Socioeconomic inequalities, psychosocial stressors at work and physician-diagnosed depression: Time-to-event mediation analysis in the presence of time-varying confounders.

OBJECTIVES: There is evidence that both low socioeconomic status (SES) and psychosocial stressors at work (PSW) increase risk of depression, but prospective studies on the contribution of PSW to the socioeconomic gradient of depression are still limited. METHODS: Using a prospective cohort of Quebec white-collar workers (n = 9188 participants, 50% women), we estimated randomized interventional analogues of the natural direct effect of SES indicators at baseline (education level, household income, occupation type and a combined measure) and of their natural indirect effects mediated through PSW (job strain and effort-reward imbalance (ERI) measured at the follow-up in 1999-2001) on incident physician-diagnosed depression. RESULTS: During 3 years of follow-up, we identified 469 new cases (women: 33.1 per 1000 person-years; men: 16.8). Mainly in men, low SES was a risk factor for depression [education: hazard ratio 1.72 (1.08-2.73); family income: 1.67 (1.04-2.67); occupational type: 2.13 (1.08-4.19)]. In the entire population, exposure to psychosocial stressors at work was associated with increased risk of depression [job strain: 1.42 (1.14-1.78); effort-reward imbalance (ERI) 1.73 (1.41-2.12)]. The estimated indirect effects of socioeconomic indicators on depression mediated through job strain ranged from 1.01 (0.99-1.03) to 1.04 (0.98-1.10), 4-15% of total effects, and for low reward from 1.02 (1.00-1.03) to 1.06 (1.01-1.11), 10-15% of total effects. DISCUSSION: Our study suggests that PSW only slightly mediate the socioeconomic gradient of depression, but that socioeconomic inequalities, especially among men, and PSW both increase the incidence of depression.

Wage losses among spouses of women with nonmetastatic breast cancer.

BACKGROUND: The aim of this study was to evaluate the wage losses incurred by spouses of women with nonmetastatic breast cancer in the 6 months after the diagnosis. METHODS: A prospective cohort study of spouses of women diagnosed with nonmetastatic breast cancer who were recruited in 8 hospitals in the province of Quebec (Canada) was performed. Information for estimating wage losses was collected by telephone interviews conducted 1 and 6 months after the diagnosis. Log-binomial regressions were used to identify personal, medical, and employment characteristics associated with experiencing wage losses, and generalized linear models were used to identify characteristics associated with the proportion of usual wages lost. RESULTS: Overall, 829 women (86% participation) and 406 spouses (75% participation) consented to participate. Among the 279 employed spouses, 78.5% experienced work absences because of breast cancer. Spouses were compensated for 66.3% of their salary on average during their absence. The median wage loss was $0 (mean, $1820) (2003 Canadian dollars). Spouses were more likely to experience losses if they were self-employed or lived 50 km or farther from the hospital. Among spouses who experienced wage losses, those who were self-employed or whose partners had invasive breast cancer lost a higher proportion of wages. CONCLUSIONS: Although spouses took some time off work, for many, the resulting wage losses were modest because of compensation received. Still, the types of compensation used may hide other forms of burden for families facing breast cancer.

Neighbourhood Material and Social Deprivation and Exposure to Antidepressant Drug Treatment: A Cohort Study Using Administrative Data.

OBJECTIVE: To assess whether neighbourhood deprivation is associated with exposure to an antidepressant drug treatment (ADT) and its quality among individuals diagnosed with unipolar depression and insured by the Quebec public drug plan. METHOD: We conducted an administrative database cohort study of adults covered by the Quebec public drug plan who were diagnosed with a new episode of unipolar depression. We assessed material and social deprivation using an area-based index. We considered exposure to an ADT as having ≥1 claim for an ADT within the 365 days following depression diagnosis. Among those exposed to ADT, ADT quality was assessed with 3 indicators: first-line recommended ADT, persistence with the ADT, and compliance with the ADT. Generalized linear models were used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (95% CI). RESULTS: Of 100,432 individuals with unipolar depression, 65,436 (65%) were exposed to an ADT in the year following the diagnosis. Individuals living in the most materially deprived areas were slightly more likely to be exposed to an ADT than those living in the least deprived areas (aPR, 1.04; 95% CI, 1.03 to 1.06). The likelihoods of being exposed to a first-line ADT, persisting for the minimum recommended duration and complying with the ADT were independent of the deprivation levels. CONCLUSIONS: Neighbourhood deprivation was not associated with ADT quality among individuals insured by the Quebec public drug plan. It might be partly attributable to the public drug plan whose goal is to provide equitable access to prescription drugs regardless of income.

Out-of-pocket costs in the year after early breast cancer among Canadian women and spouses.

