Disadvantage and male cancer incidence and mortality in New South Wales 1985-1993

Factors Contributing to Delay in Specialist Care After Colorectal Cancer Diagnosis in Kentucky

BACKGROUND

Abundant studies have associated colorectal cancer (CRC) treatment delay with advanced diagnosis and worse mortality. Delay in seeking specialist is a contributor to CRC treatment delay. The goal of this study is to investigate contributing factors to 14-d delay from diagnosis of CRC on colonoscopy to the first specialist visit in the state of Kentucky.

METHODS

The Kentucky Cancer Registry (KCR) database linked with health administrative claims data was queried to include adult patients diagnosed with stage I-IV CRC from January 2007 to December 2012. The dates of the last colonoscopy and the first specialist visit were identified through the claims. Bivariate and logistic regression analysis was performed to identify factors associated with delay to CRC specialist visit.

RESULTS

A total of 3927 patients from 100 hospitals in Kentucky were included. Approximately, 19% of patients with CRC visited a specialist more than 14 d after CRC detection on colonoscopy. Delay to specialist (DTS) was found more likely in patients with Medicaid insurance (OR 3.1, P < 0.0001), low and moderate education level (OR 1.4 and 1.3, respectively, P = 0.0127), and stage I CRC (OR 1.5, P < 0.0001). There was a higher percentage of delay to specialist among Medicaid patients (44.0%) than Medicare (18.0%) and privately insured patients (18.8%).

CONCLUSIONS

We identified Medicaid insurance, low education attainment, and early stage CRC diagnosis as independent risk factors associated with 14-d delay in seeking specialist care after CRC detection on colonoscopy.

Neighborhood socioeconomic status and behavioral pathways to risks of colon and rectal cancer in women

BACKGROUND

Neighborhood amenities and resources plausibly determine individual modifiable risk factors for colon and rectal cancer. Evidence on the associations between neighborhood socioeconomic status (SES) and incident colon and rectal cancer is limited.

METHODS

The authors analyzed a prospective cohort of 111,129 women in the Nurses' Health Study with no history of cancer in 1986 followed to 2006. Neighborhood SES was based on Census-derived characteristics of block groups of residence. Cox models were used to estimate the multivariate-adjusted associations between neighborhood SES and incident colon and rectal cancer, and to examine for effect modification. For significant associations, path models were estimated with behavioral risk factors included as potential mediators.

RESULTS

Neighborhood SES was unassociated with colon cancer among all women. However, among women with college or greater education, higher neighborhood SES was inversely related to colon cancer (P for trend = .01; P for interaction between neighborhood SES and education = .03). Path analysis suggested mediation by red meat intakes and body mass index (BMI). Higher neighborhood SES was inversely related to rectal cancer among all women (relative risk in highest quintile, 0.64; 95% confidence interval, 0.44-0.93; P for trend = .08). Path analysis was consistent with mediation by multivitamin use and BMI.

CONCLUSIONS

These findings suggest that living in a higher-SES neighborhood may protect against rectal cancer in women and colon cancer in higher-educated women, mediated by selected behavioral risk factors. Risk factor differences between colon and rectal cancer may account for discrepancies in estimated neighborhood effects by cancer site.

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 places affect the probability of death in Australia? A multilevel study of area-level disadvantage, individual-level socioeconomic position and all-cause mortality, 1998-2000

BACKGROUND

In Australia, studies finding an association between area-level socioeconomic disadvantage and mortality are often based on aggregate-ecological designs which confound area-level and individual-level sources of socioeconomic variation. Area-level socioeconomic differences in mortality therefore may be an artefact of varying population compositions and not the characteristics of areas as such.

OBJECTIVE

To examine the associations between area-level disadvantage and all-cause mortality before and after adjustment for within-area variation in individual-level socioeconomic position (SEP) using unlinked census and mortality-register data in a multilevel context. Setting, participants and

DESIGN

The study covers the total Australian continent for the period 1998-2000 and is based on decedents aged 25-64 years (n = 43,257). The socioeconomic characteristics of statistical local areas (SLA, n = 1317) were measured using an index of relative socioeconomic disadvantage, and individual-level SEP was measured by occupation.

RESULTS

Living in a disadvantaged SLA was associated with higher all-cause mortality after adjustment for within-SLA variation in occupation. Death rates were highest for blue-collar workers and lowest among white-collar employees. Cross-level interactions showed no convincing evidence that SLA disadvantage modified the extent of inequality in mortality between the occupation groups.

CONCLUSIONS

Multilevel analysis can be used to examine area variation in mortality using unlinked census and mortality data, therefore making it less necessary to use aggregate-ecological designs. In Australia, area-level and individual-level socioeconomic factors make an independent contribution to the probability of premature mortality. Policies and interventions to improve population health and reduce mortality inequalities should focus on places as well as people.

