Magnitude and Temporal Variations of Socioeconomic Inequalities in the Quality of Life After Early Breast Cancer: Results From the Multicentric French CANTO Cohort

PURPOSE

Socioeconomic status (SES) influences the survival outcomes of patients with early breast cancer (EBC). However, limited research investigates social inequalities in their quality of life (QoL). This study examines the socioeconomic inequalities in QoL after an EBC diagnosis and their time trends.

PATIENTS AND METHODS

We used data from the French prospective multicentric CANTO cohort (ClinicalTrials.gov identifier: NCT01993498), including women with EBC enrolled between 2012 and 2018. QoL was assessed using the European Organisation for Research and Treatment of Cancer QoL Core 30 questionnaire (QLQ-C30). summary score at diagnosis and 1 and 2 years postdiagnosis. We considered three indicators of SES separately: self-reported financial difficulties, household income, and educational level. We first analyzed the trajectories of the QLQ-C30 summary score by SES group. Then, social inequalities in QLQ-C30 summary score and their time trends were quantified using the regression-based slope index of inequality (SII), representing the absolute change in the outcome along socioeconomic gradient extremes. The analyses were adjusted for age at diagnosis, Charlson Comorbidity Index, disease stage, and type of local and systemic treatment.

RESULTS

Among the 5,915 included patients with data on QoL at diagnosis and at the 2-year follow-up, social inequalities in QLQ-C30 summary score at baseline were statistically significant for all SES indicators (SIIfinancial difficulties = -7.6 [-8.9; -6.2], SIIincome = -4.0 [-5.2; -2.8]), SIIeducation = -1.9 [-3.1; -0.7]). These inequalities significantly increased (interaction P < .05) in year 1 and year 2 postdiagnosis, irrespective of prediagnosis health, tumor characteristics, and treatment. Similar results were observed in subgroups defined by menopausal status and type of adjuvant systemic treatment.

CONCLUSION

The magnitude of preexisting inequalities in QoL increased over time after EBC diagnosis, emphasizing the importance of considering social determinants of health during comprehensive cancer care planning.

Progress towards universal health coverage and inequalities in infant mortality: an analysis of 4·1 million births from 60 low-income and middle-income countries between 2000 and 2019

BACKGROUND

Expanding universal health coverage (UHC) might not be inherently beneficial to poorer populations without the explicit targeting and prioritising of low-income populations. This study examines whether the expansion of UHC between 2000 and 2019 is associated with reduced socioeconomic inequalities in infant mortality in low-income and middle-income countries (LMICs).

METHODS

We did a retrospective analysis of birth data compiled from Demographic and Health Surveys (DHSs). We analysed all births between 2000 and 2019 from all DHSs available for this period. The primary outcome was infant mortality, defined as death within 1 year of birth. Logistic regression models with country and year fixed effects assessed associations between country-level progress to UHC (using WHO's UHC service coverage index) and infant mortality (overall and by wealth quintile), adjusting for infant-level, mother-level, and country-level variables.

FINDINGS

A total of 4 065 868 births to 1 833 011 mothers were analysed from 177 DHSs covering 60 LMICs between 2000 and 2019. A one unit increase in the UHC index was associated with a 1·2% reduction in the risk of infant death (AOR 0·988, 95% CI 0·981-0·995; absolute measure of association, 0·57 deaths per 1000 livebirths). An estimated 15·5 million infant deaths were averted between 2000 and 2019 because of increases in UHC. However, richer wealth quintiles had larger associated reductions in infant mortality from UHC (quintile 5 AOR 0·983, 95% CI 0·973-0·993) than poorer quintiles (quintile 1 0·991, 0·985-0·998). In the early stages of UHC, UHC expansion was generally beneficial to poorer populations (ie, larger reductions in infant mortality for poorer households [infant deaths per 1000 per one unit increase in UHC coverage: quintile 1 0·84 vs quintile 5 0·59]), but became less so as overall coverage increased (quintile 1 0·64 vs quintile 5 0·57).

INTERPRETATION

Since UHC expansion in LMICs appears to become less beneficial to poorer populations as coverage increases, UHC policies should be explicitly designed to ensure lower income groups continue to benefit as coverage expands.

FUNDING

UK National Institute for Health and Care Research.

Where are the inequalities in ovarian cancer care in a country with universal healthcare? A systematic review and narrative synthesis

INTRODUCTION

Patients diagnosed with ovarian cancer from more deprived areas may face barriers to accessing timely, quality healthcare. We evaluated the literature for any association between socioeconomic group, treatments received and hospital delay among patients diagnosed with ovarian cancer in the United Kingdom, a country with universal healthcare.

METHODS

We searched MEDLINE, EMBASE, CINAHL, CENTRAL, SCIE, AMED, PsycINFO and HMIC from inception to January 2023. Forward and backward citation searches were conducted. Two reviewers independently reviewed titles, abstracts, and full-text articles. UK-based studies were included if they reported socioeconomic measures and an association with either treatments received or hospital delay. The inclusion of studies from one country ensured greater comparability. Risk of bias was assessed using the QUIPS tool, and a narrative synthesis was conducted. The review is reported to PRISMA 2020 and registered with PROSPERO [CRD42022332071].

RESULTS

Out of 2876 references screened, ten were included. Eight studies evaluated treatments received, and two evaluated hospital delays. We consistently observed socioeconomic inequalities in the likelihood of surgery (range of odds ratios 0.24-0.99) and chemotherapy (range of odds ratios 0.70-0.99) among patients from the most, compared with the least, deprived areas. There were no associations between socioeconomic groups and hospital delay.

POLICY SUMMARY

Ovarian cancer treatments differed between socioeconomic groups despite the availability of universal healthcare. Further research is needed to understand why, though suggested reasons include patient choice, health literacy, and financial and employment factors. Qualitative research would provide a rich understanding of the complex factors that drive these inequalities.

Socioeconomic Environment and Survival in Patients with Digestive Cancers: A French Population-Based Study

Social inequalities are an important prognostic factor in cancer survival, but little is known regarding digestive cancers specifically. We aimed to provide in-depth analysis of the contextual social disparities in net survival of patients with digestive cancer in France, using population-based data and relevant modeling. Digestive cancers (n = 54,507) diagnosed between 2006-2009, collected through the French network of cancer registries, were included (end of follow-up 30 June 2013). Social environment was assessed by the European Deprivation Index. Multidimensional penalized splines were used to model excess mortality hazard. We found that net survival was significantly worse for individuals living in a more deprived environment as compared to those living in a less deprived one for esophageal, liver, pancreatic, colon and rectal cancers, and for stomach and bile duct cancers among females. Excess mortality hazard was up to 57% higher among females living in the most deprived areas (vs. least deprived) at 1 year of follow-up for bile duct cancer, and up to 21% higher among males living in the most deprived areas (vs. least deprived) regarding colon cancer. To conclude, we provide a better understanding of how the (contextual) social gradient in survival is constructed, offering new perspectives for tackling social inequalities in digestive cancer survival.

