Construction of an individual socioeconomic status index for analysing inequalities in colorectal cancer screening.

OBJECTIVE: To construct an individual socioeconomic status index (ISESI) with information available in the Population Information System of the Region of Valencia, Spain, and use it to analyse inequalities in a colorectal cancer screening programme (CRCSP). METHODS: Cross-sectional study of men and women aged between 50 and 75 at the time of the study (2020) that were selected from the target population of the Region of Valencia CRCSP. (study sample 1,150,684). First, a multiple correspondence analysis was performed to aggregate information from the Population Information System of the Region of Valencia into an ISESI. Second, data from the 2016 Region of Valencia Health Survey were used for validation, and finally the relationship between CRCSP participation and the ISESI was analysed by logistic regression models. RESULTS: The variables included in the index were nationality, employment status, disability, healthcare coverage, risk of vulnerability and family size. The most important categories for determining the highest socioeconomic status were being employed and not being at risk of social vulnerability, and being unemployed and at risk of social vulnerability for determining the lowest socioeconomic status. Index validation demonstrated internal and external coherence for measuring socioeconomic status. The relationship between CRCSP participation and the ISESI categorised by quartile (Q) showed that Q4 (the lowest socioeconomic status) was less likely to participate OR = 0.769 (0.757-0.782) than Q1 (the highest socioeconomic status), and the opposite was found for Q2 OR = 1.368 (1.347-1.390) and Q3 OR = 1.156 (1.137-1.175). CONCLUSIONS: An ISESI was constructed and validated using Population Information System data and made it possible to evaluate inequalities in colorectal cancer screening.

[Inequalities in access to cancer screening programmes in Spain and how to reduce them: data from 2013 and 2020.] / Desigualdades de acceso a los programas de cribado del cáncer en España y cómo reducirlas: datos de 2013 y 2020.

OBJECTIVE: The European Commission recommends ensuring equity in cancer screening. The aim of this study was to find out if there were inequalities in access to cancer screening programmes in Spain. METHODS: A transversal study was carried out by means of a survey addressed to the people responsible for breast, colorectal (CRC) and cervical cancer screening programmes in the 19 Autonomous Communities (AC) of Spain in 2013 and 2020. Information was collected on organizational characteristics, inequalities in access and interventions to reduce them. A descriptive analysis was made by AC and time period, by calculating frequencies and percentages, depending on the type of programme (breast, CRC and cervix). RESULTS: In 2013, 14 ACs participated for the breast programme, 8 for the CRC and 7 for the cervical programme; and in 2020, 14, 13 and 11 ACs respectively. All breast programmes were population-based in both periods (14/14 in 2013 and 14/14 in 2020), as well as CRC ones (8/8 in 2013 and 13/13 in 2020), with an increase in cervical cancer programmes (0/7 en 2013 y 6/11 en 2020). In both periods, social groups not included in the target population and groups that were less involved were identified, with differences according to the type of programme. A total of 53 interventions were carried out to reduce inequalities in access (27 in breast, 22 in RCC and 4 in cervical), 66% of them aimed at specific social groups (35/53). CONCLUSIONS: Inequalities in access to cancer screening programmes in Spain are identified, as well as interventions to reduce them.

OBJETIVO: La Comisión Europea recomienda asegurar la equidad en el cribado del cáncer. El objetivo de este estudio fue conocer si existían desigualdades en el acceso a los programas de cribado del cáncer en España. METODOS: Se realizó un estudio transversal mediante encuesta dirigida a las personas responsables de los programas de cribado del cáncer de mama, colorrectal (CCR) y cérvix de las diecinueve Comunidades Autónomas (CCAA) del Estado Español en 2013 y 2020. Se recogió información sobre características organizativas, desigualdades de acceso e intervenciones para reducirlas. Se hizo un análisis descriptivo por CCAA y periodo temporal, mediante el cálculo de frecuencias y porcentajes, en función del tipo de programa (mama, CCR y cérvix). RESULTADOS: En 2013 participaron catorce CCAA para el programa de mama, ocho para el de CCR y siete para el de cérvix, y en 2020, catorce, trece y once CCAA, respectivamente. Todos los programas de mama eran poblacionales en ambos periodos (14/14 en 2013 y 14/14 en 2020), así como los de CCR (8/8 en 2013 y 13/13 en 2020), con un aumento en el caso de los programas de cribado del cáncer de cérvix (0/7 en 2013 y 6/11 en 2020). Se identificaron en ambos periodos grupos sociales no incluidos en la población diana y grupos que, estando incluidos, participaban menos, con diferencias según el tipo de programa. Se realizaron un total de cincuenta y tres intervenciones para reducir desigualdades en el acceso (veintisiete en mama, veintidós en CCR y cuatro en cérvix), el 66% de ellas dirigidas a grupos sociales específicos (35/53). CONCLUSIONES: Se identifican desigualdades de acceso a los programas de cribado del cáncer en España, así como intervenciones para reducirlas.

