Social inequality and incidence of and survival from cancers of the colon and rectum in a population-based study in Denmark, 1994–2003

Income dynamics and risk of colorectal cancer in individuals with type 2 diabetes: a nationwide population-based cohort study

BACKGROUND

Individuals with type 2 diabetes (T2D) have increased colorectal cancer (CRC) risk, but it is unknown whether income dynamics are associated with CRC risk in these individuals. We examined whether persistent low- or high-income and income changes are associated with CRC risk in non-elderly adults with T2D.

METHODS

Using nationally representative data from the Korean Health Insurance Service database, 1,909,492 adults aged 30 to 64 years with T2D and no history of cancer were included between 2009 and 2012 (median follow-up of 7.8 years). We determined income levels based on health insurance premiums and assessed annual income quartiles for the baseline year and the four preceding years. Hazard ratios(HRs) and 95% confidence intervals(CIs) were estimated after adjusting for sociodemographic factors, CRC risk factors, and diabetes duration and treatment.

RESULTS

Persistent low income (i.e., lowest income quartile) was associated with increased CRC risk (HRn=5years vs. n=0years 1.11, 95% CI 1.04-1.18; P for trend=0.004). Income declines (i.e., a decrease≥25% in income quantile) were also associated with increased CRC risk (HR≥2 vs. 0 declines 1.10, 95% CI 1.05-1.16; p for trend=0.001). In contrast, persistent high income (i.e., highest income quartile) was associated with decreased CRC risk (HRn=5years vs. n=0years 0.81, 95% CI 0.73-0.89; p for trend<0.0001), which was more pronounced for rectal cancer (HR 0.64, 95% CI 0.53-0.78) and distal colon cancer (HR 0.70, 95% CI 0.57-0.86).

CONCLUSIONS

Our findings underscore the need for increased public policy awareness of the association between income dynamics and CRC risk in adults with T2D.

Trends and disparities in colorectal cancer hospitalizations and outcomes: a 10-year joinpoint trend study

Background

Colorectal cancer (CRC) poses a significant burden on healthcare systems globally. Sociodemographic factors intricately influence CRC epidemiology, yet their impact on inpatient care remains underexplored. This study aimed to assess trends in CRC hospitalization and the effect of sociodemographic factors on outcomes of CRC patients.

Methods

A retrospective longitudinal analysis was conducted using data from the Healthcare Cost and Utilization Project National Inpatient Sample. Trends in CRC admissions were assessed, stratified by sociodemographic variables. Disparities in hospital-associated outcomes were examined. Statistical methods included multivariable regression and joinpoint regression analysis.

Results

The prevalence of CRC hospitalizations uptrended from 760 per 100,000 hospitalizations in 2010 to 841 per 100,000 hospitalizations in 2019 (P trend < 0.001). The mean age decreased from 67 to 66 years (P < 0.001). Male gender and White race were predominant across the study period. Inpatient mortality decreased from 4.5% in 2010 to 4.16% in 2019 (P trend = 0.033). On sex subgroup analysis, men had a significantly higher mortality rate (P = 0.034). Racially, Blacks had the highest mortality rate (P = 0.550) and only Whites showed a significant decline in mortality over the study period (P = 0.003). Hospitalization length decreased while total hospital charges increased.

Conclusion

Our study highlights sociodemographic disparities in CRC outcomes, emphasizing the need for targeted interventions to address inequity in screening, diagnosis, and treatment. Continued research is needed to inform effective healthcare practices in mitigating these disparities and improving survival outcomes.

Sex and gender perspectives in colorectal cancer

Historically women were frequently excluded from clinical trials and drug usage to protect unborn babies from potential harm. As a consequence, the impact of sex and gender on both tumour biology and clinical outcomes has been largely underestimated. Although interrelated and often used interchangeably, sex and gender are not equivalent concepts. Sex is a biological attribute that defines species according to their chromosomal makeup and reproductive organ, while gender refers to a chosen sexual identity. Sex dimorphisms are rarely taken into account, in either preclinical or clinical research, with inadequate analysis of differences in outcomes according to sex or gender still widespread, reflecting a gap in our knowledge for a large proportion of the target population. Underestimation of sex-based differences in study design and analyses has invariably led to 'one-drug' treatment regimens for both males and females. For patients with colorectal cancer (CRC), sex also has an impact on the disease incidence, clinicopathological features, therapeutic outcomes, and tolerability to anticancer treatments. Although the global incidence of CRC is higher in male subjects, the proportion of patients presenting right-sided tumours and BRAF mutations is higher among females. Concerning sex-related differences in treatment efficacy and toxicity, drug dosage does not take into account sex-specific differences in pharmacokinetics. Toxicity associated with fluoropyrimidines, targeted therapies, and immunotherapies has been reported to be more extensive for females with CRC than for males, although evidence about differences in efficacy is more controversial. This article aims to provide an overview of the research achieved so far into sex and gender differences in cancer and summarize the growing body of literature illustrating the sex and gender perspective in CRC and their impact in relation to tumour biology and treatment efficacy and toxicity. We propose endorsing research on how biological sex and gender influence CRC as an added value for precision oncology.

Exposome approach for identifying modifiable factors for the prevention of colorectal cancer

Previous studies have shown certain exposure factors (such as lifestyle and metabolism) are associated with colorectal cancer (CRC) events. However, the application of the exposome theoretical frame and the extent to which the exposome domain can modulate the risk of CRC remain unknown. Our study aimed to construct valid exposome measurements and examine the relationship between exposome counts and the risk of CRC. This study included 335,370 individuals in the UK Biobank. We used exploratory factor analysis to identify a valid construct of exposome factors. We then summed the exposome counts within each domain. Cox proportional hazard models were used to estimate the hazard ratios and 95% confidence intervals of CRC risk related to the exposome factors and counts. During an 8.69 year median follow-up, 10,702 CRC cases were identified. Five domains were extracted from 12 variables, including ecosystem, lifestyle, tobacco and alcohol use, social economics, and social support. The Cox model results showed that the ecosystem was positively related to the reduced CRC risk (HR = 0.970; 95% CI 0.952-0.989). Similar results were also found among the domains of healthy lifestyles (HR = 0. 889; 95% CI 0.871-0.907), and no tobacco and alcohol use (HR = 0.892; 95% CI 0.876-0.909). The disadvantageous social economic (HR = 1.081; 95% CI 1.058-1.105) and insufficient social support domains (HR = 1.036; 95% CI 1.017-1.056) were associated with an increased risk of CRC. Similar risk trends were also observed across the exposome count groups with CRC incidence. Our findings suggest that certain exposure domains are related to the incidence of CRC. Ecosystem, lifestyle, and social factors can be incorporated into prediction models to identify individuals at high risk of CRC.

