Socioeconomic and geographic determinants of survival of patients with digestive cancer in France

Cancer Treatment Closer to the Patient Reduces Travel Burden, Time Toxicity, and Improves Patient Satisfaction, Results of 546 Consecutive Patients in a Northern Italian District

Background and Objectives: The distance to cancer facilities may cause disparities by creating barriers to oncologic diagnosis and treatment, and travel burden may cause time and financial toxicity. Materials and Methods: To relieve travel burden, a program to deliver oncologic treatment closer to the patient was initiated in the district of Piacenza (Northern Italy) several years ago. The oncologic activities are performed by oncologists and by nurses who travel from the oncologic ward of the city hospital to territorial centres to provide cancer patient management. This model is called Territorial Oncology Care (TOC): patients are managed near their home, in three territorial hospitals and in a health centre, named "Casa della Salute" (CDS). A retrospective study was performed and the records of patients with cancer managed in the TOC program were analysed. The primary endpoints were the km and time saved, the secondary endpoints: reduction of caregiver need for transport and patient satisfaction. Results: 546 cancer patients managed in the TOC program from 2 January 2021 to 30 June 2022 were included in this study. Primary endpoints: median km to reach the city hospital: 26 (range 11-79 km) median time: 44 min (range 32-116); median km to reach the territorial clinicians in the TOC program: 7 (range 1-35 km), median time: 16 minutes (range 6-54), p < 0.001. Secondary endpoints: 64.8% of patients who needed a caregiver for the city hospital could travel alone in the TOC program and 99.63% of patients were satisfied. Conclusions: The results of this retrospective study highlight the possibility of treating cancer patients near their residence, reducing travel burden and saving time.

A comparison of liver MRI and contrast enhanced CT as standard workup before treatment for rectal cancer in usual care - a Retrospective Study

BACKGROUND

The liver is the most common site for rectal cancer metastases. Recommended standard pre-treatment workup has involved computed tomography (CT) for abdominal metastases. However, few hospitals have replaced this with magnetic resonance imaging (MRI).

INTRODUCTION

The aim of this study was to compare MRI with CT as an index examination of the liver in the pre-treatment workup in usual care. The primary endpoint was the need for supplementary liver investigations.

METHOD

Consecutive patients from two hospitals during 2013-2015 were identified in the Regional Swedish Colorectal Cancer Register and included in this retrospective study. Hospital records and radiology reports were reviewed. Inconclusive reports were re-evaluated by two radiologists.

RESULT

A total of 320 patients were included, and 293 were available for analysis. Some 175 and 118 patients had undergone CT and MRI, respectively, as their index pretreatment liver examination. Thirty-four (19.4%) in the CT group and 6 (5.1%) patients in the MRI group underwent supplementary liver investigation due to inconclusive index examination (RR 3.82, 95% CI: 1.66;8.81, p=0.0017). Median time (q1;q3) from index examination to start of treatment was 50 (36;68) days in the CT group and 34 (27;45) days in the MRI group.

CONCLUSION

This retrospective study of two modalities within usual care found that MRI of the liver as index radiological workup before treatment for rectal cancer was associated with fewer supplementary liver investigations and a shorter time to start treatment. Based on these findings, a prospective trial should be undertaken before implementing MRI as a standard.

A Comparison of CT Manifestations between Coronavirus Disease 2019 (COVID-19) and Other Types of Viral Pneumonia

BACKGROUND

Though imaging manifestations of COVID-19 and other types of viral pneumonia are similar, their clinical treatment methods differ. Accurate, non-invasive diagnostic methods using CT imaging can help developing an optimal therapeutic regimen for both conditions.

OBJECTIVES

To compare the initial CT imaging features in COVID-19 with those in other types of viral pneumonia.

METHODS

Clinical and imaging data of 51 patients with COVID-19 and 69 with other types of viral pneumonia were retrospectively studied. All significant imaging features (Youden index >0.3) were included for constituting the combined criteria for COVID-19 diagnosis, composed of two or more imaging features with a parallel model. McNemar's chi-square test or Fisher's exact test was used to compare the validity indices (sensitivity and specificity) among various criteria.

