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14. The Contribution of Risk Factors to the Higher Incidence of Invasive and In Situ Breast Cancers in Women With Higher Levels of Education in the European Prospective Investigation Into Cancer and Nutrition

Author

Elio Riboli, Carla H. van Gils, Gillian K Reeves, Tonje Braaten, María José Sánchez, Kim Overvad, Naomi E. Allen, Amelia Mattiello, Eric J. Duell, Anton E. Kunst, Petra H.M. Peeters, Kay-Tee Khaw, Anne-Kathrin Illner, Domenico Palli, Pagona Lagiou, Valentina Gallo, Anja Olsen, Eiliv Lund, Eva Ardanaz, José Ramón Quirós, Signe Borgquist, Manuela M. Bergmann, Paolo Vineis, Franco Berrino, Jonas Manjer, Carmen Navarro, Veronique Chajes, Rudolf Kaaks, Sabina Rinaldi, Carlotta Sacerdote, Silke Hermann, Rosario Tumino, A. M. May, Antonia Trichopoulou, Dimitrios Trichopoulos, Evelyn M. Monninkhof, Anne Tjønneland, Gwenn Menvielle, Hendriek Boshuizen, H. Bas Bueno-de-Mesquita, Nadia Slimani, Amsterdam Public Health, Public and occupational health, Department of Public Health, Erasmus University Medical Center [Rotterdam] (Erasmus MC), Centre de recherche en épidémiologie et santé des populations (CESP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université Paris-Sud - Paris 11 (UP11)-Hôpital Paul Brousse-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Versailles Saint-Quentin-en-Yvelines (UVSQ), National Institute for Public Health and the Environment [Bilthoven] (RIVM), University of Amsterdam [Amsterdam] (UvA), Julius Center for Health Sciences and Primary Care, University Medical Center [Utrecht], Dept of Epidemiology and Public Health, Imperial College London, Department of Cardiology and Department of Clinical Epidemiology, Aarhus University Hospital, Cancer Epidemiology Institute, Danish Cancer Society, Division of Cancer Epidemiology, German Cancer Research Center - Deutsches Krebsforschungszentrum [Heidelberg] (DKFZ), Dept of Epidemiology, German Institute of Human Nutrition Potsdam-Rehbrücke (DIfE), Dept of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School [Athens], Department of Epidemiology, Havard School of Public Health, Hellenic Health Foundation, Molecular and Nutritional Epidemiology Unit, Cancer Research and Prevention Institute – ISPO, Department of Preventive & Predictive Medicine, Fondazione IRCCS-Istituto Nazionale dei Tumori, Department of Clinical and Experimental Medicine, Università degli studi di Napoli Federico II, Cancer Registry and Histopathology Unit, Civile - M.P.Arezzo Hospital, CPO Piemonte, Institute of Community Medicine, University of Tromsø (UiT), Public Health and Health Planning Directorate, Unit of Nutrition, Environment, and Cancer, Catalan Institute of Oncology, Andalusian School of Public Health [Granada], CIBERESP, CIBER Epidemiologia y Salud Pública, Epidemiology Department, Murcia Health Council, Public Health Institute of Navarra, Department of Oncology, Lund University Hospital-Lund University [Lund], Department of surgery, Lund University [Lund]-Malmö University Hospital, Dept of Public Health and Primary Care, University of Cambridge [UK] (CAM)-MRC Center for Nutritional Epidemiology and Cancer Prevention and Survival, Cancer Epidemiology Unit, University of Oxford [Oxford]-Cancer Epidemiology Unit, International Agency for Cancer Research (IACR), University of Torino and CPO-Piemonte, Università degli studi di Torino (UNITO), ISI Foundation Institute for Scientific Interchange, G Menvielle received a funding from the Fondation pour la Recherche Médicale for this analysis. The project was in part funded by the European Commission, through the Eurocadet project (from the commission of the European communities research directorate-general, grant No EUROCADET:SP23-CT-2005-006528). EPIC was supported by the European Commission: Public Health and Consumer Protection Directorate 1993-2004 and the Research Directorate-General 2005-2008. European Commission FP5 project (QLG1-CT-2001-01049). The EPIC study was funded by 'Europe Against Cancer' Programme of the European Commission (SANCO), Ligue contre le Cancer (France), Société 3M (France), Mutuelle Générale de l'Education Nationale, Institut National de la Santé et de la Recherche Médicale, German Cancer Aid, German Cancer Research Center, German Federal Ministry of Education and Research, Red Temática de Investigación Cooperativa de Centros de Cáncer (C03/10), the participating regional governments and institutions of Murcia, Navarra, Asturias, Pais Vasco y Andalucia, Spain, Cancer Research UK, Medical Research Council, United Kingdom, Stroke Association, United Kingdom, British Heart Foundation, Department of Health, United Kingdom, Food Standards Agency, United Kingdom, The Wellcome Trust, United Kingdom, Greek Ministry of Health, Stavros Niarchos Foundation, Italian Association for Research on Cancer, Dutch Ministry of Public Health, Welfare and Sports, Dutch Ministry of Health, Dutch Prevention Funds, LK Research Funds, Dutch Zorg Onderzoek Nederland, World Cancer Research Fund, Swedish Cancer Society, Swedish Scientific Council, Regional Government of Vasterbotten and Skane, Sweden, Norwegian Cancer Society, and Foundation to Promote Research into Functional Vitamin B12 Deficiency, Norway. Some authors are partners of Environmental Cancer Risk, Nutrition and Individual Susceptibility, a network of excellence of the European Commission (6FP contract 513943). Antonio Agudo and Paolo Vineis were supported by ECNIS., Schmaus, Annie, Université de Versailles Saint-Quentin-en-Yvelines (UVSQ)-Université Paris-Sud - Paris 11 (UP11)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Paul Brousse-Institut National de la Santé et de la Recherche Médicale (INSERM), University of Naples Federico II = Università degli studi di Napoli Federico II, Lund University [Lund]-Lund University Hospital, University of Oxford-Cancer Epidemiology Unit, Università degli studi di Torino = University of Turin (UNITO), Public Health, and Cell biology

