Breast cancer survival in ontario and california, 1998-2006: socioeconomic inequity remains much greater in the United States

Socioeconomic disparities in cancer survival: Relation to stage at diagnosis, treatment, and centralization of patients to accredited hospitals, 2005-2014, Japan

BACKGROUND

Cancer survival varies by socioeconomic status in Japan. We examined the extent to which survival disparities are explained by factors relevant to cancer control measures (promoting early-stage detection, standardizing treatment, and centralizing patients to government-accredited cancer hospitals [ACHs]).

METHODS

From the Osaka Cancer Registry, patients diagnosed with solid malignant tumors during 2005-2014 and aged 15-84 years (N = 376,077) were classified into quartiles using the Area Deprivation Index (ADI). Trends in inequalities were assessed for potentially associated factors: early-stage detection, treatment modality, and utilization of ACH (for first contact/diagnosis/treatment). 3-year all-cause survival was computed by the ADI quartile. Multivariable Cox regression models were used to assess survival disparities and their trends through a series of adjustment for the potentially associated factors.

RESULTS

During 2005-2014, the most deprived ADI quartile had lower rates than the least deprived quartile for early-stage detection (42.6% vs. 48.7%); receipt of surgery (58.1% vs. 64.1%); and utilization of ACH (83.5% vs. 88.4%). While rate differences decreased for receipt of surgery and utilization of ACH (Annual Percent Change = -3.2 and - 11.9, respectively) over time, it remained unchanged for early-stage detection. During 2012-2014, the most deprived ADI quartile had lower 3-year survival than the least deprived (59.0% vs. 69.4%) and higher mortality (Hazard Ratio [HR] = 1.32, adjusted for case-mix): this attenuated with additional adjustment for stage at diagnosis (HR = 1.23); treatment modality (HR = 1.20); and utilization of ACH (HR = 1.19) CONCLUSIONS: Despite improvements in equalizing access to quality cancer care during 2005-2014, survival disparities remained. Interventions to reduce inequalities in early-stage detection could ameliorate such gaps.

Social inequalities in the incidence, mortality, and survival of neoplasms in women from a municipality in Southeastern Brazil

This study aims to analyze inequalities in the incidence, mortality, and survival of the main types of cancer in women according to the Social Vulnerability Index (SVI). The study was conducted in Campinas, São Paulo State, Brazil, from 2010 to 2014, and used data from the Population-based Cancer Registry and the Mortality Information System. Incidence and mortality rates standardized by age and 5-year survival estimates were calculated according to the social vulnerability strata (SVS), based on the São Paulo Social Vulnerability Index. Three SVS were delimited, with SVS1 being the lowest level of vulnerability and SVS3 being the highest. Rate ratios and the concentration index were calculated. The significance level was 5%. Women in SVS1 had a higher risk of breast cancer (0.46; 95%CI: 0.41; 0.51), colorectal cancer (0.56; 95%CI: 0.47; 0.68), and thyroid cancer (0.32; 95%CI: 0.26; 0.40), whereas women from SVS3 had a higher risk of cervical cancer (2.32; 95%CI: 1.63; 3.29). Women from SVS1 had higher mortality rates for breast (0.69; 95%CI: 0.53; 0.88) and colorectal cancer (0.69; 95%CI: 0.59; 0.80) and women from SVS3 had higher rates for cervical (2.35; 95%CI: 1.57; 3.52) and stomach cancer (1.43; 95%CI: 1.06; 1.91). Women of highest social vulnerability had lower survival rates for all types of cancer. The observed inequalities differed according to the location of the cancer and the analyzed indicator. Inequalities between incidence, mortality, and survival tend to revert and the latter is always unfavorable to the segment of highest vulnerability, indicating the existence of inequality in access to early diagnosis and timely treatment.

Modal lifespan and disparity at older ages by leading causes of death: a Canada-U.S. comparison

The U.S. elderly experience shorter lifespans and greater variability in age at death than their Canadian peers. In order to gain insight on the underlying factors responsible for the Canada-U.S. old-age mortality disparities, we propose a cause-of-death analysis. Accordingly, the objective of this paper is to compare levels and trends in cause-specific modal age at death (M) and standard deviation above the mode (SD(M +)) between Canada and the U.S. since the 1970s. We focus on six broad leading causes of death, namely cerebrovascular diseases, heart diseases, and four types of cancers. Country-specific M and SD(M +) estimates for each leading cause of death are calculated from P-spline smooth age-at-death distributions obtained from detailed population and cause-specific mortality data. Our results reveal similar levels and trends in M and SD(M +) for most causes in the two countries, except for breast cancer (females) and lung cancer (males), where differences are the most noticeable. In both of these instances, modal lifespans are shorter in the U.S. than in Canada and U.S. old-age mortality inequalities are greater. These differences are explained in part by the higher stratification along socioeconomic lines in the U.S. than in Canada regarding the adoption of health risk behaviours and access to medical services.

