[Show abstract][Hide abstract] ABSTRACT: In New Zealand, the burden of childhood obesity is greatest in Māori and Pacific children.
In 687 infants from an internet-based birth cohort in New Zealand, we investigated ethnic differences in early life risk factors for later obesity, the degree to which these were explained by sociodemographic factors, and the extent to which ethnic differences in weight at age 3 months were explained by measured risk factors.
The risk of having an obese mother was double in Māori and Pacific infants compared with NZ European infants (prevalence 24% and 14%, respectively; OR 2.23, 95% CI 1.23 to 4.04). Māori and Pacific infants had higher weights in the first week of life and at 3 months (mean difference 0.19 kg, 95% CI 0.01 to 0.38), and their mothers had higher scores on a 'snacks' dietary pattern and lower scores on 'healthy' and 'sweet' dietary patterns. These inequalities were not explained by maternal education, maternal age or area-based deprivation. No ethnic differences were observed for maternal pre-pregnancy physical activity, hypertension or diabetes in pregnancy, exclusive breastfeeding or early introduction of solid foods. Ethnic inequalities in infant weight at 3 months were not explained by sociodemographic variables, maternal pre-pregnancy body mass index or dietary pattern scores or by other measured risk factors.
This study shows excess prevalence of early life risk factors for obesity in Māori and Pacific infants in New Zealand and suggests an urgent need for early interventions for these groups.
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Journal of epidemiology and community health 03/2015; 69(6). DOI:10.1136/jech-2014-204464 · 3.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Little research has been undertaken on the actual decision-making processes in cancer care multidisciplinary meetings (MDMs). This article was based on a qualitative observational study of two regional cancer treatment centers in New Zealand. We audiorecorded 10 meetings in which 106 patient cases were discussed. Members of the meetings categorized cases in varying ways, drew on a range of sources of authority, expressed different value positions, and utilized a variety of strategies to justify their actions. An important dimension of authority was encountered authority-the authority a clinician has because of meeting the patient. The MDM chairperson can play an important role in making explicit the sources of authority being drawn on and the value positions of members to provide more clarity to the decision-making process. Attending to issues of process, authority, and values in MDMs has the potential to improve cancer care decision making and ultimately, health outcomes.
Qualitative Health Research 10/2014; 25(3). DOI:10.1177/1049732314553010 · 2.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Māori in New Zealand have markedly higher incidence and poorer survival from stomach cancer than non-Māori. We investigated the presentation, management and survival of stomach cancer in a cohort of newly diagnosed Māori and non-Māori patients.
A clinical notes review of all Māori from the North Island diagnosed between 2006 and 2008, and a random equivalent sample of non-Māori, was conducted (final cohort n = 335). Patient characteristics, tumour characteristics, receipt and timing of treatment and cancer-specific survival were compared.
Compared to non-Māori, Māori patients had a younger average age at diagnosis, higher prevalence of congestive heart failure and renal disease, and were more likely to be diagnosed with distal disease (43 % Māori, 26 % non-Māori, p = 0.004). Stage and grade distributions were similar between ethnic groups. Two-thirds (66 %) of stage I–III patients had definitive surgery, with similar rates for Māori (71 %) and non-Māori (68 %). Māori were less likely to have surgery performed by a specialist upper gastrointestinal surgeon (38 % Māori, 79 % non-Māori, p
Gastric Cancer 08/2014; DOI:10.1007/s10120-014-0410-y · 4.83 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The reasons for the increasing breast cancer incidence in indigenous Maori compared to non-Maori New Zealand women are unknown. The aim of this study was to assess the association of an index of combined healthy lifestyle behaviours with the risk of breast cancer in Maori and non-Maori women.
A population-based case--control study was conducted, including breast cancer cases registered in New Zealand from 2005--2007. Controls were matched by ethnicity and 5-year age bands. A healthy lifestyle index score (HLIS) was generated for 1093 cases and 2118 controls, based on public health and cancer prevention recommendations. The HLIS was constructed from eleven factors (limiting red meat, cream, and cheese; consuming more white meat, fish, fruit and vegetables; lower alcohol consumption; not smoking; higher exercise levels; lower body mass index; and longer cumulative duration of breastfeeding). Equal weight was given to each factor. Logistic regression was used to estimate the associations between breast cancer and the HLIS for each ethnic group stratified by menopausal status.