Subjects
MESH: Reproductive History, Epidemiology, MESH: Risk Assessment, 0302 clinical medicine, MESH: Risk Factors, Prevalence, breast neoplasms, Mass Screening, risk factors, Prospective Studies, 030212 general & internal medicine, MESH: Incidence, Prospective cohort study, reproductive history, MESH: Aged, education, MESH: Middle Aged, Obstetrics, Incidence (epidemiology), MESH: Follow-Up Studies, Middle Aged, Nutrition Surveys, Prognosis, 3. Good health, European Prospective Investigation into Cancer and Nutrition, Europe, 030220 oncology & carcinogenesis, Educational Status, Female, Breast disease, Risk assessment, Adult, medicine.medical_specialty, Risk Assessment, Article, MESH: Prognosis, 03 medical and health sciences, Breast cancer, SDG 3 - Good Health and Well-being, MESH: Nutrition Surveys, medicine, Humans, Neoplasm Invasiveness, MESH: Mass Screening, Risk factor, MESH: Prevalence, Aged, Gynecology, MESH: Humans, business.industry, Cancer, MESH: Adult, MESH: Neoplasm Invasiveness, medicine.disease, MESH: Prospective Studies, [SDV.SPEE] Life Sciences [q-bio]/Santé publique et épidémiologie, incidence, [SDV.SPEE]Life Sciences [q-bio]/Santé publique et épidémiologie, MESH: Europe, business, MESH: Educational Status, MESH: Female, MESH: Breast Neoplasms, Follow-Up Studies
Abstract

