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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
Karolinska Institutet, Stockholm, Sweden.
Linköping University, Department of Clinical and Experimental Medicine, Oncology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center for Health and Developmental Care, Regional Cancer Center South East Sweden.
Karolinska Institutet, Stockholm, Sweden.
Karolinska Institutet, Stockholm, Sweden.
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2013 (English)In: European Journal of Cancer, ISSN 0959-8049, E-ISSN 1879-0852, Vol. 49, no 12, 2705-2716 p.Article in journal (Refereed) Published
Abstract [en]


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.


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.


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 <55years, patients with truncal tumours and during the first 5years after diagnosis.


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.

Place, publisher, year, edition, pages
Elsevier, 2013. Vol. 49, no 12, 2705-2716 p.
Keyword [en]
Melanoma, Survival, Socioeconomic status, Level of education, Stage at diagnosis, Population-based
National Category
Medical and Health Sciences Social Sciences
URN: urn:nbn:se:liu:diva-95938DOI: 10.1016/j.ejca.2013.03.013ISI: 000321336800010PubMedID: 23583439OAI: diva2:641770

Funding Agencies|Swedish Cancer Society||Radiumhemmet Research Funds||Sigurd and Elsa Goljes Memorial Foundation||Stockholm County Council||

Available from: 2013-08-19 Created: 2013-08-12 Last updated: 2015-01-28Bibliographically approved
In thesis
1. Clinical-epidemiological studies on cutaneous malignant melanoma: A register approach
Open this publication in new window or tab >>Clinical-epidemiological studies on cutaneous malignant melanoma: A register approach
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The incidence of cutaneous malignant melanoma (CMM) is steadily increasing. Most of the patients have thin CMM with a good prognosis and a 5-year survival of about 90%. The prognosis is highly related to tumour thickness and clinical stage at diagnosis. Effective systemic treatment for patients with metastatic disease has only recently been available. This thesis aims to increase knowledge of trends in tumour thickness, prognostic factors, socioeconomic differences and medical costs in patients with CMM.

The population-based Swedish melanoma register is the main source of data in all papers in the thesis. Papers I-III include patients from all of Sweden while paper IV is delimited to the County of Östergötland. Cox regression and logistic regression are the main multivariable methods used. Paper IV is focused on stage-specific costs of CMM by comparing direct healthcare costs to a general population.

For men, there has been a shift over time towards thinner tumours at diagnosis accompanied by an improved survival. Women are still diagnosed with considerably thinner tumours and they experience a better survival than men. Tumour ulceration, tumour thickness and Clark’s level of invasion all showed significant independent long-term prognostic information in T1 CMMs. By combining these factors, three distinct prognostic subgroups were identified. Lower level of education was associated with reduced CMM-specific survival, which may at least partially be attributed to a more advanced stage at diagnosis. The direct healthcare costs for CMM patients were significantly higher than for the general population, independent of clinical stage. CMM patients diagnosed in clinical stage III-IV were associated with particularly high costs.

Even though the survival among Swedish patients with CMM is among the highest in the world and still seems to improve, the results of this thesis emphasise the need of improved early detection strategies. This may be of particular concern in men, older women, and groups with a low level of education. The results also imply that the costs for the management of CMM patients may be reduced if early detection efforts are successful and lead to a more favourable stage distribution. The finding of a better risk stratification of thin CMMs may help to improve the management of this large patient group.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2015. 51 p.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1428
Melanoma, early detection, population-based, registers, time trends, survival, prognostic factors, tumour thickness, stage at diagnosis, level of education, socioeconomic status, healthcare costs
National Category
Dermatology and Venereal Diseases Public Health, Global Health, Social Medicine and Epidemiology
urn:nbn:se:liu:diva-113145 (URN)10.3384/diss.diva-113145 (DOI)978-91-7519-191-1 (print) (ISBN)
Public defence
2015-02-13, Eken, ingång 65, Campus US, Linköpings Universitet, Linköping, 09:00 (Swedish)
Available from: 2015-01-28 Created: 2015-01-12 Last updated: 2016-04-01Bibliographically approved

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