RESULTS

Ground glass opacities (GGO) dominated density, peripheral distribution, unilateral lung, clear margin of lesion, rounded morphology, long axis parallel to the pleura, vascular thickening, and crazy-paving pattern were more common in COVID-19 (p <0.05). Consolidation-dominated density, both central and peripheral distribution, bilateral lung, indistinct margin of lesion, tree-in-bud pattern, mediastinal or hilar lymphadenectasis, pleural effusion, and pleural thickening were more common in other types of viral pneumonia (p < 0.05). GGO-dominated density or long axis parallel to the pleura (with the highest sensitivity), and GGO-dominated density or long axis parallel to the pleura or vascular thickening (with the highest specificity) are good combined criteria of COVID-19.

CONCLUSION

The initial CT imaging features are helpful for differential diagnosis between COVID-19 and other types of viral pneumonia.

Educational inequalities and regional variation in colorectal cancer survival in Finland

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Correcting inaccurate background mortality in excess hazard models through breakpoints

BACKGROUND

Methods for estimating relative survival are widely used in population-based cancer survival studies. These methods are based on splitting the observed (the overall) mortality into excess mortality (due to cancer) and background mortality (due to other causes, as expected in the general population). The latter is derived from life tables usually stratified by age, sex, and calendar year but not by other covariates (such as the deprivation level or the socioeconomic status) which may lack though they would influence background mortality. The absence of these covariates leads to inaccurate background mortality, thus to biases in estimating the excess mortality. These biases may be avoided by adjusting the background mortality for these covariates whenever available.

METHODS

In this work, we propose a regression model of excess mortality that corrects for potentially inaccurate background mortality by introducing age-dependent multiplicative parameters through breakpoints, which gives some flexibility. The performance of this model was first assessed with a single and two breakpoints in an intensive simulation study, then the method was applied to French population-based data on colorectal cancer.

RESULTS

The proposed model proved to be interesting in the simulations and the applications to real data; it limited the bias in parameter estimates of the excess mortality in several scenarios and improved the results and the generalizability of Touraine's proportional hazards model.

CONCLUSION

Finally, the proposed model is a good approach to correct reliably inaccurate background mortality by introducing multiplicative parameters that depend on age and on an additional variable through breakpoints.

Artificial intelligence method to classify ophthalmic emergency severity based on symptoms: a validation study

OBJECTIVES

We investigated the usefulness of machine learning artificial intelligence (AI) in classifying the severity of ophthalmic emergency for timely hospital visits.

STUDY DESIGN

This retrospective study analysed the patients who first visited the Armed Forces Daegu Hospital between May and December 2019. General patient information, events and symptoms were input variables. Events, symptoms, diagnoses and treatments were output variables. The output variables were classified into four classes (red, orange, yellow and green, indicating immediate to no emergency cases). About 200 cases of the class-balanced validation data set were randomly selected before all training procedures. An ensemble AI model using combinations of fully connected neural networks with the synthetic minority oversampling technique algorithm was adopted.

PARTICIPANTS

A total of 1681 patients were included.

MAJOR OUTCOMES

Model performance was evaluated using accuracy, precision, recall and F1 scores.

RESULTS

The accuracy of the model was 99.05%. The precision of each class (red, orange, yellow and green) was 100%, 98.10%, 92.73% and 100%. The recalls of each class were 100%, 100%, 98.08% and 95.33%. The F1 scores of each class were 100%, 99.04%, 95.33% and 96.00%.

CONCLUSIONS

We provided support for an AI method to classify ophthalmic emergency severity based on symptoms.

Epidemiological profile of Brazilian oncological patients seen by a reference oncology center of the public health system and who migrate in search of adequate health care

INTRODUCTION

Structural disparities between different Brazilian regions in public health system cause patients to migrate in search of better conditions to treat their diseases. Besides patient's discomfort, there is a concentration of care in large centres, causing overload to current capacity.

OBJECTIVE

To evaluate migratory flow and associated factors in a reference service in oncology.

METHODS

Cross-sectional study conducted at a referral oncology service in Great ABC region of São Paulo. Patients were interviewed, and clinical and demographic data collected.

RESULTS

Between March-July 2016, 217 patients were included. Analysis showed a divergence between the postal code registered in the medical record and that recorded during the interview in approximately 10% of cases. Of these, 42.9% were residents of other states. Search for treatment motivated most patients to seek service outside their city.

CONCLUSION

Results reflect the informal search for medical care outside the home area. Besides the direct impact on patients' quality of life, migratory flow has an economic-social impact because these patients place a burden and impose costs on services of cities where they do not perform their responsibilities as citizens. Confirmation of the existence of a significant migratory flow demonstrates the need to discuss restructuring public health policies.

