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Backgrounds Socio-economic position (SEP) is linked to many health outcomes but the link between SEP and breast cancer (BC) is complex. This study explores the relationship between SEP from early life and future risk of BC. Methods We used data from the Italian component of the European prospective investigation into cancer and nutrition: EPIC-Italy (up to 26,391 women). Cox proportional hazard models were used to estimate the association between measures of life course SEP (father’s occupation, educational level, highest household occupation) with risk of BC, adjusting for health behaviours (smoking, alcohol, physical activity, Mediterranean diet), height, weight and reproductive factors (postmenopausal status, age at first full term pregnancy). To mimic life course experiences, we analysed the relationship between father’s occupation and risk of BC, sequentially adjusting for SEP in young adulthood and adulthood, as well as the impact of social mobility. Results We observed a significant association between father’s occupation and risk of BC, where participant with low SEP had lower risk to develop BC (HR[95%CI] = 0.88[0.78; 0.99]). This association was borderline significant when we analysed educational level and highest household occupation. These associations were only slightly modified after adjustment for health behaviours, height and weight but more strongly affected by reproductive factors. However, the association between father’s occupation and BC remained borderline significant in the fully adjusted model (HR[95%CI] = 0.91[0.80; 1.03]). Stable low trajectory showed a lower risk of BC (HR[95%CI] = 0.82[0.71; 0.96]) slightly attenuated after adjusted for reproductive factors (HR[95%CI] = 0.88 [0.75; 1.03]). Conclusions Our findings suggest that low early-life SEP and stable low trajectory are associated with a lower risk of BC, which is partly explained by reproductive factors. Key messages Low early life socioeconomic position and stable low trajectory are associated with a lower risk of BC. Reproductive factors, especially age at the first full term pregnancy, explain part of these associations.

Social position is known to play a role in the quality of ageing, notably through the stimulation/dysregulation of key physiological systems in response to external stresses. Using data from one wave of Understanding Society including 9088 participants, we defined, as an extension of the allostatic load, a synthetic Biological Health Score (BHS) capturing the wear-and-tear of four physiological systems (endocrine, inflammatory, cardiovascular and metabolic systems) and two organs (liver and kidney). We used 16 established blood-derived biomarkers of these systems to calculate the BHS and explored the relative contribution of socioeconomic position to the BHS and its main components across age groups. We identified a systematic decreasing education-related gradient of the BHS (p

Table S3. Bivariate associations between covariates and treatment selection in terms of Low intensive chemotherapy or BSC. (DOCX 15 kb)

Table S4. Step 1 sensitivity analysis. Survival in association with patients’ SEP adjusted for treatment, patients’ and disease characteristics. Adjusted hazard ratios [95% Confidence Intervals] of overall mortality from Adjusted Cox proportional hazards model with time dependent variables (n = 684). (DOCX 23 kb)

Table S2. Bivariate associations between covariates and treatment selection in terms of intensive chemotherapy or not. (DOCX 15 kb)

Table S5. Step 2 Sensitivity analysis. Models of the association linking patients’ SEP to receiving Intensive Chemotherapy adjusted for each confounder, and fully adjusted. Generalized linear model with logit link function, adjusted odds ratios [95% Confidence Intervals], with missing data treated by multiple imputation (n = 685). (DOCX 20 kb)

This research investigates the influence of place of residence and diabetic patient's socioeconomic position on their use of health services in a universal health care system. This retrospective cross-sectional population-based study is based on the joint use of the Health Insurance information systems, an ecological indicator of social deprivation and an indicator of potential spatial accessibility of healthcare provision in the Midi-Pyrénées region. Using French healthcare insurance population-based data on reimbursement of out-of-hospital care during the year 2012, we study the use of health services among patients aged 50 and over (n = 90,136).We built logistic regression models linking health services use to socioeconomic position by geographic area, adjusted for age, gender, healthcare provision, information regarding patients precariousness, and long-term condition, used as proxy for the state of health. After adjustment for healthcare provision, the lower population density in the geographical area of concern, the lower the access to specialised care, independent of the patients' SEP. General practitioner attendance was higher among the patients with the lowest SEP without being clearly influenced by their living place. We found no clear influence of either patients' SEP or their living place on their access to biological follow-up. This study is an attempt to account for the geographical context and to go further in studying the social determinants of health among diabetes patients.

