title: Unemployment, public-sector health-care spending and breast cancer mortality in the European Union: 1990-2009.
abstract: BACKGROUND
  The global economic crisis has been associated with increased unemployment, reduced health-care spending and adverse health outcomes. Insights into the impact of economic variations on cancer mortality, however, remain limited.
  
  
  METHODS
  We used multivariate regression analysis to assess how changes in unemployment and public-sector expenditure on health care (PSEH) varied with female breast cancer mortality in the 27 European Union member states from 1990 to 2009. We then determined how the association with unemployment was modified by PSEH. Country-specific differences in infrastructure and demographic structure were controlled for, and 1-, 3-, 5- and 10-year lag analyses were conducted. Several robustness checks were also implemented.
  
  
  RESULTS
  Unemployment was associated with an increase in breast cancer mortality [P < 0.0001, coefficient (R) = 0.1829, 95% confidence interval (CI) 0.0978-0.2680]. Lag analysis showed a continued increase in breast cancer mortality at 1, 3, 5 and 10 years after unemployment rises (P < 0.05). Controlling for PSEH removed this association (P = 0.063, R = 0.080, 95% CI -0.004 to 0.163). PSEH increases were associated with significant decreases in breast cancer mortality (P < 0.0001, R = -1.28, 95% CI -1.67 to -0.877). The association between unemployment and breast cancer mortality remained in all robustness checks.
  
  
  CONCLUSIONS
  Rises in unemployment are associated with significant short- and long-term increases in breast cancer mortality, while increases in PSEH are associated with reductions in breast cancer mortality. Initiatives that bolster employment and maintain total health-care expenditure may help minimize increases in breast cancer mortality during economic crises.
authors.affiliation: 1 Imperial College London, London SW7 2AZ, UK 2 Faculty of Arts and Sciences, Harvard University, MA 02138, USA maruthappu@post.harvard.edu.
authors.forename: Mahiben
authors.initials: M
authors.lastname: Maruthappu
authors.affiliation: 3 Institute for Mathematical & Molecular Biomedicine, King's College London, London SE1 1UL, UK.
authors.forename: Johnathan A
authors.initials: JA
authors.lastname: Watkins
authors.affiliation: 4 School of Medicine, University of Liverpool, Liverpool, Merseyside L69 3BX, UK.
authors.forename: Mueez
authors.initials: M
authors.lastname: Waqar
authors.affiliation: 5 The Economist, 25 St James's Street, London SW1A 1HG, UK 6 Faculty of History, University of Oxford, George Street, Oxford OX1 2RL, UK.
authors.forename: Callum
authors.initials: C
authors.lastname: Williams
authors.affiliation: 7 Cancer Epidemiology Unit, University of Oxford, Richard Doll Building, Roosevelt Drive, Oxford OX3 7LF, UK 8 Faculty of Medicine and Health Sciences, United Arab Emirates University, PO Box 17666, Al-Ain, United Arab Emirates.
authors.forename: Raghib
authors.initials: R
authors.lastname: Ali
authors.affiliation: 9 Harvard University, MA 02138, USA.
authors.forename: Rifat
authors.initials: R
authors.lastname: Atun
authors.affiliation: 1 Imperial College London, London SW7 2AZ, UK.
authors.forename: Omar
authors.initials: O
authors.lastname: Faiz
authors.affiliation: 10 Special Envoy for Financing to the Director General of the World Health Organization (WHO), Avenue Appia 20, 1211 Geneva 27, Switzerland 11 University of Bern, Gerechtigkeitsgasse 31, Bern, CH 3011, Switzerland.
authors.forename: Thomas
authors.initials: T
authors.lastname: Zeltner
mesh_terms: D001943:Breast Neoplasms / Q000191:economics / Q000401:mortality*; D003695:Delivery of Health Care / Q000191:economics / Q000706:statistics & numerical data; D005062:European Union / Q000191:economics / Q000706:statistics & numerical data*; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006801:Humans; D017150:Public Sector / Q000191:economics* / Q000706:statistics & numerical data*; D015996:Survival Rate; D014478:Unemployment / Q000706:statistics & numerical data*