Differential effects of colorectal cancer screening across sociodemographic groups in Denmark: a register-based study

INTRODUCTION

Colorectal cancer (CRC) does not affect different sociodemographic groups uniformly. CRC screening programmes could seek to reduce this inequality; however, the screening programmes themselves might be subject to differential participation across sociodemographic groups. This study investigates the sociodemographic inequality at all steps in Denmark's nationwide CRC screening programme: screening participation, faecal immunochemical test (FIT) results, colonoscopy compliance, CRC diagnosis, and cancer stage.

MATERIAL AND METHODS

This cohort study includes all first-time invitees from the beginning of the Danish population-based CRC screening programme from 1 March 2014 to 31 December 2017.

RESULTS

Sixty-four percent of the invitees participated in the screening programme, and of those 7% were FIT-positive. After being invited to further diagnostic procedures, 90% responded to the invitation, and among those 5% were CRC-positive. Among those diagnosed with CRC, 9% were stage IV. Through multivariable analyses, we identified sociodemographic inequalities in all steps of the screening programme from returning a stool sample to being diagnosed with CRC. Specifically, we identified inequalities across sex, age, migration status, relationship status, the screening status of one's partner, education, income, and use of health services. Women were more likely to participate compared to men (RR = 1.13; 95% CI: 1.12-1.13), but had a lower risk of a positive FIT result (RR = 0.67; 95% CI: 0.66-0.68) and of a CRC diagnosis (RR = 0.88; 95% CI: 0.82-0.93) compared to men. The likelihood of participating as well as the risk of positive FIT results and CRC diagnosis increased with age.

CONCLUSION

All steps of the screening programme were subject to sociodemographic inequalities. Interventions are needed to target groups identified as having lower uptake as well as high-risk of being FIT- and/or CRC-positive. These groups include males, individuals aged 60+ years and individuals who do not visit their GP regularly.

Social Inequalities in Cancer Survival in Belgium: A Population-Based Cohort Study

BACKGROUND

Socioeconomic status (SES) is an important factor in cancer survival; however, results are heterogeneous and linked to characteristics of the study population and health care system. This population-based cohort study evaluates the association between individual-level socioeconomic and demographic factors and cancer survival for the first time in Belgium.

METHODS

From the Belgian Cancer Registry, we identified 109,591 patients diagnosed between 2006 and 2013 with one of eight common cancer types. Information on treatment, socioeconomic parameters, and vital status were retrieved from multiple data sources and linked using a unique personal identification number. The outcome was 5-year observed survival. Associations between survival and socioeconomic and demographic factors were assessed using multivariable Cox proportional-hazard regression models.

RESULTS

Lower income, unemployment, and living alone were all associated with worse cancer survival. These associations were most pronounced for certain lifestyle-related cancer types (e.g., head and neck cancers) and those with good to moderate prognosis (e.g., colorectal and female breast cancer).

CONCLUSIONS

These results indicate that, despite a comprehensive and nationwide health insurance program in which equity in rights and access to health care are pursued, SES is associated with disparities in cancer survival in Belgium.

IMPACT

This population-based study with individual-level socioeconomic information of more than 100,000 patients with cancer identifies patient groups that may be at highest risk for socioeconomic disparities in cancer survival. Reasons behind the observed disparities are multiple and complex and should be further examined. Health policy interventions should consider the observed deprivation gap to plan targeted actions.

Stage-specific survival has improved for young breast cancer patients since 2000: but not equally

Purpose

The stage-specific survival of young breast cancer patients has improved, likely due to diagnostic and treatment advances. We addressed whether survival improvements have reached all socioeconomic groups in a country with universal health care and national treatment guidelines.

Methods

Using Norwegian registry data, we assessed stage-specific breast cancer survival by education and income level of 7501 patients (2317 localized, 4457 regional, 233 distant and 494 unknown stage) aged 30–48 years at diagnosis during 2000–2015. Using flexible parametric models and national life tables, we compared excess mortality up to 12 years from diagnosis and 5-year relative survival trends, by education and income as measures of socioeconomic status (SES).

Results

Throughout 2000–2015, regional and distant stage 5-year relative survival improved steadily for patients with high education and high income (high SES), but not for patients with low education and low income (low SES). Regional stage 5-year relative survival improved from 85 to 94% for high SES patients (9% change; 95% confidence interval: 6, 13%), but remained at 84% for low SES patients (0% change; − 12, 12%). Distant stage 5-year relative survival improved from 22 to 58% for high SES patients (36% change; 24, 49%), but remained at 11% for low SES patients (0% change; − 19, 19%).

Conclusions

Regional and distant stage breast cancer survival has improved markedly for high SES patients, but there has been little survival gain for low SES patients. Socioeconomic status matters for the stage-specific survival of young breast cancer patients, even with universal health care.

Electronic supplementary material

The online version of this article (10.1007/s10549-020-05698-z) contains supplementary material, which is available to authorized users.

Occupational Class and Cancer Survival in Korean Men: Follow-Up Study of Nation-Wide Working Population

Background: We aimed to describe inequalities in site-specific cancer survival across different occupational classes in Korean men. Methods: Subjects included cancer diagnosed members of the national employment insurance program during 1995-2008. A total of 134,384 male cases were followed by linking their data to the Death registry until 2009. Occupational classes were categorized according to the Korean Standard Occupational Classification (KSOC). Hazard ratio adjusting age and diagnosed year were calculated for each occupation by cancer sites. Results: Men in service/sales and blue-collar occupations had lower survival of all cancer sites combined and esophagus, stomach, colorectal, liver, larynx, lung, prostate, thyroid cancer and non-Hodgkin's lymphoma than men in professional and managerial positions. Cancer sites with good prognosis like prostate cancer showed wider gap across occupational class. Conclusions: Considerable inequalities in cancer survival were found by occupation among Korean men. Cancer control policy should more focus on lower socioeconomic occupational class.

Evaluation of a health service adopting proactive approach to reduce high risk of lung cancer: The Liverpool Healthy Lung Programme

OBJECTIVES

This Liverpool Healthy Lung Programme is a response to high rates of lung cancer and respiratory diseases locally and aims to diagnose lung cancer at an earlier stage by proactive approach to those at high risk of lung cancer. The objective of this study is to evaluate the programme in terms of its likely effect on mortality from lung cancer and its delivery to deprived populations.