Among Maori, the mean HLIS was 5.00 (range 1--9); among non-Maori the mean was 5.43 (range 1.5-10.5). There was little evidence of an association between the HLIS and breast cancer for non-Maori women. Among postmenopausal Maori, those in the top HLIS tertile had a significantly lower odds of breast cancer (Odds Ratio 0.47, 95% confidence interval 0.23-0.94) compared to those in the bottom tertile.
These findings suggest that healthy lifestyle recommendations could be important for reducing breast cancer risk in postmenopausal Maori women.
BMC Cancer 01/2014; 14(1):12. DOI:10.1186/1471-2407-14-12 · 3.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There are unacceptable ethnic differences in cancer survival in Aotearoa/New Zealand. For people with cancer, quality of life and survival are shaped by access to care, but research on Maori access to, and through, cancer care is limited. Internationally, research has shown that primary care plays an important role in providing patient-centred, holistic care and information throughout the cancer care journey. Additionally, Maori health providers provide practical support and facilitate access to all levels of health care. Here we describe the cancer journeys of Maori patients and whanau and identify factors that may facilitate or inhibit access to and through cancer care services.
Twelve Maori patients affected by cancer and their whanau (family) in the lower North Island took part in face-to-face semi-structured interviews exploring their experiences of cancer screening, diagnosis, treatment, survival and palliative care.
Three key areas were identified that impacted upon the cancer care journey: the experience of support; continuity of care; and the impact of financial and geographic determinants.
Primary care plays a key role in support and continuity of care across the cancer journey. Alongside interpersonal rapport, a long-term relationship with a primary health provider facilitated a more positive experience of the cancer care journey, suggesting that patients with a 'medical home' are happier with their care and report less problems with coordination between services. Positive, longstanding relationships with general practitioners and Maori health providers assisted patients and whanau with the provision and understanding of information, alongside practical support.
Journal of primary health care 12/2013; 5(4):308-14.
[Show abstract][Hide abstract] ABSTRACT: Stomach cancer is a leading cause of cancer death, especially in developing countries. Incidence has been associated with poverty and is also reported to disproportionately affect indigenous peoples, many of whom live in poor socioeconomic circumstances and experience lower standards of health. In this comprehensive assessment, we explore the burden of stomach cancer among indigenous peoples globally.
The literature was searched systematically for studies on stomach cancer incidence, mortality and survival in indigenous populations, including Indigenous Australians, Maori in New Zealand, indigenous peoples from the circumpolar region, native Americans and Alaska natives in the USA, and the Mapuche peoples in Chile. Data from the New Zealand Health Information Service and the Surveillance Epidemiology and End Results (SEER) Program were used to estimate trends in incidence.
Elevated rates of stomach cancer incidence and mortality were found in almost all indigenous peoples relative to corresponding non-indigenous populations in the same regions or countries. This was particularly evident among Inuit residing in the circumpolar region (standardised incidence ratios (SIR) males: 3.9, females: 3.6) and in Maori (SIR males: 2.2, females: 3.2). Increasing trends in incidence were found for some groups.
We found a higher burden of stomach cancer in indigenous populations globally, and rising incidence in some indigenous groups, in stark contrast to the decreasing global trends. This is of major public health concern requiring close surveillance and further research of potential risk factors. Given evidence that improving nutrition and housing sanitation, and Helicobacter pylori eradication programmes could reduce stomach cancer rates, policies which address these initiatives could reduce inequalities in stomach cancer burden for indigenous peoples.
