Education, income and risk of cancer: results from a Norwegian registry-based study

Individual and area-level socioeconomic status, Life's Simple 7, and comorbid cardiovascular disease and cancer: a prospective analysis of the UK Biobank cohort

OBJECTIVES

We aimed to investigate the associations of individual and area-level socioeconomic status (SES) with incident cardiovascular diseases (CVD) alone, cancer alone, and comorbid CVD and cancer, and the mediation role of cardiovascular health score in these associations.

STUDY DESIGN

This was a population-based prospective cohort study.

METHODS

We used data from the UK Biobank, a population-based prospective cohort study. Latent class analysis was used to create an individual-level SES index based on three indicators (household income, education level, and employment status), and the Townsend Index was defined as the area-level socioeconomic status. We used the American Heart Association's (AHA) Life's Simple 7 (smoking, body weight, physical activity, diet, blood pressure, blood glucose, and total cholesterol) to calculate the cardiovascular health score. We used Cox proportional hazard regression models to estimate the hazard ratio (HR) and 95% confidence interval (CI) adjusted for demographic, environmental, and genetic factors.

RESULTS

Compared with high SES, the HRs in participants with low individual and area-level SES were 1.33 (95% confidence interval [CI] 1.29 to 1.38) and 1.24 (95% CI 1.20 to 1.29) for incident CVD, 0.96 (95% CI 0.93 to 0.99) and 0.95 (95%CI 0.92 to 0.98) for incident cancer, 1.32 (95%CI 1.24 to 1.40) and 1.15 (95%CI 1.08 to 1.22) for incident comorbid CVD and cancer, respectively. Additionally, the mediation proportion of CVD score for individual and area-level SES was 47.93% and 48.87% for incident CVD, 44.83% and 59.93% for incident comorbid CVD and cancer. The interactions between individual-level SES and CVD scores were significant on incident CVD, and comorbid CVD and cancer, and the protective associations were stronger in participants with high individual-level SES.

CONCLUSIONS

Life's Simple 7 significantly mediated the associations between SES and comorbid CVD and cancer, while almost half of the associations remained unclear.

Racial/ethnic differences in the clinical presentation and survival of breast cancer by subtype

Background

Breast cancer (BC) affects racial and ethnic groups differently, leading to disparities in clinical presentation and outcomes. It is unclear how Hispanic ethnicity affects BC outcomes based on geographic location and proximity to the United States (U.S.)/Mexico border. We hypothesized that the impact of race/ethnicity on BC outcomes depends on geographic location and country of origin within each BC subtype.

Methods

We analyzed BC data from the Texas Cancer Registry by race/ethnicity/birthplace according to BC subtype (luminal A/luminal B/human epidermal growth factor receptor 2 [HER2]/triple-negative breast cancer[TNBC]). Other covariates included age, geographic location (U.S., Mexico), residency (border, non-border), treatments, and comorbidities. Crude and adjusted effects of race/ethnicity and birthplace on overall survival (OS) were analyzed using Cox regression methods.

Results

Our analysis of 76,310 patient records with specific BC subtypes revealed that Hispanic and non-Hispanic Black (NHB) patients were diagnosed at a younger age compared with non-Hispanic White (NHW) patients for all BC subtypes. For the 19,748 BC patients with complete data on race/ethnicity/birthplace/residency, Hispanic patients had a higher mortality risk in the Luminal A subtype, regardless of birthplace, whereas U.S.-born Hispanics had a higher risk of death in the TNBC subtype. In contrast, NHB patients had a higher mortality risk in the Luminal A and HER2 subtypes. Residence along the U.S./Mexico border had little impact on OS, with better outcomes in Luminal A patients and worse outcomes in Luminal B patients aged 60-74 years.

Conclusion

Race/ethnicity, geographic birth location, and residency were significant predictors of survival in BC. Migration, acculturation, and reduced healthcare access may contribute to outcome differences.

Analysis of exposome and genetic variability suggests stress as a major contributor for development of pancreatic ductal adenocarcinoma

BACKGROUND

The current knowledge on pancreatic ductal adenocarcinoma (PDAC) risk factors is limited and no study has comprehensively tested the exposome in combination with the genetic variability in relation to the disease susceptibility.

AIM

The aim of this study was to analyze the exposome and its interaction with known genetic susceptibility loci, in relation to PDAC risk.

METHODS

A case-control study nested in UK Biobank cohort was conducted on 816 PDAC cases and 302,645 controls. A total of 347 exposure variables, and a polygenic risk score (PRS) were analyzed through logistic regression. Gene-environment interaction analyses were conducted.

RESULTS

A total of 52 associations under the Bonferroni corrected threshold of p < 1.46 × 10-4 were observed. Known risk factors such as smoking, pancreatitis, diabetes, PRS, heavy alcohol drinking and overweight were replicated in this study. As for novel associations, a clear indication for length and intensity of mobile phone use and the stress-related factors and stressful events with increase of PDAC risk was observed. Although the PRS was associated with PDAC risk (P = 2.09 × 10-9), statistically significant gene-exposome interactions were not identified.

CONCLUSION

In conclusion, our results suggest that a stressful lifestyle and sedentary behaviors may play a major role in PDAC susceptibility independently from the genetic background.

Relationship between educational level and survival of patients with cancer: A multicentre cohort study

BACKGROUND

Although socioeconomic factors are important determinants of population mortality, the effect of educational level on the survival of patients with cancer in China is unclear. This study aimed to assess whether educational level is associated with the prognosis of patients with cancer and to explore the mediators of this association.

