Advertisement

Disparities in the survival of endometrial cancer patients in a public healthcare system: A population-based cohort study

  • Author Footnotes
    1 Current address: Division of Gynecologic Oncology, Chaim Sheba Medical Center, Tel Hashomer, Israel.
    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.
    Footnotes
    1 Current address: Division of Gynecologic Oncology, Chaim Sheba Medical Center, Tel Hashomer, Israel.
    Affiliations
    Division of Gynecologic Oncology, Juravinski Cancer Centre, Department of Obstetrics & Gynecology, McMaster University, Hamilton, ON, Canada

    Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
    Search for articles by this author
  • Gregory R. Pond
    Affiliations
    Escarpment Cancer Research Institute, McMaster University, Hamilton, ON, Canada

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

    Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
    Search for articles by this author
  • Laurie Elit
    Affiliations
    Division of Gynecologic Oncology, Juravinski Cancer Centre, Department of Obstetrics & Gynecology, McMaster University, Hamilton, ON, Canada

    Escarpment Cancer Research Institute, McMaster University, Hamilton, ON, Canada

    Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
    Search for articles by this author
  • Laura N. Anderson
    Affiliations
    Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
    Search for articles by this author
  • Iwa Kong
    Affiliations
    Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
    Search for articles by this author
  • Kara Schnarr
    Affiliations
    Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
    Search for articles by this author
  • Hsien Seow
    Affiliations
    Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada

    Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
    Search for articles by this author
  • Author Footnotes
    1 Current address: Division of Gynecologic Oncology, Chaim Sheba Medical Center, Tel Hashomer, Israel.
Published:September 30, 2022DOI:https://doi.org/10.1016/j.ygyno.2022.09.015

      Highlights

      • Endometrial cancer patients in Ontario, Canada were evaluated for social determinants of health and cancer outcomes.
      • Socioeconomic marginalization was associated with an increased risk of death in endometrial cancer patients.
      • This persisted after adjustment for patient and disease factors, and in a public healthcare system with universal access.

      Abstract

      Objective

      Social determinants of health (SDH) have been shown to correlate with adverse cancer outcomes. It is unclear if their impact goes beyond behavioral risk or healthcare access. We aimed to evaluate the association of SDH with endometrial cancer outcomes in a public healthcare system.

      Methods

      A retrospective cohort study of endometrial cancer patients diagnosed between 2009 and 2017 in Ontario, Canada. Clinical and sociodemographic variables were extracted from administrative databases. Validated multifactorial marginalization scores for domains of material deprivation, residential instability and ethnic concentration were used. Associations between marginalization and survival were evaluated using log-rank testing and Cox proportional hazards regression.

      Results

      20228 women with endometrial cancer were identified. Fewer patients in marginalized communities presented with early disease (70% vs. 76%, p < 0.001) and received surgery (89% vs. 93%, p < 0.001). Overall survival was shorter among marginalized patients (p < 0.001). On multivariable analysis adjusted for patient and disease factors, overall marginalization (HR = 1.22, 95% CI 1.03–1.08), material deprivation (HR = 1.22, 95% CI 1.10–1.35) and residential instability (HR = 1.32, 95% CI 1.19–1.46) were associated with increased risk of death (p < 0.001).

      Conclusions

      Socioeconomic marginalization is associated with an increased risk of death in endometrial cancer patients. Targetable events in the cancer care pathway should be identified to improve health equity.

      Funding

      This study was supported by a grant (#RD-196) from the Hamilton Health Sciences Juravinski Hospital and Cancer Center Foundation.