Gut 10/2013; 63(1). DOI:10.1136/gutjnl-2013-305033 · 13.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Breast cancer incidence differs by ethnicity in New Zealand (NZ) with Māori (the indigenous people) women having the highest rates followed by Pakeha (people primarily of British/European descent), Pacific and Asian women, who experience the lowest rates. The reasons for these differences are unclear. Breast density, an important risk factor for breast cancer, has not previously been studied here. We used an automated system, Volpara™, to measure breast density volume from the medio-lateral oblique view of digital mammograms, by age (≤50 years and >50 years) and ethnicity (Pakeha/Māori/Pacific/Asian) using routine data from the national screening programme: age; x-ray system and mammography details for 3,091 Pakeha, 716 Māori, 170 Pacific and 662 Asian (total n = 4,239) women. Linear regression of the natural logarithm of absolute and percent density values was used, back-transformed and expressed as the ratio of the geometric means. Covariates were age, x-ray system and, for absolute density, the natural log of the volume of non-dense tissue (a proxy for body mass index). Median age for Pakeha women was 55 years; Māori 53 years; and Pacific and Asian women, 52 years. Compared to Pakeha women (reference), Māori had higher absolute volumetric density (1.09; 95% confidence interval [95% CI] 1.03-1.15) which remained following adjustment (1.06; 95% CI 1.01-1.12) and was stronger for older compared to younger Māori women. Asian women had the greatest risk of high percentage breast density (1.35; 95% CI 1.27-1.43) while Pacific women in both the ≤50 and >50 year age groups (0.78; 95% CI 0.66-0.92 and 0.81; 95% CI 0.71-0.93 respectively) had the lowest percentage breast density compared to Pakeha. As well as expected age differences, we found differential patterns of breast density by ethnicity consistent with ethnic differences seen in breast cancer risk. Breast density may be a contributing factor to NZ's well-known, but poorly explained, inequalities in breast cancer incidence.
PLoS ONE 07/2013; 8(7):e70217. DOI:10.1371/journal.pone.0070217 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The association between breast cancer and tobacco smoke is currently unclear. The aim of this study was to assess the effect of smoking behaviours on the risk of breast cancer among three ethnic groups of New Zealand women.
A population-based case-control study was conducted including breast cancer cases registered on the New Zealand Cancer Registry between 2005 and 2007. Controls were matched by ethnicity and 5-year age-group. Logistic regression was used to estimate the association between breast cancer and smoking at different time points across the lifecourse, for each ethnic group. Estimated odds ratios (OR) were adjusted for established risk factors.
The study comprised 1,799 cases (302 Māori, 70 Pacific, 1,427 non-Māori/non-Pacific) and 2,540 controls (746 Māori, 191 Pacific, 1,603 non-Māori/non-Pacific). There was no clear association between smoking and breast cancer for non-Māori/non-Pacific women, although non-Māori/non-Pacific ex-smokers had statistically significant increased risk of breast cancer when smoking duration was 20 years or more, and this remained significant in the fully adjusted model (OR 1.31, 95% CI 1.03 to 1.66). Māori showed more consistent increased risk of breast cancer with increasing duration among current smokers (<20 years OR 1.61, 95% CI 0.55 to 4.74; 20+ years OR 2.03, 95% CI 1.29 to 3.22). There was a clear pattern of shorter duration since smoking cessation being associated with increased likelihood of breast cancer, and this was apparent for all ethnic groups.
There was no clear pattern for cigarette smoking and breast cancer incidence in non-Māori/non-Pacific women, but increased risks were observed for Māori and Pacific women. These findings suggest that lowering the prevalence of smoking, especially among Māori and Pacific women, could be important for reducing breast cancer incidence.
PLoS ONE 04/2013; 8(4):e63132. DOI:10.1371/journal.pone.0063132 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose
To investigate whether the relationships between established risk factors and breast cancer risk differ between three ethnic groups in New Zealand, namely Māori, Pacific, and non-Māori/non-Pacific women.
The study is a multi-ethnic, age-, and ethnicity-matched population-based case–control study of breast cancer in women. Women with a primary, invasive breast cancer registered on the New Zealand Cancer Registry between 1 April 2005 and 30 April 2006, and Māori or Pacific women diagnosed to 30 April 2007 were eligible. Control women were identified from the New Zealand Electoral Roll, stratified by ethnicity, then frequency matched on age to the cases. Logistic regression was used to estimate odds ratios (OR) and 95 % confidence intervals (CI) between exposures and breast cancer risk in three ethnic groups separately. Likelihood ratio tests were used to test for modification of the effects by ethnicity. Post-stratification weighting of the controls was used to account for differential non-response by deprivation category.