METHODS

This multicentre cohort study included 18,251 patients diagnosed with cancer between May 2013 and December 2018. The main parameters measured were overall survival (OS) and all-cause mortality. The relationship between educational level and all-cause mortality was assessed using multifactor-corrected Cox survival analysis. Logistic regression was used to analyze the association between educational level and patient-generated subjective global assessment (PG-SGA).

RESULTS

The mean age of the 18,251 participants (men, 9939 [54.4%]) was 57.37 ± 11.66 years. Multifactorial survival analysis showed that patients survived longer with increasing education (university and above vs. elementary school and below; p = p = <0.001, HR = 0.84, 95% CI: 0.77-0.92), and the differences were statistically significant in different subgroups. The potential impact factors included sex, age, TNM stage, and PG-SGA score. Logistic regression showed a significant negative association between educational level and the modifiable factor PG-SGA (secondary vs. primary and below; p = 0.004, HR = 0.90, 95% CI: 0.83-0.97; university and above vs. primary and below; p < 0.001, HR = 0.79, 95% CI: 0.71-0.88).

CONCLUSIONS

Educational level was a significant prognostic factor for patients with cancer, independent of other known prognostic factors. This association was further improved by modifying the nutritional status.

The Gap of Health Inequalities Amongst Lung Cancer Patients of Different Socioeconomic Status: A Brief Reference to the Greek Reality

Lung cancer treatment and patient care are constantly improving, but it remains doubtful whether this applies equally to all socioeconomic groups. It is nowadays well established that there are socioeconomic inequalities regarding lung cancer incidence, screening, effective treatment, overall survival, and prognosis. One of the key contributing factors to low socioeconomic status is low education. Low educational level is correlated with several factors, such as smoking habits, bad lifestyle behaviors, lower paid and unhealthier occupations, polluted neighborhoods, and genetic-familial risk, that lead to increased lung cancer incidence. The disparities regarding lung cancer care are further enhanced by stigma. On this basis and inspired by the gap in health equality among the Greek population, the Greek Society of Lung Cancer initiated a campaign, "MIND THE GAP", to help increase awareness and minimize the gap associated with lung cancer, both in Greece and across Europe. The aim of this review is to explore the gap of health inequalities regarding lung cancer incidence and prognosis between patients of different SES and its root of causality. Key pivotal actions towards bridging this gap are reviewed as well.

A Scoping Review of Possible Solutions for Decreasing Socioeconomic Inequalities in Type 2 Diabetes Mellitus

Background

As socioeconomic inequalities are key factors in access and utilization of type 2 diabetes (T2D) services, the purpose of this scoping review was to identify solutions for decreasing socioeconomic inequalities in T2D.

Methods

A scoping review of scientific articles from 2000 and later was conducted using PubMed, Web of Science (WOS), Scopus, Embase, and ProQuest databases. Using the Arksey and O'Malley framework for scoping review, articles were extracted, meticulously read, and thematically analyzed.

Results

A total of 7204 articles were identified from the reviewed databases. After removing duplicate and nonrelevant articles, 117 articles were finally included and analyzed. A number of solutions and passways were extracted from the final articles. Solutions for decreasing socioeconomic inequalities in T2D were categorized into 12 main solutions and 63 passways.

Conclusions

Applying identified solutions in diabetes policies and interventions would be recommended for decreasing socioeconomic inequalities in T2D. Also, the passways could be addressed as entry points to help better implementation of diabetic policies.

Educational disparities in cancer incidence, stage, and survival in Oslo

OBJECTIVES

This study aimed to examine disparities in cancer incidence, stage at diagnosis, and survival rates across districts with differences in education levels in Oslo, Norway.

METHODS

Aggregated data from the Cancer Registry of Norway in the period 2013-2021 were used to describe the distribution of cancer incidence and survival across Oslo's 15 administrative districts, subsequently grouped into three areas based on the population's level of education. Age-standardised incidence rates and five-year relative survival were calculated for colon, rectal, lung, melanoma, breast, and prostate cancer. The stage at the time of diagnosis was categorised as localised, regional, distant, and unknown for all cancer types except breast cancer, which was categorised into stage I-IV and unknown.

RESULTS

Mid- and high-education areas had higher incidences of breast, melanoma, and prostate cancer, while the low-education area had higher incidence rates for lung cancer. The low-education area had a higher proportion diagnosed at a distant stage than the other groups for all cancer types studied, except breast cancer. The mid- and high-education areas had higher five-year relative survival rates overall.

CONCLUSIONS

Incidence, stage at diagnosis, and survival varied between education areas. The variation indicates disparities in healthcare access, quality of care, and health behaviours. Addressing these disparities can help improve overall health outcomes and promote health equity.

Cancer risk in patients with rheumatoid arthritis treated with janus kinase inhibitors: a nationwide Danish register-based cohort study

OBJECTIVES

We aimed to investigate the risk of first primary cancer in patients with RA treated with janus kinase inhibitors (JAKi) compared with those who received biologic DMARDs (bDMARDs) in a real-world setting.

METHODS

We performed an observational cohort study using the nationwide registers in Denmark. Patients with RA aged 18+ years, without a previous cancer diagnosis, and who initiated treatment with JAKi or bDMARDs from 1 January 2017 to 31 December 2020 were followed for any cancer (except non-melanoma skin cancer). We applied inverse probability of treatment weighting (IPTW) to account for covariate differences between treatment groups. IPTW-generated weights were used with cause-specific Cox (CSC) models to calculate hazard ratios (HRs) for cancer incidence in JAKi-treated compared with bDMARD-treated patients with RA.