Residential proximity to green spaces and breast cancer risk: The multicase-control study in Spain (MCC-Spain).

BACKGROUND: Breast cancer is the main cause of cancer mortality among women. Green spaces have been recently associated with reduced cancer mortality among women. Mechanisms explaining the beneficial effect of green spaces include increased levels of physical activity and reduced exposure to air pollution, which have been both associated with cancer development. OBJECTIVES: To investigate the associations between presence of urban green areas, presence of agricultural areas and surrounding greenness and risk of breast cancer, and to assess whether these associations are mediated by physical activity and/or air pollution levels. METHODS: We geocoded the current residence of 1129 breast cancer cases and 1619 controls recruited between 2008 and 2013 in ten provinces of Spain, as part of the MCC-Spain study. We assigned different indicators of exposure to green spaces in a buffer of 300 m, and in nested buffers of 100 m and 500 m around the residence: presence of urban green areas according to Urban Atlas, presence of agricultural areas according to CORINE Land Cover 2006, and surrounding greenness according to the average of the Normalized Difference Vegetation Index. We used logistic mixed-effects regression models with a random effect for hospital adjusting for potential confounders. We explored the effect of several potential effect modifiers. We assessed mediation effect by physical activity and levels of air pollution. RESULTS: Presence of urban green areas was associated with reduced risk of breast cancer after adjusting for age, socio-economic status at individual and at area level, education, and number of children [OR (95%CI) = 0.65 (0.49-0.86)]. There was evidence of a linear trend between distance to urban green areas and risk of breast cancer. On the contrary, presence of agricultural areas and surrounding greenness were associated with increased risk of breast cancer [adjusted OR (95%CI) = 1.33 (1.07-1.65) and adjusted OR (95%CI) = 1.27 (0.92-1.77), respectively]. None of the associations observed were mediated by levels of physical activity or levels or air pollution. CONCLUSIONS: The association between green spaces and risk of breast cancer is dependent on land-use. The confirmation of these results in other settings and the study of potential mechanisms for the associations observed are needed to advance the understanding on the potential effects of green spaces on health.

Evaluating the Association between Artificial Light-at-Night Exposure and Breast and Prostate Cancer Risk in Spain (MCC-Spain Study).

BACKGROUND: Night shift work, exposure to light at night (ALAN) and circadian disruption may increase the risk of hormone-dependent cancers. OBJECTIVES: We evaluated the association of exposure to ALAN during sleeping time with breast and prostate cancer in a population based multicase-control study (MCC-Spain), among subjects who had never worked at night. We evaluated chronotype, a characteristic that may relate to adaptation to light at night. METHODS: We enrolled 1,219 breast cancer cases, 1,385 female controls, 623 prostate cancer cases, and 879 male controls from 11 Spanish regions in 2008-2013. Indoor ALAN information was obtained through questionnaires. Outdoor ALAN was analyzed using images from the International Space Station (ISS) available for Barcelona and Madrid for 2012-2013, including data of remotely sensed upward light intensity and blue light spectrum information for each geocoded longest residence of each MCC-Spain subject. RESULTS: Among Barcelona and Madrid participants with information on both indoor and outdoor ALAN, exposure to outdoor ALAN in the blue light spectrum was associated with breast cancer [adjusted odds ratio (OR) for highest vs. lowest tertile, OR=1.47; 95% CI: 1.00, 2.17] and prostate cancer (OR=2.05; 95% CI: 1.38, 3.03). In contrast, those exposed to the highest versus lowest intensity of outdoor ALAN were more likely to be controls than cases, particularly for prostate cancer. Compared with those who reported sleeping in total darkness, men who slept in "quite illuminated" bedrooms had a higher risk of prostate cancer (OR=2.79; 95% CI: 1.55, 5.04), whereas women had a slightly lower risk of breast cancer (OR=0.77; 95% CI: 0.39, 1.51). CONCLUSION: Both prostate and breast cancer were associated with high estimated exposure to outdoor ALAN in the blue-enriched light spectrum. https://doi.org/10.1289/EHP1837.

