Antibiotic exposure and breast cancer in New Zealand

Summary Aims To investigate the hypothesis that use of antibiotics is related to subsequent development of breast cancer and also to apply this theory to other cancer types. Materials and methods A nested case–control study was conducted, using data linkage between the RNZCGP Research Unit database and the New Zealand Hospital Separation Diagnosis database. Cancer related hospital admissions were identified between 1998 and 2002, and prior antibiotic exposure in these patients was then found.Results A total of 6678 patients were identified with a newly diagnosed cancer in this time period. A slightly increased odds ratio (OR) (95% CI) for breast cancer was seen with penicillin, 1.07 (1.02–1.13). Penicillin was also associated with an increased OR with lung and respiratory cancer, 1.13 (1.06–1.21), and skin neoplasms, 1.05 (1.02–1.08). Significant associations were seen between macrolides and leukaemia, 1.15 (1.01–1.30), lung and respiratory cancers, 1.23 (1.10–1.38) and non-Hodgkin’s lymphoma, 1.26 (1.02–1.55). Tetracyclines were significantly associated with non-Hodgkin’s lymphoma, 1.12 (1.01–1.24). Cephalosporins only showed a significant association with leukaemia, 1.35 (1.06–1.71), sulphonamides with colorectal cancers, 1.12 (1.01–1.24), and ‘other‘ antibiotic classes with bladder and renal cancers, 1.34 (1.07–1.67). Conclusions It is most likely that antibiotic exposure represents a confounding factor rather than a causation for breast cancer and other cancer types.     

Tobacco‐attributable burden of cancer according to socioeconomic position in France

Smoking is a major preventable cause of cancers and is increasingly concentrated among the most deprived individuals leading to increasing socioeconomic inequalities in the incidence of cancers linked to smoking. We aimed to estimate the tobacco‐attributable cancer burden according to socioeconomic position in France. The analysis was restricted to cancer sites for which tobacco smoking was recognized as a risk factor. Cancer cases by sex, age group and European Deprivation Index (EDI) among people aged 30–74 between 2006 and 2009 were obtained from cancer registries covering ～20% of the French population. The tobacco‐attributable burden of cancer according to EDI was estimated applying the population attributable fraction (PAF) computed with the Peto‐Lopez method. The PAF increased from 56% in the least deprived EDI quintile to 70% in the most deprived EDI quintile among men and from 26% to 38% among women. In total, 28% of the excess cancer cases in the four most deprived EDI quintiles in men and 43% in women could be prevented if smoking in these 4 EDI quintiles was similar to that of the least deprived EDI quintile. A substantial smoking‐attributable burden of cancer by socioeconomic position was observed in France. The results highlight the need for policies reducing tobacco consumption. More comprehensive interventions integrating the various dimensions of health determinants and proportionate according to socioeconomic position may essentially contribute to the reduction of socioeconomic inequalities in cancer.     

Socioeconomic environment and disparities in cancer survival for 19 solid tumor sites: An analysis of the French Network of Cancer Registries (FRANCIM) data

Social inequalities are concerning along the cancer continuum. In France, social gradient in health is particularly marked but little is known about social gradient in cancer survival. We aimed to investigate the influence of socioeconomic environment on cancer survival, for all cancers reported in the French Network of Cancer Registries. We analyzed 189,657 solid tumors diagnosed between 2006 and 2009, recorded in 18 registries. The European Deprivation Index (EDI), an ecological index measuring relative poverty in small geographic areas, assessed social environment. The EDI was categorized into quintiles of the national distribution. One- and five-year age-standardized net survival (ASNS) were estimated for each solid tumor site and deprivation quintile, among men and among women. We found that 5-year ASNS was lower among patients living in the most deprived areas compared to those living in the least deprived ones for 14/16 cancers among men and 16/18 cancers among women. The extent of cancer survival disparities according to deprivation varied substantially across the cancer sites. The reduction in ASNS between the least and the most deprived quintile reached 34% for liver cancer among men and 59% for bile duct cancer among women. For pancreas, stomach and esophagus cancer (among men), and ovary and stomach cancer (among women), deprivation gaps were larger at 1-year than 5-year survival. In conclusion, survival was worse in the most deprived areas for almost all cancers. Our results from population-based cancer registries data highlight the need for implementing actions to reduce social inequalities in cancer survival in France.     