RESULTS

We identified 875 and 4247 RA patients treated with JAKi and bDMARDs, respectively. The JAKi group contributed 1315 person years (PYRS) and 19 cancers, the bDMARD group contributed 8597 PYRS and 111 cancers, with corresponding crude incidence rates per 1000 PYRS of 14.4 and 12.9. Comparing the two groups using weighted CSC models, a HR of 1.41 (95% CI 0.76, 2.37, 95% CIs) was seen for JAKi- vs bDMARD-treated patients with RA.

CONCLUSION

JAKi treatment in real-world patients with RA was not associated with a statistically significant increased risk of first primary cancer compared with those who received bDMARDs. However, several numerically increased risk estimates were detected, and a clinically important excess risk of cancer among JAKi recipients cannot be dismissed.

Educational Attainment and Cancer Incidence in a Large Nationwide Prospective Cohort

BACKGROUND

Educational attainment is a social determinant of health and frequently used as an indicator of socioeconomic status. Educational attainment is a predictor of cancer mortality, but associations with site-specific cancer incidence are variable. The aim of this study was to evaluate the association of educational attainment and site-specific cancer incidence adjusting for known risk factors in a large prospective cohort.

METHODS

Men and women enrolled in the American Cancer Society's Cancer Prevention Study-II Nutrition Cohort who were cancer free at baseline were included in this study (n = 148,965). Between 1992 and 2017, 22,810 men and 17,556 women were diagnosed with incident cancer. Cox proportional hazards regression models were used to estimate age- and multivariable-adjusted risk and 95% confidence intervals of total and site-specific cancer incidence in persons with lower versus higher educational attainment.

RESULTS

Educational attainment was inversely associated with age-adjusted cancer incidence among men but not women. For specific cancer sites, the multivariable-adjusted risk of cancer in the least versus most educated individuals remained significant for colon, rectum, and lung cancer among men and lung and breast cancer among women.

CONCLUSIONS

Educational attainment is associated with overall and site-specific cancer risk though adjusting for cancer risk factors attenuates the association for most cancer sites.

IMPACT

This study provides further evidence that educational attainment is an important social determinant of cancer but that its effects are driven by associated behavioral risk factors suggesting that targeting interventions toward those with lower educational attainment is an important policy consideration.

No Association of Trichomonas vaginalis Seropositivity with Advanced Prostate Cancer Risk in the Multiethnic Cohort: A Nested Case-Control Study

The potential involvement of a sexually transmitted agent has been suggested to contribute to the high number of prostate cancers in the United States and worldwide. We investigated the relationship of Trichomonas vaginalis seropositivity with prostate cancer risk in a nested case-control study within the Multiethnic Cohort in Hawaii and California using blood samples collected prior to cancer diagnoses. Incident cases of advanced prostate cancer (intermediate- to high-grade based on Gleason score ≥ 7 and/or disease spread outside the prostate) were matched to controls by age, ethnicity, and the date of blood collection. T. vaginalis serostatus was measured using an ELISA detecting IgG antibodies against a recombinant T. vaginalis α-actinin protein. Seropositivity to T. vaginalis was observed in 35 of 470 (7.4%) cases and 26 of 470 (5.5%) controls (unadjusted OR = 1.47, 95% CI 0.82-2.64; adjusted OR = 1.31, 95% CI 0.67-2.53). The association was similarly not significant when cases were confined to extraprostatic tumors having regional or distant spread (n = 121) regardless of grade (unadjusted OR = 1.37, 95% CI 0.63-3.01; adjusted OR = 1.20, 95% CI 0.46-3.11). The association of T. vaginalis with prostate cancer risk did not vary by aspirin use. Our findings do not support a role for T. vaginalis in the etiology of advanced prostate cancer.

Impact of taxes and warning labels on red meat purchases among US consumers: A randomized controlled trial

BACKGROUND

Policies to reduce red meat intake are important for mitigating climate change and improving public health. We tested the impact of taxes and warning labels on red meat purchases in the United States. The main study question was, will taxes and warning labels reduce red meat purchases?

METHODS AND FINDINGS

We recruited 3,518 US adults to participate in a shopping task in a naturalistic online grocery store from October 18, 2021 to October 28, 2021. Participants were randomized to one of 4 conditions: control (no tax or warning labels, n = 887), warning labels (health and environmental warning labels appeared next to products containing red meat, n = 891), tax (products containing red meat were subject to a 30% price increase, n = 874), or combined warning labels + tax (n = 866). We used fractional probit and Poisson regression models to assess the co-primary outcomes, percent, and count of red meat purchases, and linear regression to assess the secondary outcomes of nutrients purchased. Most participants identified as women, consumed red meat 2 or more times per week, and reported doing all of their household's grocery shopping. The warning, tax, and combined conditions led to lower percent of red meat-containing items purchased, with 39% (95% confidence interval (CI) [38%, 40%]) of control participants' purchases containing red meat, compared to 36% (95% CI [35%, 37%], p = 0.001) of warning participants, 34% (95% CI [33%, 35%], p < 0.001) of tax participants, and 31% (95% CI [30%, 32%], p < 0.001) of combined participants. A similar pattern was observed for count of red meat items. Compared to the control, the combined condition reduced calories purchased (-312.0 kcals, 95% CI [-590.3 kcals, -33.6 kcals], p = 0.027), while the tax (-10.4 g, 95% CI [-18.2 g, -2.5 g], p = 0.01) and combined (-12.8 g, 95% CI [-20.7 g, -4.9 g], p = 0.001) conditions reduced saturated fat purchases; no condition affected sodium purchases. Warning labels decreased the perceived healthfulness and environmental sustainability of red meat, while taxes increased perceived cost. The main limitations were that the study differed in sociodemographic characteristics from the US population, and only about 30% to 40% of the US population shops for groceries online.

CONCLUSIONS

Warning labels and taxes reduced red meat purchases in a naturalistic online grocery store. Trial Registration: http://www.clinicaltrials.gov/ NCT04716010.

