Regional variations in cancer survival: Impact of tumour stage, socioeconomic status, comorbidity and type of treatment in Norway

Regional cancer incidence and survival in Denmark

BACKGROUND

Potential regional differences in cancer incidence and survival would demand targeted interventions to decrease cancer related death.

METHODS

This descriptive cohort study provides an overview of regional cancer incidence and relative survival (RS) in Denmark during 2007-2021. National cancer incidence and RS estimates were calculated similar to the official statistics for the Danish Cancer Registry. Specifically, we estimated age-standardized (World) cancer incidence rates (ASR), and RS in 3-year periods by sex, and the five regions of Denmark (i.e., Region of Northern Denmark, Central Denmark Region, Region of Southern Denmark, Region Zealand, and Capital Region).

RESULTS

We identified 578,107 incident cancers in Denmark during 2007-2021, of which 124 123 were diagnosed in 2019-2021. Small fluctuations were seen in ASR for cancer overall in all five regions during 2007-2018, followed by decreasing trends in 2019-2021. Men exhibited higher ASRs than women. Consistent improvements in 1- and 5-year RS were seen during the study period in all regions. However, for patients diagnosed in 2019-2021, the 5-year RS levelled off. These patients experienced 1-year RS of 83 % among men and 84 % among women, and the 5-year RS was also similar between sexes (men: 67 %, women: 70 %, overall: 68 %). Region Zealand generally presented lower RS estimates for both sexes combined.

CONCLUSION

Cancer survival improved between 2007 and 2021 in all Danish regions for both sexes. However, the improvements in cancer survival appeared to have levelled off in the most recent period, 2019-2021. For both sexes, the lowest survival was suggested for Region Zealand.

Net survival of men with localized prostate cancer after LDR brachytherapy

OBJECTIVES

To compare survival of patients who received LDR prostate brachytherapy relative to that of peers in the general population of England, UK.

PATIENTS AND METHODS

Net survival was estimated for 2472 cases treated between 2002 and 2016 using population-based analysis guidelines. Life tables adjusted for social deprivation in England from the Office for National Statistics were used to match patients by affluence based on their postcode.

RESULTS

The median (range) age at time of brachytherapy was 66 (55-84) years, 84% resided in Southeast England, 51% under an index of deprivation quintile 5 (most affluent), 55% were clinical stage T1 and the remainder T2. Death from any cause occurred in 270 patients at a median (range) of 7 (1-17) years postimplant. Five and 10-year estimates (95% CI) of overall survival were 96% (95-97) and 90% (89-92), and net survival 103% (102-104) and 109% (107-110) respectively. The net survival remained above 100% in all age-at-treatment and clinical stage groups.

CONCLUSION

Net survival above 100% indicates patients survive longer than the matched general population. The study shows for the first time the net survival of patients treated with a radical therapy for localized prostate cancer in England. The impact of treatment choice on the long-term net survival advantage requires further investigation.

Is survival rate lower after breast cancer in deprived women according to disease stage?

BACKGROUND

Socioeconomic deprivation has been associated with lower breast cancer (BC) survival, but the influence of stage at diagnosis on this association merits further study. Our aim was to investigate this association using the Loire-Atlantique/Vendee Cancer Registry (France).

METHODS

Twelve-thousand seven-hundred thirty-eight women living in the area covered by the registry and diagnosed with invasive breast carcinoma between 2008 and 2015 were included in the study. They were censored at maximal 6 years. Deprivation was measured by the French European Deprivation Index. Excess hazard and net survival were estimated for deprivation level, stage and age at diagnosis using a flexible excess mortality hazard model.

RESULTS

After adjustment by stage, women living in the most deprived areas had a borderline non-significant higher excess mortality hazard (+25% (95% CI: -3%; +62%)) compared to those living in the least deprived areas. Stage-adjusted 5-year net survival differed significantly between these two subgroups (respectively, 88.2% (95% CI:85.2%-90.5%) and 92.5% (95% CI:90.6%-93.9%)).

CONCLUSION

BC survival remained lower in deprived areas in France, despite universal access to cancer care. Intensification of prevention measures could help to reduce advanced BC, responsible for the majority of deaths from BC. A better understanding of remaining social disparities is crucial to implement specific interventions.

Is the Social Gradient in Net Survival Observed in France the Result of Inequalities in Cancer-Specific Mortality or Inequalities in General Mortality?

BACKGROUND

In cancer net survival analyses, if life tables (LT) are not stratified based on socio-demographic characteristics, then the social gradient in mortality in the general population is ignored. Consequently, the social gradient estimated on cancer-related excess mortality might be inaccurate. We aimed to evaluate whether the social gradient in cancer net survival observed in France could be attributable to inaccurate LT.

METHODS

Deprivation-specific LT were simulated, applying the social gradient in the background mortality due to external sources to the original French LT. Cancer registries' data from a previous French study were re-analyzed using the simulated LT. Deprivation was assessed according to the European Deprivation Index (EDI). Net survival was estimated by the Pohar-Perme method and flexible excess mortality hazard models by using multidimensional penalized splines.

RESULTS

A reduction in net survival among patients living in the most-deprived areas was attenuated with simulated LT, but trends in the social gradient remained, except for prostate cancer, for which the social gradient reversed. Flexible modelling additionally showed a loss of effect of EDI upon the excess mortality hazard of esophagus, bladder and kidney cancers in men and bladder cancer in women using simulated LT.

CONCLUSIONS

For most cancers the results were similar using simulated LT. However, inconsistent results, particularly for prostate cancer, highlight the need for deprivation-specific LT in order to produce accurate results.