Informed participation in the Valencian Community Colorectal Cancer Screening Programme from a gender perspective.

OBJECTIVE: To examine the factors that influence informed participation in a Colorectal Cancer Screening Programme (CRCSP) from a gender perspective. METHODS: Cross-sectional telephone survey directed to men and women invited to participate (2009-2010) in the Valencian Community CRCSP (Spain). SAMPLE SIZE: 785 subjects. OUTCOME VARIABLES: participation in CRCSP and being informed. Bivariate and multivariate analysis using logistic regression models (95% confidence interval [95%CI], p <0.05). RESULTS: Being a woman (odds ratio [OR]: 1.52; 95%CI: 1.06-2.19), receiving information from a general practitioner (OR: 1.64; 95%CI: 1.05-2.55) and being informed (OR: 1.54; 95%CI: 1.08-2.21) are related to participation. Men are more likely to participate if they live with a partner (OR: 6.26; 95%CI: 1.82-21.49); and are more informed if they have family responsibilities (OR: 2.53; 95%CI: 1.39-4.63). CONCLUSION: Information about CRCSP, involving primary health care professionals and including specific actions directed at men and at women, could contribute to improve informed participation with a gender equity perspective.

Relationship between drugs affecting the renin-angiotensin system and colorectal cancer: The MCC-Spain study.

The potential protective effect of renin-angiotensin system (RAS) inhibitors is a subject of increasing interest due to their possible role as chemopreventive agents against colorectal cancer (CRC). To evaluate this association, we conducted a case-control study with 2165 cases of colorectal cancer, diagnosed between 2007 and 2012, and 3912 population controls frequency matched (by age, sex and region) from the Spanish multicenter case-control study MCC-Spain. We found a significant protective effect of the angiotensin-converting enzyme Inhibitors (ACEIs) against CRC, limited to the under-65years group (OR=0.65 95%CI (0.48-0.89)) and to a lesser degree to men (OR=0.81 95%CI (0.66-0.99). In contrast, the angiotensin receptor blockers (ARBs) did not show a significant effect. Regarding the duration of use, a greater protection was observed in men as the length of consumption increases. In contrast, in the under-65 stratum, the strongest association was found in short-term treatments. Finally, by analyzing ACEIs effect by colon subsite, we found no differences, except for under 65years old, where the maximum protection was seen in the proximal intestine, descending in the distal and rectum (without statistical significance). In conclusion, our study shows a protective effect on CRC of the ACEis limited to males and people under 65years old, which increases in proximal colon in the latter. If confirmed, these results may suggest a novel approach to proximal CRC prevention, given the shortcomings of colonoscopy screening in this location.

Menstrual and Reproductive Factors and Risk of Gastric and Colorectal Cancer in Spain.

