Differences in cancer survival by area-level socio-economic disadvantage: A population-based study using cancer registry data

Social Determinants of Health in Cardio-Oncology: Multi-Level Strategies to Overcome Disparities in Care: JACC: CardioOncology State-of-the-Art Review

Addressing the need for more equitable cardio-oncology care requires attention to existing disparities in cardio-oncologic disease prevention and outcomes. This is particularly important among those affected by adverse social determinants of health (SDOH). The intricate relationship of SDOH, cancer diagnosis, and outcomes from cardiotoxicities associated with oncologic therapies is influenced by sociopolitical, economic, and cultural factors. Furthermore, mechanisms in cell signaling and epigenetic effects on gene expression link adverse SDOH to cancer and the CVD-related complications of oncologic therapies. To mitigate these disparities, a multifaceted strategy is needed that includes attention to health care access, policy, and community engagement for improved disease screening and management. Interdisciplinary teams must also promote cultural humility and competency and leverage new health technology to foster collaboration in addressing the impact of adverse SDOH in cardio-oncologic outcomes.

The relationship between income, health insurance, and employment status as prognostic indicators of bladder cancer: A survival analysis

BACKGROUND

Bladder cancer (BC) is one of the health problems. Socioeconomic status (SES) may correlate with patient treatment, possibly impacting patient prognosis. This study aimed to determine the relationship between income, health insurance, and employment status as prognostic indicators of BC.

METHODS

A retrospective observational study for patients diagnosed with BC in a hospital during the 5-year period between January 2019 and December 2023. Kaplan-Meier test analysis was used to generate overall survival curves stratified by income, employment status, and health insurance. Multivariate Cox proportional-hazards regression was used to identify factors associated with worse overall survival.

RESULTS

The results of the analysis on 219 patients showed no difference in patient survival based on income (p>0.05), while employment status and health insurance showed significant difference in patient survival (p<0.05). Moreover, there were 99 (45.2%) patients died, with the average patient being 58 years old and dominant in male patients.

CONCLUSIONS

Prevention of poor outcomes in patients needs to pay attention to certain characteristics, particularly for the loweconomic patients without appropriate national health insurance coverage.

Do age at diagnosis, tumour thickness and tumour site explain sex differences in melanoma survival? A causal mediation analysis using cancer registry data

Women diagnosed with melanoma have better survival than men, but little is known about potential intervention targets to reduce this survival gap by sex. We conducted a population-based study using Victorian Cancer Registry data including 5833 women and 6780 men aged 15 to 70 years when diagnosed with first primary melanoma between 2007 and 2015. Deaths to the end of 2020 were identified through linkage to the Victorian and national death registries. We estimated the effect of age at diagnosis, tumour thickness and tumour site on reducing the melanoma-specific survival gap by sex (ie, interventional indirect effects [IIEs]) on risk difference (RD) scale. Compared to women, there were 211 (95% CI: 145-278) additional deaths per 10 000 in men within 5 years following diagnosis. We estimated that 44% of this gap would be reduced by a hypothetical intervention shifting the distribution of melanoma thickness in men to be the same as that observed for women (IIEthickness RD 93 [95% CI: 75-118] per 10 000) and 20% by an intervention on tumour site (head and neck/trunk vs upper limb/lower limb; IIEsite RD 42 [95% CI: 15-72] per 10 000), while an intervention on age at diagnosis would have a negligible effect. Tumour thickness, tumour site and age at diagnosis mediated 65% of the effect of sex on 5-year melanoma survival in Victoria. Of these factors, tumour thickness had the most considerable mediating effect, suggesting that effective promotion of earlier detection of melanoma in men could potentially nearly halve the gap in melanoma-specific survival by sex.

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

OBJECTIVE

Patients diagnosed with colorectal cancer living in more deprived areas experience worse survival than those in more affluent areas. Those living in more deprived areas face barriers to accessing timely, quality healthcare. These barriers may contribute to socioeconomic inequalities in survival. We evaluated the literature for any association between socioeconomic group, hospital delay and treatments received among patients with colorectal cancer in the UK, a country with universal healthcare.

