content validity. International assessments of equivalence identified a small number of items where wording needed adjustment. Survey response patterns showed that items performed well in terms of difficulty and discrimination across countries except for awareness of cancer outcomes in Australia. Aggregate scores had consistent factor structures across countries. CONCLUSIONS: The ABC is a reliable and valid international measure of cancer awareness and beliefs. The methods used to validate and harmonise the ABC may serve as a methodological guide in international survey research.

Use of healthcare information and advice among non-urgent patients visiting emergency department or primary care.

BACKGROUND: Healthcare information provided by telephone service and internet sources is growing but has not been shown to reduce inappropriate emergency department (ED) visits. OBJECTIVE: To describe the use of advice or healthcare information among patients with non-urgent illnesses seeking care before attendance at an ED, or primary care (PC) centres in an urban region in Sweden. DESIGN: Patients with non-urgent illnesses seeking care at an ED or patients attending the PC were followed up with a combination of patient interviews, a questionnaire to the treating physician and a prospective follow-up of healthcare use through a population-based registry. RESULTS: Half of the non-urgent patients attending the ED had used healthcare information or advice before the visit, mainly from a healthcare professional source. In PC, men were more likely to have used information or advice compared with women (OR 2.5 95% CI 1.3 to 5.0), whereas the situation was reversed among ED patients (OR=0.4 95% CI 0.2 to 0.9). Men with no previous healthcare experience attending the ED had the lowest use of healthcare information (p<0.01). Very few in both groups had utilised healthcare information on the internet in a case of perceived emergency. CONCLUSION: ED patients rated as non-urgent by the triage nurse used more advice and healthcare information than PC patients, irrespective of the physician-rated urgency of the symptoms. The problem seems not to be lack of information about appropriate ED use, but to find ways to direct the information to the right target group.

Physician assessment of appropriate healthcare level among nonurgent patients.

OBJECTIVES: To analyze the appropriateness of healthcare level chosen by nonurgent patients in an emergency department (ED) compared with unscheduled primary care (PC) patients and the factors influencing physician consideration of appropriate care level. STUDY DESIGN: Cross-sectional study. METHODS: This study used structured face-to-face interviews with nonurgent patients at an urban ED and with unscheduled PC patients from a defined catchment area, concomitant with a questionnaire to the treating physician. RESULTS: General practitioners considered to a higher extent than their ED colleagues that patients chose an appropriate level of care. General practitioners were older and had longer clinical experience than physicians at the ED. Patients considered at an appropriate care level were distinguished by their symptom presentation, shorter duration of symptoms, and more regular previous healthcare use. Men with little regular previous healthcare use were more likely to present with symptoms assessed as inappropriate for the ED (P <.001). CONCLUSIONS: Patients with disorders that ED physicians considered inappropriate for the setting had little regular previous healthcare use but were also managed by less experienced physicians compared with patients in PC. General practitioners agreed with the choice of healthcare level among their patients to a large extent. It is important to meet patient demands and concerns in a professional way and to develop organizational ways to manage patient needs that are suitable for the setting.

Characteristics of non-urgent patients. Cross-sectional study of emergency department and primary care patients.

OBJECTIVE: To describe characteristics of patients seeking medical attention for non-urgent conditions at an emergency department (ED) and patients who use non-scheduled services in primary healthcare. DESIGN: Descriptive cross-sectional study. SETTING: Primary healthcare centres and an ED with the same catchment area in Stockholm, Sweden. PATIENTS: Non-scheduled primary care patients and non-referred non-urgent ED patients within a defined catchment area investigated by structured face-to-face interviews in office hours during a nine-week period. MAIN OUTCOME MEASURES: Sociodemographic characteristics, chief complaints, previous healthcare use, perception of symptoms, and duration of symptoms before seeking care. RESULTS: Of 924 eligible patients, 736 (80%) agreed to participate, 194 at the ED and 542 at nine corresponding primary care centres. The two groups shared demographic characteristics except gender. A majority (47%) of the patients at the primary care centres had respiratory symptoms, whereas most ED patients (52%) had digestive, musculoskeletal, or traumatic symptoms. Compared with primary care patients, a higher proportion (35%) of the ED patients had been hospitalized previously. ED patients were also more anxious about and disturbed by their symptoms and had had a shorter duration of symptoms. Both groups had previously used healthcare frequently. CONCLUSIONS: Symptoms, previous hospitalization and current perception of symptoms seemed to be the main factors discriminating between patients studied at the different sites. There were no substantial sociodemographic differences between the primary care centre patients and the ED patients.

