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Low level of education is associated with later stage at diagnosis and reduced survival in cutaneous malignant melanoma: A nationwide population-based study in Sweden

H. Eriksson, J. Lyth, E. Månsson-Brahme, M. Frohm-Nilsson, C. Ingvar, C. Lindholm, P. Naredi, U. Stierner, G. Wagenius, J. Carstensen, J. Hansson

European Journal of Cancer, Volume 49, Issue 12 , Pages 2705-2716, August 2013

Abstract


Background

A worse outcome has been reported for cutaneous malignant melanoma (CMM) patients with low socioeconomic status. We have investigated the association between level of education, clinical stage at diagnosis (stage at diagnosis) and CMM-specific survival in Sweden.

Methods

We identified 27,235 patients from the Swedish Melanoma Register diagnosed with a primary invasive CMM between 1990 and 2007 and linked data to nationwide, population-based, health and census registers with a follow-up to 2010.

Results

The odds ratio (OR) of higher disease stage at diagnosis was significantly increased in lower education groups (OR stage II versus I = 1.6; 95% confidence interval (CI) = 1.5–1.7. OR stage III–IV versus I = 2.3; 95% CI = 1.8–2.9). The risk of dying of CMM, was significantly increased in patients with low (hazard ratio (HR) low versus high = 2.02; 95% CI = 1.80–2.26; p < 0.0001) and intermediate (HR intermediate versus high = 1.35; 95% CI = 1.20–1.51; p  < 0.0001) level of education. After adjustment for age, gender, stage at diagnosis and other known prognostic factors, the HRs remained significant for low versus high (HR = 1.13; 95% CI = 1.01–1.27; p = 0.04) but not for intermediate versus high (HR = 1.11; 95% CI = 0.99–1.24; p  = 0.08) education. The HR associated with low level of education was significantly higher among female patients, patients <55 years, patients with truncal tumours and during the first 5 years after diagnosis.

Conclusion

Lower level of education is associated with reduced CMM-specific survival, which may at least partially be attributed to a more advanced stage at diagnosis. These results emphasise the need for improved early detection strategies.