Factors affecting pattern of care and survival in a population-based cohort of non-small-cell lung cancer incident cases

Investigating socioeconomic disparities in lung cancer diagnosis, treatment and mortality: an Italian cohort study

BACKGROUND

Lung cancer is one of the most lethal cancers worldwide and patient clinical outcomes seem influenced by their socioeconomic position (SEP). Since little has been investigated on this topic in the Italian context, our aim was to investigate the role of SEP in the care pathway of lung cancer patients in terms of diagnosis, treatment and mortality.

METHODS

This observational retrospective cohort study included patients discharged in the Lazio Region with a lung cancer diagnosis between 2014 and 2017. In the main analysis, educational level was used as SEP measure. Multivariate models, adjusted for demographic and clinical variables, were applied to evaluate the association between SEP and study outcomes, stratified for metastatic (M) and non-metastatic (NM) cancer. We defined a diagnosis as 'delayed' when patients received their initial cancer diagnosis after an emergency department admission. Access to advanced lung cancer treatments (high-cost, novel and innovative treatments) and mortality were investigated within the 24-month period post-diagnosis. Moreover, two additional indicators of SEP were examined in the sensitivity analysis: one focusing on area deprivation and the other on income-based exemption.

RESULTS

A total of 13,251 patients were identified (37.3% with metastasis). The majority were males (> 60%) and over half were older than 70 years. The distribution of SEP levels among patients was as follow: 31% low, 29% medium-low, 32% medium-high and 7% high. As SEP increased, the risks of receiving a delayed diagnosis ((high vs low: M: OR = 0.29 (0.23-0.38), NM: OR = 0.20 (0.16-0.25)) and of mortality ((high vs low M: OR = 0.77 (0.68-0.88) and NM: 0.61 (0.54-0.69)) decreased. Access to advanced lung cancer treatments increased in accordance with SEP only in the M cohort (high vs low: M: OR = 1.57 (1.18-2.09)). The primary findings were corroborated by sensitivity analysis.

CONCLUSIONS

Our study highlighted the need of public health preventive and educational programs in Italy, a country where the care pathway of lung cancer patients, especially in terms of diagnosis and mortality, appears to be negatively affected by SEP level.

Lung cancer, comorbidities, and medication: the infernal trio

Most patients with lung cancer are smokers and are of advanced age. They are therefore at high risk of having age- and lifestyle-related comorbidities. These comorbidities are subject to treatment or even polypharmacy. There is growing evidence of a link between lung cancer, comorbidities and medications. The relationships between these entities are complex. The presence of comorbidities and their treatments influence the time of cancer diagnosis, as well as the diagnostic and treatment strategy. On the other hand, cancer treatment may have an impact on the patient's comorbidities such as renal failure, pneumonitis or endocrinopathies. This review highlights how some comorbidities may have an impact on lung cancer presentation and may require treatment adjustments. Reciprocal influences between the treatment of comorbidities and anticancer therapy will also be discussed.

What health inequalities exist in access to, outcomes from and experience of treatment for lung cancer? A scoping review

OBJECTIVES

Lung cancer (LC) continues to be the leading cause of cancer-related deaths and while there have been significant improvements in overall survival, this gain is not equally distributed. To address health inequalities (HIs), it is vital to identify whether and where they exist. This paper reviews existing literature on what HIs impact LC care and where these manifest on the care pathway.

DESIGN

A systematic scoping review based on Arksey and O'Malley's five-stage framework.

DATA SOURCES

Multiple databases (EMBASE, HMIC, Medline, PsycINFO, PubMed) were used to retrieve articles.

ELIGIBILITY CRITERIA

Search limits were set to retrieve articles published between January 2012 and April 2022. Papers examining LC along with domains of HI were included. Two authors screened papers and independently assessed full texts.

DATA EXTRACTION AND SYNTHESIS

HIs were categorised according to: (a) HI domains: Protected Characteristics (PC); Socioeconomic and Deprivation Factors (SDF); Geographical Region (GR); Vulnerable or Socially Excluded Groups (VSG); and (b) where on the LC pathway (access to, outcomes from, experience of care) inequalities manifest. Data were extracted by two authors and collated in a spreadsheet for structured analysis and interpretation.

RESULTS

41 papers were included. The most studied domain was PC (32/41), followed by SDF (19/41), GR (18/41) and VSG (13/41). Most studies investigated differences in access (31/41) or outcomes (27/41), with few (4/41) exploring experience inequalities. Evidence showed race, rural residence and being part of a VSG impacted the access to LC diagnosis, treatment and supportive care. Additionally, rural residence, older age or male sex negatively impacted survival and mortality. The relationship between outcomes and other factors (eg, race, deprivation) showed mixed results.

