title: 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.
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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Oncology and Pathology, Karolinska Institutet, Karolinska University Hospital, Solna, Stockholm, Sweden. hanna.eriksson.4@ki.se
authors.forename: H
authors.initials: H
authors.lastname: Eriksson
authors.forename: J
authors.initials: J
authors.lastname: Lyth
authors.forename: E
authors.initials: E
authors.lastname: Månsson-Brahme
authors.forename: M
authors.initials: M
authors.lastname: Frohm-Nilsson
authors.forename: C
authors.initials: C
authors.lastname: Ingvar
authors.forename: C
authors.initials: C
authors.lastname: Lindholm
authors.forename: P
authors.initials: P
authors.lastname: Naredi
authors.forename: U
authors.initials: U
authors.lastname: Stierner
authors.forename: G
authors.initials: G
authors.lastname: Wagenius
authors.forename: J
authors.initials: J
authors.lastname: Carstensen
authors.forename: J
authors.initials: J
authors.lastname: Hansson
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004522:Educational Status; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008545:Melanoma / Q000175:diagnosis* / Q000453:epidemiology / Q000601:surgery; D008875:Middle Aged; D009367:Neoplasm Staging; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data; D011379:Prognosis; D016016:Proportional Hazards Models; D012042:Registries / Q000706:statistics & numerical data; D012867:Skin / Q000473:pathology*; D012878:Skin Neoplasms / Q000175:diagnosis* / Q000453:epidemiology / Q000601:surgery; D012923:Social Class; D013548:Sweden / Q000453:epidemiology
keywords: Level of education; Melanoma; Population-based; Socioeconomic status; Stage at diagnosis; Survival