The association between sociodemographic factors and time to diagnosis for colorectal cancer in northern Sweden

OBJECTIVES

This study examined whether sociodemographic factors, including distance to hospital, were associated with differences in the diagnostic interval and the treatment interval for colorectal cancer in northern Sweden.

METHODS

Data were retrieved from the Swedish cancer register on patients (n = 446) diagnosed in three northern regions during 2017-2018, then linked to data from Statistics Sweden and medical records. Also, Google maps was used to map the distance between patients' place of residence and nearest hospital. The different time intervals were analysed using Mann-Whitney U-test and Cox regression.

RESULTS

Differences in time to diagnosis were found between groups for income and distance to hospital, favouring those with higher income and shorter distance. The unadjusted regression analysis showed higher income to be associated with more rapid diagnosis (HR 1.004, CI 1.001-1.007). This association remained in the fully adjusted model for income (HR 1.004, CI 1.000-1.008), but not for distance. No differences between sociodemographic groups were found in the treatment interval.

CONCLUSION

Higher income and shorter distance to hospital were in the unadjusted models associated with shorter time to diagnosis for patients with CRC in northern Sweden. The association remained for income when adjusting for other variables even though the difference was small.

The relative effectiveness of fecal immunochemical test-based colorectal cancer screening to detect adenomas and cancer in different demographic and socioeconomic groups. A nationwide cohort study

INTRODUCTION

This study aimed at analyzing the relative effectiveness in removal of adenomas and detection of cancer of implementing colorectal cancer (CRC) screening in different demographic and socioeconomic groups.

METHODS

This register-based retrospective cohort study included residents aged 50-72 years. Those randomly selected to be invited for CRC screening from 1 March 2014 to 30 June 2015 were classified as invited; those invited from 1 January 2016 to 31 December 2017 were classified as not yet invited. Strata-specific relative risks (RRs) of having adenomas removed and CRC detected were estimated.

RESULTS

A total of 1 343 090 individuals were included. The RR of having adenomas removed were higher among men compared with women [RRwomen = 6.41 (95% confidence interval [CI]: 5.08-8.09), RRmen = 7.74 (95% CI: 6.16-9.73), P < 0.01] and among Danes compared with immigrants [RRDanes = 4.71 (95% CI: 3.73-5.93), RRWestern = 4.76 (95% CI: 3.39-6.69), RRnon-Western = 3.35 (95% CI: 2.39-4.69), P = 0.03]. Regarding detection of CRC, the effectiveness increased with increasing age ranging from RR = 1.53 (95% CI: 0.93- 2.51) to RR = 1.97 (95% CI: 1.22-3.17) (P = 0.04) and was higher among men compared with women (RRwomen = 1.75 (95% CI: 1.10-2.76), RRmen = 2.07 (95% CI: 1.32-3.26), P = 0.02.

CONCLUSION

Attention must be paid to the potential differences in screening effectiveness among diverse subpopulations; first, by securing equal opportunities for participation across subpopulations and second, by considering sex and age-specific screening programs.

Socio-Economic Position, Cancer Incidence and Stage at Diagnosis: A Nationwide Cohort Study in Belgium

Background: Socio-economic position is associated with cancer incidence, but the direction and magnitude of this relationship differs across cancer types, geographical regions, and socio-economic parameters. In this nationwide cohort study, we evaluated the association between different individual-level socio-economic and -demographic factors, cancer incidence, and stage at diagnosis in Belgium. Methods: The 2001 census was linked to the nationwide Belgian Cancer Registry for cancer diagnoses between 2004 and 2013. Socio-economic parameters included education level, household composition, and housing conditions. Incidence rate ratios were assessed through Poisson regression models. Stage-specific analyses were conducted through logistic regression models. Results: Deprived groups showed higher risks for lung cancer and head and neck cancers, whereas an inverse relation was observed for malignant melanoma and female breast cancer. Typically, associations were more pronounced in men than in women. A lower socio-economic position was associated with reduced chances of being diagnosed with known or early stage at diagnosis; the strongest disparities were found for male lung cancer and female breast cancer. Conclusions: This study identified population groups at increased risk of cancer and unknown or advanced stage at diagnosis in Belgium. Further investigation is needed to build a comprehensive picture of socio-economic inequality in cancer incidence.

Social determinants of colorectal cancer risk, stage, and survival: a systematic review

BACKGROUND

Several social determinants of health have been examined in relation to colorectal cancer incidence, stage at diagnosis, and survival including income, education, neighborhood disadvantage, immigration status, social support, and social network. Colorectal cancer incidence rates are positively associated with income and other measures of socioeconomic status. In contrast, low socioeconomic status tends to be associated with poorer survival.

METHODS

The present review is based upon bibliographic searches in PubMed and CINAHL and relevant search terms. Articles published in English from 1970 through April 1, 2019 were identified using the following MeSH search terms and Boolean algebra commands: colorectal cancer AND (incidence OR stage OR mortality) AND (social determinants OR neighborhood disadvantage OR racial discrimination OR immigration OR social support).

RESULTS

This review indicates that poverty, lack of education, immigration status, lack of social support, and social isolation play important roles in colorectal cancer stage at diagnosis and survival.

CONCLUSIONS

To address social determinants of colorectal cancer, effective interventions are needed that account for the social contexts in which patients live.

Socioeconomic inequalities in cancer incidence in Europe: a comprehensive review of population-based epidemiological studies

Background

Since the end of the previous century, there has not been a comprehensive review of European studies on socioeconomic inequality in cancer incidence. In view of recent advances in data source linkage and analytical methods, we aimed to update the knowledge base on associations between location-specific cancer incidence and individual or area-level measures of socio-economic status (SES) among European adults.

Materials and methods

We systematically searched three databases (PubMed, Scopus and Web of Science) for articles on cancer incidence and SES. Qualitative synthesis was performed on the 91 included English language studies, published between 2000 and 2019 in Europe, which focused on adults, relied on cancer registry data and reported on relative risk (RR) estimates.