      Graphical abstract

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Gynecologic Oncology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Singh G.
        • Daus G.
        • Allender M.
        • Ramey C.
        • Martin E.
        • Perry C.
        • Reyes A.
        • Vedamuthu I.
        Social determinants of health in the United States: addressing major health inequality trends for the nation, 1935-2016.
        Int. J. MCH AIDS. 2017; 6: 139-164https://doi.org/10.21106/ijma.236
        • Smedley B.D.
        • Stith A.Y.
        • Nelson A.R.
        Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (with CD).
        2003https://doi.org/10.17226/12875
        • Marmot M.
        • Friel S.
        • Bell R.
        • Houweling T.A.
        • Taylor S.
        Closing the gap in a generation: health equity through action on the social determinants of health.
        Lancet. 2008; 372: 1661-1669https://doi.org/10.1016/S0140-6736(08)61690-6
        • Alcaraz K.I.
        • Wiedt T.L.
        • Daniels E.C.
        • Yabroff K.R.
        • Guerra C.E.
        • Wender R.C.
        Understanding and addressing social determinants to advance cancer health equity in the United States: a blueprint for practice, research, and policy, CA.
        Cancer J. Clin. 2020; 70: 31-46https://doi.org/10.3322/caac.21586
        • Sayani A.
        Health equity in national cancer control plans: an analysis of the Ontario cancer plan.
        Int. J. Heal. Policy Manag. 2019; 8: 550-556https://doi.org/10.15171/ijhpm.2019.40
        • Temkin S.M.
        • Rimel B.J.
        • Bruegl A.S.
        • Gunderson C.C.
        • Beavis A.L.
        • Doll K.M.
        A contemporary framework of health equity applied to gynecologic cancer care: a Society of Gynecologic Oncology evidenced-based review.
        Gynecol. Oncol. 2018; 149: 70-77https://doi.org/10.1016/j.ygyno.2017.11.013
        • Ward E.
        • Jemal A.
        • Cokkinides V.
        • Singh G.K.
        • Cardinez C.
        • Ghafoor A.
        • Thun M.
        Cancer disparities by race/ethnicity and socioeconomic status, CA.
        Cancer J. Clin. 2004; 54: 78-93https://doi.org/10.3322/canjclin.54.2.78
        • Booth C.M.
        • Li G.
        • Zhang-Salomons J.
        • Mackillop W.J.
        The impact of socioeconomic status on stage of cancer at diagnosis and survival: a population-based study in Ontario, Canada.
        Cancer. 2010; 116: 4160-4167https://doi.org/10.1002/cncr.25427
        • WHO
        WHO Report on Cancer: Setting Priorities Investing Wisely and Providing Care for All.
        2020
        • McDaniel J.T.
        • Nuhu K.
        • Ruiz J.
        • Alorbi G.
        Social determinants of cancer incidence and mortality around the world: an ecological study.
        Glob. Health Promot. 2019; 26: 41-49https://doi.org/10.1177/1757975916686913
        • Venkataramany B.S.
        • Sutton J.M.
        Social determinants of health in oncology: towards a more personalized and equitable delivery of cancer care.
        Am. J. Clin. Oncol. 2022; 45: 273-278https://doi.org/10.1097/COC.0000000000000914
        • Yap M.L.
        • Oar A.
        • Moraes F.Y.
        • Ilbawi A.
        An evidence-based National Cancer Control Program (NCCP) quality assessment checklist.
        J. Glob. Oncol. 2018; https://doi.org/10.1200/jgo.18.66800
        • Felix A.S.
        • Brinton L.A.
        Cancer progress and priorities: uterine cancer.
        Cancer Epidemiol. Biomark. Prev. 2018; 27: 985-994https://doi.org/10.1158/1055-9965.EPI-18-0264
        • Madison T.
        • Schottenfeld D.
        • James S.A.
        • Schwartz A.G.
        • Gruber S.B.
        Endometrial cancer: socioeconomic status and racial/ethnic differences in stage at diagnosis, treatment, and survival.
        Am. J. Public Health. 2004; 94: 2104-2111https://doi.org/10.2105/AJPH.94.12.2104
        • Robinson K.M.
        • Christensen K.B.
        • Ottesen B.
        • Krasnik A.