More accurate cancer-related excess mortality through correcting background mortality for extra variables

Relative survival methods used to estimate the excess mortality of cancer patients rely on the background (or expected) mortality derived from general population life tables. These methods are based on splitting the observed mortality into the excess mortality and the background mortality. By assuming a regression model for the excess mortality, usually a Cox-type model, one may investigate the effects of certain covariates on the excess mortality. Some covariates are cancer-specific whereas others are variables that may influence the background mortality as well. The latter should be taken into account in the background mortality to avoid biases in estimating their effects on the excess mortality. Unfortunately, the available life table might not include such variables and, consequently, might provide inaccurate values of the background mortality. We propose a model that uses multiplicative parameters to correct potentially inaccurate background mortality. The model can be seen as an extension of the frequently used Estève model because we assume a Cox-type model for the excess mortality with a piecewise constant baseline function and introduce additional parameters that multiply the background mortality. The original and the extended model are compared, first in a simulation study, then in an application to colon cancer registry data.

Associations of cause-specific mortality with area level deprivation and travel time to health care in France from 1990 to 2007, a multilevel analysis

Background

It is now widely accepted that social and physical environment participate in shaping health. While mortality is used to guide public health policies and is considered as a synthetic measure of population health, few studies deals with the contextual features potentially associated with mortality in a representative sample of an entire country. This paper investigates the possible role of area deprivation (FDep99) and travel time to health care on French cause-specific mortality in a proper multilevel setting.

Methods

The study population was a 1% sample representative of the French population aged from 30 to 79 years in 1990 and followed up until 2007. A frailty Cox model was used to measure individual, contextual effects and spatial variances for several causes of death. The chosen contextual scale was the Zone d’Emploi of 1994 (348 units) which delimits the daily commute of people. The geographical accessibility to health care score was constructed with principal component analysis, using 40 variables of hospital specialties and health practitioners’ travel time.

Results

The outcomes highlight a positive and significant association between area deprivation and mortality for all causes (HR = 1.24), cancers, cerebrovascular diseases, ischemic heart diseases, and preventable and amenable diseases (HR from 1.14 to 1.29). These contextual associations exhibit no substantial differences by sex except for premature ischemic heart diseases mortality which was much greater in women. Unexpectedly, mortality decreased as the time to reach health care resources increased. Only geographical disparities in cerebrovascular and ischemic heart diseases mortality were explained by compositional and contextual effects.

Discussion

The findings suggest the presence of confounding factors in the association between mortality and travel time to health care, possibly owing to population density and health-selected migration. Although the spatial scale considered to define the context of residence was relatively large, the associations with area deprivation were strong in comparison to the existing literature and significant for almost all the causes of deaths investigated.

Conclusion

The broad spectrum of diseases associated with area deprivation and individual education support the idea of a need for a global health policy targeting both individual and territories to reduce social and socio-spatial inequalities.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4562-7) contains supplementary material, which is available to authorized users.

[The human and economic burden of cancer in France in 2014, based on the Sniiram national database]

INTRODUCTION

The national health insurance information system (Sniiram) can be used to estimate the national medical and economic burden of cancer. This study reports the annual rates, characteristics and expenditure of people reimbursed for cancer.

METHODS

Among 57 million general health scheme beneficiaries (86% of the French population), people managed for cancer were identified using algorithms based on hospital diagnoses and full refund for long-term cancer. The reimbursed costs (euros) related to the cancer, paid off by the health insurance, were estimated.

RESULTS

In 2014, 2.491 million people (4.4%) covered by the general health scheme had a cancer managed (men 1.1 million, 5.1%; women 1.3 million, 4.9%). The annual (2012-2014) average growth rate of patients was 0.8%. The spending related to the cancer was 13.5 billion: 5 billion for primary health care (drugs 2.3 billion), 7.5 billion for the hospital (drugs 1.3 billions) and 900 million for sick leave and invalidity pensions. Spending annual average growth rate (2012-2014) was 4% (drugs 2%). The rates of patients and the relative spending were 1.8% and 2.5 billion for the breast cancer (women), 1.5% and 1.0 billion for prostate cancer, 0.9% and 1.5 billion for the colon cancer, and 0.19% and 1.3 billion for lung cancer.