CONCLUSIONS

Findings offer an opportunity to reflect on the understanding of HIs in LC care and provide a platform to consider targeted efforts to improve equity of access, outcomes and experience for patients.

Surgical resection of primary tumors improved the prognosis of patients with bone metastasis of non-small cell lung cancer: a population-based and propensity score-matched study

Background

Most patients with lung cancer are in an advanced stage at the time of diagnosis due to occult onset. Bone is one of the most common sites of hematogenous metastasis of lung cancer. This study aimed to evaluate the impact of surgical resection of primary tumors on the prognosis of patients with bone metastasis of non-small cell lung cancer, using the Surveillance, Epidemiology, and End Results (SEER) database.

Methods

A total of 9,804 patients with only bone metastasis were identified from the SEER database. Propensity score matching was used to reduce the selection bias. Cancer-specific survival (CSS) and overall survival (OS) were compared between patients with or without primary tumor resection. The Cox regression model was applied to evaluate multiple prognostic factors.

Results

After propensity score matching, 424 patients were selected for survival analysis. No statistically significant differences were found in age, sex, race, tumor location, histology, T stage, and N stage between patients with or without surgical resection of primary tumors. The prognosis of patients who underwent surgical resection of primary tumors was significantly better than that of patients who had not undergone surgery. The surgical resection of primary tumors was an independent prognostic factor. The prognosis of patients who underwent lobectomy/bilobectomy was significantly better compared to other surgical types. Regional lymph node resection during surgery also significantly improved the prognosis of the patients.

Conclusions

For patients with only bone metastasis, surgical resection of primary tumors could significantly improve prognosis. Lobectomy/bilobectomy with regional lymph node resection was the best surgical strategy.

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.

Effect of Comorbidity on Lung Cancer Diagnosis Timing and Mortality: A Nationwide Population-Based Cohort Study in Taiwan

The effect of comorbidity on lung cancer patients' survival has been widely reported. The aim of this study was to investigate the effects of comorbidity on the establishment of the diagnosis of lung cancer and survival in lung cancer patients in Taiwan by using a nationwide population-based study design. This study collected various comorbidity patients and analyzed data regarding the lung cancer diagnosis and survival during a 16-year follow-up period (1995-2010). In total, 101,776 lung cancer patients were included, comprising 44,770 with and 57,006 without comorbidity. The Kaplan-Meier analyses were used to compare overall survival between lung cancer patients with and without comorbidity. In our cohort, chronic bronchitis patients who developed lung cancer had the lowest overall survival in one (45%), five (28.6%), and ten years (26.2%) since lung cancer diagnosis. Among lung cancer patients with nonpulmonary comorbidities, patients with hypertension had the lowest overall survival in one (47.9%), five (30.5%), and ten (28.2%) years since lung cancer diagnosis. In 2010, patients with and without comorbidity had 14.86 and 9.31 clinical visits, respectively. Lung cancer patients with preexisting comorbidity had higher frequency of physician visits. The presence of comorbid conditions was associated with early diagnosis of lung cancer.

A narrative synthesis of the quality of cancer care and development of an integrated conceptual framework

The general paradigms that exist to guide measures in quality of care do not sufficiently deal with the changing needs of cancer management. The aim of this study was to review the literature regarding the quality of cancer care and develop a conceptual framework relevant to current practice. A textual narrative review of the literature was conducted by searching electronic databases from the last 10 years. Articles were then screened and included if they were both relevant to the management of cancer and standards in quality of care. Thematic analysis of the included articles was performed. Eighty-three articles were included and 12 domains identified and integrated with current models to develop a conceptual framework. These included: healthcare delivery system; timeliness; access; appropriateness of care; multidisciplinary and coordinated care; patient experience; technical aspects; safety; patient-centred outcomes; disease-specific outcomes; innovation and improvement and value. We propose a conceptual framework for the quality of cancer care based on relevant and current oncology practice. This presents a more practical and comprehensive approach than general models, and can be used by healthcare providers, managers and policy makers to guide and identify the need for metrics for quality improvements.

