What might explain deprivation-specific differences in the excess hazard of breast cancer death amongst screen-detected women? Analysis of patients diagnosed in the West Midlands region of England from 1989 to 2011

Background: Breast cancer survival is higher in less deprived women, even amongst women whose tumor was screen-detected, but reasons behind this have not been comprehensively investigated. Methods: The excess hazard of breast cancer death in 20,265 women diagnosed with breast cancer, followed up to 2012, was estimated for screen-detected and non-screen-detected women, comparing more deprived to less deprived women using flexible parametric models. Models were adjusted for individual and tumor factors, treatment received and comorbidity. For screen-detected women, estimates were also corrected for lead-time and overdiagnosis. Results: The excess hazard ratio (EHR) of breast cancer death in the most deprived group, adjusted only for age and year of diagnosis, was twice that of the least deprived among screen-detected women (EHR=2.12, 95% CI 1.48-2.76) and 64% higher among non-screen-detected women (EHR=1.64, 95% CI 1.41-1.87). Adjustment for stage at diagnosis lowered these estimates by 25%. Further adjustment had little extra impact. In the final models, the excess hazard for the most deprived women was 54% higher (EHR=1.54, 95% CI 1.10-1.98) among screen-detected women and 39% higher (EHR=1.39, 95% CI 1.20-1.59) among non-screen-detected women. Conclusion: A persistent socio-economic gradient in breast cancer-related death exists in this cohort, even for screen-detected women. The impact of differential lifestyles, management and treatment warrant further investigation.