DISCUSSION

Cancers establish one of the first groups of chronic diseases pathologies in terms of patients and spending. If the numbers of patients remain stables, the spending increases, mainly for medicines.

Different survival analysis methods for measuring long-term outcomes of Indigenous and non-Indigenous Australian cancer patients in the presence and absence of competing risks

BACKGROUND

Net survival is the most common measure of cancer prognosis and has been used to study differentials in cancer survival between ethnic or racial population subgroups. However, net survival ignores competing risks of deaths and so provides incomplete prognostic information for cancer patients, and when comparing survival between populations with different all-cause mortality. Another prognosis measure, "crude probability of death", which takes competing risk of death into account, overcomes this limitation. Similar to net survival, it can be calculated using either life tables (using Cronin-Feuer method) or cause of death data (using Fine-Gray method). The aim of this study is two-fold: (1) to compare the multivariable results produced by different survival analysis methods; and (2) to compare the Cronin-Feuer with the Fine-Gray methods, in estimating the cancer and non-cancer death probability of both Indigenous and non-Indigenous cancer patients and the Indigenous cancer disparities.

METHODS

Cancer survival was investigated for 9,595 people (18.5% Indigenous) diagnosed with cancer in the Northern Territory of Australia between 1991 and 2009. The Cox proportional hazard model along with Poisson and Fine-Gray regression were used in the multivariable analysis. The crude probabilities of cancer and non-cancer methods were estimated in two ways: first, using cause of death data with the Fine-Gray method, and second, using life tables with the Cronin-Feuer method.

RESULTS

Multivariable regression using the relative survival, cause-specific survival, and competing risk analysis produced similar results. In the presence of competing risks, the Cronin-Feuer method produced similar results to Fine-Gray in the estimation of cancer death probability (higher Indigenous cancer death probabilities for all cancers) and non-cancer death probabilities (higher Indigenous non-cancer death probabilities for all cancers except lung cancer and head and neck cancers). Cronin-Feuer estimated much lower non-cancer death probabilities than Fine-Gray for non-Indigenous patients with head and neck cancers and lung cancers (both smoking-related cancers).

CONCLUSION

Despite the limitations of the Cronin-Feuer method, it is a reasonable alternative to the Fine-Gray method for assessing the Indigenous survival differential in the presence of competing risks when valid and reliable subgroup-specific life tables are available and cause of death data are unavailable or unreliable.

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.

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.

The influence of geographical access to health care and material deprivation on colorectal cancer survival: evidence from France and England

This article investigates the influence of distance to health care and material deprivation on cancer survival for patients diagnosed with a colorectal cancer between 1997 and 2004 in France and England. This population-based study included all cases of colorectal cancer diagnosed between 1997 and 2004 in 3 cancer registries in France and 1 cancer registry in England (N=40,613). After adjustment for material deprivation, travel times in England were no longer significantly associated with survival. In France patients living between 20 and 90min from the nearest cancer unit tended to have a poorer survival, although this was not statistically significant. In England, the better prognosis observed for remote patients can be explained by associations with material deprivation; distance to health services alone did not affect survival whilst material deprivation level had a major influence, with lower survival for patients living in deprived areas. Increases in travel times to health services in France were associated with poorer survival rates. The pattern of this influence seems to follow an inverse U distribution, i.e. maximal for average travel times.

Survival from breast cancer in relation to access to tertiary healthcare, body mass index, tumor characteristics and treatment: a Hellenic Cooperative Oncology Group (HeCOG) study

Apart from tumour, treatment and patient characteristics at diagnosis, access to healthcare delivery may as well play a significant role in breast cancer prognosis. This study aimed to assess the additional impact exerted on survival by travel burden-a surrogate indicator of limited access to healthcare- expressed as geographical distance and/or time needed to reach the tertiary healthcare center from the patient's residence. Between 1997 and 2005, 2,789 women participated in therapeutic clinical trials conducted by the Hellenic Cooperative Oncology Group. The effect of geographical distance and travel time between patient's residence and treating hospital on survival was estimated using Cox proportional hazards regression adjusting for age, menopausal status, tumour size/grade, positive nodes (number), hormonal receptor status, HER2 overexpression, surgery type/treatment protocol as well as for body mass index>30 kg/m2. More aggressive tumour features, older treatment protocols and modifiable patient characteristics, such as obesity (HR: 1.27) adversely impacted on breast cancer survival. In addition, less studied indicators of access to healthcare, such as geographic distance>350 km and travel time>4 h were independently and significantly associated with worse outcomes (HR=1.43 and 1.34 respectively). In conclusion, to address inequalities in breast cancer survival, improvements in access to healthcare services related to increased travel burden especially for patients of lower socioeconomic status should be considered, more than ever at times of financial crisis and independently of already known modifiable patient characteristics.