DESIGN

MEDLINE, EMBASE, CINAHL, CENTRAL, SCIE, AMED and PsycINFO were searched from inception to January 2023. Grey literature, including HMIC, BASE and Google Advanced Search, and forward and backward citation searches were conducted. Two reviewers independently reviewed titles, abstracts and full-text articles. Observational UK-based studies were included if they reported socioeconomic measures and an association with either hospital delay or treatments received. The QUIPS tool assessed bias risk, and a narrative synthesis was conducted. The review is reported to Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020.

RESULTS

41 of the 7209 identified references were included. 12 studies evaluated 7 different hospital intervals. There was a significant association between area-level deprivation and a longer time from first presentation in primary care to diagnosis. 32 studies evaluated treatments received. There were socioeconomic inequalities in surgery and chemotherapy but not radiotherapy.

CONCLUSION

Patients with colorectal cancer face inequalities across the cancer care continuum. Further research is needed to understand why and what evidence-based actions can reduce these inequalities in treatment. Qualitative research of patients and clinicians conducted across various settings would provide a rich understanding of the complex factors that drive these inequalities. Further research should also consider using a causal approach to future studies to considerably strengthen the interpretation. Clinicians can try and mitigate some potential causes of colorectal cancer inequalities, including signposting to financial advice and patient transport schemes.

PROSPERO REGISTRATION NUMBER

CRD42022347652.

Socioeconomic position and the pre-diagnostic interval among patients diagnosed with head and neck squamous cell carcinoma - a population-based study from DAHANCA

BACKGROUND

The socioeconomic differences in survival are pronounced for patients diagnosed with head and neck cancer; disease stage at diagnosis is suggested to be a main driver of this association. This nationwide, population-based study investigates socioeconomic differences in the pre-diagnostic interval and disease stage at diagnosis.

MATERIAL AND METHODS

Information on patient-reported symptoms, symptom onset and disease-specific factors was obtained from the nationwide population-based Danish Head and Neck Cancer Group (DAHANCA) database for patients diagnosed with head and neck squamous cell carcinoma between 2008 and 2019 in Denmark. Socioeconomic position (SEP) was measured by individual-level education, income and cohabitation status obtained from administrative registers. Socioeconomic differences in the interval from symptom onset to diagnosis were investigated in general linear models with 95% confidence intervals (CIs); overall and by subsite, symptom and comorbidity score. Consultation patterns prior to diagnosis were examined using methods for change-point detection. Associations with advanced-stage disease were estimated in logistic regression models.

RESULTS

Patients with low, medium and high SEP had a similar interval from patient-reported symptom onset to diagnosis of 10 weeks. Although this interval varied according to primary symptom and anatomical subsite, no apparent socioeconomic differences were observed within these subgroups. Aligned with the patient-reported symptom onset, a distinct increase in consultation rates was observed at 9 weeks (95% CI [7.3; 10.7]) for patients with low SEP and 7 weeks (95% CI [4.8; 9.2]) for patients with high SEP, with overlapping CIs. Patients with low compared to high SEP had increased odds for advanced-stage glottic and oral cavity squamous cell carcinoma. For the remaining subsites the association varied according to SEP-indicator and TNM-edition.

CONCLUSION

The interval from symptom onset to diagnosis and consultation patterns were similar across SEP groups. Still, socioeconomic differences in stage at diagnosis were observed for some - but not all - subsites.

Individual-level home values and cancer mortality in a statewide registry

BACKGROUND

Prior work assessing disparities in cancer outcomes has relied on regional socioeconomic metrics. These metrics average data across many individuals, resulting in a loss of granularity and confounding with other regional factors.

METHODS

Using patients' addresses at the time of diagnosis from the Ohio Cancer Incidence Surveillance System, we retrieved individual home price estimates from an online real estate marketplace. This individual-level estimate was compared with the Area Deprivation Index (ADI) at the census block group level. Multivariable Cox proportional hazards models were used to determine the relationship between home price estimates and all-cause and cancer-specific mortality.