The impact of the affordable care act on breast cancer care in the USA: A multi-institutional analysis

There are less data available on the effect of the ACA on breast cancer care beyond the screening level. A retrospective review at participating iCaRe2/BCCR institutions was completed before and after ACA. Post-ACA, patients were older, more urban, and more likely to be insured through Medicaid. Increased imaging use was noted post-ACA. These patients were less likely to be diagnosed with late-stage cancers, received fewer mastectomies, and were more likely to have radiation.

Socioeconomic status and breast cancer treatment

PURPOSE

Evidence suggests substantial disparities in breast cancer survival by socioeconomic status (SES). We examine the extent to which receipt of newer, less invasive, or more effective treatments-a plausible source of disparities in survival-varies by SES among elderly women with early-stage breast cancer.

METHODS

Multivariate regression analyses applied to 11,368 women (age 66-90 years) identified from SEER-Medicare as having invasive breast cancer diagnosed in 2006-2009. Socioeconomic status was defined based on Medicaid enrollment and level of poverty of the census tract of residence. All analyses controlled for demographic, clinical health status, spatial, and healthcare system characteristics.

RESULTS

Poor and near-poor women were less likely than high SES women to receive sentinel lymph node biopsy and radiation after breast-conserving surgery (BCS). Poor women were also less likely than near-poor or high SES women to receive any axillary surgery and adjuvant chemotherapy. There were no significant differences in use of aromatase inhibitors (AI) between poor and high SES women. However, near-poor women who initiated hormonal therapy were more likely to rely exclusively on tamoxifen, and less likely to use the more expensive but more effective AI when compared to both poor and high SES women.

CONCLUSIONS

Our results indicate that SES disparities in the receipt of treatments for incident breast cancer are both pervasive and substantial. These disparities remained despite women's geographic area of residence and extent of disease, suggesting important gaps in access to effective breast cancer care.

Effects of socioeconomic status on esophageal adenocarcinoma stage at diagnosis, receipt of treatment, and survival: A population-based cohort study

The incidence of esophageal adenocarcinoma (EAC) is increasing worldwide and has overtaken squamous histology in occurrence. We studied the impact of socioeconomic status (SES) on EAC stage at diagnosis, receipt of treatment, and survival. A population-based retrospective cohort study was conducted using Ontario Cancer Registry-linked administrative health data. Multinomial logistic regression was used to examine the association between SES (income quintile) and stage at EAC diagnosis and EAC treatment. Survival times following EAC diagnosis were estimated using Kaplan-Meier method. Cox proportional-hazards regression analysis was used to examine the association between SES and EAC survival. Between 2003–2012, 2,125 EAC cases were diagnosed. Median survival for the lowest-SES group was 10.9 months compared to 11.6 months for the highest-SES group; the 5-year survival was 9.8% vs. 15.0%. Compared to individuals in the highest-SES group, individuals in the lowest-SES category experienced no significant difference in EAC treatment (91.6% vs. 93.3%, P = 0.314) and deaths (78.9% vs. 75.6%, P = 0.727). After controlling for covariates, no significant associations were found between SES and cancer stage at diagnosis and EAC treatment. Additionally, after controlling for age, gender, urban/rural residence, birth country, health region, aggregated diagnosis groups, cancer stage, treatment, and year of diagnosis, no significant association was found between SES and EAC survival. Moreover, increased mortality risk was observed among those with older age (P = 0.001), advanced-stage of EAC at diagnosis (P < 0.001), and those receiving chemotherapy alone, radiotherapy alone, or surgery plus chemotherapy (P < 0.001). Adjusted proportional-hazards model findings suggest that there is no association between SES and EAC survival. While the unadjusted model suggests reduced survival among individuals in lower income quintiles, this is no longer significant after adjusting for any covariate. Additionally, there is an apparent association between SES and survival when considering only those individuals diagnosed with stage 0-III EAC. These analyses suggest that the observed direct relationship between SES and survival is explained by patient-level factors including receipt of treatment, something that is potentially modifiable.

Breast Cancer Care in California and Ontario: Primary Care Protections Greatest Among the Most Socioeconomically Vulnerable Women Living in the Most Underserved Places

BACKGROUND

Better health care among Canada's socioeconomically vulnerable versus America's has not been fully explained. We examined the effects of poverty, health insurance and the supply of primary care physicians on breast cancer care.