Education predicts cervical cancer survival: a Lithuanian cohort study

Background

: We examined inequalities in cervical cancer survival in Lithuania by education and place of residence. : The study is based on the linked dataset that includes all records of the 2001 population Census, all records from Lithuanian Cancer Registry (cancer incidence) and all death and emigration records from Statistics Lithuania for the period between 6 April 2001 and 31 December 2009. The study group includes cervical cancers registered in the Cancer Registry from 1 January 2002 to 31 December 2006. Analysis was restricted to women who were 25-64 years old at the Census date (in total 1 866 cases). : During the study period there were 671 deaths corresponding to an overall 5-year survival proportion 64.13% (95% CI 61.86-66.31). Place of residence and education of cervical cancer patients had strong impact on survival; 5-year survival was higher in women living in urban areas than in rural (68.61 and 55.93%) and survival decreased with decreasing education: from 79.77% in highest education group to 64.85 and 50.48% in groups with secondary and lower than secondary education. The effect of place of residence declined when stage of disease was included in the model and became not significant in final model with education adjustment. The effect of education declined after inclusion of stage and other variables, however, remained significant. : We found that women with higher education experienced higher survival following a cervical cancer diagnosis, and stage of disease at the time of diagnosis explains only the part of observed differences.

Socio-economic inequalities in stage at diagnosis, and in time intervals on the lung cancer pathway from first symptom to treatment: systematic review and meta-analysis

Cancer diagnosis at an early stage increases the chance of curative treatment and of survival. It has been suggested that delays on the pathway from first symptom to diagnosis and treatment may be socio-economically patterned, and contribute to socio-economic differences in receipt of treatment and in cancer survival. This review aimed to assess the published evidence for socio-economic inequalities in stage at diagnosis of lung cancer, and in the length of time spent on the lung cancer pathway. MEDLINE, EMBASE and CINAHL databases were searched to locate cohort studies of adults with a primary diagnosis of lung cancer, where the outcome was stage at diagnosis or the length of time spent within an interval on the care pathway, or a suitable proxy measure, analysed according to a measure of socio-economic position. Meta-analysis was undertaken when there were studies available with suitable data. Of the 461 records screened, 39 papers were included in the review (20 from the UK) and seven in a final meta-analysis for stage at diagnosis. There was no evidence of socio-economic inequalities in late stage at diagnosis in the most, compared with the least, deprived group (OR=1.04, 95% CI=0.92 to 1.19). No socio-economic inequalities in the patient interval or in time from diagnosis to treatment were found. Socio-economic inequalities in stage at diagnosis are thought to be an important explanatory factor for survival inequalities in cancer. However, socio-economic inequalities in stage at diagnosis were not found in a meta-analysis for lung cancer.

PROSPERO PROTOCOL REGISTRATION NUMBER

CRD42014007145.

Lived Experience among Patients Newly Diagnosed with Lung Adenocarcinoma Stage IV within One Year

BACKGROUND

lung cancer (LC) is the fifth of the 10 leading causes of death in the world. LC is in first place for cancer-related mortality for both males and females in Taiwan. It is one of the most difficult cancers to treat and is often diagnosed at a late stage. Patients with stage IV are often unprepared for the diagnosis.

MATERIALS AND METHODS

To explore lived experience among patients newly diagnosed with lung adenocarcinoma stage IV within one year.

RESULTS

Twelve participants were recruited in this study. Content analysis of the interviews revealed four themes: (1) emotional roller coaster, (2) trying to find out causes, (3) adjusting my lifestyle, and (4) cancer fighter.

CONCLUSIONS

This study provides new insight into the experiences of lung cancer patients y with newly diagnosed lung adenocarcinoma stage 4. These results will inform future supportive care service development and intervention research for patients with advanced stage cancer.

Education, survival, and avoidable deaths in Lithuanian cancer patients, 2001-2009

Background Our aim in this study is to provide a systematic assessment of the site-specific cancer survival rates of patients with different educational levels, using population-based census-linked registry data covering the entire population of Lithuania. Material and methods The study is based on the linkage between all records of the 2001 population census and all records from Lithuanian Cancer Registry (cancer incidence) and Statistics Lithuania (deaths) for the period between 6 April 2001 and 31 December 2009. Results For the vast majority of cancer sites we found an inverse gradient in survival, with the worst survival indicators in the lowest educational group. We estimated that 18.6% of the deaths in Lithuanian cancer patients could have potentially been postponed, if all the patients had the same cancer mortality as the patients with the highest educational level. Conclusion Our findings offer a warning that although the survival rates of cancer patients are improving, this progress hides disparities between different groups of patients.