Contemporary lung cancer trends among U.S. women.

The age-standardized lung cancer incidence rate among women in the United States has decreased for each of the last 3 years for which data are available (1999-2001). We conducted this study to assess the stability and near-term sustainability of this decrease. We examined temporal trends in age-specific lung cancer incidence by calendar year and birth cohort and measured trends in the age-standardized rate in each geographic area within the Surveillance, Epidemiology, and End Results (SEER) Program using joinpoint regression analyses. Age-standardized lung cancer incidence rates have peaked or are decreasing in all geographic areas within SEER, although the decline is statistically significant only in San Francisco-Oakland. Age-specific incidence rates are decreasing in six of the seven 5-year age groups between ages 50 and 84 years in all areas of SEER combined. Rates in these age groups contribute nearly 95% of the total age-standardized incidence rate; consequently, trends in incidence at these ages will determine future trends in the overall age-standardized incidence rate for the next 20 to 25 years. Birth cohort patterns suggest that the decrease in the age-standardized rate will continue for at least 20 years, but will be slowed by aging of women born in the late 1950s and early 1960s. Given calendar year and birth cohort age-specific incidence patterns, the early decline in lung cancer incidence among women is likely to persist through at least 2025. Sustaining the downward trend beyond 2025 will require continued reductions in smoking initiation among children and increases in cessation among addicted smokers.     

Socioeconomic Inequalities in Novel NSCLC Treatments During the Era of Tumor Biomarker-Guided Therapy: A Population-Based Cohort Study in a Publicly Funded Health Care System

IntroductionSocioeconomic inequalities in the utilization of conventional NSCLC treatments are well documented. Nevertheless, it is not known whether these inequalities are also observed with novel anticancer therapies. This study evaluated associations between deprivation and utilization of novel anticancer therapies targeting tumor biology, the immune system, or both, within the English national publicly funded health care system.MethodsA retrospective analysis of 90,785 patients diagnosed with having a histologically confirmed stage IV NSCLC from January 1, 2012, to December 31, 2017, sourced from the English national population-based cancer registry and linked Systemic Anti-Cancer Therapy database, was undertaken. Multivariable logistic regression evaluated the likelihood of novel anticancer therapy utilization by deprivation category of area of residence at diagnosis (measured by quintiles of the income domain of the index of multiple deprivation).ResultsMultivariable analyses revealed marked treatment inequalities by deprivation. Patients residing in the most deprived areas were more than half as likely to use any novel therapy (multivariable OR [mvOR] = 0.45, 95% confidence interval [CI]: 0.41–0.49) compared with patients residing in the most affluent areas. Deprivation associations with treatment utilization were slightly stronger with targeted treatments ([most versus least deprived] mvOR = 0.39, 95% CI: 0.35–0.43) than immune checkpoint inhibitors (mvOR = 0.58, 95% CI: 0.51–0.66).ConclusionsThere are marked socioeconomic inequalities in NSCLC novel treatment utilization, even in the English National Health Service where treatment is free at the point of delivery. These findings have important implications for equitable delivery of drugs, which have transformed outcomes in metastatic lung cancer. Further work exploring the underlying causes is now needed.     

Blood Lead Concentration Correlates with All Cause,All Cancer and Lung Cancer Mortality in Adults: A Population Based Study

Background: This study used National Health and Nutrition Examination Survey III to study the relationshipbetween blood lead concentration and all cause, all cancer and lung cancer mortality in adults. Patients andMethods: Public use National Health and Nutrition Examination Survey (NHANES III) data were used. NHANESIII uses stratified, multistage probabilistic methods to sample nationally representative samples. Household adult,laboratory and mortality data were merged. Sample persons who were available to be examined in aMobileExamination Center (MEC) were included in this study. Specialized survey analysis software was used. Results:A total of 3,482 sample participants with complete information for all variables were included in this analysis.For all cause death, the odds ratios (S.E.) for statistically significant variables were body mass index, 1.03 (1.01-1.06); 1.01 (1.01-1.01); blood lead concentration, 1.05 (1.01-1.08); poverty income ratio, 0.823 (0.76-0.89);and drinking hard liquor, 1.01 (1.00-1.02). For all cancer mortality, the odds ratios (S.E.) of the statisticallysignigicant variables were: age, 1.01 (1.01-1.01); blood lead concentration, 1.07 (1.04-1.12), black race, usingnon-Hispanic white as reference, 1.69 (1.12-2.56); and smoking, 1.02 (1.01-1.04). For lung cancer mortality, theodds ratios (S.E.) of the statistically significant variables were: age, 1.01(1.01-1.01); blood lead concentration,1.09 (1.05-1.13); Mexican Americans, using non-Hispanic white as refrence, 0.33 (0.129-0.850); other races,1.80 (0.53-6.18); and smoking, 1.03 (1.02-1.05). Conclusion: Blood lead concentration correlated with all cause,all cancer, and lung cancer mortality in adults.     