        Socio-demographic factors, comorbidity and diagnostic delay among women diagnosed with cervical, endometrial or ovarian cancer.
        Eur. J. Cancer Care (Engl). 2011; 20: 653-661https://doi.org/10.1111/j.1365-2354.2011.01259.x
        • Doll K.M.
        • Winn A.N.
        • Goff B.A.
        Untangling the Black-white mortality gap in endometrial cancer: a cohort simulation.
        Am. J. Obstet. Gynecol. 2017; 216: 324-325https://doi.org/10.1016/j.ajog.2016.12.023
        • Lyratzopoulos G.
        • Abel G.A.
        • Brown C.H.
        • Rous B.A.
        • Vernon S.A.
        • Roland M.
        • Greenberg D.C.
        Socio-demographic inequalities in stage of cancer diagnosis: evidence from patients with female breast,lung, colon, rectal, prostate, renal, bladder, melanoma, ovarian and endometrial cancer.
        Ann. Oncol. 2013; 24: 843-850https://doi.org/10.1093/annonc/mds526
        • Svanvik T.
        • Marcickiewicz J.
        • Sundfeldt K.
        • Holmberg E.
        • Strömberg U.
        Sociodemographic disparities in stage-specific incidences of endometrial cancer: a registry-based study in West Sweden, 1995–2016.
        Acta Oncol. (Madr). 2019; 58: 845-851https://doi.org/10.1080/0284186X.2019.1581947
        • Strohl A.E.
        • Feinglass J.M.
        • Shahabi S.
        • Simon M.A.
        Surgical wait time: a new health indicator in women with endometrial cancer.
        Gynecol. Oncol. 2016; 141: 511-515https://doi.org/10.1016/j.ygyno.2016.04.014
        • Fader A.N.
        • Matsuno Weise R.
        • Sinno A.K.
        • Tanner E.J.
        • Borah B.J.
        • Moriarty J.P.
        • Bristow R.E.
        • Makary M.A.
        • Pronovost P.J.
        • Hutfless S.
        • Dowdy S.C.
        Utilization of minimally invasive surgery in endometrial cancer care: a quality and cost disparity, in.
        Obstet. Gynecol. 2016; : 91-100https://doi.org/10.1097/AOG.0000000000001180
        • Fader A.N.
        • Habermann E.B.
        • Hanson K.T.
        • Lin J.F.
        • Grendys E.C.
        • Dowdy S.C.
        Disparities in treatment and survival for women with endometrial cancer: a contemporary national cancer database registry analysis.
        Gynecol. Oncol. 2016; 143: 98-104https://doi.org/10.1016/j.ygyno.2016.07.107
        • Bregar A.J.
        • Alejandro Rauh-Hain J.
        • Spencer R.
        • Clemmer J.T.
        • Schorge J.O.
        • Rice L.W.
        • del Carmen M.G.
        Disparities in receipt of care for high-grade endometrial cancer: a National Cancer Data Base analysis.
        Gynecol. Oncol. 2017; 145: 114-121https://doi.org/10.1016/j.ygyno.2017.01.024
        • Foote J.R.
        • Gaillard S.
        • Broadwater G.
        • Sosa J.A.
        • Davidson B.
        • Adam M.A.
        • Secord A.A.
        • Jones M.B.
        • Chino J.
        • Havrilesky L.J.
        Disparities in the surgical staging of high-grade endometrial cancer in the United States.
        Gynecol. Oncol. Res. Pract. 2017; 4: 1-8https://doi.org/10.1186/s40661-016-0036-3
        • Osborn V.
        • Schwartz D.
        • Lee Y.C.
        • Lee A.
        • Garay E.
        • Choi K.
        • Han P.
        • Schreiber D.
        Patterns of care of IMRT usage in postoperative management of uterine cancer.
        Gynecol. Oncol. 2017; 144: 130-135https://doi.org/10.1016/j.ygyno.2016.11.017
        • Yap O.W.S.
        • Matthews R.P.
        Racial and ethnic disparities in cancers of the uterine corpus.
        J. Natl. Med. Assoc. 2006; 98: 1930-1933
        • Randall T.C.
        • Armstrong K.
        Differences in treatment and outcome between African-American and white women with endometrial cancer.
        J. Clin. Oncol. 2003; 21: 4200-4206https://doi.org/10.1200/JCO.2003.01.218
        • Sud S.
        • Holmes J.
        • Eblan M.
        • Chen R.
        • Jones E.
        Clinical characteristics associated with racial disparities in endometrial cancer outcomes: a surveillance, epidemiology and end results analysis.
        Gynecol. Oncol. 2018; 148: 349-356https://doi.org/10.1016/j.ygyno.2017.12.021
