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。随着筛查项目的实施，欧洲的研究表明，早期乳腺癌和原位乳腺癌的发病率大幅增加。随后，晚期乳腺癌发病率下降，这与死亡率下降的幅度相近。这种通过筛查降低死亡率的途径也有望在美国出现，但目前还缺乏检查这种降低死亡率的研究。在美国各县监测乳腺癌筛查的效果显然是有益的，因为这将促进地方卫生规划和筛查资源的分配。尽管筛查的使用在地理上有所不同，但筛查效果随时间变化的程度在美国不同县之间的差异尚不清楚。对筛查的地域差异的一种解释是，来自社会经济贫困地区的妇女不太可能接受筛查。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光检查设备的可用性在区域剥夺与各种健康结果之间的中介作用，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被当地初级保健医生和乳房x光检查设备的可用性所中介。在本文的第二次修订中，我们将采用生态学研究的方法：(1)利用1988-2005年9个SEER项目和200个县的数据，研究早期乳腺癌、晚期乳腺癌和乳腺癌死亡率在县域的时空变化；(2)确定乳腺癌筛查流行率的县特异性变异与晚期乳腺癌县特异性发病率和乳腺癌死亡率的关系；(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的社会经济条件而异；(4)确定县级初级保健医生和乳房x光检查设施的可用性是否解释了富裕县和社会经济贫困县在早期乳腺癌、晚期乳腺癌发病率和乳腺癌死亡率方面的时间差异。贝叶斯方法将被用作时空模型的一部分。公共卫生相关性：在美国各县监测乳腺癌筛查的效果显然是有益的，因为这将促进地方卫生规划和筛查资源的分配。本研究采用生态学研究方法：(1)利用1988-2005年9个SEER项目和200个县的数据，研究了早期乳腺癌、晚期乳腺癌和乳腺癌死亡率在县域的时空变化；(2)确定乳腺癌筛查流行率的县特异性变异与晚期乳腺癌县特异性发病率和乳腺癌死亡率的关系；(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的社会经济条件而异；(4)确定县级初级保健医生和乳房x光检查设施的可用性是否解释了富裕县和社会经济贫困县在早期乳腺癌、晚期乳腺癌发病率和乳腺癌死亡率方面的时间差异。

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.