METHODS

Persons aged 58-75 years, with a history of smoking or a diagnosis of chronic obstructive pulmonary disease (COPD)² according to general practice records were invited for lung health check in a community health hub setting. A detailed risk assessment and spirometry were performed in eligible patients. Those with a 5% or greater five-year risk of lung cancer were referred for a low dose CT³ scan.

RESULTS

A total of 4 566 subjects attended the appointment for risk assessment and 3 591 (79%) consented to data sharing. More than 80% of the patients were in the most deprived quintile of the index of multiple deprivation. Of those attending, 63% underwent spirometry and 43% were recommended for a CT scan. A total of 25 cancers were diagnosed, of which 16 (64%) were stage I. Comparison with the national stage distribution implied that the programme was reducing lung cancer mortality by 22%.

CONCLUSIONS

Community based proactive approaches to early diagnosis of lung cancer in health deprived regions are likely to be effective in early detection of lung cancer.

Socioeconomic inequality in cancer survival - changes over time. A population-based study, Denmark, 1987-2013

Background: Socioeconomic inequality in survival after cancer have been reported in several countries and also in Denmark. Changes in cancer diagnostics and treatment may have changed the gap in survival between affluent and deprived patients and we investigated if the differences in relative survival by income has changed in Danish cancer patients over the past 25 years. Methods: The 1- and 5-year relative survival by income quintile is computed by comparing survival among cancer patients diagnosed 1987-2009 to the survival of a cancer-free matched sample of the background population. The comparison is done within the 15 most common cancers and all cancers combined. The gap in relative survival due to socioeconomic inequality for the period 1987-1991 is compared the period 2005-2009. Results: The relative 5-year survival increased for all 15 cancer sites investigated in the study period. In general, low-income patients diagnosed in 1987-1991 had between 0% and 11% units lower 5-year relative survival compared with high-income patients; however, only four sites (breast, prostate, bladder and head & neck) were statistically different. In patients diagnosed 2005-2009, the gap in 5-year RS was ranging from 2% to 22% units and statistically significantly different for 9 out of 15 sites. The results for 1-year relative survival were similar to the 5-year survival gap. An estimated 22% of all deaths at five years after diagnosis could be avoided had patients in all income groups had same survival as the high-income group. Conclusion: In this nationwide population-based study, we observed that the large improvements in both short- and long-term cancer survival among patients diagnosed 1987-2009. The improvements have been most pronounced for high-income cancer patients, leading to stable or even increasing survival differences between richest and poorest patients. Improving survival among low-income patients would improve survival rates among Danish cancer patients overall and reduce differences in survival when compared to other Western European countries.

The Inverse Equity Hypothesis: Analyses of Institutional Deliveries in 286 National Surveys

OBJECTIVES

To test the inverse equity hypothesis, which postulates that new health interventions are initially adopted by the wealthy and thus increase inequalities-as population coverage increases, only the poorest will lag behind all other groups.

METHODS

We analyzed the proportion of births occurring in a health facility by wealth quintile in 286 surveys from 89 low- and middle-income countries (1993-2015) and developed an inequality pattern index. Positive values indicate that inequality is driven by early adoption by the wealthy (top inequality), whereas negative values signal bottom inequality.

RESULTS

Absolute inequalities were widest when national coverage was around 50%. At low national coverage levels, top inequality was evident with coverage in the wealthiest quintile taking off rapidly; at 60% or higher national coverage, bottom inequality became the predominant pattern, with the poorest quintile lagging behind.

CONCLUSIONS

Policies need to be tailored to inequality patterns. When top inequalities are present, barriers that limit uptake by most of the population must be identified and addressed. When bottom inequalities exist, interventions must be targeted at specific subgroups that are left behind.

Cancer survival disparities worsening by socio-economic disadvantage over the last 3 decades in new South Wales, Australia

BACKGROUND

Public concerns are commonly expressed about widening health gaps. This cohort study examines variations and trends in cancer survival by socio-economic disadvantage, geographical remoteness and country of birth in an Australian population over a 30-year period.

METHODS

Data for cases diagnosed in New South Wales (NSW) in 1980-2008 (n = 651,245) were extracted from the population-based NSW Cancer Registry. Competing risk regression models, using the Fine & Gray method, were used for comparative analyses to estimate sub-hazard ratios (SHR) with 95% confidence intervals (CI) among people diagnosed with cancer.

RESULTS

Increased risk of cancer death was associated with living in the most socio-economically disadvantaged areas compared with the least disadvantaged areas (SHR 1.15, 95% CI 1.13-1.17), and in outer regional/remote areas compared with major cities (SHR 1.05, 95% CI 1.03-1.06). People born outside Australia had a similar or lower risk of cancer death than Australian-born (SHR 0.99, 95% CI 0.98-1.01 and SHR 0.91, 95% CI 0.90-0.92 for people born in other English and non-English speaking countries, respectively). An increasing comparative risk of cancer death was observed over time when comparing the most with the least socio-economically disadvantaged areas (SHR 1.07, 95% CI 1.04-1.10 for 1980-1989; SHR 1.14, 95% CI 1.12-1.17 for 1990-1999; and SHR 1.24, 95% CI 1.21-1.27 for 2000-2008; p < 0.001 for interaction between disadvantage quintile and year of diagnosis).

CONCLUSIONS

There is a widening gap in comparative risk of cancer death by level of socio-economic disadvantage that warrants a policy response and further examination of reasons behind these disparities.

Unemployment and HIV mortality in the countries of the Organisation for Economic Co-operation and Development: 1981-2009

OBJECTIVES

To determine an association between unemployment rates and human immunodeficiency virus (HIV) mortality in the Organisation for Economic Co-operation and Development (OECD).

DESIGN

Multivariate regression analysis.

PARTICIPANTS

OECD member states.

SETTING

OECD.

MAIN OUTCOME MEASURES

World Health Organization HIV mortality.

RESULTS

Between 1981 and 2009, a 1% increase in unemployment was associated with an increase in HIV mortality in the OECD (coefficient for men 0.711, 0.334-1.089, p = 0.0003; coefficient for women 0.166, 0.071-0.260, p = 0.0007). Time lag analysis showed a significant increase in HIV mortality for up to two years after rises in unemployment: p = 0.0008 for men and p = 0.0030 for women in year 1, p = 0.0067 for men and p = 0.0403 for women in year 2.

CONCLUSIONS

Rises in unemployment are associated with increased HIV mortality. Economic fiscal policy may impact upon population health. Policy discussions should take into consideration potential health outcomes.

Socio-economic disparities in long-term cancer survival-10 year follow-up with individual patient data

PURPOSE

Reasons for the social gradient in cancer survival are not fully understood yet. Previous studies were often only able to determine the socio-economic status of the patients from the area they live in, not from their individual socio-economic characteristics.