BACKGROUND: Sex hormones play a role in gastric cancer and colorectal cancer etiology, however, epidemiological evidence is inconsistent. This study examines the influence of menstrual and reproductive factors over the risk of both tumors. METHODS: In this case-control study 128 women with gastric cancer and 1293 controls, as well as 562 female and colorectal cancer cases and 1605 controls were recruited in 9 and 11 Spanish provinces, respectively. Population controls were frequency matched to cases by age and province. Demographic and reproductive data were directly surveyed by trained staff. The association with gastric, colon and rectal cancer was assessed using logistic and multinomial mixed regression models. RESULTS: Our results show an inverse association of age at first birth with gastric cancer risk (five-year trend: OR = 0.69; p-value = 0.006). Ever users of hormonal contraception presented a decreased risk of gastric (OR = 0.42; 95%CI = 0.26-0.69), colon (OR = 0.64; 95%CI = 0.48-0.86) and rectal cancer (OR = 0.61; 95%CI = 0.43-0.88). Postmenopausal women who used hormone replacement therapy showed a decreased risk of colon and rectal tumors. A significant interaction of educational level with parity and months of first child lactation was also observed. CONCLUSION: These findings suggest a protective role of exogenous hormones in gastric and colorectal cancer risk. The role of endogenous hormones remains unclear.

The Use of Antihypertensive Medication and the Risk of Breast Cancer in a Case-Control Study in a Spanish Population: The MCC-Spain Study.

INTRODUCTION: The evidence on the relationship between breast cancer and different types of antihypertensive drugs taken for at least 5 years is limited and inconsistent. Furthermore, the debate has recently been fueled again with new data reporting an increased risk of breast cancer among women with a long history of use of antihypertensive drugs compared with nonusers. METHODS: In this case-control study, we report the antihypertensive drugs-breast cancer relationship in 1,736 breast cancer cases and 1,895 healthy controls; results are reported stratifying by the women's characteristics (i.e., menopausal status or body mass index category) tumor characteristics and length of use of antihypertensive drugs. RESULTS: The relationship among breast cancer and use of calcium channel blockers (CCB) for 5 or more years had odds ratio (OR) = 1.77 (95% CI, 0.99 to 3.17). Stratifying by BMI, the OR increased significantly in the group with BMI ≥ 25 (OR 2.54, 95% CI, 1.24 to 5.22). CCBs were even more strongly associated with more aggressive tumors, (OR for invasive tumors = 1.96, 95% CI = 1.09 to 3.53; OR for non ductal cancers = 3.97, 95% CI = 1.73 to 9.05; OR for Erbb2+ cancer = 2.97, 95% CI: 1.20 to 7.32). On the other hand, premenopausal women were the only group in which angiotensin II receptor blockers may be associated with breast cancer (OR = 4.27, 95% CI = 1.32 to 13.84) but this could not be identified with any type or stage. Use of angiotensin-converting-enzyme inhibitors, beta blockers and diuretics were not associated with risk. CONCLUSIONS: In this large population-based study we found that long term use of calcium channel blockers is associated with some subtypes of breast cancer (and with breast cancer in overweight women).

Use of non-steroidal anti-inflammatory drugs and risk of breast cancer: The Spanish Multi-Case-control (MCC) study.

BACKGROUND: The relationship between non-steroidal anti-inflammatory drug (NSAID) consumption and breast cancer has been repeatedly studied, although the results remain controversial. Most case-control studies reported that NSAID consumption protected against breast cancer, while most cohort studies did not find this effect. Most studies have dealt with NSAIDs as a whole group or with specific drugs, such aspirin, ibuprofen, or others, but not with NSAID subgroups according to the Anatomical Therapeutic Chemical Classification System; moreover, scarce attention has been paid to their effect on different tumor categories (i.e.: ductal/non-ductal, stage at diagnosis or presence of hormonal receptors). METHODS: In this case-control study, we report the NSAID - breast cancer relationship in 1736 breast cancer cases and 1895 healthy controls; results are reported stratifying by the women's characteristics (i.e.: menopausal status or body mass index category) and by tumor characteristics. RESULTS: In our study, NSAID use was associated with a 24 % reduction in breast cancer risk (Odds ratio [OR] = 0.76; 95 % Confidence Interval [CI]: 0.64-0.89), and similar results were found for acetic acid derivatives, propionic acid derivatives and COXIBs, but not for aspirin. Similar results were found in postmenopausal and premenopausal women. NSAID consumption also protected against hormone + or HER2+ cancers, but not against triple negative breast cancers. The COX-2 selectivity showed an inverse association with breast cancer (i.e. OR < 1), except in advanced clinical stage and triple negative cancers. CONCLUSION: Most NSAIDs, but not aspirin, showed an inverse association against breast cancer; this effect seems to be restricted to hormone + or HER2+ cancers.