Results

Adults with low SES have increased risk of head and neck, oesophagogastric, liver and gallbladder, pancreatic, lung, kidney, bladder, penile and cervical cancers (highest RRs for lung, head and neck, stomach and cervix). Conversely, high SES is linked with increased risk of thyroid, breast, prostate and skin cancers. Central nervous system and haematological cancers are not associated with SES. The positive gap in testicular cancer has narrowed, while colorectal cancer shows a varying pattern in different countries. Negative associations are generally stronger for men compared to women.

Conclusions

In Europe, cancers in almost all common locations are associated with SES and the inequalities can be explained to a varying degree by known life-style related factors, most notably smoking. Independent effects of many individual and area SES measures which capture different aspects of SES can also be observed.

Low Socioeconomic Status Is Associated with Worse Outcomes After Curative Surgery for Colorectal Cancer: Results from a Large, Multicenter Study

BACKGROUND

Socioeconomic status (SES) has been associated with early mortality in cancer patients. However, the association between SES and outcome in colorectal cancer patients is largely unknown. The aim of this study was to investigate whether SES is associated with short- and long-term outcome in patients undergoing curative surgery for colorectal cancer.

METHODS

Patients who underwent curative surgery in the region of Rotterdam for stage I-III colorectal cancer between January 2007 and July 2014 were included. Gross household income and survival status were obtained from a national registry provided by Statistics Netherlands Centraal Bureau voor de Statistiek. Patients were assigned percentiles according to the national income distribution. Logistic regression and Cox proportional hazard regression were performed to assess the association of SES with 30-day postoperative complications, overall survival and cancer-specific survival, adjusted for known prognosticators.

RESULTS

For 965 of the 975 eligible patients (99%), gross household income could be retrieved. Patients with a lower SES more often had diabetes, more often underwent an open surgical procedure, and had more comorbidities. In addition, patients with a lower SES were less likely to receive (neo) adjuvant treatment. Lower SES was independently associated with an increased risk of postoperative complications (Odds ratio per percent increase 0.99, 95%CI 0.99-0.998, p = 0.004) and lower cancer-specific mortality (Hazard ratio per percent increase 0.99, 95%CI 0.98-0.99, p = 0.009).

CONCLUSION

This study shows that lower SES is associated with increased risk of postoperative complications, and poor cancer-specific survival in patients undergoing surgery for stage I-III colorectal cancer after correcting for known prognosticators.

Trends of colorectal cancer incidence by education and socioeconomic status in Finland

Background: The aim of this study was to investigate if the incidence of colorectal cancer (CRC) is associated with education and socioeconomic status (SES) in Finland, and if there are any changes in incidence differences between the groups over the period 1976-2014.Material and methods: CRC cases (N = 77,614) were retrieved from the Finnish Cancer Registry and linked with information on the education level and SES from Statistics Finland. We used Poisson regression model to quantify differences in incidence rates between the groups, and to assess changes over calendar time.Results and conclusions: Colon cancer incidence was higher among the highly educated, than in those with basic education. Similar differences were observed by SES in men. Incidence rates increased steeply over time among men with basic education (from 16.7/100,000 in 1976-1979 to 31.8 in 2010-2014), resulting in narrowed differences between the groups (p < .001). Incidence trends of proximal and distal colon and rectal cancer in men showed similar patterns. Heterogeneity across time periods by SES was observed only in colon cancer incidence in men (p = .009). No such large differences were detected in women. Steep increase in colon cancer incidence in men with basic education, and the respective persistent high incidence in the highly educated highlights the importance of focusing the preventive measures on modifiable lifestyle factors in order to reduce CRC incidence and to narrow the educational and socioeconomic health differences.

Predictive values of colorectal cancer alarm symptoms in the general population: a nationwide cohort study

Background

Alarm symptoms are used in many cancer referral guidelines. The objectives were to determine the 1-year predictive values (PVs) of colorectal cancer (CRC) alarm symptoms in the general population and to describe the proportion of alarm symptoms reported prior to diagnosis.

Methods

A nationwide prospective cohort of 69,060 individuals ≥40 years randomly selected from the Danish population was invited to complete a survey regarding symptoms and healthcare-seeking in 2012. Information on CRC diagnoses in a 12-month follow-up came from the Danish Cancer Registry. PVs and positive and negative likelihood ratios were calculated.

Results

A total of 37,455 individuals participated (response rate 54.2%). Sixty-four individuals were diagnosed with CRC. The single symptom with the highest positive PVs (PPV) and LR+ was rectal bleeding. PPVs were generally higher among individuals aged ≥75 years and highest among those reporting at least one specific alarm symptom that led to a GP contact.

Conclusion

In general, the PPVs of CRC alarm symptoms are low and the NPVs high, especially in the youngest age groups. The LR +  show a relative association with specific symptoms like rectal bleeding. Future campaigns on early diagnosis of CRC should focus on healthcare-seeking when experiencing rectal bleeding and target older people with the highest incidence.

Differences in diagnostic activity in general practice and findings for individuals invited to the danish screening programme for colorectal cancer: a population-based cohort study

OBJECTIVE

To investigate the diagnostic activity in general practice and the cumulative incidence of colorectal cancer (CRC) in individuals invited to the Danish national screening programme for CRC.

DESIGN

A historical population-based cohort study.

SETTING

The Danish CRC screening programme and general practice.

SUBJECTS

The 376,198 individuals invited to the Danish CRC screening programme from 1 March to 31 December 2014.

MAIN OUTCOME MEASURES

The diagnostic activity (consultations and haemoglobin measures) in general practice in the year preceding the screening invitation and the cumulated incidence of CRC in the year following the screening invitation.

RESULTS

Screening participants had significantly higher diagnostic activity than non-participants. Individuals with a positive faecal immunochemical test (FIT) had higher diagnostic activity compared to individuals with a negative FIT, and a small increase in the months leading up to the invitation. Individuals with a screen-detected CRC had lower diagnostic activity than individuals with no CRC. In total, 308 (25.3%) of CRCs diagnosed in the invited population were diagnosed outside the screening programme. Non-participants with CRC more often had low socio-economic status, high comorbidity and stage IV CRC than participants with CRC.