        • Dolly D.
        • Mihai A.
        • Rimel B.J.
        • Fogg L.
        • Rotmensch J.
        • Guirguis A.
        • Yordan E.
        • Dewdney S.
        A delay from diagnosis to treatment is associated with a decreased overall survival for patients with endometrial cancer.
        Front. Oncol. 2016; 6: 1-5https://doi.org/10.3389/fonc.2016.00031
        • OECD Interactive Tool: International Comparisons — Peer countries, Ontario
        • Kumachev A.
        • Trudeau M.E.
        • Chan K.K.W.
        Associations among socioeconomic status, patterns of care and outcomes in breast cancer patients in a universal health care system: Ontario’s experience.
        Cancer. 2016; 122: 893-898https://doi.org/10.1002/cncr.29838
        • Kagedan D.J.
        • Abraham L.
        • Goyert N.
        • Li Q.
        • Paszat L.F.
        • Kiss A.
        • Earle C.C.
        • Mittmann N.
        • Coburn N.G.
        Beyond the dollar: influence of sociodemographic marginalization on surgical resection, adjuvant therapy, and survival in patients with pancreatic cancer.
        Cancer. 2016; 122: 3175-3182https://doi.org/10.1002/cncr.30148
        • Allemani C.
        • Weir H.K.
        • Carreira H.
        • Harewood R.
        • Spika D.
        • Wang X.S.
        • Bannon F.
        • Ahn J.V.
        • Johnson C.J.
        • Bonaventure A.
        • Marcos-Gragera R.
        • Stiller C.
        • Azevedo G.
        • Silva E.
        • Chen W.Q.
        • Ogunbiyi O.J.
        • Rachet B.
        • Soeberg M.J.
        • You H.
        • Matsuda T.
        • Bielska-Lasota M.
        • Storm H.
        • Tucker T.C.
        • Coleman M.P.
        • Bouzbid S.
        • Hamdi-Chérif M.
        • Zaidi Z.
        • Bah E.
        • Swaminathan R.
        • Nortje S.H.
        • Stefan C.D.
        • El Mistiri M.M.
        • Bayo S.
        • Malle B.
        • Manraj S.S.
        • Sewpaul-Sungkur R.
        • Fabowale A.
        • Ogunbiyi O.J.
        • Bradshaw D.
        • Somdyala N.I.M.
        • Abdel-Rahman M.
        • Jaidane L.
        • Mokni M.
        • Kumcher I.
        • Moreno F.
        • González M.S.
        • Laura E.
        • Pugh F.V.
        • Torrent M.E.
        • Carballo Quintero B.
        • Fita R.
        • Garcilazo D.
        • Giacciani P.L.
        • Diumenjo M.C.
        • Laspada W.D.
        • Green M.A.
        • Lanza M.F.
        • Ibañez S.G.
        • Lima C.A.
        • Lobo E.
        • Daniel C.
        • Scandiuzzi C.
        • De Souza P.C.F.
        • Del Pino K.
        • Laporte C.
        • Curado M.P.
        • de Oliveira J.C.
        • Veneziano C.L.A.
        • Veneziano D.B.
        • Alexandre T.S.
        • Verdugo A.S.
        • Koifman S.
        • e Silva G. Azevedo
        • Galaz J.C.
        • Moya J.A.
        • Herrmann D.A.
        • Jofre A.M.
        • Uribe C.J.
        • Bravo L.E.
        • Guarnizo G. Lopez
        • Jurado D.M.
        • Yepes M.C.
        • Galán Y.H.
        • Torres P.
        • Martínez-Reyes F.
        • Jaramillo L.
        • Quinto R.
        • Cueva P.
        • Yépez J.
        • Torres-Cintrón C.R.
        • Tortolero-Luna G.
        • Alonso R.
        • Barrios E.
        • Russell C.
        • Shack L.
        • Coldman A.J.
        • Woods R.R.
        • Noonan G.
        • Turner D.
        • Kumar E.
        • Zhang B.
        • McCrate F.R.
        • Ryan S.
        • Hannah H.
        • Dewar R.A.D.
        • MacIntyre M.
        • Lalany A.
        • Ruta M.
        • Marrett L.
        • Nishri D.E.
        • Vriends K.A.
        • Bertrand C.
        • Louchini R.
        • Robb K.I.
        • Stuart-Panko H.
        • Demers S.
        • Wright S.
        • George J.
        • Shen X.
        • Brockhouse J.T.
        • O’Brien D.K.
        • Almon L.
        • Young J.L.
        • Bates J.
        • Rycroft R.
        • Mueller L.
        • Phillips C.
        • Ryan H.
        • Walrath J.
        • Schwartz A.
        • Vigneau F.