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.

Effect of socioeconomic status as measured by education level on survival in breast cancer clinical trials

OBJECTIVES

This paper aims to investigate the effect of socioeconomic status, as measured by education, on the survival of breast cancer patients treated on 10 studies conducted by the Cancer and Leukemia Group B.

METHODS

Sociodemographic data, including education, were reported by the patient at trial enrollment. Cox proportional hazards model stratified by treatment arm/study was used to examine the effect of education on survival among patients with early stage and metastatic breast cancer, after adjustment for known prognostic factors.

RESULTS

The patient population included 1020 patients with metastatic disease and 5146 patients with early stage disease. Among metastatic patients, factors associated with poorer survival in the final multivariable model included African American race, never married, negative estrogen receptor status, prior hormonal therapy, visceral involvement, and bone involvement. Among early stage patients, significant factors associated with poorer survival included African American race, separated/widowed, post/perimenopausal, negative/unknown estrogen receptor status, negative progesterone receptor status, >4 positive nodes, tumor diameter >2 cm, and education. Having not completed high school was associated with poorer survival among early stage patients. Among metastatic patients, non-African American women who lacked a high school degree had poorer survival than other non-African American women, and African American women who lacked a high school education had better survival than educated African American women.

CONCLUSIONS

Having less than a high school education is a risk factor for death among patients with early stage breast cancer who participated in a clinical trial, with its impact among metastatic patients being less clear. Post-trial survivorship plans need to focus on women with low social status, as measured by education.

Socio-geographical determinants of colonoscopy uptake after faecal occult blood test

BACKGROUND

Survival from colorectal cancer is poorer in patients of lower socioeconomic level, or living far from the cancer reference centre.

AIMS

To evaluate the impact of material deprivation and geographical remoteness on the uptake of colonoscopy after a positive screening faecal occult blood test.

METHODS

Data from two large French average-risk population-based trials comparing two faecal occult blood tests were used. Compliance with colonoscopy after a positive faecal occult blood test was analysed using a logistic model and a Cox model considering time between faecal occult blood test and colonoscopy. Covariates studied were sex, age, distance to nearest gastroenterologist, distance to regional capital, and Townsend's deprivation score.

RESULTS

Amongst 4320 eligible subjects, 4131 were included. The rate of colonoscopy was 83.8%, within a median time of 66.0 days after faecal occult blood test. Distance to regional capital (p-trend=0.02) and study centre (p<0.0001) were independently associated with colonoscopy uptake. Time from positive faecal occult blood test to colonoscopy, was associated only with distance to the regional capital (p<0.0001, multivariate model stratified on study centre).

CONCLUSION

Geographical remoteness but not material deprivation was responsible for lower uptake of colonoscopy. Healthcare decision-makers should focus on geographical remoteness to promote equal access to diagnostic procedures in faecal occult blood test colorectal cancer screening programmes.

Descriptive epidemiology of upper aerodigestive tract cancers in France: incidence over 1980-2005 and projection to 2010

Over the 1998-2002 period, some French Départements have been shown to have the world's highest incidence of upper aerodigestive tract (UADT) cancers in men. The objectives were to describe the changes in UADT cancer incidence in France over the 1980-2005 period, present projections for 2010, and describe the anatomical and histological characteristics of these tumours. The trend of cancer-incidence over 1980-2005 and projection up to 2010 were obtained using age-period-cohort models (data from eleven cancer registries) and incidence/mortality ratios in the area covered by these registries. The description of UADT cancers by anatomical and histological characteristics concerned data collected between 1980 and 2004 in eleven cancer registries. In men, cancer incidence decreased in all cancer sites and the world-standardized incidence rates decreased by 42.9% for lip-oral cavity-pharynx (LOCP) cancers and 50.4% for larynx cancer. In women, the world-standardized incidence rates increased by 48.6% for LOCP cancers and 66.7% for larynx cancer. Incidence increased the most for oropharynx, palate, and hypopharynx cancers. Incidence analysis by one-year cohorts revealed a progressive shift of the incidence peak towards younger and younger generations, with no change as yet in the mean age at diagnosis. In France, the incidence of these cancers is still higher than in other European and North American countries. This urges actions towards reducing the major risk factors for those cancers, namely alcohol and tobacco consumption, especially among young people, and reducing exposure to risk factors due to social inequalities.

