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Research Article| Volume 158, ISSUE 1, P130-136, July 2020

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Endometrial cancer presentation is associated with social determinants of health in a public healthcare system: A population-based cohort study

  • Limor Helpman
    Correspondence
    Corresponding author at: Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, McMaster University, Juravinski Cancer Centre, 699 Concession St., Hamilton, ON L8V5C2, Canada.
    Affiliations
    Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, McMaster University, Juravinski Cancer Centre, Hamilton, ON, Canada
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  • Greg R. Pond
    Affiliations
    Escarpment Cancer Research Institute, McMaster University, Hamilton, ON, Canada

    Department of Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, ON, Canada

    Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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  • Lorraine Elit
    Affiliations
    Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, McMaster University, Juravinski Cancer Centre, Hamilton, ON, Canada

    Department of Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, ON, Canada
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  • Laura N. Anderson
    Affiliations
    Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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  • Hsien Seow
    Affiliations
    Department of Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, ON, Canada

    Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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      Highlights

      • Social determinants of health have been linked to compromised outcomes in cancer patients.
      • Social and cultural barriers may influence recognition of symptoms, access to and compliance with care.
      • A population cohort study assesses the association of social determinants of health with uterine cancer stage distribution.
      • Marginalization is linked with advanced disease presentation even when adjusted for comorbidities, obesity and rurality.
      • Mediators of this association should be investigated in order to create opportunities for health equity promotion.

      Abstract

      Objective

      Delay in diagnosis of endometrial cancer may be associated with disease progression and impact management and outcomes. Social and cultural barriers influence recognition of symptoms and self-advocacy in seeking care. Associations between social determinants of health (SDH) and disease presentation have been shown in some settings. Our objective was to investigate these in Ontario's universal access system.

      Methods

      Endometrial cancer patients in Ontario diagnosed 2009–2017 were identified, and clinical, social and demographic information extracted from administrative databases using ICES (Institute of Evaluative Sciences) algorithms. SDH were quantified using previously validated marginalization indices for material deprivation, residential instability and ethnic concentration. Associations between SDH and disease stage were explored using logistic regression.

      Results

      20,228 patients were identified. 73% of cancers were confined to the uterus. Stage distribution differed across marginalization quintiles (p < 0.001) with advanced disease found more frequently in highly marginalized patients: 29% vs. 25% (p < 0.001) for material deprivation, OR = 1.06/quintile (CI, 1.03–1.09); 29% vs. 24% (p < 0.001) for ethnic concentration, OR = 1.05/quintile (CI, 1.03–1.08); 30% vs. 27% (p < 0.001) for residential instability, OR = 1.02/quintile (CI, 1.0–1.05). Marginalization was persistently associated with advanced disease on multivariable analysis adjusted for age, comorbidity score, obesity and disease histology (OR = 1.05/quintile, CI 1.01–1.10, p = 0.03).

      Conclusions

      Socioeconomic marginalization is associated with advanced disease at presentation among endometrial cancer patients in Ontario. Mediators of this association are likely multifactorial, and need to be further investigated in order to create opportunities for improved patient education and advocacy, redistribution of resources and the promotion of health equity.

      Graphical abstract

      Keywords

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