Socioeconomic position,population density and site‐specific cancer mortality: A multilevel analysis of Belgian adults, 2001–2011

Our study explores the association between individual and neighborhood socioeconomic position (SEP) and all‐cancer and site‐specific cancer mortality. Data on all Belgian residents are retrieved from a population‐based dataset constructed from the 2001 census linked to register data on emigration and mortality for 2001–2011. The study population contains all men and women aged 40 years or older during follow‐up. Individual SEP is measured using education, employment status and housing conditions. Neighborhood SEP is measured by a deprivation index (in quintiles). Directly age‐standardized mortality rates and multilevel Poisson models are used to estimate the association between individual SEP and neighborhood deprivation and mortality from all‐cancer and cancer of the lung, colon and rectum, pancreas, prostate and female breast. The potential confounding role of population density is assessed using multilevel models as well. Our findings show an increase in mortality from all‐cancer and site‐specific cancer by decreasing level of individual SEP for both men and women. In addition, individuals living in highly deprived neighborhoods experience significantly higher mortality from all‐cancer, lung cancer, pancreatic cancer and female colorectal cancer after controlling for individual SEP. Male colorectal and prostate cancer and female breast cancer are not associated with neighborhood deprivation. Population density acts as a confounder for female lung cancer only. Our study indicates that deprivation at both the individual and neighborhood level is associated with all‐cancer mortality and mortality from several cancer sites. More research into the role of life‐style related and clinical factors is necessary to gain more insight into causal pathway.     

Trends in skin cancer incidence by socioeconomic position in Scotland, 1978�C2004

Background:

Non-melanoma skin cancer has been little studied in relation to deprivation.

Methods:

Incident cases diagnosed in 1978–2004 were extracted from the Scottish Cancer Register and assigned to quintiles of Carstairs deprivation scores. Age-standardised incidence rates (ASRs) (European standard population) were calculated by deprivation quintile, sex, period of diagnosis, for the three main types of skin cancer.

Results and conclusion:

As age-standardised incidence of each skin cancer increased significantly over time across all deprivation categories, rates were consistently highest in the least deprived quintile.     

Cancer incidence patterns by region and socioeconomic deprivation in teenagers and young adults in England

Data on 35,291 individuals with cancer, aged 13-24 years, in England from 1979 to 2001 were analysed by region and socio-economic deprivation of census ward of residence, as measured by the Townsend deprivation index. The incidence of leukaemia, lymphoma, central nervous system tumours, soft tissue sarcomas, gonadal germ cell tumours, melanoma and carcinomas varied by region (P<0.01, all groups) but bone tumour incidence did not. Lymphomas, central nervous system tumours and gonadal germ cell tumours all had higher incidence in less deprived census wards (P<0.01), while chronic myeloid leukaemia and carcinoma of the cervix had higher incidence in more deprived wards (P<0.01). In the least deprived wards, melanoma incidence was nearly twice that in the most deprived, but this trend varied between regions (P<0.001). These cancer incidence patterns differ from those seen in both children and older adults and have implications for aetiology and prevention.     

Cancer incidence in South Asian migrants to England, 1986–2004: Unraveling ethnic from socioeconomic differentials