METHODS

We analyzed breast cancer data in Ontario (n = 950) and California (n = 6300) between 1996 and 2000 and followed until 2014. We obtained socioeconomic data from censuses, oversampling the poor. We obtained data on the supply of physicians, primary care and specialists. The optimal care criterion was being diagnosed early with node negative disease and received breast conserving surgery followed by adjuvant radiation therapy.

RESULTS

Women in Ontario received more optimal care in communities well supplied by primary care physicians. They were particularly advantaged in the most disadvantaged places: high poverty neighborhoods (rate ratio = 1.65) and communities lacking specialist physicians (rate ratio = 1.33). Canadian advantages were explained by better health insurance coverage and greater primary care access.

CONCLUSIONS

Policy makers ought to ensure that the newly insured are adequately insured. The Medicaid program should be expanded, as intended, across all 50 states. Strengthening America's system of primary care will probably be the best way to ensure that the Affordable Care Act's full benefits are realized.

Relationship of Social Determinants of Health with the Three-year Survival Rate of Breast Cancer

Background: Social determinants of health are among the key factors affecting the pathogenesis of diseases. Considering the increasingly high prevalence of breast cancer and the association of social determinants of health with its occurrence, related morbidity and mortality and survival rate, this study sought to assess the relationship of three-year survival rate of breast cancer with social determinants of health. Materials and Methods: This cohort study was conducted on males and females presenting to the Cancer Research Center of Shohada-E-Tajrish Hospital from 2006 to 2010 with definite diagnosis of breast cancer. Data were collected via phone interviews. Kaplan-Meier and Cox regression was fitted using SPSS (version 18) and PH assumption was tested by STATA (version 11) software. Results: The study was performed on 797 breast cancer patients, aged 25-93 years with mean age of 54.66 (SD=11.86) years. After 3 years from diagnosing cancer 700 (87.8%) patients were alive and 97 (12.2%) patients were dead. Using log rank test, there was relationship between 3-year survivals with age, education, childhood residence, sibling, treatment type, and district were significant (p<0.05). Using Cox PH regression, 3-year survival was related to age, level of education, municipal district of residence and childhood condition (p<0.05). Conclusion: Social determinants of health such as childhood condition, city region residency, level of education and age affect the three-year survival rate of breast cancer. Future studies must focus on the effect of childhood social class on the survival rates of cancers, which have been paid less attention to.

Socioeconomic disparities in breast cancer incidence and survival among parous women: findings from a population-based cohort, 1964-2008

Background

Socioeconomic position (SEP) has been associated with breast cancer incidence and survival. We examined the associations between two socioeconomic indicators and long-term breast cancer incidence and survival in a population-based cohort of parous women.

Methods

Residents of Jerusalem who gave birth between 1964–1976 (n = 40,586) were linked to the Israel Cancer Registry and Israel Population Registry to determine breast cancer incidence and vital status through mid-2008. SEP was assessed by husband’s occupation and the woman’s education. We used log ranks tests to compare incidence and survival curves by SEP, and Cox proportional hazard models to adjust for demographic, reproductive and diagnostic factors and assess effect modification by ethnic origin.

Results

In multivariable models, women of high SEP had a greater risk of breast cancer compared to women of low SEP (Occupation: HR 1.18, 95 % CI 1.03-1.35; Education: HR 1.39, 95 % CI 1.21-1.60) and women of low SEP had a greater risk of mortality after a breast cancer diagnosis (Occupation: HR 1.33, 95 % CI 1.04-1.70; Education: HR 1.37, 95 % CI 1.06-1.76). The association between education and survival was modified by ethnic origin, with a gradient effect observed only among women of European origin. Women of Asian, North African and Israeli origin showed no such trend.

Conclusions

SEP was associated with long-term breast cancer incidence and survival among Israeli Jews. Education had a stronger effect on breast cancer outcomes than occupation, suggesting that a behavioral mechanism may underlie disparities. More research is needed to explain the difference in the effect of education on survival among European women compared to women of other ethnicities.

Colon cancer care and survival: income and insurance are more predictive in the USA, community primary care physician supply more so in Canada

BACKGROUND

Our research group advanced a health insurance theory to explain Canada's cancer care advantages over America. The late Barbara Starfield theorized that Canada's greater primary care-orientation also plays a critically protective role. We tested the resultant Starfield-Gorey theory by examining the effects of poverty, health insurance and physician supplies, primary care and specialists, on colon cancer care in Ontario and California.

METHODS

We analyzed registry data for people with non-metastasized colon cancer from Ontario (n = 2,060) and California (n = 4,574) diagnosed between 1996 and 2000 and followed to 2010. We obtained census tract-based socioeconomic data from population censuses and data on county-level physician supplies from national repositories: primary care physicians, gastroenterologists and other specialists. High poverty neighborhoods were oversampled and the criterion was 10 year survival. Hypotheses were explored with standardized rate ratios (RR) and tested with logistic regression models.