CONCLUSIONS

There was a tendency that participants and those with a positive FIT had a higher diagnostic activity the year before the screening. This was not seen for those with CRC detected through screening. CRC must still be diagnosed in general practice in the invited population and non-participants are of special interest as they have higher risk of late stage CRC. Key Points Current awareness:Individuals with colorectal cancer (CRC) in screening may be symptomatic and CRC may still occur outside screening in the invited population. Most important points:The majority of individuals with CRC in screening cannot be expected to be diagnosed on symptomatic presentation in general practice GPs have to be aware that CRC still occurs outside screening in the invited population Non-participants with CRC are often deprived and have late stage CRC.

Reliability and validity assessment of administrative databases in measuring the quality of rectal cancer management

PURPOSE

Measurement and monitoring of the quality of care using a core set of quality measures are increasing in health service research. Although administrative databases include limited clinical data, they offer an attractive source for quality measurement. The purpose of this study, therefore, was to evaluate the completeness of different administrative data sources compared to a clinical survey in evaluating rectal cancer cases.

METHODS

Between May 2012 and November 2014, a clinical survey was done on 498 Lombardy patients who had rectal cancer and underwent surgical resection. These collected data were compared with the information extracted from administrative sources including Hospital Discharge Dataset, drug database, daycare activity data, fee-exemption database, and regional screening program database. The agreement evaluation was performed using a set of 12 quality indicators.

RESULTS

Patient complexity was a difficult indicator to measure for lack of clinical data. Preoperative staging was another suboptimal indicator due to the frequent missing administrative registration of tests performed. The agreement between the 2 data sources regarding chemoradiotherapy treatments was high. Screening detection, minimally invasive techniques, length of stay, and unpreventable readmissions were detected as reliable quality indicators. Postoperative morbidity could be a useful indicator but its agreement was lower, as expected.

CONCLUSIONS

Healthcare administrative databases are large and real-time collected repositories of data useful in measuring quality in a healthcare system. Our investigation reveals that the reliability of indicators varies between them. Ideally, a combination of data from both sources could be used in order to improve usefulness of less reliable indicators.

Residential road traffic noise exposure and colorectal cancer survival - A Danish cohort study

BACKGROUND

Residential traffic noise exposure may entail sleep disruption and compromised circadian functioning; two factors which have been associated with a poor colorectal cancer (CRC) prognosis. Hence, the aim of the present study was to investigate the association between residential road traffic noise and CRC survival.

METHODS AND MATERIALS

Road traffic noise was calculated for all residential addresses from 1987 to February 2012 for incident CRC cases (n = 1,234) in a cohort of 57,053 Danes. We used Cox Proportional Hazard Models to investigate the association between residential road traffic noise at different time-windows, and overall and CRC-specific mortality. Furthermore, we investigated interaction with sex, age, prognostic factors, and comorbidity. Mortality Rate Ratios (MRR) were calculated in unadjusted models, and adjusted for railway noise, lifestyle factors, and socioeconomic variables.

RESULTS

During a median follow-up of 4 years, 594 patients died; 447 from CRC. We found no association between road traffic noise exposure and overall (MRR 1.00 (0.88-1.13) per 10 dB) or CRC-specific mortality (MRR 0.98 (0.85-1.13) per 10 dB) over the entire follow-up period, or 1 year preceding death. Results did not differ when examining colon and rectal cancer separately. Interaction analyses suggested that patients with less clinically advanced disease could be more susceptible to harmful effects of traffic noise.

CONCLUSION

The present study suggests no overall association between residential road traffic noise and concurrent mortality in CRC patients. As it is the first study of its kind, with relatively limited power, further studies are warranted.

Sociodemographic characteristics of nonparticipants in the Danish colorectal cancer screening program: a nationwide cross-sectional study

INTRODUCTION

Fecal occult blood tests are recommended for colorectal cancer (CRC) screening in Europe. Recently, the fecal immunochemical test (FIT) has come into use. Sociodemographic differences between participants and nonparticipants may be less pronounced when using FIT as there are no preceding dietary restrictions and only one specimen is required. The aim of this study was to examine the associations between sociodemographic characteristics and nonparticipation for both genders, with special emphasis on those who actively unsubscribe from the program.

METHODS

The study was a national, register-based, cross-sectional study among men and women randomized to be invited to participate in the prevalence round of the Danish CRC screening program between March 1 and December 31, 2014. Prevalence ratios (PRs) were used to quantify the association between sociodemographic characteristics and nonparticipation (including active nonparticipation). PRs were assessed using Poisson regression with robust error variance.

RESULTS

The likelihood of being a nonparticipant was highest in the younger part of the population; however, for women, the association across age groups was U-shaped. Female immigrants were more likely to be nonparticipants. Living alone, being on social welfare, and having lower income were factors that were associated with nonparticipation among both men and women. For both men and women, there was a U-shaped association between education and nonparticipation. For both men and women, the likelihood of active nonparticipation rose with age; it was lowest among non-western immigrants and highest among social welfare recipients.

CONCLUSION

Social inequality in screening uptake was evident among both men and women in the Danish CRC screening program, even though the program is free of charge and the screening kit is based on FIT and mailed directly to the individuals. Interventions are needed to bridge this gap if CRC screening is to avoid aggravating existing inequalities in CRC-related morbidity and mortality.

Prognostic factors and survival of colorectal cancer in Kurdistan province, Iran: A population-based study (2009-2014)

Colorectal cancer (CRC) survival varies at individual and geographically level. This population-based study aimed to evaluating various factors affecting the survival rate of CRC patients in Kurdistan province.In a retrospective cohort study, patients diagnosed as CRC were collected through a population-based study from March 1, 2009 to 2014. The data were collected from Kurdistan's Cancer Registry database. Additional information and missing data were collected reference to patients' homes, medical records, and pathology reports. The CRC survival was calculated from the date of diagnosis to the date of cancer-specific death or the end of follow-up (cutoff date: October 2015). Kaplan-Meier method and log-rank test were used for the univariate analysis of survival in various subgroups. The proportional-hazard model Cox was also used in order to consider the effects of different factors on survival including age at diagnosis, place of residence, marital status, occupation, level of education, smoking, economic status, comorbidity, tumor stage, and tumor grade.A total number of 335 patients affected by CRC were assessed and the results showed that 1- and 5-year survival rate were 87% and 33%, respectively. According to the results of Cox's multivariate analysis, the following factors were significantly related to CRC survival: age at diagnosis (≥65 years old) (HR 2.08, 95% CI: 1.17-3.71), single patients (HR 1.62, 95% CI: 1.10-2.40), job (worker) (HR 2.09, 95% CI: 1.22-3.58), educational level: diploma or below (HR 0.61, 95% CI: 0.39-0.92), wealthy economic status (HR 0.51, 95% CI: 0.31-0.82), tumor grade in poorly differentiated (HR 2.25, 95% CI: 1.37-3.69), and undifferentiated/anaplastic grade (HR 2.90, 95% CI: 1.67-4.98).We found that factors such as low education, inappropriate socioeconomic status, and high tumor grade at the time of disease diagnosis were effective in the poor survival of CRC patients in Kurdistan province; this, which need more attention.