        • MacKinnon J.A.
        • Wohler B.
        • Bayakly R.
        • Ward K.C.
        • Davidson-Allen K.
        • Glaser S.
        • West D.
        • Green M.D.
        • Hernandez B.Y.
        • Johnson C.J.
        • Lynch C.F.
        • McKeen K.M.
        • Huang B.
        • Tucker T.C.
        • Deapen D.
        • Liu L.
        • Hsieh M.C.
        • Wu X.C.
        • Stern K.
        • Gershman S.T.
        • Knowlton R.C.
        • Copeland G.
        • Spivak G.
        • Rogers D.B.
        • Lemons D.
        • Williamson L.L.
        • Hood M.
        • Jerry H.
        • Hosain G.M.
        • Rees J.R.
        • Pawlish K.S.
        • Stroup A.
        • Key C.
        • Wiggins C.
        • Kahn A.R.
        • Schymura M.J.
        • Leung G.
        • Rao C.
        • Giljahn L.
        • Warther B.
        • Pate A.
        • Patil M.
        • Shipley D.K.
        • Esterly M.
        • Otto R.D.
        • Fulton J.P.
        • Rousseau D.L.
        • Janes T.A.
        • Schwartz S.M.
        • Bolick S.W.
        • Hurley D.M.
        • Tenney R.A.
        • Whiteside M.A.
        • Hakenewerth A.
        • Williams M.A.
        • Herget K.
        • Sweeney C.
        • Martin J.
        • Wang S.
        • Harrelson M.G.
        • Cheteri M.B. Keitheri
        • Hudson A.G.
        • Borchers R.
        • Stephenson L.
        • Espinoza J.R.
        • Weir H.K.
        • Edwards B.K.
        • Wang N.
        • Yang L.
        • Chen J.S.
        • Song G.H.
        • Gu X.P.
        • Zhang P.
        • Ge H.M.
        • Zhao D.L.
        • Zhang J.H.
        • Zhu F.D.
        • Tang J.G.
        • Shen Y.
        • Wang J.
        • Li Q.L.
        • Yang S.P.
        • Dong J.M.
        • Li W.W.
        • Cheng L.P.
        • Chen J.G.
        • Huang Q.H.
        • Huang S.Q.
        • Guo G.P.
        • Wei K.
        • Chen W.Q.
        • Zeng H.
        • Demetriou A.V.
        • Pavlou P.
        • Mang W.K.
        • Ngan K.C.
        • Kataki A.C.
        • Krishnatreya M.
        • Jayalekshmi P.A.
        • Sebastian P.
        • Sapkota S.D.
        • Verma Y.
        • Nandakumar A.
        • Suzanna E.
        • Keinan-Boker L.
        • Silverman B.G.
        • Ito H.
        • Hattori M.
        • Sugiyama H.
        • Utada M.
        • Katayama K.
        • Natsui S.
        • Matsuda T.
        • Nishino Y.
        • Koike T.
        • Ioka A.
        • Nakata K.
        • Kosa K.
        • Oki I.
        • Shibata A.
        • Nimri O.
        • Manan A. Ab
        • Pathy N. Bhoo
        • Ochir C.
        • Tuvshingerel S.
        • Al Khater A.M.
        • Al-Eid H.
        • Jung K.W.
        • Won Y.J.
        • Park S.
        • Chiang C.J.
        • Lai M.S.
        • Suwanrungruang K.
        • Wiangnon S.
        • Daoprasert K.
        • Pongnikorn D.
        • Geater S.L.
        • Sriplung H.
        • Eser S.
        • Yakut C.I.
        • Hackl M.
        • Zielonke N.
        • Mühlböck H.
        • Oberaigner W.
        • Piñeros M.
        • Zborovskaya A.A.
        • Henau K.
        • Van Eycken L.
        • Dimitrova N.
        • Valerianova Z.
        • Šekerija M.
        • Znaor A.
        • Zvolský M.
        • Engholm G.
        • Storm H.
        • Aareleid T.
        • Mägi M.
        • Malila N.
        • Seppä K.
        • Velten M.
        • Cornet E.
        • Troussard X.
        • Bouvier A.M.
        • Faivre J.
        • Guizard A.V.
        • Bouvier V.
        • Launoy G.
        • Arveux P.
        • Maynadié M.
        • Mounier M.
        • Woronoff A.S.
        • Daoulas M.
        • Clavel J.
        • Le Guyader-Peyrou S.
        • Monnereau A.
        • Trétarre B.
        • Colonna M.
        • Delacour-Billon S.
        • Molinié F.
        • Bara S.
        • Degré D.
        • Ganry O.
        • Lapôtre-Ledoux B.
        • Grosclaude P.
        • Lutz J.M.
        • Belot A.
        • Estève J.
        • Forman D.
        • Sassi F.
        • Stabenow R.
        • Eberle A.
        • Nennecke A.
