The role of smoking and diet in explaining educational inequalities in lung cancer incidence

Exploring the contribution of lifestyle to the impact of education on the risk of cancer through Mendelian randomization analysis

Educational attainment (EA) has been linked to the risk of several types of cancer, despite having no expected direct biological connection. In this paper, we investigate the mediating role of alcohol consumption, smoking, vegetable consumption, fruit consumption and body mass index (BMI) in explaining the effect of EA on 7 cancer groupings. Large-scale genome wide association study (GWAS) results were used to construct the genetic instrument for EA and the lifestyle factors. We conducted GWAS in the UK Biobank sample in up to 335,024 individuals to obtain genetic association data for the cancer outcomes. Univariable and multivariable two-sample Mendelian randomization (MR) analyses and mediation analyses were then conducted to explore the causal effect and mediating proportions of these relations. MR mediation analysis revealed that reduced lifetime smoking index accounted for 81.7% (49.1% to 100%) of the protective effect of higher EA on lower respiratory cancer. Moreover, the effect of higher EA on lower respiratory cancer was mediated through vegetable consumption by 10.2% (4.4% to 15.9%). We found genetic evidence that the effect of EA on groups of cancer is due to behavioural changes in avoiding well established risk factors such as smoking and vegetable consuming.

[Prevention, Diagnosis, Therapy, and Follow-up of Lung Cancer - Interdisciplinary Guideline of the German Respiratory Society and the German Cancer Society - Abridged Version]

The current S3 Lung Cancer Guidelines are edited with fundamental changes to the previous edition based on the dynamic influx of information to this field:The recommendations include de novo a mandatory case presentation for all patients with lung cancer in a multidisciplinary tumor board before initiation of treatment, furthermore CT-Screening for asymptomatic patients at risk (after federal approval), recommendations for incidental lung nodule management , molecular testing of all NSCLC independent of subtypes, EGFR-mutations in resectable early stage lung cancer in relapsed or recurrent disease, adjuvant TKI-therapy in the presence of common EGFR-mutations, adjuvant consolidation treatment with checkpoint inhibitors in resected lung cancer with PD-L1 ≥ 50%, obligatory evaluation of PD-L1-status, consolidation treatment with checkpoint inhibition after radiochemotherapy in patients with PD-L1-pos. tumor, adjuvant consolidation treatment with checkpoint inhibition in patients withPD-L1 ≥ 50% stage IIIA and treatment options in PD-L1 ≥ 50% tumors independent of PD-L1status and targeted therapy and treatment option immune chemotherapy in first line SCLC patients.Based on the current dynamic status of information in this field and the turnaround time required to implement new options, a transformation to a "living guideline" was proposed.

[Differences due to socio-economic status, genetic background and sex in cancer and precision medicine - An intersectional approach to close the care gap for marginalized groups]

Malignant tumor diseases constitute the 2^nd most common cause of death and due to our extended life expectancy cancer per se has substantially increased, being highly prevalent after cardiovascular diseases. Evidence also generated from the COVID-19 pandemic, that defined gender differences exist in symptom and disease courses, and have advocated the need to assess gender, ethnic/racial and minority differences in cancer care and treatment more meticulously. It is becoming increasingly evident that in novel cancer care/precision oncology, representation of minorities, elderly and frail patients in clinical trials remains largely unbalanced, thus distribution of cancer success is iniquitous. This article focusses on these aspects and suggests solutions, how this can be improved.

Mediating Role of Lifestyle Behaviors in the Association between Education and Cancer: Results from the European Prospective Investigation into Cancer and Nutrition

BACKGROUND

Many studies have shown that socioeconomic position (SEP) is associated with the incidence of malignant tumors at different sites. This study aims to estimate the association between educational level (as proxy for SEP) and cancer incidence and to understand whether the observed associations might be partially explained by lifestyle behaviors.

METHODS

The analyses were performed on data from the European Prospective Investigation into Cancer and Nutrition (EPIC) study, globally and by sex. We used Cox proportional hazards models together with mediation analysis to disentangle the total effect (TE) of educational level [measured through the Relative Index of Inequality (RII)] on cancer incidence into pure direct (PDE) and total indirect (TIE) effect, unexplained and explained by mediators, respectively. PDE and TIE were then combined to compute the proportions mediated (PM).

RESULTS

After an average of 14 years of follow-up, 52,422 malignant tumors were ascertained. Low educated participants showed higher risk of developing stomach, lung, kidney (in women), and bladder (in men) cancers, and, conversely, lower risk of melanoma and breast cancer (in post-menopausal women), when compared with more educated participants. Mediation analyses showed that portions of the TE of RII on cancer could be explained by site-specific related lifestyle behaviors for stomach, lung, and breast (in women).

CONCLUSIONS

Cancer incidence in Europe is determined at least in part by a socioeconomically stratified distribution of risk factors.

IMPACT

These observational findings support policies to reduce cancer occurrence by altering mediators, such as lifestyle behaviors, particularly focusing on underprivileged strata of the population.

20th Century Puerto Rico and Later-Life Health: The Association Between Multigenerational Education and Chronic Conditions in Island-Dwelling Older Adults

OBJECTIVES

Previous research on the association between education and older adult health in the U.S. has not included Puerto Rico. We investigated the effects of multigenerational educational attainment and chronic conditions among older Puerto Ricans residing on the archipelago's main island.

METHODS

Data were from the longitudinal Puerto Rican Elderly Health Conditions Project. Generalized Poisson regression models were used to examine if multigenerational educational attainment was associated with chronic disease.

RESULTS

Findings show that parental educational attainment was associated with fewer chronic conditions among females at baseline but not at follow-up, suggesting that the effects of parental education on health over time are less pronounced. For males, educational attainment across the three generations was not significantly associated with chronic disease at baseline or follow-up.

DISCUSSION

Multigenerational education is an important determinant of older adult health that continues to be relevant in Puerto Rico and the Latin American and Hispanic-Caribbean region.

Construction and case study of a novel lung cancer risk index

PURPOSE

This study constructs a lung cancer risk index (LCRI) that incorporates many modifiable risk factors using an easily reproducible and adaptable method that relies on publicly available data.

METHODS

We used meta-analysis followed by Analytic Hierarchy Process (AHP) to generate a lung cancer risk index (LCRI) that incorporates seven modifiable risk factors (active smoking, indoor air pollution, occupational exposure, alcohol consumption, secondhand smoke exposure, outdoor air pollution, and radon exposure) for lung cancer. Using county-level population data, we then performed a case study in which we tailored the LCRI for use in the state of Illinois (LCRI_IL).

RESULTS

For both the LCRI and the LCRI_IL, active smoking had the highest weights (46.1% and 70%, respectively), whereas radon had the lowest weights (3.0% and 5.7%, respectively). The weights for alcohol consumption were 7.8% and 14.7% for the LCRI and the LCRI_IL, respectively, and were 3.8% and 0.95% for outdoor air pollution. Three variables were only included in the LCRI: indoor air pollution (18.5%), occupational exposure (13.2%), and secondhand smoke exposure (7.6%). The Consistency Ratio (CR) was well below the 0.1 cut point. The LCRI_IL was moderate though significantly correlated with age-adjusted lung cancer incidence (r = 0.449, P < 0.05) and mortality rates (r = 0.495, P < 0.05).

CONCLUSION

This study presents an index that incorporates multiple modifiable risk factors for lung cancer into one composite score. Since the LCRI allows data comprising the composite score to vary based on the location of interest, this measurement tool can be used for any geographic location where population-based data for individual risk factors exist. Researchers, policymakers, and public health professionals may utilize this framework to determine areas that are most in need of lung cancer-related interventions and resources.