RESULTS

Significant inverse associations of poverty (RR = 0.79) and inadequate health insurance (RR = 0.80) with survival were observed in the California, while they were non-significant or non-existent in Ontario. The direct associations of primary care physician (RRs of 1.32 versus 1.11) and gastroenterologist (RRs of 1.56 versus 1.15) supplies with survival were both stronger in Ontario than California. The supply of primary care physicians took precedence. Probably mediated through the initial course of treatment, it largely explained the Canadian advantage.

CONCLUSIONS

Poverty and health insurance were more predictive in the USA, community physician supplies more so in Canada. Canada's primary care protections were greatest among the most socioeconomically vulnerable. The protective effects of Canadian health care prior to enactment of the Affordable Care Act (ACA) clearly suggested the following. Notwithstanding the importance of insuring all, strengthening America's system of primary care will probably be the best way to ensure that the ACA's full benefits are realized. Finally, Canada's strong primary care system ought to be maintained.

Care and survival of Mexican American women with node negative breast cancer: historical cohort evidence of health insurance and barrio advantages

We hypothesized 3-way ethnicity by barrio by health insurance interactions such that the advantages of having adequate health insurance were greatest among Mexican American (MA) women who lived in barrios. Barrios were neighborhoods with relatively high concentrations of MAs (60% or more). Data were analyzed for 194 MA and 2,846 non-Hispanic white women diagnosed with, very treatable, node negative breast cancer in California between 1996 and 2000 and followed until 2011. Significant interactions were observed such that the protective effects of Medicare or private health insurance on radiation therapy access and long term survival were largest for MA women who resided in MA barrios, neighborhoods that also tended to be extremely poor. These paradoxical findings are consistent with the theory that more facilitative social and economic capital available to MA women in barrios enables them to better absorb the indirect and direct, but uncovered, costs of breast cancer care.

Breast Cancer among Women Living in Poverty: Better Care in Canada than in the United States

This historical study estimated the protective effects of a universally accessible, single-payer health care system versus a multi-payer system that leaves many uninsured or underinsured by comparing breast cancer care of women living in high poverty neighborhoods in Ontario or California between 1996 and 2011. Women in Canada experienced better care particularly as compared to women who were inadequately insured in the United States. Women in Canada were diagnosed earlier (rate ratio [RR] = 1.12) and enjoyed better access to breast conserving surgery (RR = 1.48), radiation (RR = 1.60) and hormone therapies (RR = 1.78). Women living in high poverty Canadian neighborhoods even experienced shorter waits for surgery (RR = 0.58) and radiation therapy (RR = 0.44) than did such women in the US. Consequently, women in Canada were much more likely to survive longer. Regression analyses indicated that health insurance could explain most of the better care and better outcomes in Canada. Over this study's 15-year timeframe 31,500 late diagnoses, 94,500 sub-optimum treatment plans and 103,500 early deaths were estimated in high poverty US neighborhoods due to relatively inadequate health insurance coverage. Implications for social work practice, including advocacy for future reforms of US health care are discussed.

Socioeconomic disparity in breast cancer detection in Hong Kong--a high income city: retrospective epidemiological study using the Breast Cancer Registry

BACKGROUND

It is not known whether socioeconomic disparities affect the detection of breast cancer in Asian countries where the incidence of breast cancer is a rising trend. In this study, we explore the socioeconomic profiles of women and the stage of the disease at the time of diagnosis in breast cancer patients aged 40 or over in Hong Kong.

METHOD

During the period 2008 to 2011, 5393 breast cancer patients registered with the Hong Kong Breast Cancer Registry. Participants and their clinicians were asked to complete standardised questionnaires including patient socio-demographics, health history and risk factors, the course of the disease, post-treatment physical discomfort and psychosocial impact, follow-up recurrence and survival status.

RESULTS

Monthly household incomes, educational levels and the practice of regular screening are independently associated with the stage of the disease at diagnosis. Higher socioeconomic status and a higher educational level were associated with an earlier stage of the disease at the time of diagnosis. Yearly clinical examinations, ultrasound and mammographic screening every 2 to 3 years were significantly associated with the earlier detection of breast cancer.

CONCLUSION

There were socioeconomic disparities among Hong Kong women who were found to have breast cancer. Population-based screening policies, including raising awareness among women at risk, should be implemented.