The study comprised 1,799 cases (302 Māori, 70 Pacific, 1,427 non-Māori/non-Pacific) and 2,543 controls (746 Māori, 194 Pacific, 1,603 non-Māori/non-Pacific), based on self-identified ethnicity. Māori women were more likely to have ER and PR positive breast cancer compared to other ethnicities. There were marked differences in exposure prevalence between ethnicities and some differing patterns of risk factors for breast cancer between the three main ethnic groups. Of interest was the strong relationship between number of children and lower breast cancer risk in Pacific women (OR for 4 or more vs. 1 child OR 0.13, 95 % CI 0.05–0.35) and a higher risk of breast cancer associated with smoking (OR 1.76, 95 % CI 1.25–2.48) and binge drinking (5 or more vs. 1–2 drinks per occasion, OR 1.55, 95 % CI 1.07–2.26) in Māori women. Some of the documented results were attenuated following post-stratification weighting.
The findings of this study need to be interpreted with caution, given the possibility of selection bias due to low response rates among some groups of women. Reducing the burden of breast cancer in New Zealand is likely to require different approaches for different ethnic groups.
Cancer Causes and Control 11/2012; 24(1). DOI:10.1007/s10552-012-0099-3 · 2.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Little is known about the ethnic differences in disease presentation of uterine cancer in New Zealand women. The objectives of this study were two-fold: (1) to estimate the incidence and mortality of uterine cancer among women in New Zealand and (2) to examine the association of ethnicity and socioeconomic status with tumour stage and grade, at presentation of uterine cancer.
Retrospective survey of cancer cases identified from the New Zealand Cancer Registry. The authors analysed all 3203 uterine cancer cases registered with the New Zealand Cancer Registry during the period 1 January 1997 to 31 December 2006. Ethnic groups were defined based on the self-identified ethnicity recorded on the cancer registry: Ma-ori, Pacific and non-Māori non-Pacific women. Socioeconomic status was categorised as quintiles of the New Zealand Deprivation Index 2006. The mortality to incidence ratio was used as a measure of prognosis. Logistic regression was used to estimate age, ethnic and deprivation adjusted odds ratios (ORs) and 95% confidence intervals (CIs).
Pacific and Māori women have higher incidence (32.4 and 17.7 per 100 000 women, respectively) and mortality rates of uterine cancer (12.1 and 7.4 per 100 000 women, respectively). Women in the most deprived areas are more likely to present with an advanced stage of uterine cancer (OR 1.64, 95% CI 1.09-2.48). Māori and Pacific women are less likely to present with well-differentiated tumours (OR 0.69, 95% CI 0.52-0.92 and OR 0.72, 95% CI 0.52-0.99, respectively).
Māori and Pacific women, and those from lower socioeconomic areas, are more likely to present with advanced uterine cancer.
Journal of Family Planning and Reproductive Health Care 01/2012; 38(4):239-45. DOI:10.1136/jfprhc-2011-100113 · 2.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although musculoskeletal symptoms (MSS) are common worldwide, little is known about its prevalence amongst the working population in relation to gender, age, and occupational/industrial group. This paper describes the prevalence of MSS in a sample of 3003 men and women aged 20e64 randomly selected from the New Zealand Electoral Roll. MSS experienced during the previous 12 months in 10 body regions was assessed in telephone interviews using a modified version of the Nordic Musculoskeletal Questionnaire (NMQ). MSS prevalence was 92% (for any body region). The highest prevalence was for low back (54%), neck (43%), and shoulders (42%). Females reported a statistically significantly higher prevalence of MSS in the neck, shoulders, wrist/hands, upper back and hips/thighs/buttocks regions compared to males while males reported more symptoms of the elbows, low back and knees. There were no statistically significant differences in prevalence among age groups. In general, participants with heavy physical workloads had significantly higher prevalence of symptoms in most body regions than those with light physical workloads although women with light physical workloads reported more neck symptoms. The study indicates that the New Zealand working population has a high prevalence of MSS and that exposure in the workplace plays a role.