BACKGROUND: We lack comprehensive information about the extent of out-of-pocket costs after diagnosis of early breast cancer and their effects on the family's financial situation. METHODS: This longitudinal study assessed out-of-pocket costs and wage losses during the first year after diagnosis of early breast cancer among Canadian women and spouses. Out-of-pocket costs for treatments and follow-up, consultations with other practitioners, home help, clothing, and natural health products were estimated, with information collected from telephone interviews. Generalized linear models were used to identify women at risk of having higher costs and the effects of out-of-pocket costs on perceptions of the family's financial situation. RESULTS: Overall, 829 women (participation, 86.2%) and 391 spouses participated. Women's median net out-of-pocket costs during the year after diagnosis were $1002 (2003 Canadian dollars; mean = $1365; SD = $1238), and 74.4% of these costs resulted from treatments and follow-up. Spouses' median costs were $111 (mean = $234; SD = $320), or 9% of couples' total expenses. In multivariable analyses, the percentage of women with out-of-pocket costs of $1773 or more (upper quartile) was statistically significantly associated with higher education, working at diagnosis, living more than 50 km from the hospital where surgery was performed, and having two and three different types of adjuvant treatment (all 2-sided P values ≤ .01). However, when considered simultaneously with wage losses, out-of-pocket costs were not associated with perceived deterioration in the family's financial situation; rather, wage losses were the driving factor. CONCLUSIONS: Overall, out-of-pocket costs from breast cancer for the year after diagnosis are probably not unmanageable for most women. However, some women were at higher risk of experiencing financial burden resulting from these costs.

[Health inequities in mood disorders based on material and social deprivation in dwelling sectors ]. / Inégalités de santé des troubles de l'humeur selon la défavorisation matérielle et sociale du quartier de résidence.

OBJECTIVE: To compare mood disorder (MD) prevalence in Quebec in 2006, and compare health services and medication use, mortality and morbidity in patients with MD based on sex and the dwelling sector level of material and social deprivation. The objective was also to identify subgroups of individuals using health services in a larger proportion and having a higher risk of morbidity and mortality. METHOD: We conducted a secondary analysis of the Régie de l'assurance maladie du Québec medico-administrative data. The cohort is composed of adults diagnosed with MD and living in Quebec in 2006. Variables include: physician consultation, medication demand, consultation for substance or alcohol abuse, emergency visit, hospitalization for a mental disorder, and death. Dwelling sector types are defined by crossing Pampalon material and social deprivation quintiles. RESULTS: MD prevalence in 2006 was 3.06% (177 850 patients), with prevalence in women 1.7-fold with respect to men. Findings show a higher MD prevalence as well as a higher mortality and morbidity rate in materially and socially deprived dwelling sectors. Young men also represent a specifically vulnerable subgroup for many study variables. CONCLUSION: Public policies aimed at improving material conditions (income, education, employment) and breaking out social isolation would have an important impact on the population mental health. Public health program development should pay close attention to young men population.

Out-of-pocket costs for accessing adjuvant radiotherapy among Canadian women with breast cancer.

PURPOSE: Patients with breast cancer incur out-of-pocket costs when they receive adjuvant radiation. These treatments are administered in dedicated centers on a daily basis over 4 to 5 weeks. We assessed the extent of out-of-pocket costs to access radiotherapy and identified women at risk of experiencing higher costs. PATIENTS AND METHODS: This prospective study was conducted among 800 women from eight Quebec hospitals (participation, 86%), of whom 693 women received adjuvant radiotherapy. Costs to access treatment (transportation, parking, lodging, and meals) were estimated on the basis of information collected by telephone interviews. Generalized linear models were used to identify women at risk of having higher costs. RESULTS: Mean and median total costs (including financial aid received) to access radiotherapy were 445 Canadian dollars (Can$; standard deviation, Can$407) and Can$311, respectively. Women who lived at home but far from the radiotherapy center had the highest risk of experiencing weekly costs of at least Can$122 (highest quartile; prevalence ratio [PR], 5.8; 95% CI, 4.7 to 7.1) followed by women who lived away from home and farther from the center (PR, 4.5; 95% CI, 3.4 to 6.0) and by women who lived away from home and closer to the center (PR, 2.14; 95% CI, 1.3 to 3.5). When women stayed at a cancer lodge during treatment, costs were reduced by 80%. CONCLUSION: Considered in and of themselves, out-of-pocket costs for access to radiotherapy appeared relatively modest. Financial assistance initiatives for women who lived away from home during treatments contributed to a substantial reduction of access costs. These efforts should be maintained, but financial assistance should also target patients with cancer who live at home during treatments but have to travel relatively long distances on a daily basis.

Validity of information obtained from a method for estimating cancer costs from the perspective of patients and caregivers.