Studies on cancer in migrants are informative about the relative influence of environmental and genetic factors on cancer risk. This study investigates trends in incidence from colorectal, lung, breast and prostate cancer in England among South Asians and examines the influence of deprivation, a key environmental exposure. South Asian ethnicity was assigned to patients recorded in the population‐based National Cancer Registry of England during 1986–2004, using the computerized algorithm SANGRA: South Asian Names and Groups Recognition Algorithm. Population denominators were derived from population censuses. Multivariable flexible (splines) Poisson models were used to estimate trends and socioeconomic differentials in incidence in South Asians compared to non‐South Asians. Overall, age‐adjusted cancer incidence in South Asians was half that in non‐South Asians but rose over time. Cancer‐specific incidence trends and patterns by age and deprivation differed widely between the two ethnic groups. In contrast to non‐South Asians, lung cancer incidence in South Asians did not fall. Colorectal and breast cancer incidence rose in both groups, more steeply in South Asians though remaining less common than in non‐South Asians. The deprivation gaps in cancer‐specific incidence were much less marked among South Asians, explaining some of the ethnic differences in overall incidence. Although still lower than in non‐South Asians, cancer incidence is rising in South Asians, supporting the concept of transition in cancer incidence among South Asians living in England. Although these trends vary by cancer, they have important implications for both prevention and anticipating health‐care demand.     

Trends and inequalities in laryngeal cancer survival in men and women: England and Wales 1991-2006

Laryngeal cancer in men is a relatively common malignancy, with a marked socioeconomic gradient in survival between affluent and deprived patients. Cancer of the larynx in women is rare. Survival tends to lower than for men, and little is known about the association between deprivation and survival in women with laryngeal cancer. This paper explores the trends and socio-economic inequalities in laryngeal cancer survival in women, with comparison to men. We examined relative survival among men and women diagnosed with laryngeal cancer in England and Wales during 1991-2006, followed up to 31 December 2007. We estimated the difference in survival between the most deprived and most affluent groups (the 'deprivation gap') at one and five years after diagnosis, for each sex, anatomical subsite and calendar period. Five year survival for all laryngeal cancers combined was up to 8% lower in women than in men. This difference is only partially explained by the differential distribution of anatomical subsites in men and women. Disparities in survival between men and women were also present within specific subsites. In contrast to men, there was little evidence of a consistent deprivation gap in survival for women at any of the anatomical subsites. The stark socioeconomic inequalities in laryngeal cancer survival in men do not appear to be replicated in women. The origins of the socio-economic inequalities in survival among men, and the disparities in survival between men and women at specific tumour subsites remains unclear.     

Increasing colorectal cancer incidence rates in Japan

We examined trends of colorectal cancer incidence rates among Japanese (Miyagi Prefecture) and United States (US) whites (State of Connecticut) between 1959 and 1992. Age-standardized rates in Japan have increased dramatically and are now similar to US white rates. For both colon and rectum, age-specific rates in Japanese men born after 1930 exceed those in US whites, and the Japanese excess increases with year of birth. Similar patterns are evident for women. The current trends suggest that colorectal cancer will become a major source of morbidity and mortality in Japan, as these young Japanese age and their risks increase.     

Changes over time in socioeconomic inequalities in breast and rectal cancer survival in England and Wales during a 32-year period (1973–2004): the potential role of health care

BackgroundSocioeconomic inequalities in cancer survival are well documented but they vary for different cancers and over time. Reasons for these differences are poorly understood.Patients and methodsFor England and Wales, we examined trends in socioeconomic survival inequalities for breast cancer in women and rectal cancer in men during the 32-year period 1973–2004. We used a theoretical framework based on Victora's ‘inverse equity’ law, under which survival inequalities could change with the advent of successive new treatments, of varying effectiveness, which are disseminated with different speed among patients of different socioeconomic groups. We estimated 5-year relative survival for patients of different deprivation quintiles and examined trends in survival inequalities in light of major treatment innovations.ResultsInequalities in breast cancer survival (921,611 cases) narrowed steadily during the study (from -10% to -6%). In contrast, inequalities in rectal cancer survival (187,104 cases) widened overall (form -5% to -11%) with fluctuating periods of narrowing inequality.ConclusionsTrends in socioeconomic differences in tumour or patient factors are unlikely explanations of observed changes over time in survival inequalities. The sequential introduction into clinical practice of new treatments of progressively smaller incremental benefit may partly explain the reduction in inequality in breast cancer survival.     