Health insurance mediation of the Mexican American non-Hispanic white disparity on early breast cancer diagnosis

We examined health insurance mediation of the Mexican American (MA) non-Hispanic white (NHW) disparity on early breast cancer diagnosis. Based on social capital and barrio advantage theories, we hypothesized a 3-way ethnicity by poverty by health insurance interaction, that is, that 2-way poverty by health insurance interaction effects would differ between ethnic groups. We secondarily analyzed registry data for 303 MA and 3,611 NHW women diagnosed with breast cancer between 1996 and 2000 who were originally followed until 2011. Predictors of early, node negative (NN) disease at diagnosis were analyzed. Socioeconomic data were obtained from the 2000 census to categorize neighborhood poverty: high (30% or more of the census tract households were poor), middle (5% to 29% poor) and low (less than 5% poor). Barrios were neighborhoods where 50% or more of the residents were MA. Primary health insurers were Medicaid, Medicare, private or none. MA women were 13% less likely to be diagnosed early with NN disease (RR = 0.87), but this MA-NHW disparity was completely mediated by the main and interacting effects of health insurance. Advantages of health insurance were largest in low poverty neighborhoods among NHW women (RR = 1.20) while among MA women they were, paradoxically, largest in high poverty, MA barrios (RR = 1.45). Advantages of being privately insured were observed for all. Medicare seemed additionally instrumental for NHW women and Medicaid for MA women. These findings are consistent with the theory that more facilitative social and economic capital is available to MA women in barrios and to NHW women in more affluent neighborhoods. It is there that each respective group of women is probably best able to absorb the indirect and direct, but uncovered, costs of breast cancer screening and diagnosis.

Health systems performance and cancer outcomes

Do the characteristics of health systems influence cancer outcomes? Although caveats are required when undertaking international comparisons of both health systems and cancer outcomes, observed differences cannot solely be explained by data problems or economic development. Health systems can influence cancer outcomes through three mechanisms: coverage, innovation, and quality of care. First, in countries where population coverage is incomplete, patients may find certain services excluded or face substantial copayments or deductibles. Second, there are variations in the rate at which innovative treatments are introduced, reflecting in particular the need for publicly funded health systems to compare costs and benefits of increasingly expensive treatments given demands for other treatments. Third, systematic differences in quality of care (early diagnosis, timely and equitable access to specialist care, and existence of systematic coordination between these activities) may lead to variations in cancer outcomes.

Effects of being uninsured or underinsured and living in extremely poor neighborhoods on colon cancer care and survival in California: historical cohort analysis, 1996-2011

Background

We examined the mediating effects of health insurance on poverty-colon cancer care and survival relationships and the moderating effects of poverty on health insurance-colon cancer care and survival relationships among women and men in California.

Methods

We analyzed registry data for 3,291 women and 3,009 men diagnosed with colon cancer between 1996 and 2000 and followed until 2011 on lymph node investigation, stage at diagnosis, surgery, chemotherapy, wait times and survival. We obtained socioeconomic data for individual residences from the 2000 census to categorize the following neighborhoods: high poverty (30% or more poor), middle poverty (5-29% poor) and low poverty (less than 5% poor). Primary health insurers were Medicaid, Medicare, private or none.

Results

Evidence of mediation was observed for women, but not for men. For women, the apparent effect of poverty disappeared in the presence of payer, and the effects of all forms of health insurance seemed strengthened. All were advantaged on 6-year survival compared to the uninsured: Medicaid (RR = 1.83), Medicare (RR = 1.92) and private (RR = 1.83). Evidence of moderation was also only observed for women. The effects of all forms of health insurance were stronger for women in low poverty neighborhoods: Medicaid (RR = 2.90), Medicare (RR = 2.91) and private (RR = 2.60). For men, only main effects of poverty and payers were observed, the advantaging effect of private insurance being largest. Across colon cancer care processes, Medicare seemed most instrumental for women, private payers for men.

Conclusions

Health insurance substantially mediates the quality of colon cancer care and poverty seems to make the effects of being uninsured or underinsured even worse, especially among women in the United States. These findings are consistent with the theory that more facilitative social and economic capital is available in more affluent neighborhoods, where women with colon cancer may be better able to absorb the indirect and direct, but uncovered, costs of care.

Influence of socioeconomic status on survival of hepatocellular carcinoma in the Ontario population; a population-based study, 1990-2009

Background

Research has shown that people from higher socioeconomic status (SES) have better hepatocellular carcinoma (HCC) survival outcomes, although no such research has been carried out in Canada. We aimed to assess if an association between SES and HCC survival existed in the Canadian context.