RESULTS

A total of 667 277 patients in Ohio Cancer Incidence Surveillance System were linked to individual home prices across 16 cancers. Increasing home prices, adjusted for age, stage at diagnosis, and ADI, were associated with a decrease in the hazard of all-cause and cancer-specific mortality (hazard ratio [HR] = 0.92, 95% confidence interval [CI] = 0.92 to 0.93, and HR = 0.95, 95% CI = 0.94 to 0.95, respectively). Following a cancer diagnosis, individuals with home prices 2 standard deviations above the mean had an estimated 10-year survival probability (7.8%, 95% CI = 7.2% to 8.3%) higher than those with home prices 2 standard deviations below the mean. The association between home price and mortality was substantially more prominent for patients living in less deprived census block groups (Pinteraction < .001) than for those living in more deprived census block groups.

CONCLUSION

Higher individual home prices were associated with improved all-cause and cancer-specific mortality, even after accounting for regional measures of deprivation.

Clinical presentation, treatment patterns, and outcomes of colorectal cancer patients at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia: A prospective cohort study

BACKGROUND

Colorectal cancer (CRC) is the third most common cause of cancer death in both genders worldwide.

AIMS

This study aimed to evaluate the outcomes and prognostic factors of CRC patients at Tikur Anbessa Specialized Hospital in Ethiopia.

METHODS AND RESULTS

A prospective cohort study was conducted on 209 patients from January 2020 to September 2022. Kaplan-Meier curves and bivariate and multivariate Cox regression analyses were used to analyze overall and progression-free survival, with a significance value of P < .05. Results showed an overall mortality rate was 67.46% (95% confidence interval [CI]: 61.0-74.0), while the 1-year overall survival (OS) rate was 63.16% (95% CI: 56.23-69.29), with a median follow-up duration of 20 months. The median OS and progression-free survival times were 17 and 11 months, respectively. Age above 40 years (hazard ratio [HR] = 1.53, 1.02-2.29, p < .040), lower educational level (high school and below) (HR = 2.20, 1.24-3.90, p < .007), poor performance status (HR = 1.60, 1.03-2.48, p < .035), Hgb ≤12.5 g/dL (HR = 1.55, 1.03-2.08, p < .035), T-4 disease (HR = 6.05, 2.28-16.02, p < .000), and metastases at diagnosis (HR = 8.53, 3.77-19.25, p < .000) were all associated with poorer survival.

CONCLUSION

These findings suggest that poor survival of CRC patients in Ethiopia is largely due to advanced stage of the disease and lack of timely treatment, and highlight the urgent need for improved access to cancer treatment in the region.

Regional disparities in cancer survival in Iran: Insight from a National Surveillance of Cancer Survival in Iran (IRANCANSURV)

BACKGROUND AND OBJECTIVES

We aimed to investigate geographical disparity in cancer survival in 9 provincial population-based cancer registries in Iran from 2015 to 2016.

MATERIAL AND METHOD

In the current study, data from 90,862 adult patients (aged >15 years) diagnosed with cancer were retrieved from 9 population-based cancer registries across Iran. Five-year survival rates were estimated by applying relative survival approaches. We also applied the international cancer survival standard weights for age standardization. Finally, we calculated the excess hazard ratio (EHR) for each province adjusted for age, sex, and cancer sites to estimate the excess hazard ratio of mortality compared to the capital province (Tehran).

RESULTS

The largest gap in survival was observed in more curable cancer types, including melanoma (41.4%), ovary (32.3%), cervix (35.0%), prostate (26.7%), and rectum (21.4%), while the observed geographical disparity in lethal cancers such as lung, brain, stomach, and pancreas was less than 15%. Compared to Tehran, we found the highest excess hazard of death in Western Azerbaijan (EHR=1.60, 95% CI 1.51, 1.65), Kermanshah (EHR=1.52, 95% CI=1.44, 1.61), and Kerman (EHR=1.46, 95% CI=1.38, 1.53). The hazard ratio of death was almost identical in Isfahan (EHR=1.04, 95% CI=1.03, 1.06) and Tehran provinces.