Incidence of and survival from upper aerodigestive tract cancers in the U.K.: the influence of deprivation

The aim of the study was to investigate the effect of social deprivation on the incidence of and survival from upper aerodigestive tract (UAT) cancers in the U.K. Incidence was calculated on 25 903 cases of malignant upper aerodigestive tract cancers collected from four cancer registries in the U.K. for the period 1984–1993. A Cox proportional hazard model was used to determine the influence of deprivation, measured in Carstairs quintiles for crude and cause-specific survival on 17 393 of these cases. Patients with UAT cancers who were younger, males or of South Asian origin were more likely to live in a deprived area than in an affluent area. The incidence of UAT cancers in a district was correlated with deprivation score for the district for both men (r=0.78) and for women (r=0.60). People who lived in deprived areas had a relative risk of 1.25 (95% confidence interval (CI):1.15–1.35) of dying from their cancer and of 1.24 (95% CI: 1.13–1.35) of dying from all causes compared with people who lived in affluent areas. People living in deprived areas were more likely to get UAT cancer and were more likely to die from their cancer than people living in affluent areas.     

Lack of prospective associations between plasma and urinary phytoestrogens and risk of prostate or colorectal cancer in the European Prospective into Cancer-Norfolk study

Dietary phytoestrogens are suggested to reduce the risk of prostate and colorectal cancer, but the results of epidemiologic studies have not yielded consistent support for this proposed effect, possibly due to inadequate databases of phytoestrogen levels in foods. Biomarkers of phytoestrogen intakes may provide a clearer insight into the relationship between phytoestrogen exposure and the risk of prostate or colorectal cancer risks. From the European Prospective into Cancer-Norfolk cohort (ages 45-75), serum and urine samples were analyzed for seven phytoestrogens [daidzein, enterodiol, enterolactone, genistein, glycitein, O-desmethylangolensin (O-DMA), and equol] among 193 cases of prostate cancer and 828 controls, and 221 cases of colorectal cancer with 889 controls. Summary variables of total lignans (enterodiol and enterolactone) and total isoflavones (daidzein, genistein, O-DMA, equol, and glycitein) were created and analyzed in conjunction with individual phytoestrogens. Logistic regression analyses revealed that there was no significant association between prostate cancer risk and total serum isoflavones [odds ratio (OR), 1.01; 95% confidence interval (CI), 0.93-1.10] or total serum lignans (OR, 0.94; 95% CI, 0.86-1.04) or between colorectal cancer risk and total serum isoflavones (OR, 1.01; 95% CI, 0.94-1.08) or total serum lignans (OR, 1.03; 95% CI, 0.94-1.12). Similarly, null associations were observed for individual serum phytoestrogens and for all urinary phytoestrogen biomarkers. In conclusion, we have found no evidence to support an inverse association between phytoestrogen exposure and prostate or colorectal cancer risk.     

Trend Analysis of Lung Cancer Incidence Rates in Ninawa Province,Iraq, from 2000 to 2010 - Decrease and Recent Stability

Background: Lung cancer is the most frequent malignancy of men worldwide. In Ninawa in Iraq, lung cancerranks first among cancers diagnosed in men. Since no prior studies have been conducted on incidence trendsin our population the present investigation of rates during 2000-2010 was therefore performed. Materials andMethods: Registy data for lung cancer cases were collected from the Directorate of Health in Ninawa-MosulContinuing Medical Education Center. We restricted our analyses to men categorized according to the age groupsof 0- 39, 40-49, 50-59, 60-69 and 70+ years. The significance of incidence rate trends during 2000-2010 was testedusing Poisson regression. Age-standardized rates (ASR), and age-specific rates per 100,000 population werecalculated. Results: A total of 1,206 incident lung cancer were registered among males, accounting for 15.5%of all male cancers registered during 2000-2010. It ranked first throughout the period. Median age at diagnosiswas 69 (mean 66.8± 11.0) years. The incidence rate of all male lung cancers in Ninawa (all ages) decreased from26.4 per 100,000 in 2000 to 12.7 in 2010 (APC=-6.55%, p<.0001). The incidences in age groups 40-49, 50-59,60-69 and 70+ decreased in earlier years and recently appeared (2007-2010) stable. The incidence in age group(0-39) remained stable between 2000-2010. Squamous cell carcinoma (SCC)was the most common type of lungcancer, while adenocarcinoma was relatively rare. Conclusions: With the data from Directorate of Health inNinawa during the period 2000-2010, lung cancer is the most common cancer but generally declining. Amongall age groups, the recent incidence of lung cancer remained stable. The SCC predominance suggests change intobacco habits as an important factor in the trends observed.     