Slip! Slap! Slop! Cutaneous malignant melanoma incidence and social status in New Zealand, 1995-2000

Numerous studies have noted a strong social gradient in many types of ill health. In particular, people in more deprived areas tend to be less healthy than those in more affluent communities, even once the demographic and socio-economic differences of the people in those areas have been taken into account. The social gradient is evident for many types of health outcomes, including diseases such as cancer. However, this positive relationship is not evident for rates of melanoma incidence and mortality, with rates of the disease tending to decrease with measures of disadvantage. In this study, we assess the relationship between the incidence of melanoma and deprivation in New Zealand, a country with particularly high rates of the disease. In the light of greater public awareness of the risk factors associated with melanoma, through public awareness campaigns such as 'Slip! Slap! Slop' and 'No Suntan is Safe', we analyse small-area data on standardised rates of melanoma for the period 1995-2000. We found that melanoma rates increase with social status, even once other confounding factors are controlled for, but that the relationship is very small. Furthermore, the relationship between melanoma incidence and deprivation is context-dependent. Possible explanations for the relationship between melanoma and deprivation are discussed, including more frequent exposure to intermittent sunshine among less disadvantaged groups and the underreporting of melanoma incidence in the New Zealand cancer registry among individuals in lower social groups.

Socioeconomic differences in the prevalence of common chronic diseases: an overview of eight European countries

BACKGROUND

Few studies have compared socioeconomic inequalities in the prevalence of both fatal and non-fatal diseases. This paper aims to give the first international overview for several common chronic diseases.

METHODS

Micro-level data were pooled from non-standardized national health surveys conducted in eight European countries in the 1990s. Surveys ranged in size from 3700 to 41 200 participants. The prevalence of 17 chronic disease groups were analysed in relation to education. Standardized prevalence rates and age-adjusted odds ratios (ORs) were calculated.

RESULTS

Most diseases showed higher prevalence among the lower education group. Stroke, diseases of the nervous system, diabetes, and arthritis displayed relatively large inequalities (OR > 1.50). No socioeconomic differences were evident for cancer, kidney diseases, and skin diseases. Allergy was more common in the higher education group. Relative socioeconomic differences were often smaller among the 60-79 age group as compared with the 25-59 age group. Cancer was more prevalent among the lower educated in the 25-59 age group, but among the higher educated in the 60-79 age group. For diabetes, hypertension, and heart disease, socioeconomic differences were larger among women as compared with men. Inequalities in heart disease were larger in northern European countries as compared with southern European countries.

CONCLUSION

There are large variations between chronic diseases in the size and pattern of socioeconomic differences in their prevalence. The large inequalities that are found for some specific fatal diseases (e.g. stroke) and non-fatal diseases (e.g. arthritis) require special attention in equity-oriented research and policies.

Socio-economic mortality differentials in Sydney over a quarter of a century, 1970-94

OBJECTIVE

To examine trends in socio-economic differentials in all-cause mortality in Sydney over a 25-year period (1970-94).

METHODS

Five measures of single indicators (two for occupation, two for education and one for income) and a composite measure of socio-economic disadvantage based on Census data (the Australian Bureau of Statistics' Index of Relative Socio-Economic Disadvantage) were used as indicators of socio-economic status by local govemment area. The relationship between mortality and socio-economic status was examined using quintiles based on these six measures of socio-economic status.

RESULTS

Socio-economic differentials in mortality were evident for males and females for all periods, and over the 25-year period the relative socio-economic differentials did not decline. For males, the socio-economic status differential in mortality widened, irrespective of socio-economic status indicator used, whereas for females it widened only when certain socio-economic indicators were used: occupation (unemployment measure) and income, but was not significant for the other single indicators or for the composite indicator.

CONCLUSIONS

Sydney trends of widening inequalities are generally similar to those reported for Britain and for other industrialised countries, suggesting that this is a common phenomenon and that policies to reduce health inequalities over the past quarter of a century have not been effective.

Socioeconomic status and health in Australia

Consistent with international evidence, the findings of Australian research show that socioeconomically disadvantaged groups experience significantly higher mortality and morbidity rates. Despite marked improvements in the health of all segments of the Australian population in recent decades, during this same period there has also been an increase in socioeconomically related mortality inequalities for some conditions. Socioeconomically disadvantaged groups are more likely to engage in health-damaging behaviours, experience poorer psychosocial health, make less use of the healthcare system for preventive purposes, and have a more adverse risk factor profile. These are the main contributing factors to the poorer physiological health of low socioeconomic groups. At present, our knowledge of how socioeconomic status and health are related is limited. A necessary step in improving our understanding of this issue is to draw together all the empirical evidence and use it as the basis for developing a theory of socioeconomic health inequalities. We present a conceptual framework to facilitate this process.