        • Kieschke J.
        • Sirri E.
        • Kajueter H.
        • Emrich K.
        • Zeissig S.R.
        • Holleczek B.
        • Eisemann N.
        • Katalinic A.
        • Brenner H.
        • Asquez R.A.
        • Kumar V.
        • Ólafsdóttir E.J.
        • Tryggvadóttir L.
        • Comber H.
        • Walsh P.M.
        • Sundseth H.
        • Cappello T. Dal
        • Mazzoleni G.
        • Giacomin A.
        • Castaing M.
        • Sciacca S.
        • Sutera A.
        • Corti M.
        • Gola G.
        • Ferretti S.
        • Serraino D.
        • Zucchetto A.
        • Lillini R.
        • Vercelli M.
        • Busco S.
        • Pannozzo F.
        • Vitarelli S.
        • Ricci P.
        • Pascucci V.
        • Autelitano M.
        • Cirilli C.
        • Federico M.
        • Fusco M.
        • Vitale M.F.
        • Usala M.
        • Cusimano R.
        • Vitale F.
        • Michiara M.
        • Sgargi P.
        • Sacerdote C.
        • Tumino R.
        • Mangone L.
        • Falcini F.
        • Cremone L.
        • Budroni M.
        • Cesaraccio R.
        • Madeddu A.
        • Tisano F.
        • Maspero S.
        • Tessandori R.
        • Candela G.
        • Scuderi T.
        • Piffer S.
        • Rosso S.
        • Zanetti R.
        • Caldarella A.
        • Crocetti E.
        • La Rosa F.
        • Stracci F.
        • Contiero P.
        • Tagliabue G.
        • Zambon P.
        • Baili P.
        • Berrino F.
        • Gatta G.
        • Sant M.
        • Capocaccia R.
        • De Angelis R.
        • Verdecchia A.
        • Liepina E.
        • Maurina A.
        • Smailyte G.
        • Agius D.
        • Calleja N.
        • Siesling S.
        • Larønningen S.
        • Møller B.
        • Dyzmann-Sroka A.
        • Trojanowski M.
        • Gózdz S.
        • Mezyk R.
        • Gradalska-Lampart M.
        • Radziszewska A.U.
        • Didkowska J.
        • Wojciechowska U.
        • Blaszczyk J.
        • Kepska K.
        • Bielska-Lasota M.
        • Forjaz G.
        • Rego R.A.
        • Bastos J.
        • Antunes L.
        • Bento M.J.
        • da Costa Miranda A.M.
        • Mayer-da-Silva A.
        • Coza D.
        • Todescu A.I.
        • Krasilnikov A.
        • Valkov M.
        • Adamcik J.
        • Diba C. Safaei
        • Žakelj M. Primic
        • Žagar T.
        • Stare J.
        • Almar E.
        • Mateos A.
        • Argüelles M.V.
        • Quirós J.R.
        • Bidaurrazaga J.
        • Larrañaga N.
        • García J.M. Díaz
        • Marcos A.I.
        • Marcos-Gragera R.
        • Gil M.L. Vilardell
        • Molina-Portillo E.
        • Sánchez M.J.
        • Montserrat M. Ramos
        • Chirlaque M.D.
        • Navarro C.
        • Ardanaz E.
        • Garcia S. Felipe
        • Peris-Bonet R.
        • Galceran J.
        • Khan S.
        • Lambe M.
        • Camey B.
        • Bouchardy C.
        • Usel M.
        • Ess S.M.
        • Hermann C.
        • Levi F.G.
        • Maspoli-Conconi M.
        • Kuehni C.E.
        • Mitter V.R.
        • Bordoni A.
        • Spitale A.
        • Chiolero A.
        • Konzelmann I.
        • Dehler S.I.
        • Laue R.I.
        • Meechan D.
        • Poole J.
        • Greenberg D.
        • Rashbass J.
        • Davies E.
        • Linklater K.
        • Morris E.
        • Moran T.
        • Bannon F.
        • Gavin A.
        • Black R.J.
        • Brewster D.H.
        • Roche M.
        • McPhail S.
        • Verne J.
        • Murphy M.
        • Stiller C.
        • Huws D.W.
        • White C.
        • Lawrence G.
        • Brook C.
        • Wilkinson J.
        • Finan P.
        • Ahn J.V.
        • Allemani C.
        • Bonaventure A.
        • Carreira H.
        • Coleman M.P.
        • Harewood R.
        • Rachet B.
        • Sanz N.
        • Wang X.S.
        • Stephens R.
        • Butler J.
        • Peake M.
        • Chalker E.
        • Newman L.
        • Baker D.
        • Soeberg M.J.
        • Scott C.
        • Stokes B.C.