METHODS

In a multi-centre cohort study with 1633 cancer patients and 10-year follow-up, individual socio-economic position was measured using the indicators: education, job grade, job type, and equivalence income. The effect on survival was measured for each indicator individually, adjusting for age, gender, and medical characteristics. The mediating effect of health behaviour (alcohol and tobacco consumption) was analysed in separate models.

RESULTS

Patients without vocational training were at increased risk of dying (rate ratio (RR) 1.5, 95% confidence interval (CI) 1.1-2.2) compared to patients with the highest vocational training; patients with blue collar jobs were at increased risk (RR 1.2; 95% CI 1.0-1.5) compared to patients with white collar jobs; income had a gradual effect (RR for the lowest income compared to highest was 2.7, 95% CI 1.9-3.8). Adding health behaviour to the models did not change the effect estimates considerably. There was no evidence for an effect of school education and job grade on cancer survival.

CONCLUSIONS

Patients with higher income, better vocational training, and white collar jobs survived longer, regardless of disease stage at baseline and of tobacco and alcohol consumption.

Impact of socioeconomic inequalities on geographic disparities in cancer incidence: comparison of methods for spatial disease mapping

BACKGROUND

The reliability of spatial statistics is often put into question because real spatial variations may not be found, especially in heterogeneous areas. Our objective was to compare empirically different cluster detection methods. We assessed their ability to find spatial clusters of cancer cases and evaluated the impact of the socioeconomic status (e.g., the Townsend index) on cancer incidence.

METHODS

Moran's I, the empirical Bayes index (EBI), and Potthoff-Whittinghill test were used to investigate the general clustering. The local cluster detection methods were: i) the spatial oblique decision tree (SpODT); ii) the spatial scan statistic of Kulldorff (SaTScan); and, iii) the hierarchical Bayesian spatial modeling (HBSM) in a univariate and multivariate setting. These methods were used with and without introducing the Townsend index of socioeconomic deprivation known to be related to the distribution of cancer incidence. Incidence data stemmed from the Cancer Registry of Isère and were limited to prostate, lung, colon-rectum, and bladder cancers diagnosed between 1999 and 2007 in men only.

RESULTS

The study found a spatial heterogeneity (p < 0.01) and an autocorrelation for prostate (EBI = 0.02; p = 0.001), lung (EBI = 0.01; p = 0.019) and bladder (EBI = 0.007; p = 0.05) cancers. After introduction of the Townsend index, SaTScan failed in finding cancers clusters. This introduction changed the results obtained with the other methods. SpODT identified five spatial classes (p < 0.05): four in the Western and one in the Northern parts of the study area (standardized incidence ratios: 1.68, 1.39, 1.14, 1.12, and 1.16, respectively). In the univariate setting, the Bayesian smoothing method found the same clusters as the two other methods (RR >1.2). The multivariate HBSM found a spatial correlation between lung and bladder cancers (r = 0.6).

CONCLUSIONS

In spatial analysis of cancer incidence, SpODT and HBSM may be used not only for cluster detection but also for searching for confounding or etiological factors in small areas. Moreover, the multivariate HBSM offers a flexible and meaningful modeling of spatial variations; it shows plausible previously unknown associations between various cancers.

What might explain deprivation-specific differences in the excess hazard of breast cancer death amongst screen-detected women? Analysis of patients diagnosed in the West Midlands region of England from 1989 to 2011

BACKGROUND

Breast cancer survival is higher in less deprived women, even amongst women whose tumor was screen-detected, but reasons behind this have not been comprehensively investigated.

METHODS

The excess hazard of breast cancer death in 20,265 women diagnosed with breast cancer, followed up to 2012, was estimated for screen-detected and non-screen-detected women, comparing more deprived to less deprived women using flexible parametric models. Models were adjusted for individual and tumor factors, treatment received and comorbidity. For screen-detected women, estimates were also corrected for lead-time and overdiagnosis.

RESULTS

The excess hazard ratio (EHR) of breast cancer death in the most deprived group, adjusted only for age and year of diagnosis, was twice that of the least deprived among screen-detected women (EHR=2.12, 95%CI 1.48-2.76) and 64% higher among non-screen-detected women (EHR=1.64, 95%CI 1.41-1.87). Adjustment for stage at diagnosis lowered these estimates by 25%. Further adjustment had little extra impact. In the final models, the excess hazard for the most deprived women was 54% higher (EHR=1.54, 95%CI 1.10-1.98) among screen-detected women and 39% higher (EHR=1.39, 95%CI 1.20-1.59) among non-screen-detected women.

CONCLUSION

A persistent socio-economic gradient in breast cancer-related death exists in this cohort, even for screen-detected women. The impact of differential lifestyles, management and treatment warrant further investigation.

Impact of socio-economic position on cancer stage at presentation: Findings from a large hospital-based study in Germany

We explored the relationship between socio-economic characteristics and cancer stage at presentation. Patients admitted to a university hospital for diagnosis and treatment of cancer provided data on their education, vocational training, income, employment, job, health insurance and postcode. Tumor stage was classified according to the Union International Contre le Cancer (UICC). To analyze disparities in the likelihood of late-stage (UICC III/IV vs. I/II) diagnoses, logistic regression models adjusting for age and gender were used. Out of 1,012 patients, 572 (59%) had late-stage cancer. Separately tested, increased odds of advanced disease were associated with post-compulsory education compared to college degrees, with apprenticeship and no vocational training, with unemployment, disability pension, jobs with a low hierarchy level, blue collar jobs and with low income. Health insurance and community size were not related with late-stage cancer. Jointly modelled, there was evidence for an independent effect of unemployment (odds ratio (OR) 1.7, CI 1.0-2.8), disability pension (OR 1.8, CI 1.0-3.2) and very low income (OR 2.6, CI 1.1-6.1) on the likelihood of advanced disease stage. It is of great concern that these socio-economic gradients occur even in systems with equal access to health care.

Comparing UK and 20 Western countries' efficiency in reducing adult (55-74) cancer and total mortality rates 1989-2010: Cause for cautious celebration? A population-based study

Objective

Every Western nation expends vast sums on health, especially for cancer; thus, the question is how efficient is the UK in reducing adult (55–74) cancer mortality rates and total mortality rates (TMR) compared to the other Western nations in the context of economic-input to health, the percentage of Gross-Domestic-Product-expenditure-on-Health.

Design

WHO mortality rates for baseline 3 years 1989–1991 and 2008–2010 were analysed, and confidence intervals determine any significant differences between the UK and other countries in reducing the mortalities. Efficiency ratios are calculated by dividing reduced mortality over the period by the average % of national income.

Setting

Twenty-one similar socio-economic Western countries.

Participants

The 21 countries’ general population.

Main outcome measures

Cancer mortality rates, total mortality rates Gross Domestic Product and Efficiency Ratios.