PURPOSE: We describe a method we developed for estimating cancer costs from the perspective of patients and caregivers and evidence supporting validity of estimates obtained. METHODS: To increase validity, interview questions were anchored to treatments; costs were divided into their components; most questions focused on facts; and the research team combined responses into cost estimates. Evidence for validity comes from a prospective study of breast cancer costs using this method. RESULTS: Estimates obtained using interview responses were similar to those from independent sources. Women reported being reimbursed $205 on average for prosthesis (government reimbursement =$200); paying $15.48 per night at cancer lodge (average rate =$17.52); receiving government illness insurance for 14.6 weeks at 53% of usual salary (governmental program covers 15 weeks at 55%). A priori hypotheses about relations of costs with other characteristics were also confirmed. For example, patients' weekly travel costs increased as a function of distance from the radiotherapy center, with patients living <25, 25-49 and ≥50 km away spending $54, $141 and $240, respectively (P<.0001); and the proportion of annual salary lost was 37% for self-employed workers compared to 18% for employees (P<.0001). CONCLUSIONS: Evidence to date supports the validity of estimates obtained using this method.

Psychological distress and physical health in the year after diagnosis of DCIS or invasive breast cancer.

Ductal carcinoma in situ (DCIS) has an excellent prognosis, but its management can resemble that of early invasive breast cancer. We compared aspects of quality of life of women with DCIS to that of women with invasive disease during the first year after treatment initiation. Participants came from consecutive series of women with newly diagnosed, non-metastatic breast cancer treated in eight Quebec hospitals in 2003. Psychological distress and health-related quality of life were measured using the Psychiatric Symptom Index (PSI) and the SF-12 mental and physical component scales (MCS, PCS). Data were obtained 1, 6, and 12 months after the start of treatment. We used generalized linear models to compare mean scores and explored the possible clinical significance of between-group differences with effect size (ES). Participation and retention among eligible women were high, 86 and 97%, respectively. Among the 800 women who completed all interviews, 13.4% (n = 107) had DCIS and 86.6% (693) invasive disease. No statistically significant between-group differences were found at 1, 6, or 12 months in psychological state (PSI and MCS: P values from 0.065 to 0.904; ES from -0.01 to -0.21). Women with DCIS reported significantly higher levels of physical health, particularly when compared at 1 month to women with invasive disease who had chemotherapy (P value < 0.0001; ES = 0.82). Measured in symptoms of psychological distress, the better prognosis or less aggressive management of DCIS does not offset the general psychological effects of a cancer diagnosis to any great degree.

Wage losses in the year after breast cancer: extent and determinants among Canadian women.

BACKGROUND: Wage losses after breast cancer may result in considerable financial burden. Their assessment is made more urgent because more women now participate in the workforce and because breast cancer is managed using multiple treatment modalities that could lead to long work absences. We evaluated wage losses, their determinants, and the associations between wage losses and changes for the worse in the family's financial situation among Canadian women over the first 12 months after diagnosis of early breast cancer. METHODS: We conducted a prospective cohort study among women with breast cancer from eight hospitals throughout the province of Quebec. Information that permitted the calculation of wage losses and information on potential determinants of wage losses were collected by three pretested telephone interviews conducted over the year following the start of treatment. Information on medical characteristics was obtained from medical records. The main outcome was the proportion of annual wages lost because of breast cancer. Multivariable analysis of variance using the general linear model was used to identify personal, medical, and employment characteristics associated with the proportion of wages lost. All statistical tests were two-sided. RESULTS: Among 962 eligible breast cancer patients, 800 completed all three interviews. Of these, 459 had a paying job during the month before diagnosis. On average, these working women lost 27% of their projected usual annual wages (median = 19%) after compensation received had been taken into account. Multivariable analysis showed that a higher percentage of lost wages was statistically significantly associated with a lower level of education (P(trend) = .0018), living 50 km or more from the hospital where surgery was performed (P = .070), lower social support (P = .012), having invasive disease (P = .086), receipt of chemotherapy (P < .001), self-employment (P < .001), shorter tenure in the job (P(trend) < .001), and part-time work (P < .001). CONCLUSION: Wage losses and their effects on financial situation constitute an important adverse consequence of breast cancer in Canada.

Conceptualization and sources of costs from breast cancer: findings from patient and caregiver focus groups.

Assessment of economic burden of breast cancer to patient and family has generally been overlooked in assessing the impact of this disease. We explored economic aspects from the perspective of women and their caregivers. Focus groups were conducted in 3 Quebec cities representing urban and semi-urban settings: 3 with 26 women first treated for non-metastatic breast cancer in the past 18 months, and 3 with 24 primary caregivers. We purposefully selected participants with different characteristics likely to affect the nature or extent of costs. Thematic content analysis was conducted on verbatim transcripts. Costs of breast cancer could be substantial, but were not the most worrisome aspect of the illness during treatments. Some costs were considered unavoidable, others depended on ability to pay. Costs occurred over a long period, with long term impact, and were borne by the whole family and not just the woman. Principal cost sources discussed were those associated with accessing health care, wage losses, reorganization of everyday life, and coping with the disease. This study provided deeper understanding of cost dynamics and the experience of costs among Canadian women with non-metastatic breast cancer, whose treatment and medical follow-up costs are borne through a system of universal, publicly funded health care.