Exploring wait time variations in a prostate cancer patient pathway—A qualitative study

Norwegian health authorities emphasise that all citizens should have equal access to healthcare and implement cancer patient pathways (CPPs) to ensure medical care for all patients within the same time frame and to avoid unwanted variation. Statistics regarding prostate cancer indicate longer wait times for patients from a local hospital compared to patients from a university hospital. This study describes which health system‐related factors influence variations in wait times. Eighteen healthcare workers participated in qualitative individual interviews conducted using a semi‐structured interview guide. Transcripts were analysed by systematic text condensation, which is a cross‐case method for the thematic analysis of qualitative data. The analysis unveiled four categories describing possible health system‐related factors causing variation in times spent on diagnostics for patients in the local hospital and in university hospital, respectively: (a) capacity and competence, (b) logistics and efficiency, (c) need for highly specialised investigations, and (d) need for extra consultations. Centralisation of surgical treatment necessitated the transfer of patients, with extra steps indicated in the CPP for patients transferring from the local hospital to the university hospital for surgery. The local hospital seemed to lack capacity more frequently than the university hospital. Possible factors explaining variations in wait time between the two hospitals concern both internal conditions at the hospitals in organising CPPs and the implications of transferring patients between hospitals. Differences in hospitals' capacity can cause variations in wait time. The extra steps involved in transferring patients between hospitals can lead to additional time spent in CPP.

Centralisation of surgical treatment necessitated the transfer of patients

The extra steps involved in transferring patients between hospitals can lead to additional time spent in cancer patient pathway

It can be a demanding exercise to comply with the authorities' requirements for specific wait times and simultaneously centralise treatment

Politicians and health authorities should have these implications of contradictory quality indicators in mind when designing patient pathways

Equitable access to cancer patient pathways in Norway - a national registry-based study

Background

In 2015, cancer patient pathways (CPP) were implemented in Norway to reduce unnecessary non-medical delay in the diagnostic process and start of treatment. The main aim of this study was to investigate the equality in access to CPPs for patients with either lung, colorectal, breast or prostate cancer in Norway.

Methods

National population-based data on individual level from 2015 to 2017 were used to study two proportions; i) patients in CPPs without the cancer diagnosis, and ii) cancer patients included in CPPs. Logistic regression was applied to examine the associations between these proportions and place of residence (hospital referral area), age, education, income, comorbidity and travel time to hospital.

Results

Age and place of residence were the two most important factors for describing the variation in proportions. For the CPP patients, inconsistent differences were found for income and education, while for the cancer patients the probability of being included in a CPP increased with income.

Conclusions

The age effect can be related to both the increasing risk of cancer and increasing number of GP and hospital contacts with age. The non-systematic results for CPP patients according to income and education can be interpreted as equitable access, as opposed to the systematic differences found among cancer patients in different income groups. The inequalities between income groups among cancer patients and the inequalities based on the patients’ place of residence, for both CPP and cancer patients, are unwarranted and need to be addressed.

Supplementary Information

The online version contains supplementary material available at (10.1186/s12913-021-07250-1).

Impact of Socioeconomic Status on Cancer Incidence Risk, Cancer Staging, and Survival of Patients with Colorectal Cancer under Universal Health Insurance Coverage in Taiwan

This study examined the impact of socioeconomic status on colorectal cancer risk, staging, and survival under the National Health Insurance (NHI) system in Taiwan. Monthly salary and education level were used as measures of socioeconomic status to observe the risk of colorectal cancer among individuals aged 40 years or above in 2006-2015 and survival outcomes of patients with colorectal cancer until the end of 2016. Data from 286,792 individuals were used in this study. Individuals with a monthly salary ≤Q1 were at a significantly lower incidence risk of colorectal cancer than those with a monthly salary >Q3 (HR = 0.80, 95% CI = 0.74-0.85), while those with elementary or lower education were at a significantly higher risk than those with junior college, university, or higher education (HR = 1.18, 95% CI = 1.06-1.31). The results show that socioeconomic status had no significant impact on colorectal cancer stage at diagnosis. Although salary was not associated with their risk of mortality, patients with colorectal cancer who had elementary or lower education incurred a significantly higher risk of mortality than those who had junior college, university, or higher education (HR = 1.39, 95% CI = 1.07-1.77). Education level is a significant determinant of the incidence risk and survival in patients with colorectal cancer, but only income significantly impacts incidence risk.

Regional variation in cancer survival in Norway

BACKGROUND

Cancer services in Norway are intended to provide high quality services and equal access for all citizens. Still, regional variation in cancer survival has been reported. Currently, the public hospitals are organized in Health Trusts (HTs), respectively within one of four regional trusts (RHTs). We aimed to evaluate the extent and rank pattern of regional and intraregional variation in cancer survival systematically over the last three decades. We postulated that organizational reforms during this period might have modulated the variation.

METHODS

Excess hazard ratios (EHR) of death from cancer were estimated for all individuals identified in The Cancer Registry of Norway as diagnosed with cancer from 1984 to 2018. The model covariates included continuous age at diagnosis, sex, cancer site, stage, 5-year time period of diagnosis and place of residence. In addition to analyses for all cancers combined, selected cohorts with predominantly centralized vs. not centralized primary surgery were evaluated.

RESULTS

For all cancer sites combined and for the centralized surgery cohort, the range of variation in EHR among the four regions was in the order of 0.10. The ranks among the regions were fairly consistent over time. For the not centralized surgery cohort, the range of inter-regional EHR-variation was in the order of 0.10 - 0.15, with no consistent ranks. Intra-regionally, the ranges of EHR-variation were similar, but with more complex rank patterns.

CONCLUSIONS

The range of inter- and intra-regional variation in cancer survival was minor, as compared to the general improvement in cancer survival in the period, with no evidence of effect from organizational reforms on regional variation.

How do age and social environment affect the dynamics of death hazard and survival in patients with breast or gynecological cancer in France?