Relevance to industry: The findings of this study imply that efforts to reduce MSS in the workplace should
focus on females and employees with high physical workloads.
International Journal of Industrial Ergonomics 07/2011; 41(5):561-572. DOI:10.1016/j.ergon.2011.06.002 · 1.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study investigated the role that demographic and tumour factors play in explaining ethnic inequalities in breast cancer survival.
Breast cancer cases notified to the New Zealand Cancer Registry (NZCR) from April 2005 to April 2007 were followed up to April 2009. Māori, Pacific and non-Māori/non-Pacific women were categorised according to ethnicity on the NZCR. Deprivation was analysed as quintiles of the New Zealand area-based index of socio-economic position. Relative survival rates were estimated using ethnic-specific life tables. Missing values were imputed and excess mortality modelling was used to estimate the contribution of demographic and tumour factors to ethnic inequalities in survival.
There were 2968 breast cancer cases (76.5% non-Māori/non-Pacific, 17% Māori, and 6.5% Pacific) included and 433 recorded deaths. Relative survival rates at 4 years were 91.5% (95% confidence interval (CI) 89.7 to 92.9) for non-Māori/non-Pacific, 86.2% (CI 80.3 to 90.4) for Māori, and 79.6% (CI 68.2 to 87.2) for Pacific women. Using non-Māori/non-Pacific as the reference group, the age-adjusted hazard ratio (HR) dropped for Māori from 1.76 (CI 1.22 to 2.48) to 1.43 (CI 0.97 to 2.10) when further adjusted by deprivation. For Pacific the HR dropped from 2.49 (CI 1.57 to 3.94) to 1.94 (CI 1.20 to 3.13). Inequalities persisted after adjustment for subtype variables (ER/PR/HER2), but adjusting for access to care variables (extent/size) eliminated the ethnic inequalities in excess mortality.
Ethnic disparities in breast cancer survival in New Zealand can be attributed to deprivation and differential access to health care rather than differences in breast cancer subtypes.
Ethnicity and Health 06/2011; 16(6):535-49. DOI:10.1080/13557858.2011.583638 · 1.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Study the determinants of non-response and the potential for non-response bias in a New Zealand survey of occupational exposures and health.
A random sample of 10,000 New Zealanders aged 20-64 years were invited by mail to take part in a telephone survey. Multiple logistic regression was used to study the determinants of non-response. Whether occupational exposure, lifestyle and health indicators were associated with non-response was studied by standardising their prevalence towards the demographic distribution of the source population, and comparing early with late responders.
The response rate was 37%. Younger age, Māori descent, highest and lowest deprivation groups and being a student, unemployed, or retired were determinants of non-contact. Refusal was associated with older age and being a housewife. Prevalence of key survey variables were unchanged after standardising to the demographic distribution of the source population.
Following up the non-responders to the mailed invitations with telephone calls more than doubled the response rate and improved the representativeness of the sample. Although the response rate was low, we found no evidence of major non-response bias.
Judgement regarding the validity of a survey should not be based on its response rate.
Australian and New Zealand Journal of Public Health 06/2011; 35(3):256-63. DOI:10.1111/j.1753-6405.2011.00703.x · 1.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To investigate the differences in occupational exposure between Māori (New Zealand's indigenous people) and non-Māori.
Participants were randomly selected from the Electoral Roll. Exposure to occupational risk factors was assessed through telephone interviews and exposure prevalences of Māori (n = 273) and non-Māori (n = 2,724) were compared. Subsequently, Māori were matched with non-Māori on current occupation (n = 482) to assess whether ethnic differences also exist within occupations.
Māori were more likely to report exposure to physical strain (e.g., lifting, standing). Part of these differences remained when Māori were compared with non-Māori in the same job. In addition, Māori women were twice as likely to categorize their job as very or extremely stressful than non-Māori women in the same job, while Māori men were twice as likely to report exposure to dust.
Marked ethnic differences exist in risk factors for occupational ill-health, due to both occupational distribution and the distribution of tasks within occupations.