Individual and joint effect of socioeconomic status and lifestyle factors on cancer in Korea

BACKGROUND

There is limited evidence on the individual and joint effect of socioeconomic status (SES) and unhealthy lifestyle on cancer. Therefore, this study aimed to examine the effects of these factors on cancer incidence and mortality.

METHODS

In this population-based cohort study, income was used as the proxy of SES. A combined unhealthy lifestyle score was obtained using data on smoking, alcohol consumption, physical activity, and body mass index. Hazard ratios were estimated using a Cox proportional hazards model.

RESULTS

The study included data on 8,353,169 participants (median follow-up period, 17 years). Although the association between low income and cancer incidence varied depending on cancer type, low income consistently increased the risk of cancer-related death with a social gradient. Unhealthy behaviors increased the risk of cancer incidence and mortality, except for thyroid and breast cancer in women and prostate cancer in men. Compared with the wealthiest and healthiest individuals, the poorest and unhealthiest men and women showed 2.1-fold (2.05-2.14) and 1.36-fold (1.31-1.41) higher risk of cancer-related death, respectively. The joint effect was most robust for lung, liver, head, and neck cancers in men and liver and cervical cancers in women; further, the effect was stronger with cancer-specific mortality than with incidence.

CONCLUSION

In conclusion, income and combined healthy lifestyle behaviors have individual and joint effects on cancer incidence and mortality. The effect varies by cancer type and sex.

Effect of air pollution on the prevalence of breast and cervical cancer in China: a panel data regression analysis

The association between the prevalence of breast and cervical cancer in Chinese women and air pollution is obscure. The study aims to analyze the correlation between air pollution and the prevalence of breast and cervical cancer, and whether the gross domestic product (GDP) has a modifying effect on the impact of air pollution on the prevalence of breast and cervical cancer. Extracting panel data from 31 provinces and cities between 2006 and 2020, we evaluated the association between breast and cervical cancer prevalence and pollutant emissions from 2006 to 2015 with two-way fixed-effect models. We also analyzed the interaction between GDP and pollutant emissions and further check the robustness of the moderating effect results using group regression from 2016 to 2020. Cluster robust standard errors were used to correct for the heteroskedasticity and autocorrelation. The coefficients of models show that the coefficients of logarithmic soot and dust emissions are estimated to be significantly positive, and the coefficients of their square terms are significantly negative. The robust results suggest that the relationship between soot and dust emissions and breast or cervical cancer prevalence is non-linear, from 2006 to 2015. In the analysis of particulate matter (PM) data in 2016-2020, the PM-GDP interaction term was also significantly negative, indicating that GDP growth weakened the effect of PM on the prevalence of breast cancer and cervical cancer. In provinces with higher GDP, the indirect effect of PM emissions concerning breast cancer is -0.396 while in provinces with lower GDP, it is about -0.215. The corresponding coefficient concerning cervical cancer is about -0.209 in provinces with higher GDP but not significant in provinces with lower GDP. Our results suggest that there is an inverted U-shaped relationship between the prevalence of breast cancer and cervical cancer and air pollutants from 2006 to 2015. GDP growth has a significant negative moderating effect on the impact of air pollutants on the prevalence of breast cancer and cervical cancer. PM emissions have a higher effect on the prevalence of breast and cervical cancer in provinces with higher GDP and a lower impact in provinces with lower GDP.

Relationship between Health Inequalities and Breast Cancer Survival in Mexican Women

OBJECTIVE

We aimed to analyze the relationship between the survival of patients with breast cancer and health inequalities.

METHODS

A retrospective cohort study of women with stage III breast cancer according to public healthcare was conducted. Groups were stratified according to the course of treatment and the presence of chronic disease other than cancer. Survival functions were estimated by using the Kaplan-Meier estimator, while the Cox proportional hazards model was employed for prognostic assessment.

RESULTS

The study was performed on 964 breast cancer patients. One hundred and seventy-six patients (18.23%) died during the follow-up period and 788 (81.77%) were alive at the end of the follow-up period. Education, marital status, personal history of prior biopsies, and socioeconomic status (SES) were found to be linked with survival. However, only SES exceeded the baseline risk of mortality when the treatment cycle was interrupted (full treatment: unadjusted 4.683, p = 0.001; adjusted 4.888 p = 0.001, partial treatment: unadjusted 1.973, p = 0.012; adjusted 4.185, p = 0.001). The same effect was observed when stratifying by the presence of chronic disease other than cancer (with chronic disease adjusted HR = 4.948, p = 0.001; unadjusted HR = 3.303, p = 0.001; without chronic disease adjusted HR = 4.850, p = 0.001; unadjusted HR = 5.121, p = 0.001).

CONCLUSION

Since lower SES was linked with a worse prognosis, strategies to promote preventive medicine, particularly breast cancer screening programs and prompt diagnosis, are needed.

Association of education level with the risk of female breast cancer: a prospective cohort study

BACKGROUND

Breast cancer is a serious threat to female health, and its incidence varies with education level (EL). In the present study, the association between EL and the risk of developing female breast cancer was investigated.

METHODS

From May 2006 to December 2007, 20,400 observation subjects in Kailuan Cohort received questionnaires and were subjected to clinical examinations for data collection on baseline population characteristics, height, weight, lifestyle and past disease history. Then, these participants were followed up with from the date of recruitment to December 31, 2019. Cox proportional risk regression models were used to analyse the association between EL and the risk of developing female breast cancer.