        • Venn A.
        • Farrugia H.
        • Giles G.G.
        • Threlfall T.
        • Currow D.
        • You H.
        • Lewis C.
        • Miles S.A.
        Global surveillance of cancer survival 1995-2009: analysis of individual data for 25 676 887 patients from 279 population-based registries in 67 countries (CONCORD-2).
        Lancet. 2015; 385: 977-1010https://doi.org/10.1016/S0140-6736(14)62038-9
        • Deyo R.A.
        • Cherkin D.C.
        • Ciol M.A.
        Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.
        J. Clin. Epidemiol. 1992; 45: 613-619https://doi.org/10.1016/0895-4356(92)90133-8
        • Soobader M.J.
        • LeClere F.B.
        • Hadden W.
        • Maury B.
        Using aggregate geographic data to proxy individual socioeconomic status: does size matter?.
        Am. J. Public Health. 2001; 91: 632-636https://doi.org/10.2105/AJPH.91.4.632
        • Matheson F.I.
        • Dunn J.R.
        • Smith K.L.W.
        • Moineddin R.
        • Glazier R.H.
        Development of the Canadian marginalization index: a new tool for the study of inequality.
        Can. J. Public Heal. 2012; 103: 3-5https://doi.org/10.17269/cjph.103.3096
        • Rodriguez V.E.
        • LeBrón A.M.W.
        • Chang J.
        • Bristow R.E.
        Guideline-adherent treatment, sociodemographic disparities, and cause-specific survival for endometrial carcinomas.
        Cancer. 2021; 127: 2423-2431https://doi.org/10.1002/cncr.33502
        • McDonald J.T.
        • Farnworth M.
        • Liu Z.
        Cancer and the healthy immigrant effect: a statistical analysis of cancer diagnosis using a linked census-cancer registry administrative database.
        BMC Public Health. 2017; 17: 1-14https://doi.org/10.1186/s12889-017-4190-2
        • Cooper N.
        • Quinn M.J.
        • Rachet B.
        • Mitry E.
        • Coleman M.P.
        Survival from cancer of the uterus in England and wales up to 2001.
        Br. J. Cancer. 2008; 99: S65-S67https://doi.org/10.1038/sj.bjc.6604591
        • Njoku K.
        • Barr C.E.
        • Hotchkies L.
        • Quille N.
        • Wan Y.L.
        • Crosbie E.J.
        Impact of socio-economic deprivation on endometrial cancer survival in the North West of England: a prospective database analysis.
        BJOG An Int. J. Obstet. Gynaecol. 2021; 128: 1215-1224https://doi.org/10.1111/1471-0528.16618
        • Stanbury J.F.
        • Baade P.D.
        • Yu Y.
        • Yu X.Q.
        Cancer survival in New South Wales, Australia: socioeconomic disparities remain despite overall improvements.
        BMC Cancer. 2016; 16: 48https://doi.org/10.1186/s12885-016-2065-z
        • Helpman L.
        • Pond G.R.
        • Elit L.
        • Anderson L.N.
        • Seow H.
        Endometrial cancer presentation is associated with social determinants of health in a public healthcare system: a population-based cohort study.
        Gynecol. Oncol. 2020; 158: 130-136https://doi.org/10.1016/j.ygyno.2020.04.693
        • Helpman L.
        • Pond G.R.
        • Elit L.
        • Anderson L.N.
        • Seow H.
        Disparities in surgical management of endometrial cancers in a public healthcare system: a question of equity.
        Gynecol. Oncol. 2020; 159: 387-393https://doi.org/10.1016/j.ygyno.2020.08.029
        • Hughes M.C.
        • Baker T.A.
        • Kim H.
        • Valdes E.G.
        Health behaviors and related disparities of insured adults with a health care provider in the United States, 2015–2016.
        Prev. Med. (Baltim). 2019; 120: 42-49https://doi.org/10.1016/j.ypmed.2019.01.004
        • Danos D.
        • Leonardi C.
        • Gilliland A.
        • Shankar S.
        • Srivastava R.K.
        • Simonsen N.
        • Ferguson T.
        • Yu Q.
        • Wu X.C.
        • Scribner R.
        Increased risk of hepatocellular carcinoma associated with neighborhood concentrated disadvantage.
        Front. Oncol. 2018; 8: 1-9https://doi.org/10.3389/fonc.2018.00375
        • Jensen K.E.
        • Hannibal C.G.
        • Nielsen A.