Sozioökonomische Benachteiligung als Risikofaktor für Krebserkrankungen – „closing the care gap“

Armut ist ein Risikofaktor für Krebs. Menschen aus sozioökonomisch benachteiligten Gesellschaftsschichten erkranken häufiger und früher an Krebs, haben nach Diagnosestellung oftmals eine kürzere Lebenserwartung und profitieren hinsichtlich des Gesamtüberlebens weniger von der Therapie. Diese Beobachtung hat sich im Zuge der COVID-19-Pandemie weiter verschärft. Im vorliegenden Beitrag stellen wir zusammengefasst Ergebnisse für Deutschland dar, die diesen Zusammenhang illustrieren. Methodisch greifen wir dazu auf Erkenntnisse zurück, die sich auf individuelle Marker wie das individuelle Einkommen oder auf regionale Indizes sozialer Deprivation wie den German Index of Multiple Deprivation (GIMD) konzentrieren. Das Konzept der Klassenmedizin hinterfragt strukturelle Bedingungen, die dazu führen, dass das Versorgungssystem und die Behandler*innen selbst bestehende Unterschiede weiter fördern, anstatt diese auszugleichen. Faktoren der Ungleichheit in der Versorgung von Menschen gerade mit onkologischen Erkrankungen, seien sie sozioökonomischer, geschlechtsspezifischer oder ethnischer Art, müssen besser erfasst werden, um eine gerechte und gleichwertige Behandlung aller Menschen zu gewährleisten.

Fish Intake, Dietary Polyunsaturated Fatty Acids, and Lung Cancer: Systematic Review and Dose-Response Meta-Analysis of 1.7 Million Men and Women

To determine the association between fish intake and dietary polyunsaturated fatty acids (PUFA) and incidence of lung cancer. We systematically reviewed and meta-analyzed all available studies to quantify the associations of fish and PUFA consumption with risk of lung cancer. Relative risk (RR) with 95% confidence interval (CI) was calculated. 13 population-based prospective cohort studies involving 1,785,000 participants and two randomized control trials were included. Our study demonstrated that dietary PUFA significant reduced risk of lung cancer for men (RR 0.99, 95%CI 0.98 to 1.00) and the U.S. population (RR 0.99, 95%CI 0.98 to 1.00). Dose-response analysis indicated that a 5 g/day increment of dietary PUFA was associated with 5% lower risk of lung cancer (RR 0.95, 95%CI 0.91 to 0.99). In addition, PUFA supplementation is significant improved overall survival in patients with lung cancer (RR 1.98, 95%CI 1.09 to 3.59). Our study showed an inverse association between dietary PUFA and risk of lung cancer in males and among the U.S. population. Although smoking cessation is the single biggest factor associated with lung cancer risk reduction, this study adds to a growing body of evidence that diet may have a role in modestly reducing lung cancer risk.

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

INTRODUCTION

Several studies have shown an association between socioeconomic status and incidence of cancer. In this study, we have examined the association between socioeconomic factors, using income and education as proxies, and cancer incidence in Norway, a country known to be egalitarian, with universal access to health care and scoring high on the human development index.

METHODS

We linked individual data for the total Norwegian population with information on all cancer patients registered in the Cancer Registry of Norway (CRN) with any cancer diagnosed between 2012 and 2016. Data on education, and individual income, were provided from Statistics Norway. We used Poisson regression to obtain incidence rate ratios (IRR) across education and income levels for 23 cancer sites.

RESULTS

A total of 9 cancers among men and 13 cancers among women were observed to have significantly higher incidence rates in cases with the lowest level of education. Melanoma for both sexes, testis and prostate cancer in men, and breast cancer in women were found to have a higher incidence rate among those with the highest level of education. The largest differences in IRR were found for lung cancer, where men and women with college or university education as their highest completed education had a two- to threefold decreased risk, compared to those with primary school (IRR men; 0.40 [0.37-0.43], women 0.34 [0.31-0.37]). The results for income mirrored the results for education among men, while for women we did not observe many differences in cancer risk across income groups.

CONCLUSION

Our findings were consistent with findings from other studies showing that the incidence rate of cancer differs across levels of socioeconomic status. We may need behavioral change campaigns focused on lifestyle changes that lower the risk of cancer and target perhaps to those with lower socioeconomic status.

Social inequalities in tobacco-attributable mortality in Spain. The intersection between age, sex and educational level

INTRODUCTION

First study of social inequalities in tobacco-attributable mortality (TAM) in Spain considering the joint influence of sex, age, and education (intersectional perspective).

METHODS

Data on all deaths due to cancer, cardiometabolic and respiratory diseases among people aged ≥35 years in 2016 were obtained from the Spanish Statistical Office. TAM was calculated based on sex-, age- and education-specific smoking prevalence, and on sex-, age- and disease-specific relative risks of death for former and current smokers vs lifetime non-smokers. As inequality measures, the relative index of inequality (RII) and the slope index of inequality (SII) were calculated using Poisson regression. The RII is interpreted as the relative risk of mortality between the lowest and the highest educational level, and the SII as the absolute difference in mortality.

RESULTS

The crude TAM rate was 55 and 334 per 100,000 in women and men, respectively. Half of these deaths occurred among people with the lowest educational level (27% of the population). The RII for total mortality was 0.39 (95%CI: 0.35-0.42) in women and 1.61 (95%CI: 1.55-1.67) in men. The SII was -41 and 111 deaths per 100,000, respectively. Less-educated women aged <55 years and men (all ages) showed an increased mortality risk; nonetheless, less educated women aged ≥55 had a reduced risk.

CONCLUSIONS

TAM is inversely associated with educational level in men and younger women, and directly associated with education in older women. This could be explained by different smoking patterns. Appropriate tobacco control policies should aim to reduce social inequalities in TAM.

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

Background

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

Materials and methods

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

Results

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

Conclusions

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

Dietary Research on Coffee: Improving Adjustment for Confounding

Meta-analyses have reported higher levels of coffee consumption to be associated with lower mortality. In contrast, some systematic reviews have linked coffee consumption to increased risks for lung cancer and hypertension. Given these inconsistencies, this narrative review critically evaluated the methods and analyses of cohort studies investigating coffee and mortality. A specific focus was adjustment for confounding related to smoking, healthy and unhealthy foods, and alcohol. Assessment of 36 cohort samples showed that many did not adequately adjust for smoking. Consuming 1-5 cups of coffee per day was related to lower mortality among never smokers, in studies that adjusted for pack-years of smoking, and in studies adjusting for healthy and unhealthy foods. Possible reduced health benefits for coffee with added sugar have not been adequately investigated. Research on coffee and health should report separate analyses for never smokers, adjust for consumption of healthy and unhealthy foods, and for sugar added to coffee.

Diagnostic value of CA-153 and CYFRA 21-1 in predicting intraocular metastasis in patients with metastatic lung cancer

Lung cancer is prone to metastasis to various organs. Although intraocular metastasis (IOM) occurs at a later stage than metastasis to other organs, it often adversely affects the quality of life and suggests a poor prognosis. In this study, we selected 1608 patients with lung cancer who had metastasis to at least one site and explored clinical differences between those with IOM and non‐IOM (NIOM). An independent t test and chi‐squared test were used to analyze the clinical features of the patients. The statistically significant parameters were analyzed by binary logistic regression to determine the risk factors for IOM. A receiver operating characteristic curve was constructed to assess their diagnostic value in IOM. The results showed that no significant differences were noted in age, gender, and pathological type between the IOM and NIOM groups. However, the IOM group had higher levels of alpha‐fetoprotein, carcinoembryonic antigen, cancer antigen (CA)‐125, CA‐153, cytokeratin fragment 19 (CYFRA 21‐1), and total prostate‐specific antigen, compared with the NIOM group. Binary logistic regression indicated that CA‐153 and CYFRA 21‐1 were risk factors for IOM in patients with MLC (P < 0.05). Area under the curve of CA‐153, CYFRA 21‐1 and their combination were 0.791, 0.860, and 0.872 respectively. The cutoff values for CA‐153 and CYFRA 21‐1 were 22.2 U/mL and 6.785 ng/mL. In conclusion, both CA‐153 and CYFRA 21‐1 were independent risk factors for IOM in patients with metastatic lung cancer (MLC), whereas the combination of CA‐153 and CYFRA 21‐1 assessment yields the most value in the detection of IOM in patients with MLC.