RESULTS

The cumulative follow-up period of 20,129 observation subjects that meet the inclusion criteria of this study was 254,386.72 person-years, and the median follow-up time was 12.96 years. During the follow-up period, 279 cases of breast cancer were diagnosed. In comparison with the low EL group, the risk of developing breast cancer was significantly higher in the medium (hazard ratio [HR] (95% confidence interval [CI]) = 2.23 (1.12-4.64)] and high [HRs (95% CI) = 2.52 (1.12-5.70)] EL group.

CONCLUSION

An increased risk of breast cancer was associated with a higher EL, and some certain factors, such as alcohol use and hormone therapy, may play a mediating role.

Paternity through use of assisted reproduction technology in male adult and childhood cancer survivors: a nationwide register study

STUDY QUESTION

How does a history of cancer affect the likelihood of using assisted reproduction in order to achieve paternity?

SUMMARY ANSWER

As compared to men with no history of cancer, use of assisted reproduction to achieve paternity was more frequent in fathers with a history of cancer, mainly those with testicular, prostate, and hematological and lymphatic malignancies.

WHAT IS KNOWN ALREADY

Although it is well known that different types of cancer and their treatment may have a negative impact on fertility, there is a lack of data regarding the use of IVF and ICSI among male cancer survivors.

STUDY DESIGN, SIZE, DURATION

In this population-based nation-wide study using the Swedish Medical Birth Register, we identified all men who fathered their first-born child in Sweden between 1994 and 2014. Using personal identification numbers, anonymized data from the Swedish National Quality of Assisted Reproduction Register, Swedish Cancer Register, Swedish Multi-generation Register, and Swedish Education Register were linked with the Swedish Medical Birth Register.

PARTICIPANTS/MATERIALS, SETTING, METHODS

During the study period, a total of 1 181 488 men fathering their first-born child were identified. Of these, 26 901 fathers had a cancer diagnosis. Fathers diagnosed with cancer with <12 months from offspring conception, or with a cancer diagnosis after offspring conception, were excluded (n = 21 529). The remaining fathers who had a history of cancer (n = 5372) were divided into three groups based on age at cancer diagnosis (<15, ≥15 and <24, or ≥24 years). For subgroup analyses, they were also grouped according to the cancer location using ICD-7 codes. The fathers with no cancer diagnosis (n = 1 154 587), were included as controls. In total, 1 159 959 men were included. Associations between IVF/ICSI use and history of cancer were evaluated using logistic regression models, unadjusted and adjusted for paternal education, fathers age at childbirth, and year of conception, yielding crude and adjusted odds ratio (aOR), respectively, with a 95% CI.

MAIN RESULTS AND THE ROLE OF CHANCE

As compared to controls, childhood cancer survivors were only more likely to achieve paternity through ICSI (aOR 3.52, 95% CI 2.52-4.93; P < 0.001) but not through IVF treatment (aOR 1.02, 95% CI 0.61-1.70; P = 0.955). Similarly, teenage and young adult cancer survivors were more likely to father through ICSI treatment (aOR 6.84, 95% CI 5.64-8.30; P < 0.001) but not using IVF (aOR 1.27, 95% CI 0.90-1.80; P = 0.17). However, adult cancer survivors were more likely to conceive through either ICSI (aOR 5.52, 95% CI 4.86-6.27; P < 0.001) or IVF treatment (aOR 1.32, 95% CI 1.09-1.60; P = 0.004). In subgroup analyses, childhood survivors of testicular cancer (aOR 5.15, 95% CI 1.20-22.0; P = 0.027), soft tissue and bone cancers (aOR 4.70, 2.13-10.4; P < 0.001), hematological and lymphatic cancers (aOR 4.49, 95% CI 2.72-7.40; P < 0.001), or central nervous system (CNS) and eye cancers (aOR 2.64, 95% CI 1.23-5.67; P = 0.012), were at an increased likelihood of fathering through ICSI. Teenage and young adult survivors of testicular cancer (aOR 15.4, 95% CI 11.5-20.7; P < 0.001), hematological and lymphatic cancers (aOR 9.84, 95% CI 6.93-14.0; P < 0.001), or soft tissue and bone cancers (aOR 6.83, 95% CI 3.53-13.2; P < 0.001) were more likely to father through ICSI treatment. Adult survivors of prostate cancer (aOR 15.7, 95% CI 6.70-36.9; P < 0.001), testicular cancer (aOR 9.54, 95% CI 7.81-11.7; P < 0.001), hematological and lymphatic cancers (aOR 11.3, 95% CI 8.63-14.9; P < 0.001), digestive, respiratory, and urogenital tract cancers (aOR 2.62, 95% CI 1.75-3.92; P < 0.001), CNS and eye cancers (aOR 2.74, 95% CI 1.48-5.08; P = 0.001), or skin cancer (aOR 1.68, 95% CI 1.08-2.62; P = 0.022) were more likely to father through ICSI treatment. Only teenage and young adult survivors of hematological and lymphatic cancers (aOR 1.98, 95% CI 1.10-3.56; P = 0.022) and adult survivors of testicular cancer (aOR 1.88, 95% CI 1.37-2.58; P < 0.001) were significantly more likely to achieve fatherhood using IVF treatment.

LIMITATIONS, REASONS FOR CAUTION

Information on men failing to father children was not available, and thus our results cannot estimate the risk of infertility in men with a history of cancer.

WIDER IMPLICATIONS OF THE FINDINGS

Use of ART, in particular ICSI, was significantly more frequent in fathers with malignancies of the male reproductive tract or hematological and lymphatic systems. Our findings highlight which groups of male cancer survivors would benefit from access to fertility care, thereby improving future fertility treatment policies.

STUDY FUNDING/COMPETING INTEREST(S)

The study received funding from the Swedish Cancer Society, Swedish Childhood Cancer Society, and the Swedish Government Fund for Clinical Research. There are no competing interest.