No inequalities in survival from colorectal cancer by education and socioeconomic deprivation - a population-based study in the North Region of Portugal, 2000-2002

BACKGROUND

Association between cancer survival and socioeconomic status has been reported in various countries but it has never been studied in Portugal. We aimed here to study the role of education and socioeconomic deprivation level on survival from colorectal cancer in the North Region of Portugal using a population-based cancer registry dataset.

METHODS

We analysed a cohort of patients aged 15-84 years, diagnosed with a colorectal cancer in the North Region of Portugal between 2000 and 2002. Education and socioeconomic deprivation level was assigned to each patient based on their area of residence. We measured socioeconomic deprivation using the recently developed European Deprivation Index. Net survival was estimated using Pohar-Perme estimator and age-adjusted excess hazard ratios were estimated using parametric flexible models. Since no deprivation-specific life tables were available, we performed a sensitivity analysis to test the robustness of the results to life tables adjusted for education and socioeconomic deprivation level.

RESULTS

A total of 4,105 cases were included in the analysis. In male patients (56.3 %), a pattern of worse 5- and 10-year net survival in the less educated (survival gap between extreme education groups: -7 % and -10 % at 5 and 10 years, respectively) and more deprived groups (survival gap between extreme EDI groups: -5 % both at 5 and 10 years) was observed when using general life tables. No such clear pattern was found among female patients. In both sexes, when likely differences in background mortality by education or deprivation were accounted for in the sensitivity analysis, any differences in net survival between education or deprivation groups vanished.

CONCLUSIONS

Our study shows that observed differences in survival by education and EDI level are most likely attributable to inequalities in background survival. Also, it confirms the importance of using the relevant life tables and of performing sensitivity analysis when evaluating socioeconomic inequalities in cancer survival. Comparison studies of different healthcare systems organization should be performed to better understand its influence on cancer survival inequalities.

Risk of colorectal cancer after the diagnosis of prostate cancer: A population-based study

BACKGROUND

A rigorous assessment of the risk of colorectal cancer (CRC) among prostate cancer (PC) survivors that controls for important confounding factors and competing risks is necessary to determine the risk of CRC in this population and to inform screening guidelines.

METHODS

With data from Manitoba, Canada, subjects diagnosed with PC as their first cancer between 1987 and 2009 were age-matched with up to 5 men with no history of invasive cancer on the PC diagnosis date. Subjects were followed to the date of diagnosis of CRC or another cancer, death, emigration, or the study endpoint (December 31, 2009). Competing risk proportional hazards models were used to compare the CRC incidence between those with PC and those without PC with the following model covariates: history of lower gastrointestinal endoscopy, frequency of health care visits, diabetes, and socioeconomic status. Mutually exclusive competing outcomes included CRC, another primary cancer, and death.

RESULTS

For a total of 559,081 person-years, 14,164 men with PC and 69,051 men without PC were followed. Men diagnosed with PC had an increased risk of a subsequent diagnosis of CRC (all CRC: hazard ratio [HR], 1.14; 95% confidence interval [CI], 1.02-1.27; rectal cancer: HR, 1.36; 95% CI, 1.09-1.71). The treatment of PC with radiation was associated with an increased risk for rectal cancer (HR, 2.06; 95% CI, 1.42-2.99) in comparison with PC cases not treated with radiation.

CONCLUSIONS

The risk of CRC is increased after a diagnosis of PC and is highest for rectal cancer among those treated with radiation. CRC screening should be considered soon after the diagnosis of PC, especially for men planning for radiotherapy.

Socioeconomic inequalities in relative survival of rectal cancer most obvious in stage III

INTRODUCTION

The association between socioeconomic status (SES) and relative survival of rectal cancer is little investigated. We hypothesized that the impact on risk of death by SES would be much smaller when differences in background mortality (comorbidity, lifestyle factors) were taken into account, i.e. in modelling relative survival of rectal cancer.

METHODS

Individual data on civil status, education, and income were linked to the Swedish Rectal Cancer Registry 1995-2005 (n = 16,713). Specific life tables by socioeconomic group were used to calculate relative survival, and modelling included age, sex, stage, time period, and SES. The same covariates were applied in a Cox regression based on absolute survival.

RESULTS

Stage distribution was associated with civil status, education, and income (p < 0.001). In spite of modelling based on relative survival, an increased risk of death was found for all other patients compared with those who were married, as well as for all other patients compared with those with the highest income. The pattern was fundamentally the same as in a Cox regression model, only the point estimates were slightly reduced using the relative approach. In stage-specific modelling of relative survival, income was of particular importance in stage III; the hazard ratio (HR) for lowest versus the highest income was 1.37 [95 % confidence interval (CI) 1.15-1.64]. There were also significant differences by income among patients who had a major surgical resection (stage IV excluded).

CONCLUSION

Large and clinically relevant socioeconomic inequalities remained in stage-adjusted analyses of relative survival, also in a setting of universal healthcare and no screening program operating.

Social determinants of health and 5-year survival of colorectal cancer

BACKGROUND

Early in the 21st century, cancers are the second cause of death worldwide. Colon cancer is third most common cancer and one of the few amenable to early diagnosis and treatment. Evaluation of factors affecting this cancer is important to increase survival time. Some of these factors affecting all diseases including cancer are social determinants of health. According to the importance of this disease and relation with these factors, this study was conducted to assess the relationship between social determinants of health and colon cancer survival.