Use of sun-protective clothing at outdoor leisure settings from 1992 to 2002: serial cross-sectional observation survey.

BACKGROUND: Previous population-based surveys to monitor sun protection behavior over time have relied on self-report, which can be subject to recall and misclassification bias and social desirability bias. The present study aimed to describe the prevalence and determinants of teenagers' and adults' observed sun protection behavior while engaged in outdoor leisure activities on summer weekends, over a decade of the SunSmart skin cancer prevention program, which involved public education and advocacy. METHOD: Serial cross-sectional observational field surveys of teenagers and adults at leisure were undertaken during summer weekends between 11 a.m. and 3 p.m., from 1992 to 2002 (N = 46,810). The four types of setting for observation were parks and gardens, golf courses, tennis courts, and pools and beaches, located within a 25-km radius of Melbourne city center, Australia. The main outcome measure was a binary clothes cover index representing persons above or below the median level of body cover for each type of leisure setting. The index was based on the proportion of body surface covered by the type of hat, shirt, and leg cover garments worn. RESULTS: Body cover varied by environmental factors and the activity demands and demographic characteristics of individuals. After adjusting for covariates, significant improvements in the extent of body cover occurred over the decade, such that the odds of the proportion of people wearing clothes cover above the median level increased by 3% per year (95% confidence interval, 2-4%). CONCLUSION: Results suggest that significant gains in sun-protective behavior have occurred, coincident with the conduct of an ongoing comprehensive skin cancer prevention program.

Long-term inequalities in breast cancer survival--a ten year follow-up study of patients managed within a National Health Care System (Sweden).

INTRODUCTION: Converging epidemiological evidence based on studies of different designs in a variety of populations and settings show that cancer survival tends to be poorer in low compared to high socioeconomic groups. In an extension of an earlier register-based study, we examined the influence of socioeconomic factors on long-term survival in women with a first diagnosis of invasive breast cancer in 1993 in Sweden, a country with a policy of providing equal access to health care to all at nominal cost within a National Health Care System. MATERIAL AND METHODS: The study was based on data set generated by record linkages between the Swedish Cancer Register, Census databases and the Cause of Death Register. Four different categorical variables were used as indicators of socioeconomic standing. Cox proportional hazard regression models were used to estimate the effects of socioeconomic status on risk of death. RESULTS: Of 4 645 eligible women with breast cancer, 1 016 had died from breast cancer at the end of follow-up on December 31, 2003. After adjustment for tumour size and age at diagnosis, risk of death was 19% lower among women belonging to a household of high compared to low socioeconomic status (HR high versus low 0.81; 95% CI: 0.67-0.97). DISCUSSION: These findings indicate that social inequalities in breast cancer survival persist at least up to ten years after an initial diagnosis. While social gradients detected shortly after diagnosis may mainly reflect an influence of socioeconomic differences in overall health status and frailty, differentials persisting beyond five years rather point to a long-term influence of disparities in management of both primary tumours and recurrences. Further studies are needed to explore whether the present findings reflect amendable inequalities in access to state-of-the-art treatment. For all calendar periods, observed survival in the most privileged groups sets the goal for what is achievable for all breast cancer patients.

Is cancer risk associated with anger control and negative affect? Findings from a prospective cohort study.

OBJECTIVE: To examine the associations between anger control and negative affect and the risk of five common cancers and total cancers. Possible associations between emotional states and the risk of cancer have long been postulated. METHODS: Prospective cohort study with average follow-up of 9 years. A total of 19,730 adults (99% aged between 40 and 69 years) answered questions on negative affect and anger control at baseline. A total of 1952 cancers were diagnosed, including 352 breast cancers, 318 prostate cancers, 88 lung cancers, 280 colorectal cancers, and 261 melanomas. RESULTS: After adjustment for potential confounders, there was no significant association between anger control or negative affect and risk of breast cancer, melanoma, or total cancers. Weak associations were identified between anger control and prostate cancer, hazards ratio (HR) 1.17 (1.04-1.30) for a 1-unit increase in the standardized scale, negative affect, and lung cancer, HR 1.24 (1.01-1.52) and colorectal cancer, HR 1.14 (1.01-1.28). There was no evidence of an interaction effect between anger control and negative affect. CONCLUSIONS: Results suggest that anger control and negative affect are not associated with breast cancer, melanoma, or total cancer risk, although they may have a small role in risk of prostate, colorectal, and lung cancer. Although more research is needed to confirm these latter associations, the results suggest that if affective states are associated with cancer development, the association may differ for different cancers and argue against the use of total cancer as an outcome measure for studies in this area.