Examining the Racial Crossover in Mortality between African American and White Older Adults: A Multilevel Survival Analysis of Race, Individual Socioeconomic Status, and Neighborhood Socioeconomic Context

We examine whether individual and neighborhood socioeconomic context contributes to black/white disparities in mortality among USA older adults. Using national longitudinal data from the Americans' Changing Lives study, along with census tract information for each respondent, we conduct multilevel survival analyses. Results show that black older adults are disadvantaged in mortality in younger old age, but older black adults have lower mortality risk than whites after about age 80. Both individual SES and neighborhood socioeconomic disadvantage contribute to the mortality risk of older adults but do not completely explain race differences in mortality. The racial mortality crossover persists even after controlling for multilevel SES, suggesting that black older adults experience selective survival at very old ages. Addressing the individual and neighborhood socioeconomic disadvantage of blacks is necessary to reduce mortality disparities that culminate in older adulthood.

Survival from common and rare cancers in Germany in the early 21st century

BACKGROUND

Until recently, population-based data of cancer survival in Germany mostly relied on one registry covering ∼1 million people (1.3% of the German population). Here, we provide up-to-date cancer survival estimates for Germany based on data from 11 population-based cancer registries, covering 33 million people and compare them to survival estimates from the United States.

PATIENTS AND METHODS

Cancer patients diagnosed in 1997-2006 were included. Period analysis was employed to calculate 5-year relative survival for 38 cancers for 2002-2006. German and USA survival rates were compared utilizing the Surveillance, Epidemiology and End Results 13 database.

RESULTS

Five-year relative survival >80% was observed for testicular cancer (93.5%), skin melanoma (89.4%), cancers of the prostate (89.1%) and thyroid (87.8%), Hodgkin's lymphoma (84.5%) and cancers of the breast (83.7%) and endometrium (81.0%), which together account for almost 40% of cases. For the majority of cancers, German survival estimates were close to or below those in the United States. Exceptions with higher survival in Germany were cancers of the stomach, pancreas and kidney and Hodgkin's lymphoma.

CONCLUSIONS

German cancer survival estimates are mostly higher than the 2000-2002 pan-European estimates. Further research is needed to investigate causes responsible for differences between German and USA cancer survival rates.

A Suitable Approach to Estimate Cancer Incidence in Area without Cancer Registry

Objective. Use of cancer cases from registries and PMSI claims database to estimate Département-specific incidence of four major cancers. Methods. Case extraction used principal diagnosis then surgery codes. PMSI cases/registry cases ratios for 2004 were modelled then Département-specific incidence for 2007 estimated using these ratios and 2007 PMSI cases. Results. For 2007, only colon-rectum and breast cancer estimations were satisfactorily validated for infranational incidence not ovary and kidney cancers. For breast, the estimated national incidence was 50,578 cases and the incidence rate 98.6 cases per 100,000 person per year. For colon-rectum, incidence was 21,172 in men versus 18,327 in women and the incidence rate 38 per 100,000 versus 24.8. For ovary, the estimated incidence was 4,637 and the rate 8.6 per 100,000. For kidney, incidence was 6,775 in men versus 3,273 in women and the rate 13.3 per 100.000 versus 5.2. Conclusion. Incidence estimation using PMSI patient identifiers proved encouraging though still dependent on the assumption of uniform cancer treatments and coding.

[Social inequalities in health from observational studies to intervention: can the patient navigator reduce social inequalities in cancer patients?]

The impact of social factors on healthcare inequality is well-recognized in many industrialized countries and involves a wide range of pathological conditions (cardiovascular disease, cancer, etc.). In general, the poorest indicators of health are observed in socially disadvantaged populations. Beyond this observation is the question of actions taken to prevent the formation of social inequality in healthcare. The purpose of this work was to evaluate the potential contribution of an intervention tool called the "patient navigator", used in English-speaking countries and to determine its feasibility in France.