Several studies have investigated the association between net survival (NS) and social inequalities in people with cancer, highlighting a varying influence of deprivation depending on the type of cancer studied. However, few of these studies have accounted for the effect of social inequalities over the follow-up period, and/or according to the age of the patients. Thus, using recent and more relevant statistical models, we investigated the effect of social environment on NS in women with breast or gynecological cancer in France. The data were derived from population-based cancer registries, and women diagnosed with breast or gynecological cancer between 2006 and 2009 were included. We used the European deprivation index (EDI), an aggregated index, to define the social environment of the women included. Multidimensional penalized splines were used to model excess mortality hazard. We observed a significant effect of the EDI on NS in women with breast cancer throughout the follow-up period, and especially at 1.5 years of follow-up in women with cervical cancer. Regarding corpus uteri and ovarian cancer patients, the effect of deprivation on NS was less pronounced. These results highlight the impact of social environment on NS in women with breast or gynecological cancer in France thanks to a relevant statistical approach, and identify the follow-up periods during which the social environment may have a particular influence. These findings could help investigate targeted actions for each cancer type, particularly in the most deprived areas, at the time of diagnosis and during follow-up.

Factors associated with emergency-onset diagnosis, time to treatment and type of treatment in colorectal cancer patients in Norway

Background

International differences in survival among colorectal cancer (CRC) patients may partly be explained by differences in emergency presentations (EP), waiting times and access to treatment.

Methods

CRC patients registered in 2015–2016 at the Cancer Registry of Norway were linked with the Norwegian Patient Registry and Statistics Norway. Multivariable logistic regressions analysed the odds of an EP and access to surgery, radiotherapy and systemic anticancer treatment (SACT). Multivariable quantile regression analysed time from diagnosis to treatment.

Results

Of 8216 CRC patients 29.2% had an EP before diagnosis, of which 81.4% were admitted to hospital with a malignancy-related condition. Higher age, more advanced stage, more comorbidities and colon cancer were associated with increased odds of an EP (p < 0.001). One-year mortality was 87% higher among EP patients (HR=1.87, 95%CI:1.75–2.02). Being married or high income was associated with 30% reduced odds of an EP (p < 0.001). Older age was significantly associated with increased waiting time to treatment (p < 0.001). Region of residence was significantly associated with waiting time and access to treatment (p < 0.001). Male (OR = 1.30, 95%CI:1.03,1.64) or married (OR = 1.39, 95%CI:1.09,1.77) colon cancer patients had an increased odds of SACT. High income rectal cancer patients had an increased odds (OR = 1.48, 95%CI:1.03,2.13) of surgery.

Conclusion

Patients who were older, with advanced disease or more comorbidities were more likely to have an emergency-onset diagnosis and less likely to receive treatment. Income was not associated with waiting time or access to treatment among CRC patients, but was associated with the likelihood of surgery among rectal cancer patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08415-1.

A cross-sectional study to assess knowledge of women about cervical cancer: an urban and rural comparison

INTRODUCTION

Cervical cancer and its etiopathogenesis, the age of women in whom it is diagnosed, average life expectancy, and prognosis are information widely covered in scientific reports. However, there is no coherent information regarding which regions-urban or rural-it may occur more often. This is important because the literature on the subject reports that people living in rural areas have a worse prognosis when it comes to detection, treatment, and life expectancy than city dwellers.

MATERIAL AND METHODS

The subjects of the study were women and their knowledge about cervical cancer. The research was carried out using a survey directly distributed among respondents and via the Internet, portals, and discussion groups for women from Poland. Three hundred twenty-nine women took part in the study, including 164 from rural and 165 from urban areas. The collected data enabled the following: (1) an analysis of the studied groups, (2) assessment of the respondents' knowledge about cervical cancer, and (3) comparison of women's knowledge depending on where they live.

RESULTS

The average assessment of all respondents' knowledge was 3.59, with women living in rural areas scoring 3.18 and respondents from the city-4.01. Statistical significance (p < 0.001) between the level of knowledge and place of residence was determined. The results indicate that an increase in the level of education in the subjects significantly increases the chance of getting the correct answer. In the case of age analysis, the coefficients indicate a decrease in the chance of obtaining the correct answer in older subjects despite the fact that a statistically significant level was reached in individual questions.

CONCLUSIONS

Women living in rural areas have less knowledge of cervical cancer than female respondents from the city. There is a need for more awareness campaigns to provide comprehensive information about cervical cancer to women in rural areas. A holistic approach to the presented issue can solve existing difficulties and barriers to maintaining health regardless of the place of life and residence.

IMPLICATION FOR CANCER SURVIVORS

They need intensive care for women's groups most burdened with risk factors.

Factors associated with emergency-related diagnosis, time to treatment and type of treatment in 5713 lung cancer patients

Background

International and national differences exist in survival among lung cancer patients. Possible explanations include varying proportions of emergency presentations (EPs), unwanted differences in waiting time to treatment and unequal access to treatment.

Methods

Case-mix-adjusted multivariable logistic regressions the odds of EP and access to surgery, radiotherapy and systemic anticancer treatment (SACT). Multivariable quantile regression analyzed time from diagnosis to first treatment.

Results

Of 5713 lung cancer patients diagnosed in Norway in 2015–16, 37.9% (n = 2164) had an EP before diagnosis. Higher age, more advanced stage and more comorbidities were associated with increasing odds of having an EP (P < 0.001) and a lower odds of receiving any treatment (P < 0.001). After adjusting for case-mix, waiting times to curative radiotherapy and SACT were 12.1 days longer [95% confidence interval (CI): 10.2, 14.0] and 5.6 days shorter (95% CI: −7.3, −3.9), respectively, compared with waiting time to surgery. Patients with regional disease experienced a 4.7-day shorter (Coeff: −4.7, 95% CI:−9.4, 0.0) waiting time to curative radiotherapy when compared with patients with localized disease. Patients with a high income had a 22% reduced odds [odds ratio (OR) = 0.78, 95% CI: 0.63, 0.97] of having an EP, and a 63% (OR = 1.63, 95% CI: 1.20, 2.21) and a 40% (OR = 1.40, 95% CI: 1.12, 1.76) increased odds of receiving surgery and SACT, respectively.