Results

Economic Input: In 1980, UK national income was 5.6% and the European average was 7.1%. By 2010, UK national income was 9.4% being equal 17th of 21 averaging 7.1% over the period. Europe’s 1980–2010 average of 8.4% yields a UK to Europe ratio of 1:1.18.

Clinical output 1989–2010: UK Cancer Mortality Rates was the sixth highest, but equal sixth biggest fall, significantly greater than 14 other countries. UK Total Mortality Rates was the fifth highest but third biggest decline, significantly greater than 17 countries. UK’s cancer Efficiency Ratios is largest at 1:301 and second biggest for Total Mortality Rates at 1.1341; the USA ratios were 1:152 and 1:525, respectively.

Conclusions

UK reduced mortalities indicate that the NHS achieves proportionally more with relatively less, but UK needs to match European average Gross-Domestic-Product-expenditure-on-Health to meet future challenges.

How much do tumor stage and treatment explain socioeconomic inequalities in breast cancer survival? Applying causal mediation analysis to population-based data

Substantial socioeconomic inequalities in breast cancer survival persist in England, possibly due to more advanced cancer at diagnosis and differential access to treatment. We aim to disentangle the contributions of differential stage at diagnosis and differential treatment to the socioeconomic inequalities in cancer survival. Information on 36,793 women diagnosed with breast cancer during 2000-2007 was routinely collected by an English population-based cancer registry. Deprivation was determined for each patient according to her area of residence at the time of diagnosis. A parametric implementation of the mediation formula using Monte Carlo simulation was used to estimate the proportion of the effect of deprivation on survival mediated by stage and by treatment. One-third (35 % [23-48 %]) of the higher mortality experienced by most deprived patients at 6 months after diagnosis, and one tenth (14 % [-3 to 31 %]) at 5 years, was mediated by adverse stage distribution. We initially found no evidence of mediation via differential surgical treatment. However, sensitivity analyses testing some of our study limitations showed in particular that up to thirty per cent of the higher mortality in most deprived patients could be mediated by differential surgical treatment. This study illustrates the importance of using causal inference methods with routine medical data and the need for testing key assumptions through sensitivity analyses. Our results suggest that, although effort for earlier diagnosis is important, this would reduce the cancer survival inequalities only by a third. Because of data limitations, role of differential surgical treatment may have been under-estimated.

Impact of deprivation on breast cancer survival among women eligible for mammographic screening in the West Midlands (UK) and New South Wales (Australia): Women diagnosed 1997-2006

Women diagnosed with breast cancer in the UK display marked differences in survival between categories defined by socio-economic deprivation. Timeliness of diagnosis is one of the possible explanations for these patterns. Women whose cancer is screen-detected are more likely to be diagnosed at an earlier stage. We examined deprivation and screening-specific survival in order to evaluate the role of early diagnosis upon deprivation-specific survival differences in the West Midlands (UK) and New South Wales (Australia). We estimated net survival for women aged 50-65 years at diagnosis and whom had been continuously eligible for screening from the age of 50. Records for 5,628 women in West Midlands (98.5% of those eligible, mean age at diagnosis 53.7 years) and 6,396 women in New South Wales (99.9% of those eligible, mean age at diagnosis 53.8 years). In New South Wales, survival was similar amongst affluent and deprived women, regardless of whether their cancer was screen-detected or not. In the West Midlands, there were large and persistent differences in survival between affluent and deprived women. Deprivation differences were similar between the screen-detected and non-screen detected groups. These differences are unlikely to be solely explained by artefact, or by patient or tumour factors. Further investigations into the timeliness and appropriateness of the treatments received by women with breast cancer across the social spectrum in the UK are warranted.

Cancer survival in New South Wales, Australia: socioeconomic disparities remain despite overall improvements

Background

Disparities in cancer survival by socioeconomic status have been reported previously in Australia. We investigated whether those disparities have changed over time.

Methods

We used population-based cancer registry data for 377,493 patients diagnosed with one of 10 major cancers in New South Wales (NSW), Australia. Patients were assigned to an area-based measure of socioeconomic status. Five-year relative survival was estimated for each socioeconomic quintile in each ‘at risk’ period (1996–2000 and 2004–2008) for the 10 individual cancers. Poisson-regression modelling was used to adjust for several prognostic factors. The relative excess risk of death by socioeconomic quintile derived from this modelling was compared over time.

Results

Although survival increased over time for most individual cancers, Poisson-regression models indicated that socioeconomic disparities continued to exist in the recent period. Significant socioeconomic disparities were observed for stomach, colorectal, liver, lung, breast and prostate cancer in 1996–2000 and remained so for 2004–2008, while significant disparities emerged for cervical and uterus cancer in 2004–2008 (although the interaction between period and socioeconomic status was not significant). About 13.4 % of deaths attributable to a diagnosis of cancer could have been postponed if this socioeconomic disparity was eliminated.

Conclusion

While recent health and social policies in NSW have accompanied an increase in cancer survival overall, they have not been associated with a reduction in socioeconomic inequalities.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2065-z) contains supplementary material, which is available to authorized users.

Selection for surgery and survival of synchronous colorectal liver metastases; a nationwide study

BACKGROUND

Resection of colorectal liver metastases (CRLM) is associated with improved survival but we currently have limited population-based data on selection for surgery.

METHODS

Patients in the Swedish Colorectal Cancer Register reported with liver metastases at diagnosis in 2007-2011 were identified. Clinical characteristics including American Society of Anesthesiologists classification, type of hospital and health care region were retrieved. Linkage to the National Patient Register and Statistics Sweden provided information on liver resection and socioeconomic variables.

RESULTS

Synchronous CRLM was found in 4243/27,990 (15.2%) patients, of whom 1094 (25.8%) also had concurrent lung metastases. Of 3149 patients with liver-only metastases, 556 (17.8%) were subjected to liver resection. The resection rate varied by subsite; right-sided 11.7%, left-sided 19.7% and rectal cancer 22.7% (p = 0.001). It varied by type of hospital 14.1-23.6%, by region 11.5-22.7%, and was 19.8% in men and 14.9% in women (all p < 0.001). The adjusted odds were 0.74 (0.59-0.93) for females, 0.58 (0.46-0.74) for general district and 0.50 (0.37-0.68) for district hospital patients, and there were large regional differences. Patients >75 years were very unlikely to receive liver surgery 0.22 (0.15-0.32). In patients subjected to liver surgery, median survival was 57 months, 5-year survival rate was 45.4%, and those with left-sided colon cancer had the best outcome (48.8%; p = 0.02). Five-year hazard ratio for patients not subjected to liver surgery was 4.3 (3.7-5.0).