Socioeconomic Inequalities in Total and Site-Specific Cancer Incidence in Germany: A Population-Based Registry Study

Most chronic diseases follow a socioeconomic gradient with higher rates in lower socioeconomic groups. A growing body of research, however, reveals cancer to be a disease group with very diverse socioeconomic patterning, even demonstrating reverse socioeconomic gradients for certain cancers. To investigate this matter at the German national level for the first time, this study examined socioeconomic inequalities in cancer incidence in Germany, both for all cancers combined as well as for common site-specific cancers. Population-based data on primary cancers newly diagnosed in 2010-2013 was obtained from the German Centre for Cancer Registry Data. Socioeconomic position was assessed at the district level using the German Index of Socioeconomic Deprivation, which is a composite index of area-based socioeconomic indicators. Absolute and relative socioeconomic inequalities in total and site-specific cancer incidence were analyzed using multilevel Poisson regression models with the logarithm of the number of residents as an offset. Among men, socioeconomic inequalities in cancer incidence with higher rates in more deprived districts were found for all cancers combined and various site-specific cancers, most pronounced for cancers of the lung, oral and upper respiratory tract, stomach, kidney, and bladder. Among women, higher rates in more deprived districts were evident for kidney, bladder, stomach, cervical, and liver cancer as well as for lymphoid/hematopoietic neoplasms, but no inequalities were evident for all cancers combined. Reverse gradients with higher rates in less deprived districts were found for malignant melanoma and thyroid cancer in both sexes, and in women additionally for female breast and ovarian cancer. Whereas in men the vast majority of all incident cancers occurred at cancer sites showing higher incidence rates in more deprived districts and cancers with a reverse socioeconomic gradient were in a clear minority, the situation was more balanced for women. This is the first national study from Germany examining socioeconomic inequalities in total and site-specific cancer incidence. The findings demonstrate that the socioeconomic patterning of cancer is diverse and follows different directions depending on the cancer site. The area-based cancer inequalities found suggest potentials for population-based cancer prevention and can help develop local strategies for cancer prevention and control.

Tobacco-attributable burden of cancer according to socioeconomic position in France

Smoking is a major preventable cause of cancers and is increasingly concentrated among the most deprived individuals leading to increasing socioeconomic inequalities in the incidence of cancers linked to smoking. We aimed to estimate the tobacco-attributable cancer burden according to socioeconomic position in France. The analysis was restricted to cancer sites for which tobacco smoking was recognized as a risk factor. Cancer cases by sex, age group and European Deprivation Index (EDI) among people aged 30-74 between 2006 and 2009 were obtained from cancer registries covering ∼20% of the French population. The tobacco-attributable burden of cancer according to EDI was estimated applying the population attributable fraction (PAF) computed with the Peto-Lopez method. The PAF increased from 56% in the least deprived EDI quintile to 70% in the most deprived EDI quintile among men and from 26% to 38% among women. In total, 28% of the excess cancer cases in the four most deprived EDI quintiles in men and 43% in women could be prevented if smoking in these 4 EDI quintiles was similar to that of the least deprived EDI quintile. A substantial smoking-attributable burden of cancer by socioeconomic position was observed in France. The results highlight the need for policies reducing tobacco consumption. More comprehensive interventions integrating the various dimensions of health determinants and proportionate according to socioeconomic position may essentially contribute to the reduction of socioeconomic inequalities in cancer.

Socioeconomic Correlates and Determinants of Cardiorespiratory Fitness in the General Adult Population: a Systematic Review and Meta-Analysis

BACKGROUND

This review aims to (1) consolidate evidence regarding the association between socioeconomic status (SES) and cardiorespiratory fitness (CRF), (2) conduct a meta-analysis of the association between SES and CRF using methodologically comparable data, stratified by sex, and (3) test whether the association varies after adjustment for physical activity (PA).

METHODS

A systematic review of studies from MEDLINE, EMBASE, Latin American and Caribbean Health Sciences (LILACS), Scientific Electronic Library Online (ScIELO), and Cochrane Library without time or language restrictions, which investigated associations between SES and CRF. Risk of bias within studies was assessed using a customized quality assessment tool. Results were summarized in table format and methodologically similar studies were synthesized using meta-analysis of Hedges' g effect sizes. Synthesized results were appraised for cross-study bias. Results were tested for the impact of PA adjustment using meta-regression.

RESULTS

Compared to individuals with low education, both men and women showed higher CRF among individuals with high education (men 0.12 [0.04-0.20], women 0.19 [0.02-0.36]), while participants with medium education showed no significant difference in CRF (men 0.03 [- 0.04-0.11], women 0.09 [- 0.03-0.21]). Adjustment for PA did not significantly impact the association between education and CRF.

CONCLUSIONS

There is fair evidence for an association between high levels of education and increased CRF. This could have implications for monitoring, of health target compliance and of chronic disease risk among higher risk populations, to detect and prevent non-communicable diseases (NCDs) and to diminish social health inequalities.

TRIAL REGISTRATION

PROSPERO, CRD42017055456.

Lung cancer and socioeconomic status in a pooled analysis of case-control studies

BACKGROUND

An association between low socioeconomic status (SES) and lung cancer has been observed in several studies, but often without adequate control for smoking behavior. We studied the association between lung cancer and occupationally derived SES, using data from the international pooled SYNERGY study.

METHODS

Twelve case-control studies from Europe and Canada were included in the analysis. Based on occupational histories of study participants we measured SES using the International Socio-Economic Index of Occupational Status (ISEI) and the European Socio-economic Classification (ESeC). We divided the ISEI range into categories, using various criteria. Stratifying by gender, we calculated odds ratios (OR) and 95% confidence intervals (CI) by unconditional logistic regression, adjusting for age, study, and smoking behavior. We conducted analyses by histological subtypes of lung cancer and subgroup analyses by study region, birth cohort, education and occupational exposure to known lung carcinogens.

RESULTS

The analysis dataset included 17,021 cases and 20,885 controls. There was a strong elevated OR between lung cancer and low SES, which was attenuated substantially after adjustment for smoking, however a social gradient persisted. SES differences in lung cancer risk were higher among men (lowest vs. highest SES category: ISEI OR 1.84 (95% CI 1.61-2.09); ESeC OR 1.53 (95% CI 1.44-1.63)), than among women (lowest vs. highest SES category: ISEI OR 1.54 (95% CI 1.20-1.98); ESeC OR 1.34 (95% CI 1.19-1.52)).

CONCLUSION

SES remained a risk factor for lung cancer after adjustment for smoking behavior.

Occupational prestige trajectory and the risk of lung and head and neck cancer among men and women in France

OBJECTIVES

This study aimed at investigating the associations between occupational prestige trajectories and lung and head and neck (HN) cancer risk and to assess to what extent smoking, alcohol drinking, and occupational exposures contribute to these associations.

METHODS

Using data from the ICARE case-control study (controls (2676 men/715 women), lung cancers (2019 men/558 women), HN cancers (1793 men/305 women), we defined occupational prestige trajectories using group-based modeling of longitudinal data. We conducted logistic regression models.

RESULTS

Among men, a gradient was observed from the downward "low to very low" trajectory to the stable very high trajectory. The associations were reduced when adjusting for tobacco and alcohol consumption and occupational exposures. Among women, when compared to the stable high trajectory, there was an increased cancer risk in all trajectories. The associations remained globally unchanged or even increased after adjustment for tobacco and alcohol consumption and did not change when adjusting for occupational exposures. The ORs were smaller for lung than for HN cancers in men.

CONCLUSIONS

Occupational prestige trajectory is strongly associated with lung and HN cancer risk in men and women.