Association of diabetes and diabetes treatment with incidence of breast cancer.

AIMS: The aim of this study was to evaluate the association of diabetes and diabetes treatment with risk of postmenopausal breast cancer. METHODS: Histologically confirmed incident cases of postmenopausal breast (N = 916) cancer were recruited from 23 Spanish public hospitals. Population-based controls (N = 1094) were randomly selected from primary care center lists within the catchment areas of the participant hospitals. ORs (95 % CI) were estimated using mixed-effects logistic regression models, using the recruitment center as a random effect term. Breast tumors were classified into hormone receptor positive (ER+ or PR+), HER2+ and triple negative (TN). RESULTS: Diabetes was not associated with the overall risk of breast cancer (OR 1.09; 95 % CI 0.82-1.45), and it was only linked to the risk of developing TN tumors: Among 91 women with TN tumors, 18.7 % were diabetic, while the corresponding figure among controls was 9.9 % (OR 2.25; 95 % CI 1.22-4.15). Regarding treatment, results showed that insulin use was more prevalent among diabetic cases (2.5 %) as compared to diabetic controls (0.7 %); OR 2.98; 95 % CI 1.26-7.01. They also showed that, among diabetics, the risk of developing HR+/HER2- tumors decreased with longer metformin use (ORper year 0.89; 95 % CI 0.81-0.99; based on 24 cases and 43 controls). CONCLUSION: This study reinforces the need to correctly classify breast cancers when studying their association with diabetes. Given the low survival rates in women diagnosed with TN breast tumors and the potential impact of diabetes control on breast cancer prevention, more studies are needed to better characterize this association.

Walking, biking or sport: how Spanish women attending breast cancer screening meet physical activity recommendations?

BACKGROUND: The aim is to analyse physical activity (PA), the fulfillment recommendation of at least 150 min of moderate PA, through walking/biking (W&B), sport, both types of PA and the factors associated with inactivity by Spanish women who attended breast cancer screening programmes. METHODS: The DDM-Spain is a multicentre cross-sectional study involving 3584 women, aged 45-68, attending screening in seven Spanish cities. Data were collected using a questionnaire, including age, socio-demographic and lifestyle characteristics, family burden and PA. PA was converted into metabolic equivalent of task (METs), categorized as low ≤ 600 METs min per week (m/w), moderate 600-3000 METs m/w and high ≥ 3000 METs m/w. A multivariate logistic regression was performed to identify variables associated with inactivity for each type of PA. RESULTS: No women achieved a high level of PA through sport. 79.2% achieved a high or moderate level of PA by W&B. Lack of sport was associated with being overweight (odds ratio OR = 1.31; 95% confidence interval CI: 1.06 to 1.62), body mass index (BMI) ≥ 30 (OR = 1.85; 95% CI: 1.44 to 2.38), smoking (OR = 1.56; 95% CI: 1.22 to 2.00) and living with a disabled person (OR = 1.64; 95% CI: 1.0 to 2.81), whereas enough sport practice was associated with higher educational or socio-economic level (SEL). Regarding W&B, inactivity was associated with BMI ≥ 30 (OR = 1.91; 95% CI: 1.49 to 2.45) and living with someone >74 (OR = 1.96; 95% CI: 1.48 to 2.58). Inactivity for both types of exercise was associated with a BMI ≥ 30 (OR = 2.13; 95% CI: 1.63 to 2.8), smoking (OR = 1.41; 95% CI: 1.09 to 1.81) and living with someone >74 (OR = 1.69; 95% CI: 1.24 to 2.28). CONCLUSIONS: Family burden and BMI ≥ 30 are inversely associated with both types of PA. W&B is the most common type of PA regardless of educational and SEL.

Reasons for participating in the Valencian Community Colorectal Cancer Screening Programme by gender, age, and social class.