Disparities in cancer incidence by area-level socioeconomic status in the French West Indies

Purpose

Social inequalities in cancer incidence and mortality have been reported in France, but no data are available for the French overseas territories. Our objective was to explore the association between cancer incidence and the socioeconomic level of the residence area in the French West Indies.

Methods

Cancer incidence data were obtained from the cancer registries of Guadeloupe and Martinique (2009–2010). To assess socioeconomic status, we developed a specific index of social deprivation from census data at a small area level. We used Bayesian methods to evaluate the association between cancer incidence and the deprivation index, for all cancers combined and for the major cancer sites.

Results

There was no clear association between area-based deprivation and the incidence of all cancers combined. In men, higher area deprivation was associated with a higher incidence of prostate cancer (relative risk (RR) 1.25, 95% credible interval (CI) 1.04–1.49; RR 1.08, CI 0.91–1.29 in the categories of intermediate and high deprivation, respectively, compared to low deprivation), but was not associated with respiratory cancer. Women living in the most deprived areas had a higher incidence of stomach (RR 1.77, CI 1.12–2.89), breast (RR 1.15, CI 0.90–1.45), and cervical (RR 1.13, CI 0.63–2.01) cancers and a lower incidence of respiratory cancer (RR 0.65, CI 0.38–1.11).

Conclusion

These first results in the French West Indies suggest specific patterns for some cancer sites that need to be further investigated.

     

Cancer survival in England and Wales at the end of the 20th century

Survival has risen steadily since the 1970s for most cancers in adults in England and Wales, but persistent inequalities exist between those living in affluent and deprived areas. These differences are not seen for children. For many of the common adult cancers, these inequalities in survival (the 'deprivation gap') became more marked in the 1990s. This volume presents extended analyses of survival for adults diagnosed during the 14 years 1986-1999 and followed up to 2001, including trends in overall survival in England and Wales and trends in the deprivation gap in survival. The analyses include individual tumour data for 2.2 million cancer patients. This article outlines the structure of the supplement - an article for each of the 20 most common cancers in adults, followed by an expert commentary from one of the leading UK clinicians specialising in malignancies of that organ or system. The available data, quality control and methods of analysis are described here, rather than repeated in each of the 20 articles. We open the discussion between clinicians and epidemiologists on how to interpret the observed trends and inequalities in cancer survival, and we highlight some of the most important contrasts in these very different points of view. Survival improved substantially for adult cancer patients in England and Wales up to the end of the 20th century. Although socioeconomic inequalities in survival are remarkably persistent, the overall patterns suggest that these inequalities are largely avoidable.     

Breast cancer incidence trends in deprived and affluent Scottish women

OBJECTIVE : Breast cancer is commoner in the affluent and breast cancer rates in many countries are rising; it remains unclear whether this incidence rise is consistent across the different socio-economic groups. The rising incidence of breast cancer may be related to changes in population risk factor profiles. This study aimed to determine breast cancer incidence trends in women of different socio-economic categories and whether these trends were related to breast cancer risk factor trends. DESIGN : Data on breast cancer incidence rates by deprivation quintile in Scotland 1991-2000 were analysed using linear regression. Data on first births at late maternal age, BMI trends (based on the Scottish Health Surveys) and breast screening uptake trends in the different categories were also analysed and their relation to breast cancer incidence trends explored. POPULATION AND SETTING : Breast cancer incidence data was based on all women in Scotland. BMI data was based on representative cross-sectional survey data from the Scottish Health Surveys-women in the 1995, 1998 and 2003 surveys were 16-64, 16-74 and aged 16 and over, respectively. First birth data was based on all women aged 35-39 in Scotland. Breast screening uptake data was studied in women of screening age, that is, aged 50-64. RESULTS : Breast cancer incidence rates in Scottish women are rising in parallel across all socio-economic categories and the incidence gap between deprived and affluent still remains. Since the late 1980s, numbers of first birth in Scottish women aged 35-39 have risen dramatically, especially in the affluent, but numbers were stable before this. The prevalence of obesity and mean BMI has increased over time in all socio-economic classes but BMI continues to be higher in the deprived. Uptake of screening invitations has increased in all socio-economic groups. CONCLUSIONS : Breast cancer is rising in women of all socio-economic status in Scotland and the deprived-affluent gap remains. Trends in late age at first pregnancy, prevalence of obesity and screening uptake do not fully explain the observed trends.