CONCLUSION

Provinces with higher HDI had better survival rates. IRANCANSURV study showed regional disparities in cancer survival in Iran. Cancer patients in provinces with a higher Human Development Index (HDI) had a higher survival rate and lived longer compared to the patients in provinces with medium and low HDI regions.

Worry About COVID-19 and Other Extreme Events Amongst Educators in Australia

The significant disruption of COVID-19 on schooling has heightened concerns about its impact on educators' wellbeing. The current study examined how educators' worry regarding the COVID-19 pandemic compared to their worry about other extreme events, such as natural disasters and critical incidents (a death or suicide of a child, young person, or colleague). Educators report that they were most worried about COVID-19. Educators working in preschools were more worried about COVID-19 and natural disasters than those in primary and secondary schools. However, worry regarding critical incidents increased with the age of students taught. Worry was influenced by socio-economic advantage (SEIFA), whereby educators working in higher SEIFA communities were less worried about natural disasters and critical incidents but shared similar levels of worry about COVID-19 as educators in lower SEIFA communities. With a better understanding about how different types of worry and levels of worry vary across different educator groups and different contexts, more effective supports can be developed and offered.

Global disparities in patients with multiple myeloma: a rapid evidence assessment

There are disparities in outcomes for patients with multiple myeloma (MM). We evaluated the influence of sociodemographic factors on global disparities in outcomes for patients with MM. This rapid evidence assessment (PROSPERO, CRD42021248461) followed PRISMA-P guidelines and used the PICOS framework. PubMed and Embase® were searched for articles in English from 2011 to 2021. The title, abstract, and full text of articles were screened according to inclusion/exclusion criteria. The sociodemographic factors assessed were age, sex, race/ethnicity, socioeconomic status, and geographic location. Outcomes were diagnosis, access to treatment, and patient outcomes. Of 84 articles included, 48 were US-based. Worldwide, increasing age and low socioeconomic status were associated with worse patient outcomes. In the US, men typically had worse outcomes than women, although women had poorer access to treatment, as did Black, Asian, and Hispanic patients. No consistent disparities due to sex were seen outside the US, and for most factors and outcomes, no consistent disparities could be identified globally. Too few studies examined disparities in diagnosis to draw firm conclusions. This first systematic analysis of health disparities in patients with MM identified specific populations affected, highlighting a need for additional research focused on assessing patterns, trends, and underlying drivers of disparities in MM.

The contribution of prognostic factors to socio-demographic inequalities in breast cancer survival in Victoria, Australia

BACKGROUND

Breast cancer survival in Australia varies according to socio-economic status (SES) and between rural and urban places of residence. Part of this disparity may be due to differences in prognostic factors at the time of diagnosis.

METHODS

Women with invasive breast cancer diagnosed from 2008 until 2012 (n = 14,165) were identified from the Victorian Cancer Registry and followed up for 5 years, with death from breast cancer or other causes recorded. A prognostic score, based on stage at diagnosis, cancer grade, whether the cancer was detected via screening, reported comorbidities and age at diagnosis, was constructed for use in a mediation analysis.

RESULTS

Five-year breast cancer mortality for women with breast cancer who were in the lowest quintile of SES (10.3%) was almost double that of those in the highest quintile (5.7%). There was a small survival advantage (1.7% on average, within each socio-economic quintile) of living in inner-regional areas compared with major cities. About half of the socio-economic disparity was mediated by prognostic factors, particularly stage at diagnosis and the presence of comorbidities. The inner-regional survival advantage was not due to differences in prognostic factors.

CONCLUSIONS

Part of the socio-economic disparity in breast cancer survival could be addressed by earlier detection in, and improved general health for, more disadvantaged women. Further research is required to identify additional causes of socio-economic disparities as well as the observed inner-regional survival advantage.