Socioeconomic status and gastric cancer survival in Japan

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Education, survival and avoidable deaths in cancer patients in Finland

BACKGROUND

Relative survival after cancer in Finland is at the highest level observed in Europe and has, in general, been on a steady increase. The aim of this study is to assess whether the high survival is equally shared by different population subgroups and to estimate the possible gains that might be achieved if equity prevailed.

MATERIALS AND METHOD

The educational level and occupation before the cancer diagnosis of patients diagnosed in Finland in 1971-2005 was derived from an antecedent population census. The cancers were divided into 27 site categories. Cancer (cause)-specific 5-year survival proportions were calculated for three patient categories based on the educational level and for an occupational group of potentially health-conscious patients (physicians, nurses, teachers etc.). Proportions of avoidable deaths were derived by assuming that the patients from the two lower education categories would have the same mortality owing to cancer, as those from the highest educational category. Estimates were also made by additionally assuming that even the mortalities owing to other causes of death were all equal to those in the highest category.

RESULTS

For almost all the sites considered, survival was consistently highest for patients with the highest education and lowest for those with only basic education. The potentially health-conscious patients had an even higher survival. The differences were, in part, attributable to less favourable distributions of tumour stages in the lower education categories. In 1996-2005, 4-7% of the deaths in Finnish cancer patients could have potentially been avoided during the first 5-year period after diagnosis, if all the patients had the same cancer mortality as the patients with the highest educational background. The proportion would have also been much higher, 8-11%, if, in addition, the mortality from other causes had been the same as that in the highest educational category.

INTERPRETATION

Even in a potentially equitable society with high health care standards, marked inequalities persist in cancer survival. Earlier cancer diagnosis and the ability to cope within the health care system may be a partly relevant explanation, but personal habits and lifestyles also have a role, particularly for the cancer patients' mortality from other causes of death than cancer.

A multilevel study of the determinants of area-level inequalities in colorectal cancer survival

Background

In Australia, associations between geographic remoteness, socioeconomic disadvantage, and colorectal cancer (CRC) survival show that survival rates are lowest among residents of geographically remote regions and those living in disadvantaged areas. At present we know very little about the reasons for these inequalities, hence our capacity to intervene to reduce the inequalities is limited.

Methods/Design

This study, the first of its type in Australia, examines the association between CRC survival and key area- and individual-level factors. Specifically, we will use a multilevel framework to investigate the possible determinants of area- and individual-level inequalities in CRC survival and quantify the relative contribution of geographic remoteness, socioeconomic and demographic factors, disease stage, and access to diagnostic and treatment services, to these inequalities. The multilevel analysis will be based on survival data relating to people diagnosed with CRC in Queensland between 1996 and 2005 (n = 22,723) from the Queensland Cancer Registry (QCR), area-level data from other data custodians such as the Australian Bureau of Statistics, and individual-level data from the QCR (including extracting stage from pathology records) and Queensland Hospitals. For a subset of this period (2003 and 2004) we will utilise more detailed, individual-level data (n = 1,966) covering a greater range of risk factors from a concurrent research study. Geo-coding and spatial technology will be used to calculate road travel distances from patients' residence to treatment centres. The analyses will be conducted using a multilevel Cox proportional hazards model with Level 1 comprising individual-level factors (e.g. occupation) and level 2 area-level indicators of remoteness and area socioeconomic disadvantage.

Discussion

This study focuses on the health inequalities for rural and disadvantaged populations that have often been documented but poorly understood, hence limiting our capacity to intervene. This study utilises and develops emerging statistical and spatial technologies that can then be applied to other cancers and health outcomes. The findings of this study will have direct implications for the targeting and resourcing of cancer control programs designed to reduce the burden of colorectal cancer, and for the provision of diagnostic and treatment services.

The performance of multiple imputation for missing covariate data within the context of regression relative survival analysis

Relative survival assesses the effects of prognostic factors on disease-specific mortality when the cause of death is uncertain or unavailable. It provides an estimate of patients' survival, allowing for the effects of other independent causes of death. Regression-based relative survival models are commonly used in population-based studies to model the effects of some prognostic factors and to estimate net survival. Most often, studies focus on routinely collected prognostic factors for which the proportion of missing values is usually low (around 5 per cent). However, in some cases, additional factors are collected with a greater proportion of missingness. In the present article, we systematically assess the performance of multiple imputation in regression analysis of relative survival through a series of simulation experiments. According to the assumptions concerning the missingness mechanism (completely at random, at random, and not at random) and the missingness pattern (monotone, non-monotone), several strategies were considered and compared: all cases analysis, complete cases analysis, missing data indicator analysis, and multiple imputation by chained equations (MICE) analysis. We showed that MICE performs well in estimating the hazard ratios and the baseline hazard function when the missing mechanism is missing at random (MAR) conditionally on the vital status. In the situations where the missing mechanism was not MAR conditionally on vital status, complete case behaves consistently. As illustration, we used data of the French Cancer Registries on relative survival of patients with colorectal cancer.

