• Mahiben Maruthappu, Johnathan A Watkins, Mueez Waqar, Callum Williams, Raghib Ali, Rifat Atun, Omar Faiz, and Thomas Zeltner.
• 1 Imperial College London, London SW7 2AZ, UK 2 Faculty of Arts and Sciences, Harvard University, MA 02138, USA maruthappu@post.harvard.edu.
• Eur J Public Health. 2015 Apr 1; 25 (2): 330-5.

BackgroundThe 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.MethodsWe 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.ResultsUnemployment 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.ConclusionRises 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.© The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

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