International audience; The authors investigated the role of known risk factors in educational differences in breast cancer incidence. Analyses were based on the European Prospective Investigation Into Cancer and Nutrition and included 242,095 women, 433 cases of in situ breast cancer, and 4,469 cases of invasive breast cancer. Reproductive history (age at first full-term pregnancy and parity), exposure to endogenous and exogenous hormones, height, and health behaviors were accounted for in the analyses. Relative indices of inequality (RII) for education were estimated using Cox regression models. A higher risk of invasive breast cancer was found among women with higher levels of education (RII = 1.22, 95% confidence interval (CI): 1.09, 1.37). This association was not observed among nulliparous women (RII = 1.13, 95% CI: 0.84, 1.52). Inequalities in breast cancer incidence decreased substantially after adjusting for reproductive history (RII = 1.11, 95% CI: 0.98, 1.25), with most of the association being explained by age at first full-term pregnancy. Each other risk factor explained a small additional part of the inequalities in breast cancer incidence. Height accounted for most of the remaining differences in incidence. After adjusting for all known risk factors, the authors found no association between education level and risk of invasive breast cancer. Inequalities in incidence were more pronounced for in situ breast cancer, and those inequalities remained after adjustment for all known risk factors (RII = 1.61, 95% CI: 1.07, 2.41), especially among nulliparous women.

Published
2011
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15. Social Inequalities and Mortality in Europe - Results from a Large Multi-National Cohort