Conclusion

Patients who were older, had advanced disease or increased comorbidities were more likely to have an EP and less likely to receive treatment. While income did not affect the waiting time for lung cancer treatment in Norway, it did affect the likelihood of receiving surgery and SACT.

Regional inequalities in cervical cancer survival in Minas Gerais State, Brazil

BACKGROUND

Cervical cancer survival is marked by socioeconomic and demographic inequalities. We investigated differences in survival across health regions in Minas Gerais, Brazil, in cervical cancer patients who underwent treatment in the Brazilian Public Health System.

METHODS

From a database developed through probabilistic and deterministic linkage of data from information systems of the Brazilian Public Health System, we identified cervical cancer cases, diagnosed between 2002 and 2010, who underwent radiation and/or chemotherapy and lived in Minas Gerais, Brazil. Five-year overall and cause-specific survivals were estimated by the Kaplan-Meier method and compared using the log-rank test. We used extended Cox models to assess the relationship between the health region of residence and the overall and cause-specific death risk, adjusting for relevant variables.

RESULTS

We included 5613 patients with a median age of 55.0 years. Median follow-up time was 70.0 months. Five-year overall and cause-specific survivals were 56.3 % and 63.6 %, respectively. Across the 13 health regions, 5-year survival ranged from 46.6%-64.2% (p < 0.001) in the overall analysis and from 52.0% to 72.0% (p < 0.001) in the cause-specific analysis. Multivariate models revealed a significantly higher death risk for most health regions in comparison to the reference health region (Norte). Adjustment by age, tumor stage, comorbidity, treatment, travel time, and year of diagnosis had little effect on the association.

CONCLUSION

We found regional disparities in cervical cancer survival that persisted after relevant adjustments. Uneven regional provision of health services might be implicated in these disparities, affecting timely access to treatment for cervical cancer patients.

Educational inequalities and regional variation in colorectal cancer survival in Finland

BACKGROUND

Previous studies have reported lower colorectal cancer (CRC) survival in patients with low compared to high educational levels. We investigated the impact of education on CRC survival by using both individual and area-based information on education.

METHODS

Patients diagnosed with CRC in Finland in 2007-2016 were followed up for death until the end of 2016. Age-standardized relative survival and relative excess risk of death (RER) were estimated by sex using period approach. RERs were adjusted for age, stage at diagnosis, cancer site, urbanity, hospital district and municipality by using Bayesian piecewise constant excess hazard models. Analyses were conducted including individual (basic, secondary, high) and area-based (quartiles Q1-Q4 based on the proportion of population with basic education) education separately as well as both measures in one model.

RESULTS

We analysed in all 24 462 CRC patients. There was a clear gradient in 5-year relative survival across education groups (men: basic 62 %, secondary 64 %, high 69 %; women: basic 61 %, secondary 67 %, high 71 %). Compared to the basic education group, RER in the high education group was significantly lower. This association was still present after including area-based education in the models (men: RER 0.72, 95 % Confidence interval (CI) 0.64-0.81; women: RER 0.76, 95 % CI 0.59-0.96). Area-based education revealed smaller effect estimates than individual education in CRC survival and no association for men.

CONCLUSION

Individual education information should be preferred over area-based when survival differences are studied by education. Educational differences in CRC survival are still present in Finland.

Cancer incidence in non-immigrants and immigrants in Norway

BACKGROUND

Major cancers are associated with lifestyle, and previous studies have found that the non-immigrant populations in the Nordic countries have higher incidence rates of most cancers than the immigrant populations. However, rates are changing worldwide - so these differences may disappear with time. Here we present recent cancer incidence rates among immigrant and non-immigrant men and women in Norway and investigate whether previous differences still exist.

MATERIAL AND METHODS

We took advantage of a recent change in the Norwegian Cancer Registry regulations that allow for the registry to have information on country of birth. The number of person years for 2014-2018 was aggregated for every combination of sex, five-year age-group and country of birth, by summing up each year's population in these groups. The number of cancer cases was then counted for the same groups, and age-standardised incidence rates calculated by weighing the age-specific incidence rates by the Nordic and World standard populations. Further, we calculated incidence rate ratios using the non-immigrant population as a reference.

RESULTS

Immigrants from Eastern Europe, the Middle East, Africa and Asia had lower incidence of total cancer compared to the non-immigrant population in Norway and immigrants born in the other Nordic or high-income countries. However, some cancers were more common in certain immigrant groups. Asian men and women had threefold the incidence of liver cancer than non-immigrant men and women. Men from the other Nordic countries and from Eastern Europe had higher lung cancer rates than non-immigrant men.

CONCLUSION

National registries should continuously monitor and present cancer incidence stratified on important population subgroups such as country of birth. This can help assess population subgroup specific needs for cancer prevention and treatment, and could eventually help reduce the morbidity and mortality of cancer.

Variation in cancer survival between hospital districts and within them in Finland

BACKGROUND

Monitoring regional variation in population-based cancer survival is useful for assessing equity in national health-care system. This study quantifies variation in survival between municipalities and hospital districts responsible for primary care and for specialised care, respectively, in Finland.