CONCLUSION

Nationwide outcome after resection of synchronous CRLM was impressing but ambiguous selection mechanisms and inaccessibility need to be resolved. The implications of subsite deserve further attention.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Socioeconomic disparity in survival after breast cancer in ireland: observational study

We evaluated the relationship between breast cancer survival and deprivation using data from the Irish National Cancer Registry. Cause-specific survival was compared between five area-based socioeconomic deprivation strata using Cox regression. Patient and tumour characteristics and treatment were compared using modified Poisson regression with robust variance estimation. Based on 21356 patients diagnosed 1999-2008, age-standardized five-year survival averaged 80% in the least deprived and 75% in the most deprived stratum. Age-adjusted mortality risk was 33% higher in the most deprived group (hazard ratio 1.33, 95% CI 1.21-1.45, P<0.001). The most deprived groups were more likely to present with advanced stage, high grade or hormone receptor-negative cancer, symptomatically, or with significant comorbidity, and to be smokers or unmarried, and less likely to have breast-conserving surgery. Cox modelling suggested that the available data on patient, tumour and treatment factors could account for only about half of the survival disparity (adjusted hazard ratio 1.18, 95% CI 0.97-1.43, P = 0.093). Survival disparity did not diminish over time, compared with the period 1994-1998. Persistent survival disparities among Irish breast cancer patients suggest unequal use of or access to services and highlight the need for further research to understand and remove the behavioural or other barriers involved.

Linking of primary care records to census data to study the association between socioeconomic status and cancer incidence in Southern Europe: a nation-wide ecological study

BACKGROUND

Area-based measures of economic deprivation are seldom applied to large medical records databases to establish population-scale associations between deprivation and disease.

OBJECTIVE

To study the association between deprivation and incidence of common cancer types in a Southern European region.

METHODS

Retrospective ecological study using the SIDIAP (Information System for the Development of Research in Primary Care) database of longitudinal electronic medical records for a representative population of Catalonia (Spain) and the MEDEA index based on urban socioeconomic indicators in the Spanish census. Study outcomes were incident cervical, breast, colorectal, prostate, and lung cancer in 2009-2012. The completeness of SIDIAP cancer recording was evaluated through linkage of a geographic data subset to a hospital cancer registry. Associations between MEDEA quintiles and cancer incidence was evaluated using zero-inflated Poisson regression adjusted for sex, age, smoking, alcoholism, obesity, hypertension, and diabetes.

RESULTS

SIDIAP sensitivity was 63% to 92% for the five cancers studied. There was direct association between deprivation and lung, colorectal, and cervical cancer: incidence rate ratios (IRR) 1.82 [1.64-2.01], IRR 1.60 [1.34-1.90], IRR 1.22 [1.07-1.38], respectively, comparing the most deprived to most affluent areas. In wealthy areas, prostate and breast cancers were more common: IRR 0.92 [0.80-1.00], IRR 0.91 [0.78-1.06]. Adjustment for confounders attenuated the association with lung cancer risk (fully adjusted IRR 1.16 [1.08-1.25]), reversed the direction of the association with colorectal cancer (IRR 0.90 [0.84-0.95]), and did not modify the associations with cervical (IRR 1.27 [1.11-1.45]), prostate (0.74 [0.69-0.80]), and breast (0.76 [0.71-0.81]) cancer.

CONCLUSIONS

Deprivation is associated differently with the occurrence of various cancer types. These results provide evidence that MEDEA is a useful, area-based deprivation index for analyses of the SIDIAP database. This information will be useful to improve screening programs, cancer prevention and management strategies, to reach patients more effectively, particularly in deprived urban areas.

Socioeconomic inequalities in cancer survival: a population-based study of adult patients diagnosed in Osaka, Japan, during the period 1993-2004

BACKGROUND

Long-term recession of the Japanese economy during the 1990s led to growing social inequalities whilst health inequalities also appeared. The 2007 National Cancer Control Program of Japan targeted "equalisation of cancer medical services", but the system to monitor health inequalities was still inadequate. We aimed to measure socioeconomic inequalities in cancer survival in Japan.

MATERIAL AND METHODS

We analysed 13 common invasive, primary, malignant tumours diagnosed from 1993 to 2004 and registered by the population-based Cancer Registry of Osaka Prefecture. An ecological socioeconomic deprivation index based on small area statistics, divided into quintile groups, was linked to patients according to their area of residence at the time of diagnosis. We estimated one-, five-year and conditional five-year net survival by sex, period of diagnosis (1993-1996/1997-2000/2001-2004) and deprivation group. Changes in survival over time, deprivation gap in survival, and change in deprivation gap were estimated at one and five years after diagnosis using variance-weighted least square regression.

RESULTS

The deprivation gap in one-year net survival was narrower than in five-year net survival and conditional five-year survival. During the study period, there was no change in deprivation gap, except for reductions for pancreas (men) and stomach (women), and an increase for lung (men) in one-year survival. We observed a linear association between level of survival and deprivation gap at five years and conditional five years, but no association at one-year survival.

CONCLUSION

A wide deprivation gap in survival was observed in most of the adult, solid, malignant tumours, within the universal healthcare system in Japan. Overall, cancer survival improved in Osaka without any widening of inequalities in cancer survival in 1993-2004, shortly after the long-term economic recession and deep modifications in the social and work environments in Japan. The longer term impact of the recession on inequalities in cancer survival needs to be monitored using population-based cancer registry data.

Unemployment, public-sector health-care spending and breast cancer mortality in the European Union: 1990-2009

BACKGROUND

The global economic crisis has been associated with increased unemployment, reduced health-care spending and adverse health outcomes. Insights into the impact of economic variations on cancer mortality, however, remain limited.

METHODS

We used multivariate regression analysis to assess how changes in unemployment and public-sector expenditure on health care (PSEH) varied with female breast cancer mortality in the 27 European Union member states from 1990 to 2009. We then determined how the association with unemployment was modified by PSEH. Country-specific differences in infrastructure and demographic structure were controlled for, and 1-, 3-, 5- and 10-year lag analyses were conducted. Several robustness checks were also implemented.

RESULTS

Unemployment was associated with an increase in breast cancer mortality [P < 0.0001, coefficient (R) = 0.1829, 95% confidence interval (CI) 0.0978-0.2680]. Lag analysis showed a continued increase in breast cancer mortality at 1, 3, 5 and 10 years after unemployment rises (P < 0.05). Controlling for PSEH removed this association (P = 0.063, R = 0.080, 95% CI -0.004 to 0.163). PSEH increases were associated with significant decreases in breast cancer mortality (P < 0.0001, R = -1.28, 95% CI -1.67 to -0.877). The association between unemployment and breast cancer mortality remained in all robustness checks.