Author

Larraitz Arriola, Eiliv Lund, Anne Tjønneland, Johan P. Mackenbach, Gwenn Menvielle, Nicholas J. Wareham, Anton E. Kunst, Rudolf Kaaks, Manuela M. Bergmann, Sabine Rohrmann, Kay-Tee Khaw, Göran Hallmans, Petra P.H. Peeters, Antonio Agudo, Aurelio Barricante Gurrea, Antonia Trichopoulou, Valentina Gallo, Majid Ezzati, Androniki Naska, Birgit Teucher, Sophia Zackrisson, Martin Almquist, H. Bas Bueno-de-Mesquita, Dimitrios Trichopoulos, Traci Mouw, Timothy J. Key, Elio Riboli, Peter D. Siersema, Heiner Boeing, Kim Overvad, Susanne Oksbjerg Dalton, Rosario Tumino, Carmen Navarro, María-Luisa Redondo, Tonje Braaten, Giovanna Masala, Salvatore Panico, Guri Skeie, Anne-Kathrin Illner, Paolo Vineis, Sture Eriksson, Paolo Contiero, Antonio Daponte, APH - Amsterdam Public Health, Public and occupational health, University of Zurich, Vineis, Paolo, [Gallo,V, Ezzati,M, Mouw,T, Riboli,E, Vineis,P] Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom. [Gallo,V] Social and Environmental Health Research,London School of Hygiene and Tropical Medicine, London, United Kingdom. [Mackenbach,JP] Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands. [Menvielle,G] Epidemiology of Occupational and Social Determinants of Health, INSERM, Villejuif, France. [Menvielle,G] Universite of Versailles Saint Quentin, Versailles, France. [Kunst,AE] Department of Public Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands. [Rohrmann,S] Division of Cancer Epidemiology and Prevention, Institute of Social and Preventive Medicine, University of Zurich, Zurich, Switzerland. [Kaaks,R, Teucher,B] Division of Clinical Epidemiology, German Cancer Research Centre, Heidelberg, Germany. [Boeing,H, Bergmann,MM] Institute of Human Nutrition, Potsdam-Rehbrücke, Germany. [Tjønneland,A, Dalton,SO] Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark. [Overvad,K] Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark. [Redondo,M] Public Health and Participation Directorate, Health and Health Care Services Council, Oviedo, Asturias, Spain. [Agudo,A] Unit of Nutrition, Environment and Cancer, Catalan Institute of Oncology, Barcelona, Spain. [Daponte,A, Arriola,L, Navarro,C, Barricante Gurrea,A] CIBER Epidemiologia y Salud Publica, Barcelona, Spain. [Daponte,A] Andalusian School of Public Health, Granada, Spain. [Arriola,L] Public Health Division of Gipuzkoa, Basque Government, Spain. [Navarro,C] Department of Epidemiology, Regional Health Authority, Murcia, Spain. [Navarro,C] Departamento de Ciencias Sociosanitarias, University of Murcia School of Medicine, Murcia, Spain. [Barricante Gurrea,A] Navarra Public Health Institute, Pamplona, Spain. [Khaw,KT] University of Cambridge, Cambridge, United Kingdom. [Wareham,N] Medical Research Council – Epidemiology Unit, Cambridge, United Kingdom. [Key,T] Cancer Epidemiology Unit, University of Oxford, Oxford, United Kingdom. [Naska,A, Trichopoulou,A] World Health Organisation Collaborating Centre for Food and Nutrition Policies, Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, Athens, Greece. [Trichopoulou,A] Hellenic Health Foundation, Athens, Greece. [Trichopoulos,D] Department of Epidemiology, Harvard School of Public Health, Boston, United States of America. [Trichopoulos,D] Bureau of Epidemiologic Research, Academy of Athens, Greece. [Masala,G] Molecular and Nutritional Epidemiology Unit, Cancer Research and Prevention Institute, Florence, Italy. [Panico,S] Department of Clinical and Experimental Medicine, Federico II University, Naples, Italy. [Contiero,T] Cancer Registry and Environmental Epidemiology, Istituto Nazionale Tumori, Milan, Italy. [Tumino,R] Cancer Registry and Histopathological Unit, Civile M. P. Arezzo Hospital, Ragusa, Italy. [Bueno-de-Mesquita,HB] National Institute for Public Health and the Environment, Bilthoven, The Netherlands. [Bueno-de-Mesquita,HB, Siersema,PD] Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands. [Peeters,PP] Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands. [Zackrisson,S] Department of Clinical Sciences in Malmö , Diagnostic Radiology, Lund University, Sweden. [Almquist,M] Department of Surgery, University Hospital Lund and Lund University, Lund, Sweden. [Eriksson,S, Hallmans,G] Department of Community Medicine and Rehabilitation, Umea University, Umea, Sweden. [Skeie,G, Braaten,T, Lund,E] Institutt for samfunnsmedisin, Universitetet i Tromsø, Tromsø, Norway. [Illner,A] Dietary Exposure Assessment Group, Nutrition and Metabolism Section, International Agency for Research on Cancer, Lyon, France., This research has been made possible thanks to a grant of the European Community (5th Framework Programme) to PV (grant QLK4CT199900927), and a grant of the Compagnia di San Paolo to the ISI Foundation. All authors are independent form founders. Mortality data from the Netherlands were obtained from 'Statistics Netherlands'. In addition we would like to thank for their financial support: Europe Against cancer Program of the European Commission (SANCO), ISCIII, Red de Centros RCESP, C03/09, Deutsche Krebshilfe, Deutsches Krebsforschungszentrum, German Federal Ministry of Education and Research, Danish Cancer Society, Health Research Fund (FIS) of the Spanish Ministry of Health, Spanish Regional Governments of Andalucia, Asturias, Basque Country, Murcia and Navarra, Cancer Research U.K., Medical Research Council, United Kingdom, Stroke Association, United Kingdom, British Heart Foundation, Department of Health, United Kingdom, Food Standards Agency, United Kingdom, Wellcome Trust, United Kingdom, Greek Ministry of Health and Social Solidarity, Stavros Niacrchos Foundation, Hellenic Health Foundation, Italian Association for Research on Cancer (AIRC), Italian National Research Council, Dutch Ministry of Public Health, Welfare and Sports, World Cancer Research Fund, Swedish Cancer, Swedish Scientific Council, Regional Government of Skane, Sweden, Norwegian Cancer Society, Research Council of Norway, French League against Cancer, Inserm, Mutuelle Generale l’Education National and IGR. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript., Gallo, V, Mackenbach, Jp, Ezzati, M, Menvielle, G, Kunst, Ae, Rohrmann, S, Kaaks, R, Teucher, B, Boeing, H, Bergmann, Mm, Tj?nneland, A, Dalton, So, Overvad, K, Redondo, Ml, Agudo, A, Daponte, A, Arriola, L, Navarro, C, Gurrea, Ab, Khaw, Kt, Wareham, N, Key, T, Naska, A, Trichopoulou, A, Trichopoulos, D, Masala, G, Panico, Salvatore, Contiero, P, Tumino, R, Bueno de Mesquita, Hb, Siersema, Pd, Peeters, Pp, Zackrisson, S, Almquist, M, Eriksson, S, Hallmans, G, Skeie, G, Braaten, T, Lund, E, Illner, Ak, Mouw, T, Riboli, E, Vineis, P., Public Health, Epidemiology, and Gastroenterology & Hepatology