Cancer Prevention Literacy among Different Population Subgroups: Challenges and Enabling Factors for Adopting and Complying with Cancer Prevention Recommendations

It is estimated that 40% of the cancer cases in Europe could be prevented if people had better information and tools to make healthier choices and thereby reduce some of the most important cancer risk factors. The aim of this study is to gain knowledge and understanding about cancer prevention literacy among people with intellectual disabilities, immigrants, young people and young cancer survivors. In this qualitative study, we conducted six online focus-group interviews, including forty participants, to explore the cancer prevention literacy of four population subgroups and determine how cancer prevention recommendations according to the European Code Against Cancer (ECAC) were perceived. The analysis resulted in the following main categories: current health beliefs and their impacts on how the ECAC recommendations were perceived, communication strategies and sources benefiting or hindering cancer prevention information from reaching out, and how vulnerabilities in these subgroups impact cancer prevention literacy. To improve cancer prevention literacy in Europe, more attention is needed this topic to overcome barriers among different population subgroups. Recommendations include improved and adapted cancer prevention information, support to individuals, as well as societal support, such as easy-access screening and vaccination programmes and regulations related to tobacco, alcohol, and diet.

Does women's empowerment and their socioeconomic condition affect the uptake of breast cancer screening? Findings from NFHS-5, India

BACKGROUND

Screening for breast cancer results in early diagnosis of the disease and improves survival. However, increasing participation of women in screening programs is challenging since it is influenced by socioeconomic and cultural factors. This study explores the relationship of socioeconomic and women empowerment factors with breast cancer screening uptakes in the states and union territories of India.

METHODS

We used summary reports of secondary data from all the states and union territories based on the fifth wave of the National Family Health Survey in India. This ecological study compares the uptake of breast cancer screening across states of India. We considered socioeconomic status (SES) and women empowerment status (WES) indicators from the survey as independent variables and state-wise breast cancer screening uptake as dependent variables for studying their association. The determinants of breast cancer screening were calculated using a simple linear regression model.

RESULTS

We found that socioeconomic status and women empowerment status moderately correlated with breast cancer screening uptake (correlation coefficient 0.34 and 0.38, respectively). States with higher rates of literacy among women and of women who had their own bank accounts that they decided how to use reported higher uptake of breast cancer screening (p = 0.01 and 0.03, respectively). However, the correlation was not uniform across all the states. The states of Chandigarh, Delhi, Telangana, and Karnataka showed lower participation despite a higher percentage of literate women and women with their own bank accounts.

CONCLUSION

This study indicates that women's literacy and having their own bank account may moderately improve their participation in cancer screening. However, higher SES and WES did not translate into better screening in many of the states. More research is needed, especially for states which had low screening uptake despite relatively higher rates of women empowerment.

Small-Area Geographic and Socioeconomic Inequalities in Colorectal Cancer in Cyprus

Colorectal cancer (CRC) is one of the leading causes of death and morbidity worldwide. To date, the relationship between regional deprivation and CRC incidence or mortality has not been studied in the population of Cyprus. The objective of this study was to analyse the geographical variation of CRC incidence and mortality and its possible association with socioeconomic inequalities in Cyprus for the time period of 2000-2015. This is a small-area ecological study in Cyprus, with census tracts as units of spatial analysis. The incidence date, sex, age, postcode, primary site, death date in case of death, or last contact date of all alive CRC cases from 2000-2015 were obtained from the Cyprus Ministry of Health's Health Monitoring Unit. Indirect standardisation was used to calculate the sex and age Standardise Incidence Ratios (SIRs) and Standardised Mortality Ratios (SMRs) of CRC while the smoothed values of SIRs, SMRs, and Mortality to Incidence ratio (M/I ratio) were estimated using the univariate Bayesian Poisson log-linear spatial model. To evaluate the association of CRC incidence and mortality rate with socioeconomic deprivation, we included the national socioeconomic deprivation index as a covariate variable entering in the model either as a continuous variable or as a categorical variable representing quartiles of areas with increasing levels of socioeconomic deprivation. The results showed that there are geographical areas having 15% higher SIR and SMR, with most of those areas located on the east coast of the island. We found higher M/I ratio values in the rural, remote, and less dense areas of the island, while lower rates were observed in the metropolitan areas. We also discovered an inverted U-shape pattern in CRC incidence and mortality with higher rates in the areas classified in the second quartile (Q2-areas) of the socioeconomic deprivation index and lower rates in rural, remote, and less dense areas (Q4-areas). These findings provide useful information at local and national levels and inform decisions about resource allocation to geographically targeted prevention and control plans to increase CRC screening and management.