MATERIAL AND METHODS

Five-year relative survival of 11 cancers and close to 700,000 patients was estimated by municipality in Finland over 1962-2016 using hierarchical Bayesian modelling. Variation (i) between hospital districts, (ii) between municipalities within hospital districts, and (iii) between all municipalities (total variation) were quantified by the standard deviation of 5-year relative survival standardised by the average survival level.

RESULTS

In 2007-2016, the largest variation in 5-year relative survival between all municipalities was in stomach, prostate, kidney and liver cancer and skin melanoma. In male skin melanoma, prostate, and kidney cancer and in male and female pancreatic cancer, there was substantial and statistically significant variation between hospital districts, too. Variation within hospital districts was on average 67% (95% posterior interval [58%,76%]) out of the total variation and had decreased by 18% [2%, 33%] from 1997-2006.

CONCLUSION

The decrease in variation within hospital districts suggests that equity in diagnostics and primary care has improved in Finland. However, the variation between hospital districts in skin melanoma, prostate and kidney cancer reflects differences in early diagnostics. In pancreatic cancer, substantial variation between hospital districts may relate to regional differences in the accessibility and the quality of cancer treatments.

Association of postoperative influenza vaccine on overall mortality in patients undergoing curative surgery for solid tumors

Recent findings have found that the influenza vaccine induces changes in the immune system in favor of antitumor cytotoxicity. The aim of our study was to investigate if an influenza vaccine given in the postoperative period decreased overall and cancer-specific mortality in patients undergoing curative surgery for solid cancers. We conducted a registry-based national observational study in Denmark in the period January 1, 2010 to December 31, 2015 with a follow-up period of 3 years starting from 180 days after surgery. Patients with solid cancers undergoing curative surgery were included. The primary outcome was overall mortality. The secondary outcome was cancer-specific mortality. A total of 21 462 patients were included in the study with 2557 patients receiving an influenza vaccine within 6 months after surgery. In a Cox regression model, a decrease in overall mortality (hazard ratio [HR] = 0.89, 95% confidence interval [CI] = 0.81-0.99, P = .03) and cancer-related mortality (HR = 0.82, 95% CI = 0.71-0.93, P = .003) was found among patients given a vaccine vs patients never receiving a vaccine. In a predefined subgroup of patients receiving a vaccine within 30 days after surgery, a decrease in overall mortality (HR = 0.82, 95% CI = 0.72-0.94, P = .007) and cancer-specific mortality (HR = 0.70, 95% CI = 0.53-0.91, P = .009) was found. No association was evident in patients receiving the vaccine after 30 days to 6 months after surgery (overall mortality: HR = 0.96, 95% CI = 0.86-1.07, P = .46); cancer-specific mortality: HR = 0.88, 95% CI = 0.76-1.03, P = .12). These findings must be investigated in larger clinical trials where both immunological biomarkers and survival outcomes are included.

Social Inequalities in Cancer Survival in Belgium: A Population-Based Cohort Study

BACKGROUND

Socioeconomic status (SES) is an important factor in cancer survival; however, results are heterogeneous and linked to characteristics of the study population and health care system. This population-based cohort study evaluates the association between individual-level socioeconomic and demographic factors and cancer survival for the first time in Belgium.

METHODS

From the Belgian Cancer Registry, we identified 109,591 patients diagnosed between 2006 and 2013 with one of eight common cancer types. Information on treatment, socioeconomic parameters, and vital status were retrieved from multiple data sources and linked using a unique personal identification number. The outcome was 5-year observed survival. Associations between survival and socioeconomic and demographic factors were assessed using multivariable Cox proportional-hazard regression models.

RESULTS

Lower income, unemployment, and living alone were all associated with worse cancer survival. These associations were most pronounced for certain lifestyle-related cancer types (e.g., head and neck cancers) and those with good to moderate prognosis (e.g., colorectal and female breast cancer).

CONCLUSIONS

These results indicate that, despite a comprehensive and nationwide health insurance program in which equity in rights and access to health care are pursued, SES is associated with disparities in cancer survival in Belgium.

IMPACT

This population-based study with individual-level socioeconomic information of more than 100,000 patients with cancer identifies patient groups that may be at highest risk for socioeconomic disparities in cancer survival. Reasons behind the observed disparities are multiple and complex and should be further examined. Health policy interventions should consider the observed deprivation gap to plan targeted actions.

Patient and tumour characteristics associated with inclusion in Cancer patient pathways in Norway in 2015-2016

BACKGROUND

Cancer patient pathways (CPPs) were implemented in 2015 to reduce waiting time, regional variation in waiting time, and to increase the predictability of cancer care for the patients. The aims of this study were to see if the national target of 70% of all cancer patients being included in a CPP was met, and to identify factors associated with CPP inclusion.

METHODS

All patients registered with a colorectal, lung, breast or prostate cancer diagnosis at the Cancer Registry of Norway in the period 2015-2016 were linked with the Norwegian Patient Registry for CPP information and with Statistics Norway for sociodemographic variables. Multivariable logistic regression examined if the odds of not being included in a CPP were associated with year of diagnosis, age, sex, tumour stage, marital status, education, income, region of residence and comorbidity.

RESULTS

From 2015 to 2016, 30,747 patients were diagnosed with colorectal, lung, breast or prostate cancer, of whom 24,429 (79.5%) were included in a CPP. Significant increases in the probability of being included in a CPP were observed for colorectal (79.1 to 86.2%), lung (79.0 to 87.3%), breast (91.5 to 97.2%) and prostate cancer (62.2 to 76.2%) patients (p < 0.001). Increasing age was associated with an increased odds of not being included in a CPP for lung (p < 0.001) and prostate cancer (p < 0.001) patients. Colorectal cancer patients < 50 years of age had a two-fold increase (OR = 2.23, 95% CI: 1.70-2.91) in the odds of not being included in a CPP. The odds of no CPP inclusion were significantly increased for low income colorectal (OR = 1.24, 95%CI: 1.00-1.54) and lung (OR = 1.52, 95%CI: 1.16-1.99) cancer patients. Region of residence was significantly associated with CPP inclusion (p < 0.001) and the probability, adjusted for case-mix ranged from 62.4% in region West among prostate cancer patients to 97.6% in region North among breast cancer patients.