Socioeconomic position and mortality risk of smoking: evidence from the English Longitudinal Study of Ageing (ELSA)

Background

It is not clear whether the harm associated with smoking differs by socioeconomic status. This study tests the hypothesis that smoking confers a greater mortality risk for individuals in low socioeconomic groups, using a cohort of 18 479 adults drawn from the English Longitudinal Study of Ageing. Methods:- Additive hazards models were used to estimate the absolute smoking-related risk of death due to lung cancer or Chronic Obstructive Pulmonary Disease (COPD). Smoking was measured using a continuous index that incorporated the duration of smoking, intensity of smoking and the time since cessation. Attributable death rates were reported for different levels of education, occupational class, income and wealth.

Results

Smoking was associated with higher absolute mortality risk in lower socioeconomic groups for all four socioeconomic indicators. For example, smoking 20 cigarettes per day for 40 years was associated with 898 (95% CI 738, 1058) deaths due to lung cancer or COPD per 100 000 person-years among participants in the bottom income tertile, compared to 327 (95% CI 209, 445) among participants in the top tertile.

Conclusions

Smoking is associated with greater absolute mortality risk for individuals in lower socioeconomic groups. This suggests greater public health benefits of smoking prevention or cessation in these groups.

Changing smoking-mortality association over time and across social groups: National census-mortality cohort studies from 1981 to 2011

The difference in mortality between current and never-smokers varies over time, affecting future projections of health gains from tobacco control. We examine this heterogeneity by sex, ethnicity and cause of death on absolute and relative scales using New Zealand census data. These data included smoking status, and were linked to subsequent mortality records in 1981-84, 1996-99 and 2006-11 for 25-74 year olds (16.1 million person-years of follow-up). Age-standardised mortality rates and rate differences (SRDs) were calculated comparing current to never-smokers, and Poisson regression was used to adjust for multiple socioeconomic factors and household smoking. We found that mortality declined over time in never-smokers; however, mortality trends in current-smokers varied by sex, ethnicity and cause of death. SRDs were stable over time in European/Other men, moderately widened in European/Other women and markedly increased in Māori men and women (Indigenous population). Poisson smoking-mortality rate ratios (RRs) increased from 1981-84 to 1996-99 with a moderate increase from 1996-99 to 2006-11 (RRs 1.48, 1.77, 1.79 in men and 1.51, 1.80, 1.90 in women). Socioeconomic confounding increased over time. In summary, this marked heterogeneity in smoking-mortality RRs over time has implications for estimating the future health and inequality impacts of tobacco control interventions.

Lung cancer incidence trends in California by race/ethnicity, histology, sex, and neighborhood socioeconomic status: An analysis spanning 28 years

OBJECTIVES

Lung cancer incidence trends by histology, sex, race/ethnicity, and neighborhood socioeconomic status (nSES) have not been previously reported. We conducted a population-based study of lung cancer incidence over three peri-censal periods: 1988-1992, 1998-2002, and 2008-2012.

MATERIALS AND METHODS

We abstracted lung cancer cases from the California Cancer Registry and used US Census and American Community Survey data to develop multidimensional nSES indices for each census period. We calculated nSES tertile-specific incidence rates and rate ratios for each peri-censal period and used incidence rate ratios (IRR) to assess changes in rates from 1988 to 1992 to 1998-2002 and 2008-2012.

RESULTS

There were a total of 231,205 lung cancer cases. Males: Among males, incidence rates of lung cancer decreased over time, all race/ethnicities, and all nSES tertiles, with larger declines among males in higher nSES areas. Rates either declined or were stable for adenocarcinoma, with larger declines for other histologic subtypes. Females: Among females, declines in incidence rates of lung cancer were more pronounced for females in higher nSES areas, but diverged more so than for males, with variations by histology and race/ethnicity. Incidence rates of adenocarcinoma increased over time among all females, with greater increase among females in low nSES areas.

CONCLUSIONS

Our findings demonstrate differences in incidence trends over three decades by histology, gender, race/ethnicity, and nSES. While incidence rates consistently declined over time for males, there were greater declines in incidence for high nSES populations. In contrast, among females, there was evidence of increases in lung cancer incidence among low SES API females, and for adenocarcinoma.

Everyday tactics in local moral worlds: E-cigarette practices in a working-class area of the UK

Research into e-cigarette use has largely focused on their health effects and efficacy for smoking cessation, with little attention given to their potential effect on health inequalities. Drawing on three years of ethnographic research between 2012 and 2015, I investigate the emerging e-cigarette practices of adult smokers and quitters in a working-class area of the UK. I first use de Certeau's notion of ‘tactics’ to describe the informal economy of local e-cigarette use. Low-priced products were purchased through personal networks and informal sources for financial reasons, but also as a solution to the moral problems of addiction and expenditure on the self, particularly for older smokers. E-cigarette practices were produced in local moral worlds where smoking and cessation had a complex status mediated through norms of age and gender. For younger men, smoking cessation conflicted with an ethic of working-class hedonism but e-cigarette use allowed cessation to be incorporated into male sociality. Continued addiction had moral implications which older men addressed by constructing e-cigarette use as functional rather than pleasurable, drawing on a narrative of family responsibility. The low priority which older women with a relational sense of identity gave to their own health led to a lower tolerance for e-cigarette unreliability. I draw on Kleinman's local moral worlds to make sense of these findings, arguing that smoking cessation can be a risk to moral identity in violating local norms of age and gender performance. I conclude that e-cigarettes did have some potential to overcome normative barriers to smoking cessation and therefore to reduce health inequalities, at least in relation to male smoking. Further research which attends to local meanings of cessation in relation to age and gender will establish whether e-cigarettes have similar potential elsewhere.

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Smokers and e-cigarette users bought cheap products for moral and financial reasons.

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Smoking cessation conflicted with an ethic of hedonism but e-cigarettes did not.

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Older men saw e-cigarette use as functional in a narrative of family responsibility.

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Older women gave their health low priority and found e-cigarettes too much trouble.

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E-cigarettes had potential to overcome some normative barriers to smoking cessation.

Anthropometry and the Risk of Lung Cancer in EPIC

The associations of body mass index (BMI) and other anthropometric measurements with lung cancer were examined in 348,108 participants in the European Investigation Into Cancer and Nutrition (EPIC) between 1992 and 2010. The study population included 2,400 case patients with incident lung cancer, and the average length of follow-up was 11 years. Hazard ratios were calculated using Cox proportional hazard models in which we modeled smoking variables with cubic splines. Overall, there was a significant inverse association between BMI (weight (kg)/height (m)(2)) and the risk of lung cancer after adjustment for smoking and other confounders (for BMI of 30.0-34.9 versus 18.5-25.0, hazard ratio = 0.72, 95% confidence interval: 0.62, 0.84). The strength of the association declined with increasing follow-up time. Conversely, after adjustment for BMI, waist circumference and waist-to-height ratio were significantly positively associated with lung cancer risk (for the highest category of waist circumference vs. the lowest, hazard ratio = 1.25, 95% confidence interval: 1.05, 1.50). Given the decline of the inverse association between BMI and lung cancer over time, the association is likely at least partly due to weight loss resulting from preclinical lung cancer that was present at baseline. Residual confounding by smoking could also have influenced our findings.

Quantifying the mediating effects of smoking and occupational exposures in the relation between education and lung cancer: the ICARE study

Smoking only partly explains the higher lung cancer incidence observed among socially deprived people. Occupational exposures may account for part of these inequalities, but this issue has been little investigated. We investigated the extent to which smoking and occupational exposures to asbestos, silica and diesel motor exhaust mediated the association between education and lung cancer incidence in men. We analyzed data from a large French population-based case-control study (1976 lung cancers, 2648 controls). Detailed information on lifelong tobacco consumption and occupational exposures to various carcinogens was collected. We conducted inverse probability-weighted marginal structural models. A strong association was observed between education and lung cancer. The indirect effect through smoking varied by educational level, with the strongest indirect effect observed for those with the lowest education (OR = 1.34 (1.14-1.57)). The indirect effect through occupational exposures was substantial among men with primary (OR = 1.22 (1.15-1.30) for asbestos and silica) or vocational secondary education (OR = 1.18 (1.12-1.25)). The contribution of smoking to educational differences in lung cancer incidence ranged from 22 % (10-34) for men with primary education to 31 % (-3 to 84) for men with a high school degree. The contribution of occupational exposures to asbestos and silica ranged from 15 % (10-20) for men with a high school degree to 20 % (13-28) for men with vocational secondary education. Our results highlight the urgent need for public health policies that aim at decreasing exposure to carcinogens at work, in addition to tobacco control policies, if we want to reduce socioeconomic inequalities in the cancer field.