Survival of primary liver cancer for people from culturally and linguistically diverse backgrounds in Australia

BACKGROUND

Survival for Primary Liver Cancer (PLC) has been investigated in Australia, but limited work has been conducted on the burden for people with different socioeconomic status, region of residence, causes of PLC, and culturally and linguistically diverse (CALD) backgrounds. This study aimed to cover this gap in the literature by investigating PLC survival with the aforementioned factors.

METHODS

This study linked four administrative datasets: Victorian Cancer Registry, Admitted Episodes Dataset, Emergency Minimum Dataset, and Death Index. The cohort was all cases with a PLC notification within the Victorian Cancer Registry between 01/01/2008 and 01/01/2016. The Kaplan-Meier method was used to estimate survival probabilities and the log-rank test was used to compare the difference in survival between subgroups. The Cox proportional hazard model was used to explore factors associated with PLC survival.

RESULTS

The 1-, 3- and 5-year survival rates were 50.0%, 28.1% and 20.6%, respectively, with a median survival of 12.0 months (95% confidence interval (CI): 11.0 - 12.9 months). Higher survival was associated with younger age, hepatocellular carcinoma, and higher socio-economic status. People born in Asian, African, and American regions had higher survival than those born in Australia and New Zealand. Cases with viral hepatitis as an identified aetiology had higher survival than those whose PLC was related to alcohol consumption (hazard ratio=1.52, 95% CI: 1.19 - 1.96), diabetes and fatty liver disease (hazard ratio=1.35, 95% CI: 1.08 - 1.68).

CONCLUSION

Survival outcomes for people diagnosed with PLC were still poor and affected by many factors. Asian and African cases had better survival than Australian and New Zealand patients as PLC in Asian and African cases was mostly caused by viral hepatitis. Metropolitan areas were associated with a higher survival than rural areas, not only due to accessibility to surveillance and healthcare services but also because the majority of overseas-born patients reside in metropolitan areas.

Association of Smoking, Comorbidity, Clinical Stage, and Treatment Intent With Socioeconomic Differences in Survival After Oropharyngeal Squamous Cell Carcinoma in Denmark

IMPORTANCE

The socioeconomic gap in survival after cancer is pronounced among patients with head and neck cancer. Understanding the mechanisms of this gap is crucial to target intervention strategies.

OBJECTIVE

To investigate socioeconomic differences in survival after oropharyngeal squamous cell carcinoma (OPSCC) according to human papillomavirus (HPV) status and the extent to which smoking, comorbidity, clinical stage, and treatment intent explain the survival gap.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide, population-based cohort study was based on prospectively collected information on all patients with a diagnosis of OPSCC from the Danish Head and Neck Cancer Group database and administrative registries. The study included 4600 patients born in 1921 or later, aged 30 years or older, and residing in Denmark 1 year prior to OPSCC diagnosis. Patients with missing information (547 [12%]) were excluded. Patients were diagnosed between January 1, 2008, and December 31, 2019, and followed up until December 31, 2021. Data were analyzed from June 6 to October 4, 2022.

EXPOSURE

Socioeconomic position (educational level, disposable income, or cohabiting status).