Patient education level as a predictor of survival in lung cancer clinical trials

PURPOSE

To investigate the effect of socioeconomic status, as measured by education, on the survival of 1,577 lung cancer patients treated on 11 studies conducted by the Cancer and Leukemia Group B.

PATIENTS AND METHODS

Sociodemographic data, including education, was reported by the patient at the time of clinical trial accrual. Cox proportional hazards model stratified by treatment arm/study was used to examine the effect of education on survival after adjustment for known prognostic factors.

RESULTS

The patient population included 1,177 patients diagnosed with non-small-cell lung cancer (NSCLC; stage III or IV) and 400 patients diagnosed with small-cell lung cancer (SCLC; extensive or limited). Patients with less than an eighth grade education (13% of patients) were significantly more likely to be male, nonwhite, and older; have a performance status (PS) of 1 or 2; and have chest pain. Significant predictors of poor survival in the final model included male sex, PS of 1 or 2, dyspnea, weight loss, liver or bone metastases, unmarried, presence of adrenal metastases and high alkaline phosphatase levels among patients with NSCLC, and high WBC levels among patients with advanced disease. Education was not predictive of survival.

CONCLUSION

The physical condition of patients with low education who enroll onto clinical trials is worse than patients with higher education. Once enrolled onto a clinical trial, education does not affect the survival of patients with SCLC or stage III or IV NSCLC. The standardization of treatment and follow-up within a clinical trial, regardless of education, is one possible explanation for this lack of effect.

Cancer survival in New Zealand: ethnic, social and geographical inequalities

This study investigated the combined effects of ethnicity, deprivation and geographical access to health services on the likelihood of survival from a range of common cancers in New Zealand. Individual cancer registry records of 99,062 cases of melanoma, colorectal, lung, breast and prostate cancers diagnosed in the period 1994-2004 were supplemented with small area information on social deprivation and estimates of travel time to the nearest primary care and cancer centre. Logistic regression was used to identify the variables associated with advanced extent of the disease at diagnosis. Adverse influences on survival were investigated using Cox proportional hazards models. Controlling for age and gender, Māori and Pacific peoples' ethnicity was strongly associated with poorer survival, partly because ethnicity was also linked to the likelihood of advanced disease at diagnosis. Living in a deprived area was related to later stage presentation and poorer survival of people with melanoma, but there was no other evidence that living in a deprived area or in a remote location were associated with later stage presentation. Some disease-specific trends in survival were observed. Colorectal and lung cancers were more likely to be fatal for people living in deprived areas, survival from prostate cancer was poor for men living remote from primary care, and people with colorectal, breast and prostate cancers had adverse survival chances if they lived distant from a cancer centre.

Access to care, socioeconomic deprivation and colon cancer survival

BACKGROUND

The influence of socioeconomic environment on cancer survival has been established in numerous studies in the EU and the US, prognosis being constantly poorer for the most underprivileged patients.

AIM

To investigate the influence of distance to care centre and deprivation on colon cancer survival, using a multilevel Cox model and taking into account cancer stage at diagnosis and treatment modalities.

METHODS

The study population comprised all cases of colon cancer diagnosed between 1997 and 2000 in two French areas covered by specialized cancer registries (n = 2066).

RESULTS

Road distance to the nearest reference care centre was associated with poorer prognosis even after adjustment for stage at diagnosis (P for trend = 0.01). Subgroups analysis showed that this association was maximal for patients with advanced cancer [RR = 1.27 (1.04-1.51); P for trend = 0.015] for whom access to chemotherapy varying according to distance explained the major part of geographic inequalities in survival.

CONCLUSIONS

The major effect of distance from reference care centre on survival suggests that current regional health planning does not guarantee equity in cancer management. Improvement in access to adjuvant therapy, especially for patients with advanced cancers, seems crucial for reducing geographic disparities in colon cancer survival.