TRIAL REGISTRATION NUMBER

N/A.

Higher Admittance to Specialized Palliative Care for Patients with High Education and Income: A Nationwide Register-Based Study

Background: While associations between socioeconomic position, that is, income and education and admittance to specialized palliative care (SPC) have been investigated previously, no prior national studies have examined admittance to all types of SPC, that is, hospital-based palliative care team/units and hospice. Aim: To investigate whether cancer patients' education and income were associated with admittance to SPC (hospital-based palliative care team/unit, hospice). Design: Data sources were several nationwide registers. The association between SPC and education and income, respectively, was investigated using logistic regression analyses. Setting/Participants: Patients dying from cancer in Denmark 2010-12 (n = 41,741). Results: In the study population, 45% had lower secondary school, and 6% had an academic education. Patients with an academic education were more often admitted to SPC than those having lower secondary school (odds ratio [OR] = 1.69; 95% confidence interval [CI]: 1.51-1.89). Patients in the highest income quartile (Q4) were more often admitted than those in the lowest income quartile (Q1) (OR = 1.46; 95% CI: 1.37-1.56). This association was stronger for hospice (OR = 1.67 (95% CI: 1.54-1.81)) than for admittance to hospital-based palliative care team/unit (OR = 1.23 (95% CI: 1.14-1.31)). Compared with patients who had lower secondary school and the lowest income, the OR of admittance to SPC among the most affluent academics was 1.96 (95% CI: 1.71-2.25). Conclusion: This nationwide study indicates that admittance to SPC was clearly associated with education and income. We believe that the associations indicate inequity. Initiatives to improve access for patients with low education or income should be established.

Trends in Socioeconomic Inequalities in Breast Cancer Incidence Among Women in Canada

INTRODUCTION

Breast cancer is the most common cancer among females in Canada. This study examines trends in socioeconomic inequalities in the incidence of breast cancer in Canada over time from 1992 to 2010.

METHODS

A census division level dataset was constructed using the Canadian Cancer Registry, Canadian Census of the Population and National Household Survey. A summary measure of the Concentration index (C), which captures inequality across socioeconomic groups, was used to measure income and education inequalities in breast cancer incidence over the 19-year period.

RESULTS

The crude breast cancer incidence increased in Canada between 1992 and 2010. Age-standardized C values indicated no income or education inequalities in breast cancer incidence in the years from 1992 to 2004. However, the incidence was significantly concentrated among females in high income and highly educated neighbourhoods almost half the time in the 6 most recent years (2005-2010). The trend analysis indicated an increase in breast cancer incidence among females living in high income and highly educated neighbourhoods.

CONCLUSION

Breast cancer incidence in Canada was associated with increased socioeconomic status in some more recent years. Our study findings provide previously unavailable empirical evidence to inform discussions on socioeconomic inequalities in breast incidence.

Risk of Non-cutaneous Cancers in Individuals with Basal Cell Carcinoma: A Population-based Cohort Study

Evidence of the association between a personal history of basal cell carcinoma and the risk of non-cutaneous malignancies is conflicting. The aim of this study was to retrospectively clarify the risk of non-cutaneous cancers in individuals with basal cell carcinoma using nationwide Finnish registry data for 96,304 patients and 394,503 randomly selected population controls. In this study, individuals with basal cell carcinoma have an increased risk of other cancers (odds ratio (OR) 1.38; 95% confidence interval (95% CI) 1.36-1.40). The risk was most prominent for lip cancer (OR 5.29; 95% CI 4.50-6.21), mycosis fungoides (OR 3.13; 95% CI 2.31-4.23) and soft tissue cancers (OR 2.77; 95% CI 2.43-3.16). In age-adjusted model, men had higher risk of cancers overall compared with women (p < 0.05). In conclusion, the study found increased overall cancer risk among patients with basal cell carcinoma compared with randomly selected population controls.

Factors associated with health care utilization and catastrophic health expenditure among cancer patients in China: Evidence from the China health and retirement longitudinal study

Background

Cancer, the leading cause of mortality in China, is a significant burden on patients, their families, the medical system, and society at large. However, there is minimal data on health service utilization and catastrophic health expenditure (CHE) among cancer patients in China. The objective of this study was to identify factors associated with health care utilization and CHE in Chinese cancer patients.

Methods

The 2018 wave of a nationally representative dataset, the China Health and Retirement Longitudinal Study, was used in our study. Of 18,968 respondents recruited for the analysis, 388 were clinically diagnosed with cancer. CHE was defined as household health expenditure that exceeded 40% of non-food household expenses. A binary logistic regression model was used to identify the risks of cancer exposure among all participants, along with the likelihood of CHE in households with cancer patients at the 40% threshold. A negative binomial regression model was used to identify determinants of health service utilization among cancer patients.

Results

Contracting a family physician (incidence rate ratio IRR: 2.38, 1.18-4.77), Urban Employee Basic Medical Insurance (IRR: 4.02, 1.91-8.46, compared to the uninsured), Urban and Rural Resident Basic Medical Insurance (IRR: 3.08, 1.46-6.49, compared to the uninsured), and higher per-capita household consumption were positively associated with inpatient service utilization. Patients with a college education and above reported a greater number of outpatient visits (IRR: 5.78, 2.56-13.02) but fewer inpatient hospital days (IRR: 0.37, 0.20-0.67). Being diagnosed with a non-cancer chronic non-communicable disease was associated with an increased number of outpatient visits (IRR: 1.20, 1.10-1.31). Of the 388 participants, 50.1% of households had CHE, which was negatively correlated with a larger household size (odds ratio OR: 0.52, 0.32-0.86) and lower socioeconomic status [for quintile 5 (lowest group) OR: 0.32, 0.14-0.72].