OBJECTIVE: To know the reasons to participate or not in a colorectal cancer (CCR) screening programme and to analyze the differences by sex, age and social class. METHODS: Cross-sectional study by a telephone survey directed to a sample of men and women aged between 50-74 year old,participants (n = 383) and non participants (n = 383) in the CCR screening programme of Valencian Community. Descriptive analysis and logistic regression models estimating the Odds Ratio (p < 0.05). RESULTS: The main reasons to participate are "it is important for health" (97.9 %) and "the test is easy" (97.6 %); and to nonparticipate are "no CCR symptoms" (49.7 %) and "didn't receive invitation letter" (48.3 %). Women are more likely not to participate if the reason was to consider the "test unpleasant" (OR: 1.82; IC: 1.00-3.28), and men if the reason was "lack of time" (OR 0.51;IC: 0.27-0.97); persons 60 or more years old if the reason was "diagnostic fear" (OR: 2.31; IC: 1.11-4.80), and persons 50-59 years old if was "lack of time" (OR 0.44; IC: 0.23-0.85); non manual social class persons if the reason was "lack of time" (OR: 2.66; IC: 1.40-5.10); manual women if the reason was "embarrassment to perform the test" (OR: 0.37; IC: 0.14-0.97); and non manual men if was "lack of time" (OR: 4.78; IC: 1.96-11.66). CONCLUSIONS: There are inequalities in the reasons for not participating in CCR screening programmes by sex, age and social class. It would be advisable to design actions that incorporate specific social group needs in order to reduce inequalities in participation.

Gender sensitivity in national health plans in Latin America and the European Union.

OBJECTIVES: To evaluate the situation regarding gender sensitivity in national health plans in Latin America and the European Union for the decade 2000-2010. METHODS: A systematic search and content analysis of national health plans were carried out within 37 countries. Gender sensitivity, defined as the extent to which a health plan considers gender as a central category and develops measures to reduce any gender-related inequalities, was analysed through an ad hoc checklist. RESULTS: The description of health problems by sex was more frequent than intervention proposals aimed at reducing gender health disparities. The greatest number of specific intervention proposals targeted at overcoming gender-based health inequalities were associated with sexual and/or reproductive health, gender based violence, the working environment and human resources training. Compared to the European Union member states, Latin American health plans were found to be generally more gender sensitive. CONCLUSIONS: National health plans are still generally lacking in gender sensitivity. Disparities exist in health policy formulation in favour of men, whilst women's health continues to be identified mainly with reproductive health. If gender sensitivity is not taken into account, efforts to improve the quality of clinical care will be insufficient as gender inequalities will persist.

Mapping the awareness of inequalities in health programs in Spanish communities: moving forward together.

The aim of this study is to map the awareness of gender, socioeconomic, immigrant and ethnic health inequalities in health at schools, maternal health and traffic injury health prevention programs. The study was conducted in the 19 health descentralized areas in Spain, 17 autonomous community (ACs) and the 2 autonomous cities (ACities). The data were collected from May 2008 to January 2009. The unit of analysis was the collection of policy documents setting out the programs mentioned above and the related support material in each AC. A reading guide was used to analyze the awareness of inequalities. With regard to health at schools, 2 of 10 programs show a high awareness of inequalities and include many specific proposals to be implemented at the local level. Regarding maternal health, 13 ACs have prepared support material with high awareness of inequalities to be implemented. A traffic injury program has been created in two ACs. We map the whole situation in Spain regarding the health programs that we have used as examples and their awareness of inequalities. We can conclude that there are differences between the regions studied in Spain and in general, the awareness of inequalities is low.

[Child health]. / La salud en la infancia.

Children in Spain are considered as being a population group with few health problems and needs therefore making it almost invisible in research and services' planning. Generally, it is not taken into account that this is a development period with very high vulnerability to physical and psychosocial risks whereas there is a positive response to protective factors. This article covers some data and thoughts on their health problems that are improving (mortality, cancer), those that persist or worsen (environmental quality, abuse, mental health, obesity, disabilities and lifestyles) and new challenges relating to quality of life and gender and social class equity. Responses provided by the health services are reviewed, as are environmental policies and health promotion and specific care is proposed for boys' and girls' health from a children's human rights-focused perspective.