CONCLUSIONS

The national target of 70% was met within 1 year of CPP implementation in Norway. Although all patients should have equal access to CPPs, a prostate cancer diagnosis, older age, high level of comorbidity or low income were significantly associated with an increased odds of not being included in a CPP.

Predictors of the regional variation of prostatectomy or radiotherapy: evidence from German cancer registries

OBJECTIVE

To assess the association of public health parameters with the regional variation in the initial treatment for prostate cancer.

METHODS

We used data from German epidemiologic cancer registries for the years 2009-2013. Presence of a certified cancer center, a radiotherapy and/or urology institution, the district-specific GDP, and population density were used as predictors. Patients with indication for adjuvant treatment were excluded (T3b). Only districts with defined quality criteria were eligible. We used general linear mixed models (equivalent to logistic regression) with a covariance matrix weighted by the Euclidean distances between districts. Models were adjusted for age, grading, and TNM stage. We performed sensitivity analyses by imputing missing data with multiple imputation and considering extreme case scenarios. We applied inverse probability weighting to account for missing values.

RESULTS

When radiotherapy/surgery is compared to neither treatment, the probability for the latter was higher in East than in West Germany (OR 1.7, 95% CI 1.43-2.02). The same was true for districts with both, a radiotherapy and urologic treatment facility (OR 1.43, 1.19-1.72). Analyzing radiotherapy vs. surgery, the probability for prostatectomy was inversely associated with the presence of a radiotherapy unit when compared to districts with neither treatment facility (OR 0.52, 95% CI 0.38-0.73). Patients treated in East Germany were more likely to receive a surgical treatment (OR 1.34, 95% CI 1.08-1.66). Sensitivity analyses revealed no relevant change of effect estimates.

CONCLUSION

Treatment differs between East and West Germany and is associated with the presence of a radiotherapy or urology clinic.

Decreasing waiting time for treatment before and during implementation of cancer patient pathways in Norway

BACKGROUND

In 2015, Norway implemented cancer patient pathways to reduce waiting times for treatment. The aims of this paper were to describe patterns in waiting time and their association with patient characteristics for colorectal, lung, breast and prostate cancers.

METHODS

National, population-based data from 2007 to 2016 were used. A multivariable quantile regression examined the association between treatment period, age, stage, sex, place of residence, and median waiting times.

RESULTS

Reduction in median waiting times for radiotherapy among colorectal, lung and prostate cancer patients ranged from 14 to 50 days. Median waiting time for surgery remained approximately 21 days for both colorectal and breast cancers, while it decreased by 7 and 36 days for lung and prostate cancers, respectively. The proportion of lung and prostate cancer patients with metastatic disease at the time of diagnosis decreased, while the proportion of colorectal patients with localised disease and patients with stage I breast cancer increased (p < 0.001). After adjusting for case-mix, a patient's place of residence was significantly associated with waiting time for treatment (p < 0.001), however, differences in waiting time to treatment decreased over the study period.

CONCLUSIONS

Between 2007 and 2016, Norway experienced improved stage distributions and consistently decreasing waiting times for treatment. While these improvements occurred gradually, no significant change was observed from the time of cancer patient pathway implementation.

Rural-urban residence and cancer survival in high-income countries: A systematic review

There is some evidence that place of residence is associated with cancer survival, but the findings are inconsistent, and the underlying mechanisms by which residential location might affect survival are not well understood. We conducted a systematic review of observational studies investigating the association of rural versus urban residence with cancer survival in high-income countries. We searched the Ovid Medline, EMBASE, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases up to May 31, 2016. Forty-five studies published between 1984 and 2016 were included. We extracted unadjusted and adjusted relative risk estimates with the corresponding 95% confidence intervals. Most studies reported worse survival for cancer patients living in rural areas than those in urban regions. The most consistent evidence, observed across several studies, was for colorectal, lung, and prostate cancer. Of the included studies, 18 did not account for socio-economic position. Lower survival for more disadvantaged patients is well documented; therefore, it could be beneficial for future research to take socio-economic factors into consideration when assessing rural/urban differences in cancer survival. Some studies cited differential stage at diagnosis and treatment modalities as major contributing factors to regional inequalities in cancer survival. Further research is needed to disentangle the mediating effects of these factors, which may help to establish effective interventions to improve survival for patients living outside major cities.

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.

The effect of centralization on short term outcomes of pancreatoduodenectomy in a universal health care system

BACKGROUND

Centralization of pancreatic resections is advocated due to a volume-outcome association. Pancreatic surgery is in Norway currently performed only in five teaching hospitals. The aim was to describe the short-term outcomes after pancreatoduodenectomy (PD) within the current organizational model and to assess for regional disparities.

METHODS

All patients who underwent PD in Norway between 2012 and 2016 were identified. Mortality (90 days) and relaparotomy (30 days) were assessed for predictors including demographic data and multi-visceral or vascular resection. Aggregated length-of-stay and national and regional incidences of the procedure were also analysed.

RESULTS

A total of 930 patients underwent PD during the study period. In-hospital mortality occurred in 20 patients (2%) and 34 patients (4%) died within 90 days. Male gender, age, multi-visceral resection and relaparotomy were independent predictors of 90-day mortality. Some 131 patients (14%) had a relaparotomy, with male gender and multi-visceral resection as independent predictors. There was no difference between regions in procedure incidence or 90-day mortality. There was a disparity within the regions in the use of vascular resection (p = 0.021).