Conclusions

The socioeconomic characteristics of cancer patients had a considerable impact on their healthcare utilization. Individualized and targeted strategies for cancer management should be implemented to identify high-risk populations and trace the utilization of care among Chinese cancer patients. Strategic purchasing models in cancer care and social health insurance with expanded benefits packages for cancer patients are crucial to tackling the cancer burden in China.

Current and future applications of biomarkers in samples collected through minimally invasive methods for cancer medicine and population-based research

Despite advances in cancer medicine and research, invasive and potentially risky procedures such as biopsies, venous blood tests, imaging, colonoscopy, and pap smear tests are still primarily used for screening, staging, and assessing response to therapy. The development and interdisciplinary use of biomarkers from urine, feces, saliva, scent, and capillary blood collected with minimally invasive methods represents a potential opportunity for integration with biomarker analysis for cancers, both in clinical practice (e.g., in screening, treatment, and disease monitoring, and improved quality of life for patients) and population-based research (e.g., in epidemiology/public health, studies of social and environmental determinants, and evolutionary medicine). In this article, we review the scientific rationale, benefits, challenges, and potential opportunities for measuring cancer-related biomarkers in samples collected through minimally invasive methods.

Is psychedelic use associated with cancer?: Interrogating a half-century-old claim using contemporary population-level data

BACKGROUND

In 1967, concerns about the carcinogenic potential of psychedelics arose after a study reported chromosomal damage in human leukocytes following in vitro lysergic acid (LSD) exposure. Worries were further heightened by subsequent reports of leukemia and other cancers in LSD users. Additional investigations of psychedelics' effects on chromosomes were published over the next decade, with the majority suggesting these concerns were unfounded. However, the relationship between psychedelics and cancer has been explored only minimally from an epidemiological perspective.

AIMS

To determine whether associations exist between psychedelic use and either lifetime cancer or hematologic cancer diagnoses.

METHODS

We analyzed data from adult participants in the 2015-2019 administrations of the National Survey on Drug Use and Health for associations between lifetime use of psychedelics and lifetime diagnosis of either any cancer or hematologic cancer.

RESULTS

We identified no associations between lifetime psychedelic use and either lifetime cancer diagnosis or hematologic cancer diagnosis. Sub-analyses of lifetime lysergamide, phenethylamine, and tryptamine use also revealed no associations with lifetime cancer or hematologic cancer diagnosis.

CONCLUSIONS

While laboratory studies and case reports from the 1960s and 1970s generated concerns about psychedelics' carcinogenic potential, this analysis of recent epidemiological data does not support an association between psychedelic use and development of cancer in general or hematologic cancer. Important study limitations to consider include a lack of information about psychedelic dosage, number of lifetime psychedelic exposures, and the temporal relationship between psychedelic use and cancer diagnosis.

Characteristics of non-participants in a randomized colorectal cancer screening trial comparing sigmoidoscopy and faecal immunochemical testing

Public health systems should guarantee universal access to health care services, including cancer screening. We assessed whether certain population subgroups were underrepresented among participants in colorectal cancer screening with sigmoidoscopy and faecal immunochemical testing (FIT). Between 2012 and 2019, about 140 000 individuals aged 50 to 74 years were randomly invited to once‐only sigmoidoscopy or first round of FIT screening. Our study included 46 919 individuals invited to sigmoidoscopy and 70 019 to FIT between 2012 and 2017. We used logistic regression models to evaluate if demographic and socioeconomic factors and use of certain drugs were associated with participation. Twenty‐four thousand one hundred and fifty‐nine (51.5%) individuals attended sigmoidoscopy and 40 931 (58.5%) FIT screening. Male gender, young age, low education and income, being retired or unemployed, living alone, being an immigrant, long driving time to screening centre, and use of antidiabetic and psychotropic drugs were associated with low participation in both screening groups. Many of these factors also predicted low acceptance of colonoscopy after positive FIT. While male gender, young age and living alone were more strongly associated with nonparticipation in FIT than sigmoidoscopy, low education and income, being retired or immigrant and long driving time were more strongly associated with nonparticipation in sigmoidoscopy than FIT. In conclusion, participation was lower in sigmoidoscopy than FIT. Predictors of nonparticipation were similar between arms. However, low socioeconomic status, being an immigrant and long driving time affected participation more in sigmoidoscopy screening, suggesting that FIT may guarantee more equal access to screening services than sigmoidoscopy.

C‐Reactive Protein Trajectories and the Risk of All Cancer Types: A Prospective Cohort Study

A single CRP measurement is insufficient to examine the association of long‐term patterns of CRP concentration with cancer risk. We prospectively examined the relationship between CRP trajectory patterns and new‐onset cancers among 52 276 participants. Latent mixture modeling was used to identify CRP trajectories. Cox proportional hazards regression models were used to evaluate the association between CRP trajectory patterns and the risk of overall and specific‐site cancer. Four CRP trajectories patterns were identified: low‐stable pattern (n = 43 258), moderate‐increasing pattern (n = 2591), increasing‐decreasing pattern (n = 2068) and elevated‐decreasing pattern (n = 4359). Relative to the low‐stable pattern, the moderate‐increasing trajectory pattern was associated with an elevated risk of overall, lung, breast, leukemia, bladder, stomach, colorectal, liver, gallbladder or extrahepatic bile duct cancer and leukemia. Participants in the increasing‐decreasing trajectory pattern were associated with an elevated risk of overall, lung, breast, bladder, pancreatic and liver cancer. The increasing‐decreasing trajectory pattern was also associated with decreased risk of colorectal cancer in the multivariate analyses. Elevated‐decreasing trajectory pattern was associated with increased risk of leukemia and decreased risk of esophageal and colorectal cancer. CRP trajectories play an important role in the occurrence of cancers, especially in the lung, breast, bladder, stomach, colorectal, liver, gallbladder and extrahepatic bile duct cancer and leukemia.