Introduction Several studies highlight the influence of socioeconomic position (SEP) on cancer survival, especially through treatment choice. However, data on hemopathy are scarce. Specific studies on acute myeloid leukaemia (AML) found an association between educational level and access to transplantation, SEP and survival or neighborhood SEP and access to chemotherapy and transplantation. However, these studies were done in countries with heath systems that are not the same as in France. In this study, we investigate the influence of SEP on the treatment received among patients of at least 60 y with AML using data from France, i.e. in settings of tax-supported Health Care System and policy aiming at harmonizing the quality of care as the National ‘cancer plans’. Methods We used data from an observational cohort representative of AML patients of at least 60y treated in MP. This represented 697 patients with an AML diagnosed between 1st January 2009 to 31st December 2014, excluding AML 3 - promyelocytic - subtypes. We built a theoretical model of clinical decision process in which we distinguished 2 steps: access to chemotherapy (first step), and access to an alternative to best supportive care among patients who were not eligible for intensive chemotherapy (second step). Logistic models were used to test, independently for each step, the effect of PSE on treatment received, first without adjustment, and then, after successive adjustment for confounders identified with bivariate analyses (a = 0.2). We measured PSE by the French version of the European Deprivation Index (EDI), an ecological deprivation index already used in several studies addressing social inequalities in cancer management and outcome. Results Analyses on complete data (n = 593 - 85% of included patients) show that, in the first step, disadvantaged patients had a lower probability to be treated by intensive chemotherapy compared to most advantaged patients. However, this association did not persist after adjusting for ‘initial status’, i.e. whether it was an AML de novo or a post-affection AML. No statistically significant association was found between SEP and treatment choice in the second step among patients who was not eligible to intensive chemotherapy. Consistent results were found in sensitivity analyses using alternative coding of EDI and after dealing with missing data using multiple imputation. Conclusion No direct influence of PSE on treatment choice was found in our study among a sample representative of patients of at least 60 y treated for AML in the Midi-Pyrenees region. These results might be seen as an evidence of the efficacy of the regional organization in care network to provide homogeneous quality of care in the territory. Nevertheless, further studies are needed to explore the influence of SEP on the initial status, i.e. AML de novo or AML post-affection.

Introduction En France, les travaux s’interessant aux determinants de l’acces au soin et a la prevention chez les personnes diabetiques se sont focalisees sur l’influence de la position sociale individuelle d’abord, puis, pour pallier a une proportion trop grande de donnees manquantes, sur un proxy de la position sociale individuelle obtenue a partir d’indicateurs ecologiques de position sociale. Les resultats de ces travaux montrent globalement que les patients de faible niveau socio-economique etaient plus souvent diagnostiques tardivement, presentaient davantage de complications, etaient plus frequemment suivis par le medecin generaliste mais frequentaient moins souvent les endocrinologues, les ophtalmologues et les dentistes. Ces observations ne tiennent toutefois pas compte de la dimension geographique en supposant une meme influence de la position sociale des individus quel que soit le territoire ou ils vivent et evoluent. L’objectif de notre etude est ainsi d’investiguer l’influence du contexte geographique, de la position sociale des patients, et leur interaction sur le recours aux soins et a la prevention des personnes traitees pour un diabete. Methodes Sur l’ensemble de l’ex-region Midi-Pyrenees, a partir des donnees de remboursement des trois principaux regimes de l’assurance maladie (le Regime general, la mutualite sociale agricole et le Regime social des independants), 957,911 beneficiaires ont ete identifies comme ayant 50 ans et vivant dans la metropole toulousaine, dans une zone urbaine en dehors de la metropole toulousaine ou dans le reste du territoire regional. Parmi ces individus, 90,136 etaient diabetiques, c’est-a-dire qu’ils avaient recu au moins trois remboursements de medicament antidiabetique durant l’annee. Le recours au soin et a la prevention a ete caracterise par la probabilite d’etre diabetique, d’avoir consulte un medecin generaliste au moins trois fois, d’avoir beneficie d’un examen ophtalmologique au moins une fois, d’avoir beneficie d’au moins trois dosages d’hemoglobine glyquee et d’au moins un dosage de micro-albuminurie. Resultats Apres ajustement sur l’offre de soin, l’acces aux soins de specialite etait d’autant plus faible pour les individus vivant dans les zones les moins densement peuplees, independamment de la position sociale des individus. La frequentation des medecins generalistes etait plus elevee chez les individus les plus defavorises mais ne semblait pas etre influencee par le contexte territorial. Nos resultats ne montrent pas d’influence claire de la position sociale ni de la zone geographique sur l’acces au monitoring biologique. Conclusion Independamment de la position sociale des individus, ce travail montre une influence du contexte geographique dans lequel ils vivent sur la frequentation des services de specialites. Notre travail complete la litterature sur les determinants de l’utilisation du systeme de sante en apportant notamment une dimension territoriale.