Subjects
Gerontology, Male, Survival, Epidemiology, lcsh:Medicine, Poison control, Educational inequalities, DETERMINANTS, 0302 clinical medicine, SOCIOECONOMIC INEQUALITIES, Medicine, Socioeconomic inequalities, Cardiac and Cardiovascular Systems, 030212 general & internal medicine, lcsh:Science, Determinants, media_common, Multidisciplinary, VDP::Medisinske Fag: 700::Helsefag: 800::Samfunnsmedisin, sosialmedisin: 801, Lung-cancer incidence, Relative index of inequality, Mortality rate, CARDIOVASCULAR RISK, Geographicals::Geographic Locations::Europe [Medical Subject Headings], WOMEN, Epidemiology of Aging, Public Health, Global Health, Social Medicine and Epidemiology, SDG 10 - Reduced Inequalities, ASSOCIATION, Middle Aged, Socioeconomic Aspects of Health, 3. Good health, European Prospective Investigation into Cancer and Nutrition, Health Care::Health Services Administration::Patient Care Management::Delivery of Health Care::Healthcare Disparities [Medical Subject Headings], Health, 030220 oncology & carcinogenesis, Cohort, SURVIVAL, Science & Technology - Other Topics, Female, NUTRITION, Public Health, HEALTH, Europa, Behavioral and Social Aspects of Health, Cancer Epidemiology, Research Article, Adult, Clinical Research Design, 610 Medicine & health, Social epidemiology, 1100 General Agricultural and Biological Sciences, Association, 03 medical and health sciences, Sex Factors, SDG 3 - Good Health and Well-being, 1300 General Biochemistry, Genetics and Molecular Biology, media_common.cataloged_instance, Humans, Women, European Union, European union, Mortality, Socioeconomic status, Biology, EDUCATIONAL INEQUALITIES, Cardiovascular Disease Epidemiology, Nutrition, 1000 Multidisciplinary, Science & Technology, Population Biology, business.industry, MULTIDISCIPLINARY SCIENCES, lcsh:R, Analytical, Diagnostic and Therapeutic Techniques and Equipment::Investigative Techniques::Epidemiologic Methods::Data Collection::Vital Statistics::Mortality [Medical Subject Headings], 10060 Epidemiology, Biostatistics and Prevention Institute (EBPI), Cardiovascular risk, Social Epidemiology, LUNG-CANCER INCIDENCE, Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi, Social Class, Socioeconomic Factors, Mortalidad, lcsh:Q, VDP::Medical disciplines: 700::Health sciences: 800::Community medicine, Social medicine: 801, Disparidades en atención de salud, business, Demography, Follow-Up Studies
Abstract

Journal Article; Research Support, Non-U.S. Gov't; BACKGROUND Socio-economic inequalities in mortality are observed at the country level in both North America and Europe. The purpose of this work is to investigate the contribution of specific risk factors to social inequalities in cause-specific mortality using a large multi-country cohort of Europeans. METHODS A total of 3,456,689 person/years follow-up of the European Prospective Investigation into Cancer and Nutrition (EPIC) was analysed. Educational level of subjects coming from 9 European countries was recorded as proxy for socio-economic status (SES). Cox proportional hazard model's with a step-wise inclusion of explanatory variables were used to explore the association between SES and mortality; a Relative Index of Inequality (RII) was calculated as measure of relative inequality. RESULTS Total mortality among men with the highest education level is reduced by 43% compared to men with the lowest (HR 0.57, 95% C.I. 0.52-0.61); among women by 29% (HR 0.71, 95% C.I. 0.64-0.78). The risk reduction was attenuated by 7% in men and 3% in women by the introduction of smoking and to a lesser extent (2% in men and 3% in women) by introducing body mass index and additional explanatory variables (alcohol consumption, leisure physical activity, fruit and vegetable intake) (3% in men and 5% in women). Social inequalities were highly statistically significant for all causes of death examined in men. In women, social inequalities were less strong, but statistically significant for all causes of death except for cancer-related mortality and injuries. DISCUSSION In this European study, substantial social inequalities in mortality among European men and women which cannot be fully explained away by accounting for known common risk factors for chronic diseases are reported. Yes

Published
2012
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