Methodology/Prinicpal Findings

We conducted a population-based cohort study linking HCC cases identified in the Ontario Cancer Registry between 1990 and 2009 to administrative and hospital data. Logistic regression and chi-squared tests were used to evaluate associations between SES (income quintile) and covariates. The Kaplan-Meier method was used to estimate survival. Sequential analysis of the proportional-hazards models were used to determine the association between SES and HCC survival controlling for potential prognostic covariates. During the period 1990–2009, 5,481 cases of HCC were identified. A significant association was found between SES and curative treatment (p = 0.0003), but no association was found between SES and non-curative treatment (p = 0.064), palliative treatment (p = 0.680), or ultrasound screening (p = 0.615). The median survival for the lowest SES was 8.5 months, compared to 8.8 months for the highest SES group. The age- and sex-adjusted proportional-hazards model showed statistically significant difference in HCC survival among the SES groups, with hazard ratio 0.905 (95% confidence intervals 0.821, 0.998) when comparing highest to lowest SES group. Further adjustments indicated that potentially curative treatment was the likely explanation for the association between SES and HCC survival.

Conclusions/Significance

Our findings suggest that a 10% HCC survival advantage exists for the higher SES groups. This association between SES and HCC survival is most likely a reflection of lack of access to care for low SES groups, revealing inequities in the Canadian healthcare system.

Use and timeliness of radiation therapy after breast-conserving surgery in low-income women with early-stage breast cancer

PURPOSE

To characterize overall receipt and timeliness of radiation therapy (RT) following breast-conserving surgery among Medicaid-insured patients.

METHOD

State cancer registry data linked with Medicaid claims from 2003 to 2009 were analyzed. Multivariate logistic and Cox proportional hazards regressions were employed.

RESULTS

Overall, 81% of patients received guideline-recommended RT. Significant variation in timing of RT initiation was documented. Having fewer comorbitidies and receiving chemotherapy were correlated with higher odds of RT initiation within 1 year.

CONCLUSION

Although RT use in Medicaid-insured women appears to have improved since earlier studies, documented delays in RT are troublesome and warrant further investigation.

How many deaths would be avoidable if socioeconomic inequalities in cancer survival in England were eliminated? A national population-based study, 1996-2006

AIM

Inequalities in survival between rich and poor have been reported for most adult cancers in England. This study aims to quantify the public health impact of these inequalities by estimating the number of cancer-related deaths that would be avoidable if all patients were to have the same cancer survival as the most affluent patients.

METHODS

National Cancer Registry data for all adults diagnosed with one of 21 common cancers in England were used to estimate relative survival. We estimated the number of excess (cancer-related) deaths that would be avoidable within three years after diagnosis if relative survival for patients in all deprivation groups was as high as the most affluent group.

RESULTS

For patients diagnosed during 2004-2006, 7122 of the 64,940 excess deaths a year (11%) would have been avoidable if three-year survival for all patients had been as high as in the most affluent group. The annual number of avoidable deaths fell from 8435 (13%) a year for patients diagnosed during 1996-2000. Over 60% of the total number of avoidable deaths occurred within six months after diagnosis and approximately 70% occurred in the two most deprived groups.

CONCLUSION

The downward trend in the annual number of avoidable deaths reflects more an improvement in survival in England overall, rather than a narrowing of the deficit in cancer survival between poor and rich. The lack of any substantial change in the percentage of avoidable excess deaths highlights the persistent nature of the deficit in survival between affluent and deprived groups.

The supply of physicians and care for breast cancer in Ontario and California, 1998 to 2006

INTRODUCTION

We examined the differential effects of the supply of physicians on care for breast cancer in Ontario and California. We then used criteria for optimum care for breast cancer to estimate the regional needs for the supply of physicians.

METHODS

Ontario and California registries provided 951 and 984 instances of breast cancer diagnosed between 1998 and 2000 and followed until 2006. These cohorts were joined with the supply of county-level primary care physicians (PCPs) and specialists in cancer care and compared on care for breast cancer.

RESULTS

Significant protective PCP thresholds (7.75 to = 8.25 PCPs per 10 000 inhabitants) were observed for breast cancer diagnosis (odds ratio [OR] 1.62), receipt of adjuvant radiotherapy (OR 1.64) and 5-year survival (OR 1.87) in Ontario, but not in California. The number of physicians seemed adequate to optimize care for breast cancer across diverse places in California and in most Ontario locations. However, there was an estimated need for 550 more PCPs and 200 more obstetrician-gynecologists in Ontario's rural and small urban areas. We estimated gross physician surpluses for Ontario's 2 largest cities.

CONCLUSION

Policies are needed to functionally redistribute primary care and specialist physicians. Merely increasing the supply of physicians is unlikely to positively affect the health of Ontarians.