Introduction Plusieurs etudes ont mis en evidence une influence de la position socioeconomique (PSE) sur la survie, notamment via le choix du traitement. Pour les hemopathies les donnees sont plus rares. Des etudes specifiques a la leucemie aigue myeloide (LAM) ont retrouve des associations entre le niveau d’education et l’acces a la greffe, la categorie socio-professionnelle et la survie ou encore la PSE du quartier et l’acces a la chimiotherapie et la greffe. Ces donnees sont neanmoins issues de pays dont le systeme de sante est different de la France. L’objectif de notre etude est de tester l’influence de la PSE sur le choix du traitement chez des patients d’au moins 60 ans traites pour une LAM a partir de donnees francaises, c’est-a-dire dans un contexte de systeme finance par l’impot et en presence de dispositifs d’harmonisation de la qualite des soins notamment par les plans cancers. Methodes A partir d’une base de donnees representatives des cas de LAM passes en Reunion de concertation pluridisciplinaire en Midi-Pyrenees, nous avons inclus 697 patients âges de 60 ans ou plus, traites pour une LAM diagnostiquee entre le 1er janvier 2009 et le 31 decembre 2014 hors sous-type LAM3. Nous avons construit un modele theorique du raisonnement clinique distinguant l’acces a la chimiotherapie intensive (etape 1) et l’acces a une alternative aux soins de support chez les patients non eligibles a la chimiotherapie intensive (etape 2). Chaque etape a ete modelisee independamment par des modeles logistiques testant l’effet de la PSE sur le choix du traitement, d’abord seule, puis avec ajustements successifs sur les facteurs de confusion identifies en analyse bivarie (risque alpha = 0,2). La PSE etait mesuree par un indicateur ecologique de defavorisation, la version francaise de l’« European Deprivation Index » (EDI), deja utilise dans plusieurs etudes sur les inegalites sociales de survie et prise en charge des cancers. Resultats L’analyse sur donnees completes (n = 593 (85 % des sujets inclus)) montre qu’a l’etape1, les patients des zones les plus defavorisees avaient une probabilite plus faible d’acceder a la chimiotherapie intensive que ceux vivant dans les zones les plus favorisees. Cette association n’etait plus retrouvee apres l’ajustement sur le statut a la prise en charge (LAM de novo versus LAM secondaire). Aucune association statistiquement significative entre la PSE et le choix du traitement n’a ete retrouvee a l’etape 2 chez les patients non eligibles a la chimiotherapie intensive. Les analyses de sensibilite testant differents codages de l’EDI et apres imputation des donnees manquantes retrouvaient les memes resultats. Discussion Aucune influence directe de la PSE des patients n’etait retrouvee sur le choix du traitement dans notre population representative des patients traites en Midi-Pyrenees. Ces resultats pourraient etre interpretes comme un temoignage de l’efficacite du reseau regional a dispenser une prise en charge homogene sur le territoire. Neanmoins, ce travail appelle a explorer l’influence de la PSE des patients sur le fait de presenter une LAM de novo ou secondaire.