MATERIALS AND METHODS

This was a cross-sectional, descriptive study for patients with colon cancer registered in the Cancer Research Center of Shahid Beheshti University of Medical Science, from April 2005 to November 2006, performed using questionnaires filled by telephone interview with patients (if patients had died, with family members). Data was analyzed with SPSS software (version 19) for descriptive analysis and STATA software for survival analysis including log rank test and three step Cox Proportional Hazard regression.

RESULTS

Five hundred fifty nine patients with ages ranging from 23 to 88 years with mean ± standard deviation of 63 ± 11.8 years were included in the study. The five year survival was 68.3%( 387 patients were alive and 172 patients were dead by the end of the study). The Cox proportional hazard regression showed 5-year survival was related to age (HR=0.53, p=0.042 for>50 years versus<50 years old) in first step, gender (HR=0.60, p=0.006 for female versus male) in second step, job (HR=1.7, p=0.001 for manual versus non manual jobs), region of residency (HR=3.49, p=0.018 for west versus south regions), parents in childhood (HR=2.87, p=0.012 for having both parents versus not having), anatomical cancer location (HR=2.16, p<0.033 for colon versus rectal cancer) and complete treatment (HR=5.96, p<0.001 for incomplete versus complete treatment).

CONCLUSIONS

Social determinants of health such as job, city region residency and having parents during childhood have significant effects in 5-year survival of colon cancer and it may be better to consider these factors in addition to developing cancer treatment and to focus on these determinants of health in long-time planning.

Cohort profile: the Social Inequality in Cancer (SIC) cohort study

The Social Inequality in Cancer (SIC) cohort study was established to determine pathways through which socioeconomic position affects morbidity and mortality, in particular common subtypes of cancer. Data from seven well-established cohort studies from Denmark were pooled. Combining these cohorts provided a unique opportunity to generate a large study population with long follow-up and sufficient statistical power to develop and apply new methods for quantification of the two basic mechanisms underlying social inequalities in cancer-mediation and interaction. The SIC cohort included 83 006 participants aged 20-98 years at baseline. A wide range of behavioural and biological risk factors such as smoking, physical inactivity, alcohol intake, hormone replacement therapy, body mass index, blood pressure and serum cholesterol were assessed by self-administered questionnaires, physical examinations and blood samples. All participants were followed up in nationwide demographic and healthcare registries. For those interested in collaboration, further details can be obtained by contacting the Steering Committee at the Department of Public Health, University of Copenhagen, at inan@sund.ku.dk.

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.

Risk of colorectal cancer after diagnosis of endometrial cancer: a population-based study

PURPOSE

Site-specific risk of colorectal cancer (CRC) among survivors of endometrial cancer (EC) is not known. The objective of the present study was to assess the risk of CRC (overall and subsite specific) among EC survivors.

METHODS

A historical cohort study was performed by linking the Manitoba Cancer Registry and the Manitoba Health administrative databases. Each subject diagnosed with EC as her first cancer between 1987 and 2008 was age matched with up to five women with no history of invasive cancer on the index date (date of EC diagnosis). All subjects were followed up to the date of diagnosis of CRC or another cancer, death, migration, or study end point (December 31, 2009). Competing-risk proportional hazards models were used to compare the CRC incidence rates with adjustment for age, history of lower gastrointestinal endoscopy, and socioeconomic status. There were three mutually exclusive (and competing) outcomes: CRC, another primary cancer, and death.

RESULTS

A total of 3,115 women with EC and 15,084 without EC were followed up for a total of 145,502 person-years. Women diagnosed with EC at age ≤ 50 years had an increased risk of being diagnosed with CRC (all CRC: hazard ratio [HR] = 4.41; 95% CI, 1.47 to 13.26; right-sided CRC: HR = 7.48; 95% CI, 1.29 to 43.28). There was no increased risk of all CRC among women 51 to 65 years of age or those older than 65 years at the time of EC diagnosis. However, women 51 to 65 years of age at EC diagnosis had an increased risk of right-sided CRC (HR = 2.30; 95% CI, 1.05 to 5.01).

CONCLUSION

This study suggests young women (age ≤ 50 years) with EC are at increased risk of CRC; risk of right-sided CRC is also increased in women 51 to 65 years old at EC diagnosis.

The association between cancer incidence and family income: analysis of Korean National Health Insurance cancer registration data

BACKGROUND

Economic status is known to be directly or indirectly related to cancer incidence since it affects accessibility to health-related social resources, preventive medical checkups, and lifestyle. This study investigates the relationship between cancer incidence and family income in Korea.

METHODS

Using the Korean National Health Insurance cancer registration data in 2009, the relationship between their family income class and cancer risk was analyzed. The age-standardized incidence rates of the major cancers were calculated for men and women separately. After adjusting for age, residential area, and number of family members, cancer risks for major cancers according to family income class were estimated using a logistic regression model.

RESULTS

In men, the risk of stomach cancer for Income Class 5 (lowest) was 1.12 times (95% CI 1.02-1.23) higher than that of Income Class 1 (highest), for lung cancer 1.61 times (95% CI 1.43- 1.81) higher, for liver cancer 1.22 times (95% CI 1.08-1.37) higher, and for rectal cancer 1.37 times higher (95% CI 1.18-1.59). In women, the risk of stomach cancer for Income Class 5 was 1.22 times higher (95% CI 1.08-1.37) than that for Income Class 1, while for cervical cancer it was 2.47 times higher (95% CI 2.08- 2.94). In contrast, in men, Income Class 1 showed a higher risk of thyroid cancer and prostate cancer than that of Income Class 5, while, in women the same was the case for thyroid cancer.

CONCLUSIONS

The results show the relationship between family income and cancer risk differs according to type of cancer.

The transition between work, sickness absence and pension in a cohort of Danish colorectal cancer survivors

OBJECTIVES

The aim of this study was to evaluate the impact of socioeconomic and clinical factors on the transitions between work, sickness absence and retirement in a cohort of Danish colorectal cancer survivors.

DESIGN

Register-based cohort study with up to 10 years of follow-up.

SETTING

Population-based study with use of administrative health-related and socioeconomic registers.

PARTICIPANTS

All persons (N=4343) diagnosed with colorectal cancer in Denmark during the years 2001-2009 while they were in their working age (18-63 years) and who were part of the labour force 1 year postdiagnosis.