        • Jensen A.
        • Nøhr B.
        • Munk C.
        • Kjær S.K.
        Social inequality and incidence of and survival from cancer of the female genital organs in a population-based study in Denmark, 1994-2003.
        Eur. J. Cancer. 2008; 44: 2003-2017https://doi.org/10.1016/j.ejca.2008.06.014
        • Wen X.
        • Wen D.
        • Yang Y.
        • Chen Y.
        • Wang G.
        • Shan B.
        Urban-rural disparity in helicobacter pylori infection–related upper gastrointestinal cancer in china and the decreasing trend in parallel with socioeconomic development and urbanization in an endemic area.
        Ann. Glob. Heal. 2017; 83: 444-462https://doi.org/10.1016/j.aogh.2017.09.004
        • Raglan O.
        • Kalliala I.
        • Markozannes G.
        • Cividini S.
        • Gunter M.J.
        • Nautiyal J.
        • Gabra H.
        • Paraskevaidis E.
        • Martin-Hirsch P.
        • Tsilidis K.K.
        • Kyrgiou M.
        Risk factors for endometrial cancer: an umbrella review of the literature.
        Int. J. Cancer. 2019; 145: 1719-1730https://doi.org/10.1002/ijc.31961
        • Allen N.E.
        • Key T.J.
        • Dossus L.
        • Rinaldi S.
        • Cust A.
        • Lukanova A.
        • Peeters P.H.
        • Onland-Moret N.C.
        • Lahmann P.H.
        • Berrino F.
        • Panico S.
        • Larrahaga N.
        • Pera G.
        • Tormo M.J.
        • Sánchez M.J.
        • Quirós J.R.
        • Ardanaz E.
        • Tjønneland A.
        • Olsen A.
        • Chang-Claude J.
        • Linseisen J.
        • Schulz M.
        • Boeing H.
        • Lundin E.
        • Palli D.
        • Overvad K.
        • Clavel-Chapelon F.
        • Boutron-Ruault M.C.
        • Bingham S.
        • Khaw K.T.
        • Bueno-De-Mesquita H.B.
        • Trichopoulou A.
        • Trichopoulos D.
        • Naska A.
        • Tumino R.
        • Riboli B.
        • Kaaks R.
        Endogenous sex hormones and endometrial cancer risk in women in the European Prospective Investigation into Cancer and Nutrition (EPIC).
        Endocr. Relat. Cancer. 2008; 15: 485-497https://doi.org/10.1677/ERC-07-0064
        • Feinberg J.
        • Albright B.
        • Black J.
        • Lu L.
        • Passarelli R.
        • Gysler S.
        • Whicker M.
        • Altwerger G.
        • Menderes G.
        • Hui P.
        • Santin A.D.
        • Azodi M.
        • Silasi D.A.
        • Ratner E.S.
        • Litkouhi B.
        • Schwartz P.E.
        Ten-year comparison study of type 1 and 2 endometrial cancers: risk factors and outcomes.
        Gynecol. Obstet. Investig. 2019; 84: 290-297https://doi.org/10.1159/000493132
        • Busch E.L.
        • Crous-Bou M.
        • Prescott J.
        • Chen M.M.
        • Downing M.J.
        • Rosner B.A.
        • Mutter G.L.
        • De Vivo I.
        Endometrial cancer risk factors, hormone receptors, and mortality prediction.
        Cancer Epidemiol. Biomark. Prev. 2017; 26: 727-735https://doi.org/10.1158/1055-9965.EPI-16-0821
        • Newton S.
        • Braithwaite D.
        • Akinyemiju T.F.
        Socio-economic status over the life course and obesity: systematic review and meta-analysis.
        PLoS One. 2017; 12e0177151https://doi.org/10.1371/journal.pone.0177151
        • Ward K.K.
        • Shah N.R.
        • Saenz C.C.
        • McHale M.T.
        • Alvarez E.A.
        • Plaxe S.C.
        Cardiovascular disease is the leading cause of death among endometrial cancer patients.
        Gynecol. Oncol. 2012; 126: 176-179https://doi.org/10.1016/j.ygyno.2012.04.013
        • Nicholas Z.
        • Hu N.
        • Ying J.
        • Soisson P.
        • Dodson M.
        • Gaffney D.K.
        Impact of comorbid conditions on survival in endometrial cancer.
        Am. J. Clin. Oncol. 2014; 37: 131-134https://doi.org/10.1097/COC.0b013e318277d5f4
        • National Collaborating Centre for Healthy Public Policy, Thirteen public interventions in Canada that have contributed to a reduction in health inequalities