Socioeconomic status and risk of lung cancer by histological subtype in the Nordic countries

BACKGROUND

While the excess in lung cancer risk among lower socioeconomic status individuals has been widely described, the magnitude of this association across lung cancer subtypes, as well as histotype-related long-term incidence trends, are inconclusively reported.

AIMS

We explored the variation in the incidence of the three main lung cancer histotypes (i.e. squamous cell carcinoma, small cell carcinoma and adenocarcinoma) by socioeconomic status (SES, i.e. upper and lower white collar, upper and lower blue collar, and farming/forestry/fishing) in the adult population of four Nordic countries (i.e. Sweden, Norway, Finland and Denmark).

MATERIALS & METHODS

We have used data from the Nordic Occupational Cancer Study (NOCCA), computing age-standardized incidence rates per 100,000 person-years truncated at ages 50-69 years, by sex, histotype, country and SES, for the period 1971-2005. We estimated relative risks and the corresponding 95% confidence intervals through Poisson regression models, including terms for SES, age, sex and country, as indicated.

RESULTS

A clear socioeconomic gradient, with a progressive increase in lung cancer risk as SES level decreases, was observed in all subtypes and in both sexes. Favourable lung cancer incidence trends were seen among men for squamous cell and small cell carcinomas, although for adenocarcinomas rates were increasing everywhere except for Finland. Among women, upward temporal trends were seen in all SES groups and for all subtypes, although rates increased to a greater extent for low, compared to high, SES, especially in Denmark and Norway. Farmers showed comparatively lower risks compared to other SES categories.

DISCUSSION

This prospective cohort study shows that substantial socioeconomic inequalities in the incidence of the most important lung cancer histotypes exist in the Nordic Countries, and that these inequalities are on the rise, especially among women.

CONCLUSION

Smoking habits are likely to largely explain the observed social gradient for lung cancer histotypes in both sexes.

Cancer incidence in primary Sjögren's syndrome: Data from the French hospitalization database

The relationship between cancer and primary Sjögren's syndrome (pSS) is uncertain. While the increased risk of hematological malignancies is well-known, data on the comparative incidence of solid neoplasms is conflicting. This study aimed to explore the associations between cancer and pSS. This nationwide population-based retrospective study from the French health insurance database (PMSI) evaluated patients hospitalized with new-onset pSS from 2011 to 2018 against age- and sex-matched hospitalized controls (1:10). The incidence of hematological malignancies and solid neoplasms was compared between the two groups. Mortality and multiple cancer incidence were also evaluated. Adjusted Hazard Ratios (aHR) calculations included confounding factors, such as low socioeconomic status. Among 25,661 hospitalized patients with pSS versus 252,543 matched patients (median follow-up of 3.96 years), we observed a higher incidence rate of lymphomas (aHR, 1.97 [95% CI, 1.59-2.43]), Waldenström macroglobulinemia (aHR, 10.8 [6.5-18.0]), and leukemia (aHR, 1.61 [1.1-2.4]). Thyroid cancer incidence was higher (aHR, 1.7 [1.1-2.8]), whereas bladder and breast cancer incidences were lower (aHR, 0.58 [0.37-0.89] and 0.60 [0.49-0.74], respectively). pSS patients with breast cancer exhibited a lower mortality rate. A limitation was that the database only encompasses hospitalized patients, and immunological and histological details are not listed. We confirmed the increased risk of hematological malignancies and thyroid cancers among patients with pSS. The lower risk of breast cancer suggests a role of hormonal factors and raises questions of the concept of immune surveillance within breast tissue. Epidemiological and translational studies are required to elucidate the relationships between pSS and cancer.

Trajectories of Suffering in the Last Year of Life Among Patients With a Solid Metastatic Cancer

BACKGROUND

Reducing suffering at the end of life is important. Doing so requires a comprehensive understanding of the course of suffering for patients with cancer during their last year of life. This study describes trajectories of psychological, spiritual, physical, and functional suffering in the last year of life among patients with a solid metastatic cancer.

PATIENTS AND METHODS

We conducted a prospective cohort study of 600 patients with a solid metastatic cancer between July 2016 and December 2019 in Singapore. We assessed patients' psychological, spiritual, physical, and functional suffering every 3 months until death. Data from the last year of life of 345 decedents were analyzed. We used group-based multitrajectory modeling to delineate trajectories of suffering during the last year of a patient's life.

RESULTS

We identified 5 trajectories representing suffering: (1) persistently low (47% of the sample); (2) slowly increasing (14%); (3) predominantly spiritual (21%); (4) rapidly increasing (12%); and (5) persistently high (6%). Compared with patients with primary or less education, those with secondary (high school) (odds ratio [OR], 3.49; 95% CI, 1.05-11.59) education were more likely to have rapidly increasing versus persistently low suffering. In multivariable models adjusting for potential confounders, compared with patients with persistently low suffering, those with rapidly increasing suffering had more hospital admissions (β=0.24; 95% CI, 0.00-0.47) and hospital days (β=0.40; 95% CI, 0.04-0.75) during the last year of life. Those with persistently high suffering had more hospital days (β=0.70; 95% CI, 0.23-1.17).

CONCLUSIONS

The course of suffering during the last year of life among patients with cancer is variable and related to patients' hospitalizations. Understanding this variation can facilitate clinical decisions to minimize suffering and reduce healthcare costs at the end of life.