PRIMARY AND SECONDARY OUTCOME MEASURES

By the use of multistate models in Cox proportional hazards models, we analysed the HR for re-employment, sickness absence and retirement in models including clinical as well as health-related variables.

RESULTS

1 year after diagnosis, 62% were working and 58% continued until the end of follow-up. Socioeconomic factors were found to be associated with retirement but not with sickness absence and return to work. The risk for transition from work to sickness absence increased if the disease was diagnosed at a later stage (stage III) 1.52 (95% CI 1.21 to 1.91), not operated curatively 1.35 (95% CI 1.11 to 1.63) and with occurrence of postoperative complications 1.25 (95% CI 1.11 to 1.41). The opposite was found for the transition from sickness absence back to work.

CONCLUSIONS

This nationwide study of colorectal cancer patients who have survived 1 year shows that the stage of disease, general health condition of the individual, postoperative complications and the history of sickness absence and unemployment have an impact on the transition between work, sickness absence and disability pension. This leads to an increased focus on the rehabilitation process for the more vulnerable persons who have a combination of severe disease and a history of work-related problems with episodes outside the working market.

Socio-economic inequalities: a review of methodological issues and the relationships with cancer survival

During the past few decades, many studies on socio-economic factors and health outcomes have been developed using various methodologies with differing approaches. A bibliographic research in MEDLINE/PubMed and SCOPUS was carried out for the period 2000-2011 to describe the influence of socio-economic status (SES) on cancer survival, in particular with reference to the outcome of European research results and the results of some cases of other Western studies. This review is divided into two sections: the first describing the different approaches of the study on individuals and populations of the concept of "social class" as well as methods used to measure the association between deprivation and health (i.e. ecological level studies, deprivation indexes, etc.); and the second discussing the association between socio-economic factors and cancer survival, describing the roles of various determinants of differences in survival, such as clinical and pathological prognostic factors, together with consideration of diagnosis and treatment and some patients' characteristics.

Hospital factors and patient characteristics in the treatment of colorectal cancer: a population based study

BACKGROUND

The present study focuses on the analysis of social, clinical and hospital characteristics that can lead to disparities in the management and outcome of care. To that end, indicators of the quality of initial treatment delivered to newly-diagnosed colorectal cancer patients in a North-Western Region of Italy, were investigated using administrative data.

METHODS

The cohort includes all incident colorectal cancer patients (N = 24,187) selected by a validated algorithm from the Piedmont Hospital Discharge Record system over an 8-year period (2000-2007).Three indicators of quality of care in this population-based cohort were evaluated: the proportion of preoperative radiotherapy (RT) and of abdominoperineal (AP) resection in rectal cancer patients, and the proportion of postoperative in-hospital mortality in colorectal cancer patients.

RESULTS

Among rectal cancers, older patients were less likely to have preoperative RT, and more likely to receive an AP resection compared to younger patients. The probability of undergoing preoperative RT and AP resection was reduced in females compared to males (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.64-0.93 and OR 0.78, 95%CI 0.69-0.89, respectively). However, there was a trend of increasing RT over time (p for trend <0.01). The probability of undergoing AP resection was increased in less-educated patients and in hospitals with a low caseload.A higher risk of postoperative in-hospital mortality was found among colorectal cancer patients who were older, male, (female versus male OR 0.71, 95%CI 0.60-0.84), unmarried (OR 1.32, 95%CI 1.09-1.59) or with unknown marital status.

CONCLUSIONS

The study provides evidence of the importance of social, clinical and hospital characteristics on the equity and quality of care in a Southern European country with an open-access public health care system.

Adherence to a healthy Nordic food index is associated with a lower incidence of colorectal cancer in women: the Diet, Cancer and Health cohort study

Colorectal cancer (CRC) is a multi-factorial disease in which diet is believed to play a role. Little is known about the health effects of specific regional diets. The Nordic diet is high in fat and sugar but also includes a range of traditional products with anticipated health-promoting effects. The aim of this cohort study was to determine whether a healthy Nordic food index consisting of fish, cabbage, rye bread, oatmeal, apples, pears and root vegetables was related to CRC incidence. Data were obtained from a prospective cohort study of 57,053 Danish men and women aged 50-64 years, of whom 1025 developed CRC (13 years' follow-up). Incidence rate ratios (IRR) with 95 % CI were calculated from Cox proportional hazard models. Women who strongly adhered to a healthy Nordic food index had a 35 % lower incidence of CRC than women with poor adherence (adjusted IRR, 0·65; 95 % CI 0·46, 0·94); a similar tendency was found for men. Women had a 9 % lower incidence of CRC per point adherence to the healthy Nordic food index, but no significant effect was found for men. A regional diet based on healthy Nordic food items was therefore associated with a lower incidence of CRC in women. The protective effect was of the same magnitude as previously found for the Mediterranean diet, suggesting that healthy regional diets should be promoted in order to ensure health; this will also preserve cultural heredity and the environment.

Educational inequalities in cancer incidence and mortality in Lithuania: a record linkage study

BACKGROUND

The aim of this study is to describe associations between incidence and mortality by major cancer sites and education in Lithuania.

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 1 July 2001 and 31 December 2004. Education-specific incidence and mortality rate ratios were estimated by means of multivariate Poisson regression models.

RESULTS

We found both the positive and inverse educational gradients in cancer incidence and mortality. The risk of developing cancer (all sites) was lower among men and women with the lowest education, whereas cancer mortality was higher among lower educated men. The higher educational level was also associated with an increased risk of prostate cancer among men and an increased risk of breast cancer among women. However, prostate cancer mortality was the highest in the lowest education group, whereas breast cancer mortality among women did not show any statistically significant differences. Lower educated men had significantly higher incidence and mortality due to lung and stomach cancers. Strikingly high incidence and mortality due to cervix cancer was observed among women with secondary and lower than secondary education.

CONCLUSION

The results point to inequalities in early diagnosis and survival from cancer and failures ensuring equal access to medical care. Further more in-depth studies are needed in order to understand the nature and determinants of these inequalities.