Socioeconomic status and survival after an invasive breast cancer diagnosis

BACKGROUND

Women who live in geographic areas with high poverty rates and low levels of education experience poorer survival after a breast cancer diagnosis than women who live in communities with indicators of high socioeconomic status (SES). However, very few studies have examined individual-level SES in relation to breast cancer survival or have assessed the contextual role of community-level SES independent of individual-level SES.

METHODS

The authors of this report examined both individual-level and community-level SES in relation to breast cancer survival in a population-based cohort of women ages 20 to 69 years who were diagnosed with breast cancer in Wisconsin between 1995 and 2003 (N = 5820).

RESULTS

Compared with college graduates, women who had no education beyond high school were 1.39 times more likely (95% confidence interval [CI], 1.10-1.76) to die from breast cancer. Women who had household incomes <2.5 times the poverty level were 1.46 times more likely (95% CI, 1.10-1.92) to die from breast cancer than women who had household incomes ≥5 times the poverty level. Adjusting the analysis for use of screening mammography, disease stage at diagnosis, and lifestyle factors eliminated the disparity by income, but the disparity by education persisted (hazard ratio [HR], 1.27; 95% CI, 0.99-1.61). In multilevel analyses, low community-level education was associated with increased breast cancer mortality even after adjusting for individual-level SES (HR, 1.57; 95% CI, 1.09-2.27 for ≥20% vs <10% of adults without a high school degree).

CONCLUSIONS

The current results indicated that screening and early detection explain some of the disparity according to SES, but further research will be needed to understand the additional ways in which individual-level and community-level education are associated with survival.

Socioeconomic status and gastric cancer survival in Japan

BACKGROUND

Few studies have investigated the association between socioeconomic status and the survival of cancer patients in Japan.

METHODS

We examined whether occupation or educational level was associated with the survival of 725 gastric cancer patients who were diagnosed within an ongoing large population-based cohort study.

RESULTS

After adjustment for age at diagnosis, and sex, we found that, compared with professionals or office workers, unemployed subjects (hazard ratio [HR], 2.23; 95% confidence interval [CI], 1.27-3.92) and manual laborers (HR, 1.68; 95% CI, 1.07-2.62) had an increased risk of gastric cancer death. After further adjustment for the clinical extent of disease, the increased risk disappeared. Educational level was not associated with the risk.

CONCLUSIONS

These findings suggest that a disparity in survival by occupation exists among Japanese gastric cancer patients, largely due to a lower proportion of early disease among the unemployed and manual laborers.

Socioeconomic inequalities in cancer survival in England after the NHS cancer plan

Background:

Socioeconomic inequalities in survival were observed for many cancers in England during 1981–1999. The NHS Cancer Plan (2000) aimed to improve survival and reduce these inequalities. This study examines trends in the deprivation gap in cancer survival after implementation of the Plan.

Materials and method:

We examined relative survival among adults diagnosed with 1 of 21 common cancers in England during 1996–2006, followed up to 31 December 2007. Three periods were defined: 1996–2000 (before the Cancer Plan), 2001–2003 (initialisation) and 2004–2006 (implementation). We estimated the difference in survival between the most deprived and most affluent groups (deprivation gap) at 1 and 3 years after diagnosis, and the change in the deprivation gap both within and between these periods.

Results:

Survival improved for most cancers, but inequalities in survival were still wide for many cancers in 2006. Only the deprivation gap in 1-year survival narrowed slightly over time. A majority of the socioeconomic disparities in survival occurred soon after a cancer diagnosis, regardless of the cancer prognosis.

Conclusion:

The recently observed reduction in the deprivation gap was minor and limited to 1-year survival, suggesting that, so far, the Cancer Plan has little effect on those inequalities. Our findings highlight that earlier diagnosis and rapid access to optimal treatment should be ensured for all socioeconomic groups.

Income and long-term breast cancer survival: comparisons of vulnerable urban places in Ontario and California

Effects of socioeconomic status on the long-term survival of 808 women with node-negative breast cancer in Canada and the United States were observed. Ontario and California samples diagnosed between 1988 and 1990 were followed until 2006. Socioeconomic data were taken from population censuses. Compared with their California counterparts, residents of low-income urban areas in Ontario experienced a significant 15-year survival advantage (RR = 1.66 [95% CI: 1.00, 2.76]). In these and other vulnerable, lower-middle- to working-class neighborhoods, significantly more Ontario residents gained access to adjuvant radiation therapy (RR = 1.75 [1.21, 2.53]) which seemed associated with better long-term survival (RR = 1.36 [0.99, 1.86]). This stage-adjusted, historical cohort analysis suggests much greater cancer care equity in Canada than in the United States.