CONCLUSION

Rises in unemployment are associated with significant short- and long-term increases in breast cancer mortality, while increases in PSEH are associated with reductions in breast cancer mortality. Initiatives that bolster employment and maintain total health-care expenditure may help minimize increases in breast cancer mortality during economic crises.

Influence of socioeconomic status on survival and clinical outcomes in patients with advanced gastric cancer after chemotherapy

BACKGROUND

Socioeconomic inequalities are known to influence the survival of cancer patients due to differences in treatment modalities and disease extent at diagnosis. However, there are few studies regarding the influence of socioeconomic status on patient survival, especially after palliative chemotherapy for advanced gastric cancer.

PATIENTS AND METHODS

This retrospective study was performed on 138 advanced gastric cancer patients who received palliative chemotherapy. Demographic, socioeconomic, and cancer-related variables were analyzed according to education level. Effects of socioeconomic factors and cancer-related variables on patient survival were also evaluated.

RESULTS

In our study, higher education level (> 6 years of schooling; p = 0.01), disease control (p < 0.01), and a greater number of chemotherapeutic agents (≥ 5 drugs; p < 0.01) were associated with a significant increase in median survival. Multivariate analysis showed that a higher education level (hazard ratio (HR) 0.53; 95% confidence interval (CI) 0.35-0.82; p < 0.01), disease control (HR 0.21; 95% CI 0.13-0.34), and total number of chemotherapeutic agents used (HR 0.44; 95% CI 0.26-0.73) were significantly associated with prolonged survival.

CONCLUSIONS

Among socioeconomic factors, only higher education level was associated with better survival. Increase in survival was also associated with clinical outcomes, including total number of chemotherapeutic agents used and disease control after chemotherapy.

Deprivation and access to treatment for colorectal cancer in Southeast Scotland 2003-2009

AIM

Socioeconomic deprivation is associated with poorer survival from colorectal cancer. We examined the association of deprivation with access to treatment, disease stage at presentation and choice of treatment for colorectal cancer within a regional managed clinical network.

METHOD

We performed a retrospective analysis of data from the Southeast Scotland Cancer Network colorectal database for the period 2003-2009. Socioeconomic status was assigned into five categories using postcode of residence and the Scottish Index of Multiple Deprivation score. Outcomes were access to consultation and treatment, stage of disease at presentation and treatment factors (type of surgery, adjuvant radiotherapy and adjuvant chemotherapy).

RESULTS

Of 4960 colorectal cancer patients, 4016 patients (81%) underwent operative treatment. Deprivation was not associated with age, gender, tumour site, disease stage, delay in treatment pathway or permanent stoma rate. Primary tumour resection (P = 0.006) and chemotherapy treatment (P = 0.018) were higher in the least deprived compared with the most deprived quintile. Socioeconomic status was associated with both primary tumour resection [odds ratio for the most affluent compared with the most deprived quintiles (OR) 1.34, 95% confidence interval (CI) 1.05-1.72, P = 0.018] and chemotherapy treatment (OR 1.44, 95% CI 1.15-1.80, P = 0.001). However, when health board of treatment was added to the model, only chemotherapy treatment was independently associated with deprivation (OR 1.46, 95% CI 1.16-1.83, P = 0.001).

CONCLUSION

Deprivation is not associated with treatment delay or more advanced disease stage at presentation. An apparent association between deprivation and treatment choice may be explained by other differences between patients treated in different areas.

[Perception of risk factors for cancer in the Spanish population]

OBJECTIVE

To analyze the perception of the Spanish population of risk factors for cancer.

METHODS

Data were extracted from the OncoBarometro 2010 survey. Multivariate logistic models were applied to analyze the perception of the population on the importance of various risk factors: smoking, alcohol, sun, food, weight, sexually transmitted diseases, family history, radiation exposure, exposure to toxic substances and air pollution. The answers were rated on a 0 to 10 scale and were converted to low (0-6) and high (7-10) categories. The measure of association used was the prevalence ratio (PR).

RESULTS

The greatest importance was assigned to smoking (high importance: 83.1%), whereas the least importance was assigned to weight (26.5%). In general, the probability of perceiving risk factors as important was lower among men (PR sun: 0.87; PR sexually transmitted diseases: 0.78) and increased among people who received professional advice on cancer prevention (PR alcohol: 1.11; PR sun: 1.18; PR food; 1.31; PR weight: 1.92). In particular, knowledge of symptoms and extreme fear of cancer were associated with perceiving smoking as an important risk factor, whereas a high perceived vulnerability to cancer was associated with perceiving exposure to toxic substances, pollution and smoking as important risk factors.

CONCLUSIONS

Greater awareness is required of the association of cancer with overweight and sexually transmitted diseases. The recommendations given by health professionals on cancer prevention are key to increasing the population's awareness of risk factors for cancer.

Geographic remoteness, area-level socioeconomic disadvantage and inequalities in colorectal cancer survival in Queensland: a multilevel analysis

Background

To explore the impact of geographical remoteness and area-level socioeconomic disadvantage on colorectal cancer (CRC) survival.

Methods

Multilevel logistic regression and Markov chain Monte Carlo simulations were used to analyze geographical variations in five-year all-cause and CRC-specific survival across 478 regions in Queensland Australia for 22,727 CRC cases aged 20–84 years diagnosed from 1997–2007.

Results

Area-level disadvantage and geographic remoteness were independently associated with CRC survival. After full multivariate adjustment (both levels), patients from remote (odds Ratio [OR]: 1.24, 95%CrI: 1.07-1.42) and more disadvantaged quintiles (OR = 1.12, 1.15, 1.20, 1.23 for Quintiles 4, 3, 2 and 1 respectively) had lower CRC-specific survival than major cities and least disadvantaged areas. Similar associations were found for all-cause survival. Area disadvantage accounted for a substantial amount of the all-cause variation between areas.

Conclusions

We have demonstrated that the area-level inequalities in survival of colorectal cancer patients cannot be explained by the measured individual-level characteristics of the patients or their cancer and remain after adjusting for cancer stage. Further research is urgently needed to clarify the factors that underlie the survival differences, including the importance of geographical differences in clinical management of CRC.

The association of waiting times from diagnosis to surgery with survival in women with localised breast cancer in England

BACKGROUND

Survival from breast cancer in the United Kingdom is lower than in other developed countries. It is unclear to what extent waiting times for curative surgery affect survival.

METHODS

Using national databases for England (cancer registries, Hospital Episode Statistics and Office of National Statistics), we identified 53 689 women with localised breast cancer, aged ≥ 15 years, diagnosed between 1996 and 2009, who had surgical resection with curative intent within 62 days of diagnosis. We used relative survival and excess risk modelling to determine associations between waiting times and 5-year survival.