Occupational prestige, social mobility and the association with lung cancer in men

BACKGROUND

The nature of the association between occupational social prestige, social mobility, and risk of lung cancer remains uncertain. Using data from the international pooled SYNERGY case-control study, we studied the association between lung cancer and the level of time-weighted average occupational social prestige as well as its lifetime trajectory.

METHODS

We included 11,433 male cases and 14,147 male control subjects. Each job was translated into an occupational social prestige score by applying Treiman's Standard International Occupational Prestige Scale (SIOPS). SIOPS scores were categorized as low, medium, and high prestige (reference). We calculated odds ratios (OR) with 95 % confidence intervals (CI), adjusting for study center, age, smoking, ever employment in a job with known lung carcinogen exposure, and education. Trajectories in SIOPS categories from first to last and first to longest job were defined as consistent, downward, or upward. We conducted several subgroup and sensitivity analyses to assess the robustness of our results.

RESULTS

We observed increased lung cancer risk estimates for men with medium (OR = 1.23; 95 % CI 1.13-1.33) and low occupational prestige (OR = 1.44; 95 % CI 1.32-1.57). Although adjustment for smoking and education reduced the associations between occupational prestige and lung cancer, they did not explain the association entirely. Traditional occupational exposures reduced the associations only slightly. We observed small associations with downward prestige trajectories, with ORs of 1.13, 95 % CI 0.88-1.46 for high to low, and 1.24; 95 % CI 1.08-1.41 for medium to low trajectories.

CONCLUSIONS

Our results indicate that occupational prestige is independently associated with lung cancer among men.

[Health care use by free complementary health insurance coverage beneficiaries in France in 2012]

BACKGROUND

The objective was to investigate healthcare use among people covered by one of the two complementary healthcare insurance schemes available for people with low annual income: CMUC (universal complementary healthcare insurance) and, for people whose income exceeds the CMUC ceiling, ACS (aid for complementary healthcare insurance). Comparisons were made between CMUC and ACS beneficiaries versus CMUC and ACS non-beneficiaries and between CMUC beneficiaries and ACS beneficiaries.

METHODS

Using the national health insurance information system (SNIIRAM), people less than 60 years old covered by the general national health insurance (86% of the 66 million inhabitants) and with ACS or CMUC coverage in 2012 were selected. Diseases were identified using hospital diagnosis, drugs refunds and long-term chronic disease status. Hospital related diagnoses were categorized in major hospital activity groups. Sex- and age-standardized relative risk (RR) were calculated.

RESULTS

There were 4.4 million (9.6%) CMUC beneficiaries and 732,000 (1.6%) ACS beneficiaries (56% and 54% women; mean age: 24 years and 29 years respectively versus 52% and 30 years for CMUC or ACS non-beneficiaries). CMUC or ACS beneficiaries had more often cardiovascular diseases (RR=1.4;2.1) and diabetes (RR=2.2;2.4). Their sex- and age-standardized hospitalisation rates for all diagnosis were higher (18%; 17%, RR=1.3;1.4) than CMUC or ACS non-beneficiaries (13%). This was especially the case for the following major groups: toxicology, intoxications, alcohol major group (RR=3.8;4.0); psychiatry (RR=2.8;4.1); respiratory disease (RR=1.9;2.3); infectious disease (RR=1.9;2.7). Compared with CMUC beneficiaries, ACS beneficiaries had more often cancer (RR=1.5), cardiovascular disease (RR=1.5), neurological disease (RR=2.7), psychiatric illness (RR=2.6), end-stage renal disease (RR=2.8), hemophilia (RR=1.4) or cystic fibrosis (RR=1.6) and they received also more often disability allowance (20%, 4%).

CONCLUSION

The disease and hospitalisation rates of ACS beneficiaries are similar or higher than those of CMUC beneficiaries, especially for disabling diseases. Both CMUC and ACS beneficiaries received healthcare for chronic diseases that can be targeted by prevention and screening programs for more optimal healthcare.

Population health and status of epidemiology in Western European, Balkan and Baltic countries

BACKGROUND

This article is part of a series commissioned by the International Epidemiological Association, aimed at describing population health and epidemiological resources in the six World Health Organization (WHO) regions. It covers 32 of the 53 WHO European countries, namely the Western European countries, the Balkan countries and the Baltic countries.

METHODS

The burdens of mortality and morbidity and the patterns of risk factors and inequalities have been reviewed in order to identify health priorities and challenges. Literature and internet searches were conducted to stock-take epidemiological teaching, research activities, funding and scientific productivity.

FINDINGS

These countries have among the highest life expectancies worldwide. However, within- and between-country inequalities persist, which are largely due to inequalities in distribution of main health determinants. There is a long tradition of epidemiological research and teaching in most countries, in particular in the Western European countries. Cross-national networks and collaborations are increasing through the support of the European Union which fosters procedures to standardize educational systems across Europe and provides funding for epidemiological research through framework programmes. The number of Medline-indexed epidemiological research publications per year led by Western European countries has been increasing. The countries accounts for nearly a third of the global epidemiological publication.

CONCLUSIONS

Although population health has improved considerably overall, persistent within- and between-country inequalities continue to challenge national and European health institutions. More research, policy and action on the social determinants of health are required in the region. Epidemiological training, research and workforce in the Baltic and Balkan countries should be strengthened. European epidemiologists can play pivotal roles and must influence legislation concerning production and access to high-quality data.

Convergence of decreasing male and increasing female incidence rates in major tobacco-related cancers in Europe in 1988-2010

INTRODUCTION

Smoking prevalence has been declining in men all over Europe, while the trend varies in European regions among women. To study the impact of past smoking prevalence, we present a comprehensive overview of the most recent trends in incidence, during 1988-2010, in 26 countries, of four of the major cancers in the respiratory and upper gastro-intestinal tract associated with tobacco smoking.

METHODS

Data from 47 population-based cancer registries for lung, laryngeal, oral cavity and pharyngeal, and oesophageal cancer cases were obtained from the newly developed data repository within the European Cancer Observatory (http://eco.iarc.fr/). Truncated age-standardised incidence rates (35-74 years) by calendar year, average annual percentage change in incidence over 1998-2007 were calculated. Smoking prevalence in selected countries was extracted from the Organisation for Economic Co-operation and Development and the World Health Organization databases.

RESULTS

There remained great but changing variation in the incidence rates of tobacco-related cancers by European region. Generally, the high rates among men have been declining, while the lower rates among women are increasing, resulting in convergence of the rates. Female lung cancer rates were above male rates in Denmark, Iceland and Sweden (35-64 years). In lung and laryngeal cancers, where smoking is the main risk factor, rates were highest in central and eastern Europe, southern Europe and the Baltic countries. Despite a lowering of female smoking prevalence, female incidence rates of lung, laryngeal and oral cavity cancers increased in most parts of Europe, but were stable in the Baltic countries. Mixed trends emerged in oesophageal cancer, probably explained by differing risk factors for the two main histological subtypes.

CONCLUSIONS

This data repository offers the opportunity to show the variety of incidence trends by sex among European countries. The diverse patterns of trends reflect varied exposure to risk factors. Given the heavy cancer burden attributed to tobacco and the fact that tobacco use is entirely preventable, tobacco control remains a top priority in Europe. Prevention efforts should be intensified in central and eastern Europe, southern Europe and the Baltic countries.