Influence of socioeconomic environment on survival in patients diagnosed with esophageal cancer: a population-based study

The influence of social environment on survival in patients with cancer has been demonstrated in many studies, subjects living in the most deprived areas having a poorer prognosis. Geographic remoteness and limited access to specialized care centers are often associated with socioeconomic deprivation. The aim was to assess the influence of social environment and geographic remoteness on the relative survival of patients diagnosed with esophageal cancer between 1997 and 2004 in the department of Calvados in France. The study population, which was provided by the Calvados digestive cancer registry, included 629 patients. Relative survival was used to estimate the influence of social environment and geographic remoteness on patient survival. Five-year survival rates were 14.1%, 15.1%, 11.8%, 8.8%, and 11.4%, respectively, for patients living in the least to the most deprived areas (P= 0.39). The influence of social environment was significant after adjustment for clinical variables, patients living in the most deprived areas having the worst survival. These discrepancies cannot totally be explained by differences in access to care, cancer extension, or morphology at diagnosis. No association was observed between distance to the nearest cancer center and survival. Social environment appears to induce disparities among patients diagnosed with esophageal cancer, with a worse prognosis for patients living in the most deprived areas.

Socioeconomic status and changing inequalities in colorectal cancer? A review of the associations with risk, treatment and outcome

BACKGROUND

Upcoming mass screening for colorectal cancer (CRC) makes a review of recent literature on the association with socioeconomic status (SES) relevant, because of marked and contradictory associations with risk, treatment and outcome.

METHODS

The Pubmed database using the MeSH terms 'Neoplasms' or 'Colorectal Neoplasms' and 'Socioeconomic Factors' for articles added between 1995 and 1st October 2009 led to 62 articles.

RESULTS

Low SES groups exhibited a higher incidence compared with high SES groups in the US and Canada (range risk ratio (RR) 1.0-1.5), but mostly lower in Europe (RR 0.3-0.9). Treatment, survival and mortality all showed less favourable results for people with a lower socioeconomic status: Patients with a low SES received less often (neo)adjuvant therapy (RR ranging from 0.4 to 0.99), had worse survival rates (hazard ratio (HR) 1.3-1.8) and exhibited generally the highest mortality rates up to 1.6 for colon cancer in Europe and up to 3.1 for rectal cancer.

CONCLUSIONS

A quite consistent trend was observed favouring individuals with a high SES compared to those with a low SES that still remains in terms of treatment, survival and thus also mortality. We did not find evidence that the low/high SES gradients for treatment chosen and outcome are decreasing. To meet increasing inequalities in mortality from CRC in Europe for people with a low SES and to make mass screening successful, a high participation rate needs to be realised of low SES people in the soon starting screening program.

Do patient characteristics, disease, or treatment explain social inequality in survival from colorectal cancer?

This paper investigates the association between individually measured socioeconomic status (SES) and all-cause survival in colorectal cancer patients, and explores whether factors related to the patient, the disease, or the surgical treatment mediate the observed social gradient. The data were derived from a nationwide clinical database of all adenocarcinomas of the colon or rectum diagnosed in Denmark between 2001 and 2004 (inclusive). These data were linked to those from several central registries providing information on income, education, and housing status, as well as to data on comorbidity from previous hospitalizations and use of medication. Only patients with colorectal cancer as their first primary tumour and those born after 1920 were included. A total of 8763 patients were included in the study. Cox proportional hazard regression models revealed a positive social gradient in survival for increasing levels of education and income, and in owners versus renters of housing. A series of regression analyses were used to test potential mediators of the association between the socioeconomic indicators and survival by stepwise inclusion of lifestyle factors (smoking, alcohol intake, body mass index), comorbidity, stage of disease, mode of admission, type of operation, specialization of the surgeon, and curative versus palliative resection. A causal diagram guided the analyses. Inclusion of comorbidity, and to a lesser extent lifestyle, reduced the variation associated with SES, while no evidence of a mediating effect was found for disease or surgical treatment factors. This indicates that the difference in survival among colorectal cancer patients from different social groups was probably not caused by unintentional differences in treatment factors related to surgery, and suggests that primary prevention of chronic diseases among the socially deprived might be one way to reduce social differences in prognosis.

Socioeconomic deprivation adversely affects survival of patients with rectal cancer

Background

The aim was to examine the influence of socioeconomic deprivation on stage at presentation, perioperative mortality, permanent stoma rates and overall survival in patients with rectal cancer.

Methods

Data on patient demographics, mode and stage of presentation, and short- and longer-term outcomes were extracted from a database of patients with rectal cancer. Comparisons were made after stratification into quintiles of socioeconomic deprivation.

Results

In total 486 patients were identified. Fewer patients from the most deprived group than from the least deprived group underwent resectional surgery (79·2 versus 93 per cent; P = 0·005). Permanent stoma rates among patients who had surgery were 40·8 and 30 per cent respectively (P = 0·110). The overall 5-year survival rate was 32·8 per cent for the most deprived compared with 64·0 per cent for the least deprived patients (P &lt; 0·001). Respective rates for those who underwent resectional surgery were 49·9 and 72 per cent (P = 0·030).

Conclusion

In rectal cancer, socioeconomic deprivation appears to be associated with poorer outcomes and survival. This has important implications for healthcare planning.

Social inequality in incidence of and survival from cancer in a population-based study in Denmark, 1994-2003: Summary of findings

The purpose of this nationwide, population register-based study was to describe variations in cancer incidence and survival by social position in a social welfare state, Denmark, on the basis of a range of socioeconomic, demographic and health-related indicators. Our study population comprised all 3.22 million Danish residents born in 1925-1973 and aged >or=30 years, who were followed up for cancer incidence in 1994-2003 and for survival in 1994-2006, yielding 147,973 cancers. The incidence increased with lower education and income, especially for tobacco- and other lifestyle-related cancers, although for cancers of the breast and prostate and malignant melanoma the association was inverse. Conversely there was a general increase in incidence among early retirement pensioners, persons living in rented housing and those living in the smallest dwellings. Also incidence rates were generally higher in persons living alone compared to those living with a partner and in the capital area compared to the rural areas. Social inequality in the prognosis of most cancers was observed, despite the equal access to health care in Denmark, with poorer relative survival related to fewer advantages, regardless of how they were measured, often most pronounced in the first year after diagnosis. Also living alone and having somatic or psychiatric comorbidity negatively impacted the relative survival after most cancers. Our study shows that inequalities in cancer incidence and survival must be addressed in all aspects of public health, with interventions both to reduce incidence and to prolong survival.