Spatial, Temporal, Social Disparities in Breast Cancer

描述（由申请人提供）：乳腺癌筛查可降低死亡率。欧洲研究表明，筛查计划实施后，早期乳腺癌和原位乳腺癌的发病率大幅增加。随后晚期乳腺癌的发病率下降，其下降幅度与死亡率下降的幅度大致相当。在美国，这种因筛查而降低死亡率的效果也是可以预期的，但目前还缺乏检验这种降低死亡率的研究。监测美国各县乳腺癌筛查的效果显然是有益的，因为这将有助于当地的卫生规划和筛查资源的分配。尽管筛查的使用因地理位置而异，但美国不同县之间筛查效果随时间变化的程度尚不清楚。对筛查存在地域差异的一种解释是，来自社会经济贫困地区的女性接受筛查的可能性较小。由于医生推荐对乳腺癌筛查的重要性以及初级保健医生和乳房 X 光检查设施的可用性在区域剥夺与各种健康结果之间的关系中的中介作用，我们假设不同社会经济条件的县之间乳腺癌筛查效果的差异将由当地初级保健医生和乳房 X 光检查设施的可用性来调节。在本提案的第二次修订中，我们将采用生态研究的方式：（1）利用1988-2005年9个SEER项目和200个县的数据，调查县级早期乳腺癌、晚期乳腺癌和乳腺癌死亡率的时空变化； (2) 确定县域乳腺癌筛查患病率差异与县域晚期乳腺癌发病率和乳腺癌死亡率之间的关系； (3) 确定早期乳腺癌、晚期乳腺癌和乳腺癌死亡率的时间变化是否因县社会经济条件而异； (4) 确定县一级初级保健医生和乳房 X 光检查设施的可用性是否可以解释富裕县和社会经济贫困县之间早期乳腺癌、晚期乳腺癌和乳腺癌死亡率的时间差异。贝叶斯方法将用作时空模型的一部分。公共卫生相关性：监测美国各县乳腺癌筛查的效果显然是有益的，因为这将促进当地的健康规划和筛查资源的分配。我们将通过生态研究：（1）利用1988-2005年9个SEER项目和200个县的数据，调查县级早期乳腺癌、晚期乳腺癌和乳腺癌死亡率的时空变化； (2) 确定县域乳腺癌筛查患病率差异与县域晚期乳腺癌发病率和乳腺癌死亡率之间的关系； (3) 确定早期乳腺癌、晚期乳腺癌和乳腺癌死亡率的时间变化是否因县社会经济条件而异； (4) 确定县一级初级保健医生和乳房 X 光检查设施的可用性是否可以解释富裕县和社会经济贫困县之间早期乳腺癌、晚期乳腺癌和乳腺癌死亡率的时间差异。

DESCRIPTION (provided by applicant): Screening for breast cancer reduces mortality. Following the implementation of screening programs, European studies have shown that the incidence of early-stage and in situ breast cancers increased substantially. This was followed by a decline in the incidence of advanced-stage breast cancers, which approximated the size of the reduction in mortality rates. This pathway of effects towards mortality reduction resulting from screening would also be expected in the United States, but studies examining such reduction are currently lacking. Monitoring the effects of breast cancer screening in the United States among counties is clearly beneficial since this will facilitate local health planning and allocation of screening resources. Although screening use varies geographically, the extent to which changes over time in the effects of screening have varied among different counties in the United States is unclear. One explanation for the geographic variation in screening is that women from socioeconomically deprived areas are less likely to be screened. Because of the importance of physician recommendation to breast cancer screening and the mediating effect of primary care physician and mammography facility availability in the association between area deprivation and various health outcomes, we hypothesize that the differences in effect of breast cancer screening among counties with varying socioeconomic conditions will be mediated by the availability of primary care physicians and mammography facilities locally. In the second revision of this proposal, we will use an ecological study to: (1) Investigate the spatio-temporal variation of early stage breast cancer, advanced stage breast cancer, and breast cancer mortality at the county-level using 1988-2005 data from nine SEER programs and 200 counties; (2) Determine the association of the county-specific variation of breast cancer screening prevalence with the county-specific incidence of advanced stage breast cancer and with breast cancer mortality; (3) Determine if temporal changes in early stage breast cancer, advanced stage breast cancer, and breast cancer mortality vary by county socioeconomic conditions; and (4) Determine if the availability of primary care physicians and mammography facilities at the county level explains the temporal differences between affluent and socioeconomically deprived counties in the incidence of early stage breast cancer, advanced stage breast cancer, and breast cancer mortality. Bayesian methods will be used as part of spatio-temporal models. PUBLIC HEALTH RELEVANCE: Monitoring the effects of breast cancer screening in the United States among counties is clearly beneficial since this will facilitate local health planning and allocation of screening resources. We will use an ecological study to: (1) Investigate the spatio-temporal variation of early stage breast cancer, advanced stage breast cancer, and breast cancer mortality at the county-level using 1988-2005 data from nine SEER programs and 200 counties; (2) Determine the association of the county-specific variation of breast cancer screening prevalence with the county-specific incidence of advanced stage breast cancer and with breast cancer mortality; (3) Determine if temporal changes in early stage breast cancer, advanced stage breast cancer, and breast cancer mortality vary by county socioeconomic conditions; and (4) Determine if the availability of primary care physicians and mammography facilities at the county level explains the temporal differences between affluent and socioeconomically deprived counties in the incidence of early stage breast cancer, advanced stage breast cancer, and breast cancer mortality.