Introduction Breast cancer is the most common type of cancer
Breast cancer is the most common type of cancer in women, accounting for 28% of total cancer cases across Europe . In 2014, 92,500 women died from breast cancer in the EU-28 . Through better diagnostic techniques and advancement in surgical and pharmacological treatment, mortality rates from breast cancer are decreasing . However, there are substantial socio-economic inequalities in breast cancer prevalence and mortality: women in more socio-economically deprived areas have lower breast cancer incidence, but higher mortality rates . For example, in England, incidence rates for breast cancer are 14% lower for women living in the most deprived areas, compared to the least deprived, while people living in the most deprived areas have a significantly higher mortality rate – with an estimated 350 yearly excess deaths . This breast cancer paradox may be attributable to later diagnosis , suboptimal cancer care , co-morbidities that may limit treatment options or increase the possibility of developing treatment complications , and – most notably in terms of prevention – lower rates of breast cancer screening uptake.
In Europe, most countries have implemented or are developing mammography-based universal breast cancer screening programmes. It has been widely acknowledged that breast cancer screening is not without disadvantages, including breast cancer over diagnosis, which can lead to unnecessary surgical and pharmacological intervention. In view of this, many experts believe that the risks of breast cancer screening can outweigh the benefits, and women should always be fully informed about the risks and benefits of screening. Despite these limitations, the literature has shown that breast cancer screening can positively impact on survival . However, even with universal screening programmes available in many European countries, there are still distinct area-based inequalities in breast cancer screening uptake related to socio-economic deprivation [, , , , ].
A systematic review by Pruitt et al.  examined the association between socio-economic deprivation and breast, cervical and colorectal cancer screening. The work included 13 studies for breast cancer screening – all of which were conducted in North America, and showed some positive associations between socio-economic status (SES) and screening uptake , indicating that as SES increased (i.e. increasing income and education, decreasing unemployment and poverty), the odds of attending cancer screening increased. However, no European studies were included in this Actinomycin D systematic review and given the substantial differences in healthcare systems and screening coverage between the USA and Europe, Slow-stop dna mutant is important to examine if there is also an association in universal European health systems. Our systematic review, therefore, aimed to examine the association between area-level socio-economic deprivation and breast cancer screening uptake in Europe.
Materials and methods
Discussion This review has found consistent, medium-high quality evidence of a negative association between area-level socio-economic deprivation and breast cancer screening uptake in Europe (i.e. as area level socio-economic deprivation increases, breast cancer screening uptake decreases). This work updates a previous systematic review exploring the association between breast cancer, colorectal cancer, and cervical cancer screening and area-level deprivation . In this systematic review, which only included studies from outside Europe, thirteen studies focused on breast cancer screening; eight of which showed significant positive associations between SES and screening uptake. Our work, which focused on studies in Europe, supports the findings of the previous review by Pruitt et al. and provides evidence that even in the more universal health systems of Europe, women living in the least deprived areas are more likely to attend breast cancer screening than women living in the most deprived areas. Our work also builds on previous findings that as individual level SES increases, the uptake of breast cancer screening also increases [36,37], although the relationship between individual and area-level factors are thought to be complex with one not being a simple proxy for the other in terms of breast cancer risk . Qualitative research provides contextual information to understand the reasons for low rates of screening in deprived areas. Evidence suggests that women living in areas of high deprivation had limited knowledge about mammography screening programmes or had misconceptions regarding cancer and mammography [12,39]. Embarrassment, fear and inconvenience have also been cited as possible reasons for low screening rates in these communities . Furthermore, passive and practical barriers have been highlighted by an Australian Government Report  suggesting women in deprived communities find it difficult to attend mammography, because of transport (cost, availability) or family commitments.