RESULTS

The median diagnosis to curative surgery waiting time among breast cancer patients was 22 days (interquartile range (IQR): 15-30). Relative survival was similar among women waiting between 25 and 38 days (RS: 93.5%; 95% CI: 92.8-94.2%), <25 days (RS: 93.0%; 95% CI: 92.5-93.4%) and between 39 and 62 days (RS: 92.1%; 95% CI: 90.8-93.4%). There was little evidence of an increase in excess mortality with longer waiting times (excess hazard ratio (EHR): 1.06; 95% CI: 0.88-1.27 comparing waiting times 39-62 with 25-38 days). Excess mortality was associated with age (EHR 65-74 vs 15-44 year olds: 1.23; 95% CI: 1.07-1.41) and deprivation (EHR most vs least deprived: 1.28; 95% CI: 1.09-1.49), but waiting times did not explain these differences.

CONCLUSION

Within 62 days of diagnosis, decreasing waiting times from diagnosis to surgery had little impact on survival from localised breast cancer.

How much of the deprivation gap in cancer survival can be explained by variation in stage at diagnosis: an example from breast cancer in the East of England

Socioeconomic differences in cancer patient survival exist in many countries and across cancer sites. In our article, we estimated the number of deaths in women with breast cancer that could be avoided within 5 years from diagnosis if it were possible to eliminate socioeconomic differences in stage at diagnosis. We analysed data on East of England women with breast cancer (2006-2010). We estimated survival for different stage-age-deprivation strata using both the observed and a hypothetical stage distribution (assuming all women acquired the stage distribution of the most affluent women). Data were analysed on 20,738 women with complete stage information (92%). Affluent women were less likely to be diagnosed in advanced stage. Relative survival decreased with increasing level of deprivation. Eliminating differences in stage at diagnosis could be expected to nearly eliminate differences in relative survival for women in deprivation groups 3 and 4, but would only approximately halve the difference in relative survival for women in the most deprived group (5). This means, for a typical cohort of women diagnosed in a calendar year with breast cancer, eliminating deprivation differences in stage at diagnosis would prevent ∼40 deaths in the East of England from occurring within 5 years from diagnosis. Using appropriate weighting we estimated the respective number of avoidable deaths for the whole of England to be ∼450. The findings suggest that policies aimed at reducing inequalities in stage at diagnosis between women with breast cancer are important to reduce inequalities in breast cancer survival.

Citations of scientific results and conflicts of interest: the case of mammography screening

Introduction

In 2001, a Cochrane review of mammography screening questioned whether screening reduces breast cancer mortality, and a more comprehensive review in Lancet, also in 2001, reported considerable overdiagnosis and overtreatment. This led to a heated debate and a recent review of the evidence by UK experts intended to be independent.

Objective

To explore if general medical and specialty journals differed in accepting the results and methods of three Cochrane reviews on mammography screening.

Methods

We identified articles citing the Lancet review from 2001 or updated versions of the Cochrane review (last search 20 April 2012). We explored which results were quoted, whether the methods and results were accepted (explicit agreement or quoted without caveats), differences between general and specialty journals, and change over time.

Results

We included 171 articles. The results for overdiagnosis were not quoted in 87% (148/171) of included articles and the results for breast cancer mortality were not quoted in 53% (91/171) of articles. 11% (7/63) of articles in general medical journals accepted the results for overdiagnosis compared with 3% (3/108) in specialty journals (p=0.05). 14% (9/63) of articles in general medical journals accepted the methods of the review compared with 1% (1/108) in specialty journals (p=0.001). Specialty journals were more likely to explicitly reject the estimated effect on breast cancer mortality 26% (28/108), compared with 8% (5/63) in general medical journals, p=0.02.

Conclusions

Articles in specialty journals were more likely to explicitly reject results from the Cochrane reviews, and less likely to accept the results and methods, than articles in general medical journals. Several specialty journals are published by interest groups and some authors have vested interests in mammography screening.

Interventions to increase the uptake of mammography amongst low income women: a systematic review and meta-analysis

Background

Two previous reviews found that access-enhancing interventions were effective in increasing mammography uptake amongst low-income women. The purpose of this study was to estimate the magnitude of the effect of interventions used to increase uptake of mammography amongst low-income women.

Methods

Searches were conducted in MEDLINE and EMBASE (2002–April 2012) using relevant MeSH terms and keywords. Randomised controlled trials which aimed to increase mammography use in an asymptomatic low-income population and which had as an outcome receipt of a mammogram, were eligible for inclusion. The primary outcome was the post-intervention difference in the proportion of women who had a mammogram in the intervention and control groups. The quality of the studies was assessed using the Cochrane risk of bias tool. We calculated summary estimates using random effects meta-analyses. Possible reasons for heterogeneity were investigated using sub-group analyses and meta-regression. Publication bias was assessed using Egger's test.

Results

Twenty-one studies met the inclusion criteria, including 33 comparisons. Interventions increased the uptake of mammography in low income women by an additional 8.9% (95% CI 7.3 to 10.4%) compared to the control group. There was some evidence that interventions with multiple strategies were more effective than those with single strategies (p  = 0.03). There was some suggestion of publication bias. The quality of the included studies was often unclear. Omitting those with high risk of bias has little effect on the results.

Conclusions

Interventions can increase mammography uptake among low-income women, multiple interventions being the most effective strategy. Given the robustness of the results to sensitivity analyses, the results are likely to be reliable. The generalisability of the results beyond the US is unclear.

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

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

Comparing cancer mortality and GDP health expenditure in England and Wales with other major developed countries from 1979 to 2006

Background:

Cancer and gross-domestic-product on health expenditure (GDPHE) are critical issues for major developed countries (MDC). Each country's economic input, GDPHE 1980–2005 is contrasted with clinical outputs, cancer mortality rates (CMRs), to compare their efficiency and effectiveness in reducing CMR.

Methods:

World Health Organization's CMR data for baseline years (1979–1981) are compared with 2004–2006 by sex and age. The χ²-tests are used to determine differences between MDC. Efficiency is analysed by calculating a ratio of average GDPHE to reduced CMR over the period.

Results:

Inputs: All the countries GDPHE grew substantially. For the United Kingdom this reached 9.3%, which is below the MDC average (10%). Outputs: CMR fell substantially (>20%) in six of the ten countries. The male average (15–74 years) CMR in England and Wales had been third highest but by 2004–2006 was sixth, a 31% reduction, which was significantly greater than seven other countries. Initially England and Wales female average CMR was the highest of all countries and is now the second highest. There were significantly greater reductions for the 55–64 and 65–74 years old than in seven and four countries, respectively. GDPHE reduced CMR ratios – the average GDPHE:reduced CMR ratio of England and Wales was 1 : 120, greater than all MDC and double that in four countries.

Conclusion:

Comparing GDPHE input with CMR output showed that relatively the NHS achieved more with proportionately less than other MDC.