Social inequalities and smoking-associated breast cancer - Results from a prospective cohort study

OBJECTIVE

The association between smoking and breast cancer has been found in most recent, large cohort studies. We wanted to investigate how smoking-associated breast cancer varies by level of education, a well-established measure of socioeconomic status.

METHODS

We included 302,865 women with 7490 breast cancer cases. Participants were assigned to low, moderate or high level of education and analyzed by smoking status (ever/never), and stratified by birth cohorts (≤1950>). We used Cox proportional hazard to estimate hazard ratios (HRs) and confidence intervals (CIs), adjusting for age, number of children, age at first childbirth, BMI, age at enrollment and physical activity.

RESULTS

Women born ≤1950 with low and moderate levels of education had a 40% increase in smoking-associated breast cancer risk (HR=1.40, 95% CI 1.25-1.57 and HR=1.14, 95% CI 1.05-1.24, respectively). Women in the same age group with high level of education did not have an increase in risk. No increased breast cancer risk was found among women born after 1950 for any level of education, when analyzed by smoking status. Longer duration of smoking before first childbirth was consistently associated with increasing risk of breast cancer in all three categories of education (all p for trends<0.01).

CONCLUSION

Smoking for several years before first childbirth increases the risk of breast cancer, regardless of educational level.

Pollution in the working place and social status: co-factors in lung cancer carcinogenesis

INTRODUCTION

Apart from the association with tobacco consumption, other factors of importance for prevention and early diagnosis of lung cancer have received little attention. We present a case-control study focusing on professional exposure to carcinogens and social status.

METHODS

A written questionnaire was completed by 551 consecutive patients with lung cancer and 494 patients with large bowel cancer. The groups were balanced regarding gender and age distribution. The questionnaire included data on place of birth, education, smoking history, diet and alcohol intake, body weight and height, occupation, housing conditions and family income. According to standard epidemiological criteria, professional exposure to carcinogens was classified as professions with exposure to confirmed lung cancer carcinogens, professions with exposure to suspected lung cancer carcinogens and other professions.

RESULTS

As expected, there were significant differences between the two groups regarding smoking status. While there were no significant differences in educational levels, more immigrants were among patients with lung cancer (17.9% vs 11.6%, p=0.005). On average, lung cancer patients had a lower body mass index (BMI) at 24.77, as compared to 26.14 for large bowel cancer (p=0.000). Lung cancer patients had lower income and poorer housing conditions; the bivariate difference was significant both for income levels (p=0.046) and type of residence (p=0.009). The proportion of patients working in professions with exposures to known carcinogens was 33.5% for lung cancer, and 17.1% for large bowel cancer (p=0.000). In the multivariate analysis, smoking (p=0.000), BMI (p=0.000) and type of occupation (p=0.001) were significant factors.

CONCLUSIONS

While there is no doubt about smoking in lung cancer carcinogenesis, professional exposure to carcinogens and belonging to lower socio-economic strata also play an important role.

Use of multiple imputation to correct for bias in lung cancer incidence trends by histologic subtype

BACKGROUND

Over the past several decades, advances in lung cancer research and practice have led to refinements of histologic diagnosis of lung cancer. The differential use and subsequent alterations of nonspecific morphology codes, however, may have caused artifactual fluctuations in the incidence rates for histologic subtypes, thus biasing temporal trends.

METHODS

We developed a multiple imputation (MI) method to correct lung cancer incidence for nonspecific histology using data from the Surveillance, Epidemiology, and End Results Program during 1975 to 2010.

RESULTS

For adenocarcinoma in men and squamous in both genders, the change to an increasing trend around 2005, after more than 10 years of decreasing incidence, is apparently an artifact of the changes in histopathology practice and coding system. After imputation, the rates remained decreasing for adenocarcinoma and squamous in men, and became constant for squamous in women.

CONCLUSIONS

As molecular features of distinct histologies are increasingly identified by new technologies, accurate histologic distinctions are becoming increasingly relevant to more effective "targeted" therapies, and therefore, are important to track in patients. However, without incorporating the coding changes, the incidence trends estimated for histologic subtypes could be misleading.

IMPACT

The MI approach provides a valuable tool for bridging the different histology definitions, thus permitting meaningful inferences about the long-term trends of lung cancer by histologic subtype.

Association between socioeconomic factors and cancer risk: a population cohort study in Scotland (1991-2006)

BACKGROUND

Lung and upper aero-digestive tract (UADT) cancer risk are associated with low socioeconomic circumstances and routinely measured using area socioeconomic indices. We investigated effect of country of birth, marital status, one area deprivation measure and individual socioeconomic variables (economic activity, education, occupational social class, car ownership, household tenure) on risk associated with lung, UADT and all cancer combined (excluding non melanoma skin cancer).

METHODS

We linked Scottish Longitudinal Study and Scottish Cancer Registry to follow 203,658 cohort members aged 15+ years from 1991-2006. Relative risks (RR) were calculated using Poisson regression models by sex offset for person-years of follow-up.

RESULTS

21,832 first primary tumours (including 3,505 lung, 1,206 UADT) were diagnosed. Regardless of cancer, economically inactivity (versus activity) was associated with increased risk (male: RR 1.14, 95% CI 1.10-1.18; female: RR 1.06, 95% CI 1.02-1.11). For lung cancer, area deprivation remained significant after full adjustment suggesting the area deprivation cannot be fully explained by individual variables. No or non degree qualification (versus degree) was associated with increased lung risk; likewise for UADT risk (females only). Occupational social class associations were most pronounced and elevated for UADT risk. No car access (versus ownership) was associated with increased risk (excluding all cancer risk, males). Renting (versus home ownership) was associated with increased lung cancer risk, UADT cancer risk (males only) and all cancer risk (females only). Regardless of cancer group, elevated risk was associated with no education and living in deprived areas.

CONCLUSIONS

Different and independent socioeconomic variables are inversely associated with different cancer risks in both sexes; no one socioeconomic variable captures all aspects of socioeconomic circumstances or life course. Association of multiple socioeconomic variables is likely to reflect the complexity and multifaceted nature of deprivation as well as the various roles of these dimensions over the life course.

Socioeconomic inequalities in mortality in 16 European cities

AIMS

To explore inequalities in total mortality between small areas of 16 European cities for men and women, as well as to analyse the relationship between these geographical inequalities and their socioeconomic indicators.

METHODS

A cross-sectional ecological design was used to analyse small areas in 16 European cities (26,229,104 inhabitants). Most cities had mortality data for a period between 2000 and 2008 and population size data for the same period. Socioeconomic indicators included an index of socioeconomic deprivation, unemployment, and educational level. We estimated standardised mortality ratios and controlled for their variability using Bayesian models. We estimated relative risk of mortality and excess number of deaths according to socioeconomic indicators.

RESULTS

We observed a consistent pattern of inequality in mortality in almost all cities, with mortality increasing in parallel with socioeconomic deprivation. Socioeconomic inequalities in mortality were more pronounced for men than women, and relative inequalities were greater in Eastern and Northern European cities, and lower in some Western (men) and Southern (women) European cities. The pattern of excess number of deaths was slightly different, with greater inequality in some Western and Northern European cities and also in Budapest, and lower among women in Madrid and Barcelona.

CONCLUSIONS

In this study, we report a consistent pattern of socioeconomic inequalities in mortality in 16 European cities. Future studies should further explore specific causes of death, in order to determine whether the general pattern observed is consistent for each cause of death.

Global cancer patterns: causes and prevention

Cancer is a global and growing, but not uniform, problem. An increasing proportion of the burden is falling on low-income and middle-income countries because of not only demographic change but also a transition in risk factors, whereby the consequences of the globalisation of economies and behaviours are adding to an existing burden of cancers of infectious origin. We argue that primary prevention is a particularly effective way to fight cancer, with between a third and a half of cancers being preventable on the basis of present knowledge of risk factors. Primary prevention has several advantages: the effectiveness could have benefits for people other than those directly targeted, avoidance of exposure to carcinogenic agents is likely to prevent other non-communicable diseases, and the cause could be removed or reduced in the long term--eg, through regulatory measures against occupational or environmental exposures (ie, the preventive effort does not need to be renewed with every generation, which is especially important when resources are in short supply). Primary prevention must therefore be prioritised as an integral part of global cancer control.