Comorbidity and Survival in Lung Cancer Patients

BACKGROUND

As the population of the United States ages, there will be increasing numbers of lung cancer patients with comorbidities at diagnosis. Comorbid conditions are important factors in both the choice of the lung cancer treatment and outcomes. However, the impact of individual comorbid conditions on patient survival remains unclear.

METHODS

A population-based cohort study of 5,683 first-time diagnosed lung cancer patients was captured using the Nebraska Cancer Registry (NCR) linked with the Nebraska Hospital Discharge Data (NHDD) between 2005 and 2009. A Cox proportional hazards model was used to analyze the effect of comorbidities on the overall survival of patients stratified by stage and adjusting for age, race, sex, and histologic type.

RESULTS

Of these patients, 36.8% of them survived their first year after lung cancer diagnosis, with a median survival of 9.3 months for all stages combined. In this cohort, 26.7% of the patients did not have any comorbidity at diagnosis. The most common comorbid conditions were chronic pulmonary disease (52.5%), diabetes (15.7%), and congestive heart failure (12.9%). The adjusted overall survival of lung cancer patients was negatively associated with the existence of different comorbid conditions such as congestive heart failure, diabetes with complications, moderate or severe liver disease, dementia, renal disease, and cerebrovascular disease, depending on the stage.

CONCLUSIONS

The presence of comorbid conditions was associated with worse survival. Different comorbid conditions were associated with worse outcomes at different stages.

IMPACT

Future models for predicting lung cancer survival should take individual comorbid conditions into consideration.

The economic burden of caregiving on families of children and adolescents with cancer: a population-based assessment

BACKGROUND

Childhood cancer represents a relevant economic burden on families. The preferred tool to investigate family expenditure is the retrospective questionnaire, which is subject to recall errors and selection bias. Therefore, in the present study the economic burden of caregiving on families of children and adolescents (0-19 years of age) with cancer was analysed using administrative data as an alternative to retrospective questionnaires.

PROCEDURE

Incident cases of cancer diagnosed in children and adolescents in 2000-2005 (N = 917) were identified from the Piedmont Childhood Cancer Registry and linked to available administrative databases to identify episodes of care during the 3 years after diagnosis (N = 13,433). The opportunity cost of informal caregiving was estimated as the value of the time spent by one of the parents, and was assumed to be equal to the number of days during which the child received inpatient care, day-care or outpatient radiotherapy. Factors affecting the level of economic burden of caregiving on families were analysed in a multivariable model.

RESULTS

The economic burden of caregiving increased when care was supplied at the Regional Referral Centre, or when treatment complexity was high. Families with younger children had a higher level of economic burden of caregiving. Leukaemia required a higher family commitment than any other cancer considered.

CONCLUSIONS

Estimates of the economic burden of caregiving on families of children and adolescents with cancer derived from administrative data should be considered a minimum burden. The estimated effect of the covariates is informative for healthcare decision-makers in planning support programmes.

γ -H2AX: A Novel Prognostic Marker in a Prognosis Prediction Model of Patients with Early Operable Non-Small Cell Lung Cancer

Cancer is a leading cause of death worldwide and the prognostic evaluation of cancer patients is of great importance in medical care. The use of artificial neural networks in prediction problems is well established in human medical literature. The aim of the current study was to assess the prognostic value of a series of clinical and molecular variables with the addition of γ -H2AX-a new DNA damage response marker-for the prediction of prognosis in patients with early operable non-small cell lung cancer by comparing the γ -H2AX-based artificial network prediction model with the corresponding LR one. Two prognostic models of 96 patients with 27 input variables were constructed by using the parameter-increasing method in order to compare the predictive accuracy of neural network and logistic regression models. The quality of the models was evaluated by an independent validation data set of 11 patients. Neural networks outperformed logistic regression in predicting the patient's outcome according to the experimental results. To assess the importance of the two factors p53 and γ -H2AX, models without these two variables were also constructed. JR and accuracy of these models were lower than those of the models using all input variables, suggesting that these biological markers are very important for optimal performance of the models. This study indicates that neural networks may represent a potentially more useful decision support tool than conventional statistical methods for predicting the outcome of patients with non-small cell lung cancer and that some molecular markers, such as γ -H2AX, enhance their predictive ability.

The impact of comorbidity on cancer survival: a review

Background

A number of studies have shown poorer survival among cancer patients with comorbidity. Several mechanisms may underlie this finding. In this review we summarize the current literature on the association between patient comorbidity and cancer prognosis. Prognostic factors examined include tumor biology, diagnosis, treatment, clinical quality, and adherence.