CONCLUSION

The short-term outcomes after PD in Norway are acceptable and the 90-day mortality rate is low. The outcomes may reflect centralization of pancreatic surgery.

Robustness of individual and marginal model-based estimates: A sensitivity analysis of flexible parametric models

BACKGROUND

Flexible parametric survival models (FPMs) are commonly used in epidemiology. These are preferred as a wide range of hazard shapes can be captured using splines to model the log-cumulative hazard function and can include time-dependent effects for more flexibility. An important issue is the number of knots used for splines. The reliability of estimates are assessed using English data for 10 cancer types and the use of online interactive graphs to enable a more comprehensive sensitivity analysis at the control of the user is demonstrated.

METHODS

Sixty FPMs were fitted to each cancer type with varying degrees of freedom to model the baseline excess hazard and the main and time-dependent effect of age. For each model, we obtained age-specific, age-group and internally age-standardised relative survival estimates. The Akaike Information Criterion and Bayesian Information Criterion were also calculated and comparative estimates were obtained using the Ederer II and Pohar Perme methods. Web-based interactive graphs were developed to present results.

RESULTS

Age-standardised estimates were very insensitive to the exact number of knots for the splines. Age-group survival is also stable with negligible differences between models. Age-specific estimates are less stable especially for the youngest and oldest patients, of whom there are very few, but for most scenarios perform well.

CONCLUSION

Although estimates do not depend heavily on the number of knots, too few knots should be avoided, as they can result in a poor fit. Interactive graphs engage researchers in assessing model sensitivity to a wide range of scenarios and their use is highly encouraged.

Disparities in colorectal cancer between Northern and SouthernSweden - a report from the new RISK North database

BACKGROUND

Geographic cancer health disparities have been reported in Sweden. The disparities are not fully understood, but may be attributed to differences in exposure to risk factors as well as differences in health care, socioeconomics and demography. The aim of this study was to describe the new nationwide population based RISK North database and its potential by analysing health disparities in colorectal cancer between Northern and Southern Sweden.

METHODS

Cancer-specific data from the National Cancer Quality Registers for colorectal, gastric and oesophageal cancer and brain tumours were linked to several nationwide registers hereby creating a new database - RISK North. To exemplify the potential of RISK North, we analyzed differences in colorectal cancer incidence, mortality and survival in relation to gender, age, cohabitation and education between Northern and Southern Sweden 2007-2013.

RESULTS

In colon cancer, the age-adjusted incidence per 100.000 was lower in Northern than Southern Sweden, 35.9 in the North vs. 41.1 in the South (p < .01); mortality rates were 11.0 vs. 12.2 (p < .01). For rectal cancer, incidence rates were 17.6 vs. 19.7 (p < .01) and mortality rates 5.33 vs. 5.89 (p = .07), respectively. The largest difference in incidence was demonstrated for colon cancer among individuals >79 years old (190. vs. 237, i.e., ∼20%). Survival in colon cancer was higher in Southern Sweden, HR 0.92 (0.87-0.98) adjusted for age, gender, co-habiting, education and m-stage at diagnosis. No difference in survival was seen for rectal cancer.

CONCLUSIONS

The new RISK North database enabled analysis of cancer disparities between Northern and Southern Sweden. The incidence of colorectal cancer were lower in the North of Sweden whereas colon cancer survival was higher in the South. These differences can be further analysed utilising the RISK North database.

Socioeconomic Differences and Lung Cancer Survival-Systematic Review and Meta-Analysis

Background: The impact of socioeconomic differences on cancer survival has been investigated for several cancer types showing lower cancer survival in patients from lower socioeconomic groups. However, little is known about the relation between the strength of association and the level of adjustment and level of aggregation of the socioeconomic status measure. Here, we conduct the first systematic review and meta-analysis on the association of individual and area-based measures of socioeconomic status with lung cancer survival.

Methods: In accordance with PRISMA guidelines, we searched for studies on socioeconomic differences in lung cancer survival in four electronic databases. A study was included if it reported a measure of survival in relation to education, income, occupation, or composite measures (indices). If possible, meta-analyses were conducted for studies reporting on individual and area-based socioeconomic measures.

Results: We included 94 studies in the review, of which 23 measured socioeconomic status on an individual level and 71 on an area-based level. Seventeen studies were eligible to be included in the meta-analyses. The meta-analyses revealed a poorer prognosis for patients with low individual income (pooled hazard ratio: 1.13, 95 % confidence interval: 1.08–1.19, reference: high income), but not for individual education. Group comparisons for hazard ratios of area-based studies indicated a poorer prognosis for lower socioeconomic groups, irrespective of the socioeconomic measure. In most studies, reported 1-, 3-, and 5-year survival rates across socioeconomic status groups showed decreasing rates with decreasing socioeconomic status for both individual and area-based measures. We cannot confirm a consistent relationship between level of aggregation and effect size, however, comparability across studies was hampered by heterogeneous reporting of socioeconomic status and survival measures. Only eight studies considered smoking status in the analysis.

Conclusions: Our findings suggest a weak positive association between individual income and lung cancer survival. Studies reporting on socioeconomic differences in lung cancer survival should consider including smoking status of the patients in their analysis and to stratify by relevant prognostic factors to further explore the reasons for socioeconomic differences. A common definition for socioeconomic status measures is desirable to further enhance comparisons between nations and across different levels of aggregation.