A socially situated approach to inform ways to improve health and wellbeing

Mainstream health psychology supports neoliberal notions of health promotion in which self-management is central. The emphasis is on models that explain behaviour as individually driven and cognitively motivated, with health beliefs framed as the favoured mechanisms to target in order to bring about change to improve health. Utilising understandings exemplified in critical health psychology, we take a more socially situated approach, focusing on practicing health, the rhetoric of modernisation in UK health care and moves toward democratisation. While recognising that within these new ways of working there are opportunities for empowerment and user-led health care, there are other implications. How these changes link to simplistic cognitive behavioural ideologies of health promotion and rational decision-making is explored. Utilising two different empirical studies, this article highlights how self-management and expected compliance with governmental authority in relation to health practices position not only communities that experience multiple disadvantage but also more seemingly privileged social actors. The article presents a challenge to self-management and informed choice, in which the importance of navigational networks is evident. Because health care can become remote and inaccessible to certain sections of the community, yet pervasive and deterministic for others, we need multiple levels of analysis and different forms of action.

Dietary patterns of patients with advanced lung or colorectal cancer

The purpose of this study was to identify dietary patterns among patients with advanced cancer. Differences between cancer groups are described, and food groups contributing higher proportions to overall caloric intake are identified. Patients with advanced cancer (n=51) were recruited from a regional cancer centre and completed a three-day dietary record. Food items were categorized according to macronutrient content. After adjustment for body weight, substantial variation in energy intake was observed (range: 13.7 to 55.4 kcal/kg/day). For 49% of patients, protein intake was below recommendations. Overall, patients consumed the largest proportion of their calories from meat (16%), other foods (11%), dessert (9%), fruit (9%), white bread (7%), and milk (7%). Only 5% of patients consumed meal replacement supplements. The results of this descriptive study provide important insights into the dietary habits of patients with advanced cancer. These insights could be translated into the development of effective recommendations for maintaining or improving health and quality of life.

Measuring socioeconomic disparities in cancer incidence in Tehran, 2008

BACKGROUND

Health disparities exist among and within countries, while developing and low income countries suffer more. The aim of this study was to quantify cancer disparities with regard to socioeconomic position (SEP) in 22 districts of Tehran, Iran.

METHOD

According to the national cancer registry, 7599 new cancer cases were recorded within 22 districts of Tehran in 2008. Based on combined data from census and a population-based health equity study (Urban HEART), socioeconomic position (SEP) was calculated for each district. Index of disparity, absolute and relative concentration indices (ACI and RCI) were used for measuring disparities in cancer incidence.

RESULTS

The overall cancer age standardised rate (ASR) was 117.2 per 100,000 individuals (120.4 for men and 113.5 for women). Maximum ASR in both genders was seen in districts 6, 3, 1 and 2. Breast, colorectal, stomach, skin and prostate were the most common cancers. Districts with higher SEP had higher ASR (r=0.9, p<0.001). Positive ACI and RCI indicated that cancer cases accumulated in districts with high SEP. Female disparity was greater than for men in all measures. Breast, colorectal, prostate and bladder ASR ascended across SEP groups. Negative ACI and RCI in cervical and skin cancers in women indicate their aggregation in lower SEP groups. Breast cancer had the highest absolute disparities measure.

CONCLUSION

This report provides an appropriate guide and new evidence on disparities across geographical, demographic and particular SEP groups. Higher ASR in specific districts warrants further research to investigate the background predisposing factors.

Socioeconomic inequalities in occupational, leisure-time, and transport related physical activity among European adults: a systematic review

Background

This study systematically reviewed the evidence pertaining to socioeconomic inequalities in different domains of physical activity (PA) by European region.

Methods

Studies conducted between January 2000 and December 2010 were identified by a systematic search in Pubmed, Embase, Web of Science, Psychinfo, Sportdiscus, Sociological Abstracts, and Social Service Abstracts. English-language peer-reviewed studies undertaken in the general population of adults (18–65 years) were classified by domain of PA (total, leisure-time including sport, occupational, active transport), indicator of socioeconomic position (education, income, occupation), and European region. Distributions of reported positive, negative, and null associations were evaluated.

Results

A total of 131 studies met the inclusion criteria. Most studies were conducted in Scandinavia (n = 47). Leisure-time PA was the most frequently studied PA outcome (n = 112). Considerable differences in the direction of inequalities were seen for the different domains of PA. Most studies reported that those with high socioeconomic position were more physically active during leisure-time compared to those with low socioeconomic position (68% positive associations for total leisure-time PA, 76% for vigorous leisure-time PA). Occupational PA was more prevalent among the lower socioeconomic groups (63% negative associations). Socioeconomic differences in total PA and active transport PA did not show a consistent pattern (40% and 38% positive associations respectively). Some inequalities differed by European region or socioeconomic indicator, however these differences were not very pronounced.

Conclusions

The direction of socioeconomic inequalities in PA in Europe differed considerably by domain of PA. The contradictory results for total PA may partly be explained by contrasting socioeconomic patterns for leisure-time PA and occupational PA.

Social inequalities and mortality in Europe--results from a large multi-national cohort

BACKGROUND

Socio-economic inequalities in mortality are observed at the country level in both North America and Europe. The purpose of this work is to investigate the contribution of specific risk factors to social inequalities in cause-specific mortality using a large multi-country cohort of Europeans.

METHODS

A total of 3,456,689 person/years follow-up of the European Prospective Investigation into Cancer and Nutrition (EPIC) was analysed. Educational level of subjects coming from 9 European countries was recorded as proxy for socio-economic status (SES). Cox proportional hazard model's with a step-wise inclusion of explanatory variables were used to explore the association between SES and mortality; a Relative Index of Inequality (RII) was calculated as measure of relative inequality.

RESULTS

Total mortality among men with the highest education level is reduced by 43% compared to men with the lowest (HR 0.57, 95% C.I. 0.52-0.61); among women by 29% (HR 0.71, 95% C.I. 0.64-0.78). The risk reduction was attenuated by 7% in men and 3% in women by the introduction of smoking and to a lesser extent (2% in men and 3% in women) by introducing body mass index and additional explanatory variables (alcohol consumption, leisure physical activity, fruit and vegetable intake) (3% in men and 5% in women). Social inequalities were highly statistically significant for all causes of death examined in men. In women, social inequalities were less strong, but statistically significant for all causes of death except for cancer-related mortality and injuries.

DISCUSSION

In this European study, substantial social inequalities in mortality among European men and women which cannot be fully explained away by accounting for known common risk factors for chronic diseases are reported.

Lower educational level is a predictor of incident type 2 diabetes in European countries: the EPIC-InterAct study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is one of the most common chronic diseases worldwide. In high-income countries, low socioeconomic status seems to be related to a high incidence of T2DM, but very little is known about the intermediate factors of this relationship. Method We performed a case-cohort study in eight Western European countries nested in the EPIC study (n = 340, 234, 3.99 million person-years of follow-up). A random sub-cohort of 16,835 individuals and a total of 12,403 incident cases of T2DM were identified. Crude and multivariate-adjusted hazard ratios (HR) were estimated for each country and pooled across countries using meta-analytical methods. Age-, gender- and country-specific relative indices of inequality (RII) were used as the measure of educational level and RII tertiles were analysed.

RESULTS

Compared with participants with a high educational level (RII tertile 1), participants with a low educational level (RII tertile 3) had a higher risk of T2DM [HR: 1.77, 95% confidence interval (CI): 1.69-1.85; P-trend < 0.01]. The HRs adjusted for physical activity, smoking status and propensity score according to macronutrient intake were very similar to the crude HR (adjusted HR: 1.67, 95% CI: 1.52-1.83 in men; HR: 1.88, 95% CI: 1.73-2.05 in women). The HRs were attenuated only when they were further adjusted for BMI (BMI-adjusted HR: 1.36, 95% CI: 1.23-1.51 in men; HR: 1.32, 95% CI: 1.20-1.45 in women).