Effects of socioeconomic status on colon cancer treatment accessibility and survival in Toronto, Ontario, and San Francisco, California, 1996-2006

OBJECTIVES

We examined the differential effects of socioeconomic status on colon cancer care and survival in Toronto, Ontario, Canada, and San Francisco, California.

METHODS

We analyzed registry data for colon cancer patients from Ontario (n = 930) and California (n = 1014), diagnosed between 1996 and 2000 and followed until 2006, on stage, surgery, adjuvant chemotherapy, and survival. We obtained socioeconomic data for individuals' residences from population censuses.

RESULTS

Income was directly associated with lymph node evaluation, chemotherapy, and survival in San Francisco but not in Toronto. High-income persons had better survival rates in San Francisco than in Toronto. After adjustment for stage, survival was better for low-income residents of Toronto than for those of San Francisco. Middle- to low-income patients were more likely to receive indicated chemotherapy in Toronto than in San Francisco.

CONCLUSIONS

Socioeconomic factors appear to mediate colon cancer care in urban areas of the United States but not in Canada. Improvements are needed in screening, diagnostic investigations, and treatment access among low-income Americans.

Breast cancer care in the Canada and the United States: ecological comparisons of extremely impoverished and affluent urban neighborhoods

This study examined the differential effect of extreme impoverishment on breast cancer care in urban Canada and the United States. Ontario and California registry-based samples diagnosed between 1998 and 2000 were followed until 2006. Extremely poor and affluent neighborhoods were compared. Poverty was associated with non-localized disease, surgical and radiation therapy (RT) waits, non-receipt of breast conserving surgery, RT and hormonal therapy, and shorter survival in California, but not in Ontario. Extremely poor Ontario women were consistently advantaged on care indices over their California counterparts. More inclusive health insurance coverage in Canada seems the most plausible explanation for such Canadian breast cancer care advantages.

Associations of physician supplies with breast cancer stage at diagnosis and survival in Ontario, 1988 to 2006

BACKGROUND

The authors examined whether the supply of primary care physicians had protective effects on breast cancer stage and survival in Ontario and whether supply losses during the 1990s were associated with diminished protection.

METHODS

Random samples of the Ontario Cancer Registry, respectively, provided 879 women and 951 women who were diagnosed with breast cancer between 1988 and 1990 (followed until 1996) and 1998 and 2000 (followed until 2006), respectively. Active physician supply data (1991 and 2001) joined to each woman's census division of residence was taken from the Scott's Medical Database.

RESULTS

Protective thresholds were observed among the earlier cohort for supplies of general practitioners (7 per 10,000 population) and supplies of obstetricians/gynecologists (6 per 100,000 population) at or above which women with breast cancer were significantly more likely to have been diagnosed with localized disease and to have survived for >or=5 years. These protective effects seemed generally attenuated among the more recent cohort. The risk of living in primary care physician-undersupplied areas increased significantly between 1991 and 2001 (10%-30%), and such physician supply losses were associated with reduced cancer care protection, including less prevalent early diagnoses (odds ratio [OR], 1.60; 95% confidence interval [95% CI], 1.00-2.58) and lower 5-year survival rates (OR, 1.62; 95% CI, 1.03-2.55).

CONCLUSIONS

Primary care physician supplies appeared to matter very much in the effective provision of cancer care in Canada. Community healthcare service endowments that include adequate physician supplies may be particularly critical to the performance of a healthcare system such as that in Canada, which provides universal accessibility to medically necessary care.

Breast cancer survival in Canada and the USA: meta-analytic evidence of a Canadian advantage in low-income areas

BACKGROUND

This study tested the hypothesis that relatively poor Canadian women with breast cancer have a survival advantage over their counterparts in the USA.

METHODS

Seventy-eight independent retrospective cohort (incidence between 1984 and 2000, followed until 2006) outcomes were synthesized. Fixed effects meta-regression models compared women with breast cancer in low-income areas of Canada and the USA.

RESULTS

Low-income Canadian women were advantaged on survival [rate ratio (RR) = 1.14; 95% confidence interval (CI) 1.13-1.15] and their advantage was even larger among women <65 years of age who are not yet eligible for Medicare coverage in the USA (RR = 1.21, 95% CI 1.18-1.24). Canadian advantages were also larger for node positive breast cancer, which may present with greater clinical and managerial discretion (RR = 1.40, 95% CI 1.30-1.50), and smaller when Hawaii, the state providing the most Canadian-like access, was the US comparator (RR = 1.12, 95% CI 1.01-1.20).

CONCLUSIONS

More inclusive health care insurance coverage in Canada vs the USA, particularly among each country's relatively poor people, seems the most plausible explanation for such Canadian advantages. Provision of health care for all Americans would likely prevent countless early deaths, particularly among the relatively poor.