Methods

All English-language articles published during 2002–2012 on the association between comorbidity and survival among patients with colon cancer, breast cancer, and lung cancer were identified from PubMed, MEDLINE and Embase. Titles and abstracts were reviewed to identify eligible studies and their main results were then extracted.

Results

Our search yielded more than 2,500 articles related to comorbidity and cancer, but few investigated the prognostic impact of comorbidity as a primary aim. Most studies found that cancer patients with comorbidity had poorer survival than those without comorbidity, with 5-year mortality hazard ratios ranging from 1.1 to 5.8. Few studies examined the influence of specific chronic conditions. In general, comorbidity does not appear to be associated with more aggressive types of cancer or other differences in tumor biology. Presence of specific severe comorbidities or psychiatric disorders were found to be associated with delayed cancer diagnosis in some studies, while chronic diseases requiring regular medical visits were associated with earlier cancer detection in others. Another finding was that patients with comorbidity do not receive standard cancer treatments such as surgery, chemotherapy, and radiation therapy as often as patients without comorbidity, and their chance of completing a course of cancer treatment is lower. Postoperative complications and mortality are higher in patients with comorbidity. It is unclear from the literature whether the apparent undertreatment reflects appropriate consideration of greater toxicity risk, poorer clinical quality, patient preferences, or poor adherence among patients with comorbidity.

Conclusion

Despite increasing recognition of the importance of comorbid illnesses among cancer patients, major challenges remain. Both treatment effectiveness and compliance appear compromised among cancer patients with comorbidity. Data on clinical quality is limited.

The association of race with timeliness of care and survival among Veterans Affairs health care system patients with late-stage non-small cell lung cancer

Background

Non-small cell lung cancer is the leading cause of cancer-related mortality in the United States. Patients with late-stage disease (stage 3/4) have five-year survival rates of 2%–15%. Care quality may be measured as time to receiving recommended care and, ultimately, survival. This study examined the association between race and receipt of timely non-small cell lung cancer care and survival among Veterans Affairs health care system patients.

Methods

Data were from the External Peer Review Program, a nationwide Veterans Affairs quality-monitoring program. We included Caucasian or African American patients with pathologically confirmed late-stage non-small cell lung cancer in 2006 and 2007. We examined three quality measures: time from diagnosis to (1) treatment initiation, (2) palliative care or hospice referral, and (3) death. Unadjusted analyses used log-rank and Wilcoxon tests. Adjusted analyses used Cox proportional hazard models.

Results

After controlling for patient and disease characteristics using Cox regression, there were no racial differences in time to initiation of treatment (72 days for African American versus 65 days for Caucasian patients, hazard ratio 1.04, P = 0.80) or palliative care or hospice referral (129 days versus 116 days, hazard ratio 1.10, P = 0.34). However, the adjusted model found longer survival for African American patients than for Caucasian patients (133 days versus 117 days, hazard ratio 0.31, P < 0.01).

Conclusion

For process measures of care quality (eg, time to initiation of treatment and referral to supportive care) the Veterans Affairs health care system provides racially equitable care. The small racial difference in survival time of approximately 2 weeks is not clinically meaningful. Future work should validate this possible trend prospectively, with longer periods of follow-up, in other veteran groups.

A checklist for ascertaining study cohorts in oncology health services research using secondary data: report of the ISPOR oncology good outcomes research practices working group

OBJECTIVES

The ISPOR Oncology Special Interest Group formed a working group at the end of 2010 to develop standards for conducting oncology health services research using secondary data. The first mission of the group was to develop a checklist focused on issues specific to selection of a sample of oncology patients using a secondary data source.

METHODS

A systematic review of the published literature from 2006 to 2010 was conducted to characterize the use of secondary data sources in oncology and inform the leadership of the working group prior to the construction of the checklist. A draft checklist was subsequently presented to the ISPOR membership in 2011 with subsequent feedback from the larger Oncology Special Interest Group also incorporated into the final checklist.

RESULTS

The checklist includes six elements: identification of the cancer to be studied, selection of an appropriate data source, evaluation of the applicability of published algorithms, development of custom algorithms (if needed), validation of the custom algorithm, and reporting and discussions of the ascertainment criteria. The checklist was intended to be applicable to various types of secondary data sources, including cancer registries, claims databases, electronic medical records, and others.