CONCLUSION

This study demonstrates the inequalities in the risk of T2DM in Western European countries, with an inverse relationship between educational level and risk of T2DM that is only partially explained by variations in BMI.

Mediating role of education and lifestyles in the relationship between early-life conditions and health: evidence from the 1958 British cohort

The paper focuses on the long-term effects of early-life conditions with comparison to lifestyles and educational attainment on health status in a cohort of British people born in 1958. Using the longitudinal follow-up data at age 23, 33, 42 and 46, we build a dynamic model to investigate the influence of each determinant on health and the mediating role of education and lifestyles in the relationship between early-life conditions and later health. Direct and indirect effects of early-life conditions on adult health are explored using auxiliary linear regressions of education and lifestyles and panel Probit specifications of self-assessed health with random effects addressing individual unexplained heterogeneity. Our study shows that early-life conditions are important parameters for adult health accounting for almost 20% of explained health inequality when mediating effects are identified. The contribution of lifestyles reduces from 32% down to 25% when indirect effects of early-life conditions and education are distinguished. Noticeably, the absence of father at the time of birth and experience of financial hardships represent the lead factors for direct effects on health. The absence of obesity at 16 influences health both directly and indirectly working through lifestyles.

Time trends in educational differences in lung and upper aero digestive tract cancer mortality in France between 1990 and 2007

BACKGROUND

We investigated the magnitude of educational differences in lung and upper aero digestive tract (UADT) cancer mortality in France from 1990 to 2007.

METHODS

The analyses were based on census data from a representative sample of the French population. Educational level was used as the indicator for socioeconomic status. Educational differences in mortality from lung and UADT cancer were calculated among people aged 30-74 and by birth cohort. Two periods were compared: 1990-1998 and 1999-2007. Mortality rates, hazard ratios and relative indices of inequality (RII) were computed.

RESULTS

We found higher lung and UADT cancer mortality among those with less education. Inequalities in male UADT cancer mortality remained stable over time (RII(1990-1998)=0.21 (95% confidence interval 0.15-0.29); RII(1999-2007)=0.17 (0.11-0.26)) whereas inequalities in lung cancer mortality increased among the younger men (RII(1990-1998)=0.48 (0.28-0.83); RII(1999-2007)=0.16 (0.09-0.31)). Among women, inequalities in lung cancer mortality became apparent during the second period with higher mortality among those with less education. This trend was exclusively driven by the younger women, among whom inequalities reached about the same magnitude as among younger men (RII(1999-2007)=0.21 (0.08-0.56)).

CONCLUSION

UADT cancer mortality rates strongly decreased over time for every educational level. This implies that the burden of health associated with socioeconomic inequalities in UADT cancer mortality decreased substantially. Inequalities in lung cancer mortality are increasing among the younger generation and are expected to increase even more. Differences in magnitude of inequalities among men and women may disappear in the coming decades.

Socioeconomic inequalities in incidence of lung and upper aero-digestive tract cancer by age, tumour subtype and sex: a population-based study in Scotland (2000-2007)

BACKGROUND

Lung and upper aero-digestive tract (UADT) cancer risk is associated with socioeconomic inequality (SEI) but the degree of socioeconomic burden by age, tumour subtype, and sex is not known.

METHODS

We reviewed 216,305 cases excluding non melanoma skin cancer (All Cancer) comprising 37,274 lung; 8216 head and neck; and 6534 oesophageal cancers from 2000 to 2007 classified into anatomical or morphology subtypes. Deprivation was measured using the Scottish Index of Multiple Deprivation and SEI was measured using the Slope Index of Inequality and the Relative Index of Inequality (RII). Analyses were partitioned by 5-year age group and sex. RII was adapted to rank tumour type contribution to All Cancer SEI and to examine subtype by age and sex simultaneously. Rank was defined as proportion of All Cancer SEI.

RESULTS

All Cancer SEI was greater for males (RII=0.366; female RII=0.279); the combination of lung and UADT SEI contributed 91% and 81% respectively to All Cancer SEI. For both sexes lung and UADT subtypes showed significant SEI (P<0.001) except oesophageal adenocarcinoma in males (P=0.193); for females, SEI was borderline significant (P=0.048). Although RII rank differed by sex, all lung and larynx subtypes contributed most to All Cancer SEI with RII rank for oral cavity, oesophagus-squamous cell, and oropharynx following. For males 40-44 years, SEI increased abruptly peaking at 55-59 years. For females, SEI gradually peaked 10 years later. In both sexes, the SEI peak preceded peak incidence.

CONCLUSION

SEI in lung and UADT cancers vary greatly by age, tumour subtype and sex; these variations are likely to largely reflect differences between the sexes in risk behaviours which vary by birth cohort and are socioeconomically patterned.

Educational level and risk of colorectal cancer in EPIC with specific reference to tumor location

Existing evidence is inconclusive on whether socioeconomic status (SES) and educational inequalities influence colorectal cancer (CRC) risk, and whether low or high SES/educational level is associated with developing CRC. The aim of our study was to investigate the relationship between educational level and CRC. We studied data from 400,510 participants in the EPIC (European Prospective Investigation into Cancer and Nutrition) study, of whom 2,447 developed CRC (colon: 1,551, rectum: 896, mean follow-up 8.3 years). Cox proportional hazard regression analysis stratified by age, gender and center, and adjusted for potential confounders were used to estimate hazard ratios (HR) and 95% confidence intervals (95%CI). Relative indices of inequality (RII) for education were estimated using Cox regression models. We conducted separate analyses for tumor location, gender and geographical region. Compared with participants with college/university education, participants with vocational secondary education or less had a nonsignificantly lower risk of developing CRC. When further stratified for tumor location, adjusted risk estimates for the proximal colon were statistically significant for primary education or less (HR 0.73, 95%CI 0.57-0.94) and for vocational secondary education (HR 0.76, 95%CI 0.58-0.98). The inverse association between low education and CRC risk was particularly found in women and Southern Europe. These associations were statistically significant for CRC, for colon cancer and for proximal colon cancer. In conclusion, CRC risk, especially in the proximal colon, is lower in subjects with a lower educational level compared to those with a higher educational level. This association is most pronounced in women and Southern Europe.

Parity and risk of lung cancer in women: systematic review and meta-analysis of epidemiological studies

Multiple studies have assessed parity as a risk factor for lung cancer but results have been inconclusive. We searched MEDLINE (through August 2010) and the Institute of Scientific Information Web of Knowledge database (through April 2011) to identify studies investigating the association of parity with lung cancer and allowing the calculation of dose-response trends using a linear model. Between-study heterogeneity was assessed using Cochran's Q statistic and the I(2) index. Summary per-child relative risks (RRs) with their 95% confidence interval (CI) were estimated using random effects meta-analysis. Sixteen eligible studies (8077 lung cancer patients; 350,295 unaffected individuals) provided data for meta-analysis. There was significant between-study heterogeneity (p<0.001; I(2)=73%). The summary per livebirth RR was 0.98 (95% CI, 0.95-1.02), indicating no effect of parity on lung cancer risk. Results were consistent in case-control (n=11), RR=0.99 (95% CI, 0.94-1.04), and cohort studies (n=5), RR=0.97 (95% CI, 0.92-1.03). Studies not including small-cell lung cancer patients found a borderline protective effect of parity, RR=0.94 (95% CI, 0.88-1.00). In contrast, no effect was observed in studies including small-cell lung cancer patients, RR=1.00 (95% CI, 0.98-1.03); p for difference=0.05. Overall, there was little evidence of a dose-response relationship between increasing number of livebirths and lung cancer; however, studies have produced heterogeneous results. Future studies should include analyses in well-defined histological disease subgroups.