Differences in cancer survival between immigrants in Norway and the host population

Cancer survival is an important indicator for quality of cancer care. We sought to determine if there are differences in cancer survival between immigrants and the host population in Norway. We performed a nationwide registry-based study comprising subjects diagnosed with cancer between 1990 and 2014, and followed until the end of 2016. Survival was estimated for 13 cancer sites with cause-specific survival. Adjustments were made for common confounders (age, sex, year of diagnosis and place of residence) and defined mediators (stage at diagnosis, comorbidity and socioeconomic factors). A total of 500,255 subjects were available for analysis, of which 11,252 were Western and 8,701 non-Western immigrants. We did not find differences in cancer survival between Western immigrants and Norwegians, while non-Western immigrants, with some exceptions, had similar or better survival. Better lung cancer survival in non-Western immigrants than Norwegians was notable (hazard ratio (95% confidence interval): 0.78 (0.71-0.85)), and not explained by defined mediators. Immigrants from Eastern Europe and Balkan with melanoma (hazard ratio: 1.54 (1.12-2.12)) and prostate cancer (hazard ratio: 1.34 (1.08-1.67)), and possibly from sub-Saharan Africa with breast cancer (hazard ratio: 1.41 (0.94-2.12)) had worse survival than Norwegians. The results suggest that immigrants in Norway have good cancer survival relative to the host population. Poor survival in immigrants from Eastern Europe and Balkan with melanoma and prostate cancer, and sub-Saharan Africa with breast cancer might be a concern.

Describing the association between socioeconomic inequalities and cancer survival: methodological guidelines and illustration with population-based data

BACKGROUND

Describing the relationship between socioeconomic inequalities and cancer survival is important but methodologically challenging. We propose guidelines for addressing these challenges and illustrate their implementation on French population-based data.

METHODS

We analyzed 17 cancers. Socioeconomic deprivation was measured by an ecological measure, the European Deprivation Index (EDI). The Excess Mortality Hazard (EMH), ie, the mortality hazard among cancer patients after accounting for other causes of death, was modeled using a flexible parametric model, allowing for nonlinear and/or time-dependent association between the EDI and the EMH. The model included a cluster-specific random effect to deal with the hierarchical structure of the data.

RESULTS

We reported the conventional age-standardized net survival (ASNS) and described the changes of the EMH over the time since diagnosis at different levels of deprivation. We illustrated nonlinear and/or time-dependent associations between the EDI and the EMH by plotting the excess hazard ratio according to EDI values at different times after diagnosis. The median excess hazard ratio quantified the general contextual effect. Lip-oral cavity-pharynx cancer in men showed the widest deprivation gap, with 5-year ASNS at 41% and 29% for deprivation quintiles 1 and 5, respectively, and we found a nonlinear association between the EDI and the EMH. The EDI accounted for a substantial part of the general contextual effect on the EMH. The association between the EDI and the EMH was time dependent in stomach and pancreas cancers in men and in cervix cancer.

CONCLUSION

The methodological guidelines proved efficient in describing the way socioeconomic inequalities influence cancer survival. Their use would allow comparisons between different health care systems.

Disparities by Age, Sex, Tumor Stage, Diagnosis Path, and Area-level Socioeconomic Status in Survival Time for Major Cancers: Results from the Busan Cancer Registry

Our goal was to examine the effect of area-level deprivation on patient survival time for seven major cancers - stomach, colon, liver, lung, breast, cervix, and thyroid cancer. Data on 10,902 subjects who were diagnosed with major cancers from 2010 and 2011 in Busan were collected regarding the survival time along with several important prognostic factors and an area-level deprivation index was constructed from education, income, unemployment, and welfare assistance, to assess the comprehensive area-level socioeconomic status. A multilevel Cox proportional hazard model was used to investigate the effects of multiple risk factors such as gender, age, tumor stage, diagnosis path, and the area-level deprivation. After adjusting for risk factors the area-level deprivation index was found to be significant in associating with higher hazard rate for several cancers. Estimated hazard ratios (95% CI) were 1.08 (0.99-1.18), 1.23 (1.12-1.36), 1.36 (1.21-1.53) for the second, the third, and the fourth quartile of deprivation index groups, respectively, when compared to the least deprived group. When compared with the least deprived group, the more deprived group showed significant decrease in survival time for major cancers. This novel finding may contribute to the literature regarding the association of area-level socioeconomic status and highlight the importance of careful monitoring of socioeconomic characteristics for cancer prevention and care services.

Regional variation in the treatment of pancreatic adenocarcinoma: Decreasing disparities with multimodality therapy

BACKGROUND

Survival in pancreatic cancer remains poor with curative potential dependent on operative resection. We reviewed national adherence to practice guidelines to evaluate regional variation in the treatment and survival of patients with pancreatic cancer.

METHODS

Retrospective cohort review of adults with pancreatic adenocarcinoma using the National Cancer Data Base from 2006 to 2013. Overall survival was compared by the Kaplan-Meier method and Cox proportional hazards models. Sequential multivariate logistic regression models were generated for odds of: a) diagnosis in stage I/II, b) resection, and c) receipt of multimodality therapy, defined as operative resection plus chemotherapy with or without radiation. Five geographic regions of the United States were used for analyses.

RESULTS

A total of 115,952 patients were identified. At least 22% of patients in all stages received no treatment, with only 38.4% and 32.3% of stage I and II patients receiving multimodality therapy. On unadjusted analysis, the Northeast had the greatest survival for all stages of disease, most pronounced for stage I where patients lived 2 to 3 more months (log-rank P < .0001). While adjusted odds of early diagnosis and resection were comparable or greater across regions relative to the Northeast, patients who underwent resection in the Northeast were significantly more likely to receive multimodality therapy. Multivariate Cox modeling for patients receiving multimodality therapy accounted for differences in 3 of 4 remaining regions.

CONCLUSION

Regional variations exist in pancreatic cancer treatment and survival. While providing multimodality cancer-directed therapy can help mitigate these differences, survival with pancreatic cancer needs to be interpreted in the context of overall health, underlying risk factors, and life expectancy.