CONCLUSIONS

This checklist makes two important contributions to oncology health services research. First, it can assist decision makers and reviewers in evaluating the quality of studies using secondary data. Second, it highlights methodological issues to be considered when researchers are constructing a study cohort from a secondary data source.

Socioeconomic inequalities in lung cancer treatment: systematic review and meta-analysis

BACKGROUND

Intervention-generated inequalities are unintended variations in outcome that result from the organisation and delivery of health interventions. Socioeconomic inequalities in treatment may occur for some common cancers. Although the incidence and outcome of lung cancer varies with socioeconomic position (SEP), it is not known whether socioeconomic inequalities in treatment occur and how these might affect mortality. We conducted a systematic review and meta-analysis of existing research on socioeconomic inequalities in receipt of treatment for lung cancer.

METHODS AND FINDINGS

MEDLINE, EMBASE, and Scopus were searched up to September 2012 for cohort studies of participants with a primary diagnosis of lung cancer (ICD10 C33 or C34), where the outcome was receipt of treatment (rates or odds of receiving treatment) and where the outcome was reported by a measure of SEP. Forty-six papers met the inclusion criteria, and 23 of these papers were included in meta-analysis. Socioeconomic inequalities in receipt of lung cancer treatment were observed. Lower SEP was associated with a reduced likelihood of receiving any treatment (odds ratio [OR] = 0.79 [95% CI 0.73 to 0.86], p<0.001), surgery (OR = 0.68 [CI 0.63 to 0.75], p<0.001) and chemotherapy (OR = 0.82 [95% CI 0.72 to 0.93], p = 0.003), but not radiotherapy (OR = 0.99 [95% CI 0.86 to 1.14], p = 0.89), for lung cancer. The association remained when stage was taken into account for receipt of surgery, and was found in both universal and non-universal health care systems.

CONCLUSIONS

Patients with lung cancer living in more socioeconomically deprived circumstances are less likely to receive any type of treatment, surgery, and chemotherapy. These inequalities cannot be accounted for by socioeconomic differences in stage at presentation or by differences in health care system. Further investigation is required to determine the patient, tumour, clinician, and system factors that may contribute to socioeconomic inequalities in receipt of lung cancer treatment.

Impact of initial pattern of care on hospital costs in a cohort of incident lung cancer cases

RATIONALE, AIMS AND OBJECTIVES

Lung cancer is a disease with high consumption of health care resources. The aim of this study was to describe hospital costs due to lung cancer care from diagnosis until death or end of the study follow-up, in a cohort of incident cases, by using administrative data.

METHODS

Particular attention was given to the determinants of total costs and the impact of the initial treatment approach on the process of costs accumulation. Incident cases were identified by the local Cancer Registry (January 2000-December 2003) among the residents of Turin (Italy). Per patient hospital care has been determined from administrative databases (outpatient radiotherapy records and hospital discharge records). Costs determinants were identified via a multivariable generalized linear model (GLM), with a Gamma cost distribution and a logarithmic link function. To assess the time effect over the cost accumulation process for non-small-cell lung cancer cases, the same GLM Gamma model was repeated at different follow-up periods. Analyses were stratified by cancer histotype.

RESULTS

Results evidenced the relevant role of initial patterns of care on the cost accumulation process, with increased midterm costs associated with curative patterns of care.

CONCLUSION

The use of administrative data enabled hospital lung cancer care to be described, and related costs to be estimated.

The socioeconomic determinants of cancer

This paper provides a synthesis on socioeconomic inequalities in cancer incidence, mortality and survival across countries and within countries, with particular focus on the Italian context; the paper also describes the underlying mechanisms documented for cancer incidence, and reports some remarks on policies to tackle inequalities.From a worldwide perspective, the burden of cancer appears to be particularly increasing in developing countries, where many cancers with a poor prognosis (liver, stomach and oesophagus) are much more common than in richer countries. As in the case of incidence and mortality, also in cancer survival we observe a great variability across countries. Different studies have suggested a possible impact of health care on the social gradients in cancer survival, even in countries with a National Health System providing equitable access to care.In developed countries, there is increasing awareness of social inequalities as an important public health issue; as a consequence, there is a variety of strategies and policies being implemented throughout Europe. However, recent reviews emphasize that present knowledge on effectiveness of policies and interventions on health inequalities is not sufficient to offer a robust and evidence-based guide to the choice and design of interventions, and that more evaluation studies are needed.The large disparities in health that we can measure within and between countries represent a challenge to the world; social health inequalities are avoidable, and their reduction therefore represents an achievable goal and an ethical imperative.