American Journal of Industrial Medicine 05/2011; 54(5):410-8. DOI:10.1002/ajim.20934 · 1.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The authors conducted a population-based survey to examine gender differences in occupational exposure patterns and to investigate whether any observed differences are due to: (a) gender differences in occupational distribution; and/or (b) gender differences in tasks within occupations.
Men and women aged 20-64 years were randomly selected from the Electoral Roll and invited to take part in a telephone interview, which collected information on self-reported occupational exposure to specific dusts and chemicals, physical exposures and organisational factors. The authors used logistic regression to calculate prevalence ORs and 95% CIs comparing the exposure prevalence of males (n=1431) and females (n=1572), adjusting for age. To investigate whether men and women in the same occupation were equally exposed, the authors also matched males to females on current occupation using the five-digit code (n=1208) and conducted conditional logistic regression adjusting for age.
Overall, male workers were two to four times more likely to report exposure to dust and chemical substances, loud noise, irregular hours, night shifts and vibrating tools. Women were 30% more likely to report repetitive tasks and working at high speed, and more likely to report exposure to disinfectants, hair dyes and textile dust. When men were compared with women with the same occupation, gender differences were attenuated. However, males remained significantly more likely to report exposure to welding fumes, herbicides, wood dust, solvents, tools that vibrate, irregular hours and night-shift work. Women remained more likely to report repetitive tasks and working at high speed, and in addition were more likely to report awkward or tiring positions compared with men with the same occupation.
This population-based study showed substantial differences in occupational exposure patterns between men and women, even within the same occupation. Thus, the influence of gender should not be overlooked in occupational health research.
Occupational and environmental medicine 04/2011; 68(12):888-94. DOI:10.1136/oem.2010.064097 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aims of this study were to gain an understanding of pregnant women's oral health care practices, access to information, and dental care usage in New Zealand, and to investigate whether these differed between sociodemographic groups.
One researcher visited 69 antenatal classes in the Wellington region to explain the study. Women self-completed the questionnaire and returned it by post.
A total of 405 women (55% response rate) took part. 79.2% of participants identified as New Zealand European and most were of high income and education levels, 32% visited the dentist during pregnancy and more than 60% reported bleeding gums. Women with a household income under NZ$70,000 per year were significantly less likely to report access to oral health information (OR 0.27, 95%CI 0.10-0.76) and more likely to report the need to see a dentist (OR 2.55, 95%CI 1.08-5.99) compared to women with an income over NZ$100,000 per year.
Visits to the dentist and access to oral health information were more common among New Zealand European women with higher education achievements and higher socioeconomic backgrounds with only a third of women went seeing a dentist during pregnancy. Improving the oral health of pregnant women will have follow-on benefits of improved oral health outcomes for their children.
The New Zealand medical journal 01/2011; 124(1339):37-50.
[Show abstract][Hide abstract] ABSTRACT: This study investigated the role that demographic and tumour factors play in explaining socioeconomic inequalities in breast cancer survival.
Breast cancer cases notified to the New Zealand Cancer Registry (NZCR) from April 2005 to April 2007 were followed up to April 2009. The New Zealand area-based deprivation index (NZDep) was used as a measure of socioeconomic position. Relative survival rates were estimated using sex-, deprivation- and ethnic-specific life tables. Multiple imputation was used to impute missing data. Excess mortality modelling was used to estimate the contribution of demographic and tumour factors to inequalities in survival.
There were 2968 breast cancer cases included and 433 recorded deaths. Relative survival rates at 4 years varied across deprivation groups. Using NZDep deciles 1-4 (least deprived) as the reference group, the age- and ethnicity-adjusted hazard ratio (HR) for NZDep deciles 7-8 was 2.03 (CI 1.36-3.04) and for NZDep deciles 9-10 was 1.93 (CI 1.28-2.92). In the fully adjusted model there remained 50% excess mortality for the two most deprived groups compared to the most affluent. Variables which measured timely access to care (extent/size) accounted for more of the survival disparity than breast cancer subtype variables (ER/PR/HER2).
Women from deprived areas in New Zealand who are diagnosed with breast cancer are less likely to survive as long as those from affluent areas. A substantial proportion of these socioeconomic disparities can be attributed to differential access to health care although other factors, currently unknown, are also likely to play an important role.