MAIN OUTCOMES AND MEASURES

Socioeconomic differences in 5-year overall survival were estimated in Cox proportional hazards regression models by HPV status. The indirect effect and proportion mediated by smoking, comorbidity, clinical stage, and treatment intent were estimated based on a counterfactual approach.

RESULTS

The analyzed cohort comprised 4053 patients (1045 women [26%] and 3008 men [74%]). The median age was 61 years (IQR, 55-68 years), and 2563 patients (63%) had HPV-positive OPSCC while 1490 patients (37%) had HPV-negative OPSCC. The 5-year standardized overall survival was 10% to 15% lower among patients with a lower educational level, with low disposable income, or who were living alone (patients with HPV-positive OPSCC, 68%-71%; patients with HPV-negative OPSCC, 31%-34%) than patients with a higher educational level, high disposable income, or a cohabiting partner (patients with HPV-positive OPSCC, 81%-86%; patients with HPV-negative OPSCC, 43%-46%). Among patients with HPV-positive OPSCC, a considerable part of this survival gap was estimated to be associated with differences in smoking (27%-48%), comorbidity (10%-19%), clinical stage (8%-19%), and treatment intent (16%-28%). Among those with HPV-negative OPSCC, comorbidity (12%-22%) and treatment intent (16%-42%) were the primary potential mediators.

CONCLUSIONS AND RELEVANCE

This cohort study suggests that, regardless of HPV status, patients with low socioeconomic position had 10% to 15% lower 5-year overall survival than patients with high socioeconomic position. A substantial part of this survival gap was associated with differences in smoking, comorbidity, clinical stage, or treatment intent at diagnosis.

Socioeconomic disadvantage and its impact on colorectal cancer in Australia: a scoping review

BACKGROUND

Social disparities in cancer survival have been demonstrated in Australia despite a universal healthcare insurance system. Colorectal cancer is common, and reasons for survival disparities related to socioeconomic status need to be investigated and addressed. The aim is to evaluate the current Australian literature concerning the impact of socioeconomic status on colorectal cancer survival and stage at presentation.

METHODS

A systematic search of PUBMED, EMBASE, SCOPUS and Clarivate Web of Science databases from January 2010 to March 2022 was performed. Studies investigating the impact of socioeconomic status on colorectal stage at presentation or survival in Australia were included. Data were extracted on author, year of publication, state or territory of origin, patient population, other exposure variables, outcomes and findings and adjustments made.

RESULTS

Of the 14 articles included, the patient populations examined varied in size from 207 to 100 000+ cases. Evidence that socioeconomic disadvantage was associated with poorer survival was demonstrated in eight of 12 studies. Evidence of effect on late stage at presentation was demonstrated in two of seven studies. Area-level measures were commonly used to assess socioeconomic status, with varying indices utilized.

CONCLUSION

There is limited evidence that socioeconomic status is associated with late-stage at presentation. More studies provide evidence of an association between socioeconomic disadvantage and poorer survival, especially larger studies utilizing less clinically-detailed cancer registry data. Further investigation is required to analyse why socioeconomic disadvantage may be associated with poorer survival.

ESO-ESMO fifth international consensus guidelines for breast cancer in young women (BCY5)

We dedicate this manuscript in memory of a dear friend and colleague Bella Kaufman. The fifth International Consensus Symposium for Breast Cancer in Young Women (BCY5) took place virtually in October 2020, organized by the European School of Oncology (ESO) and the European Society of Medical Oncology (ESMO). Consensus recommendations for the management of breast cancer in young women were updated from BCY4 with incorporation of new evidence to inform the guidelines. Areas of research priorities as well as specificities in different geographic and minority populations were identified. This manuscript summarizes the ESO-ESMO international consensus recommendations, which are also endorsed by the European Society of Breast Specialists (EUSOMA).

Are deprivation-specific cancer survival patterns similar according to individual-based and area-based measures? A cohort study of patients diagnosed with five malignancies in England and Wales, 2008-2016

OBJECTIVE

To investigate if measured inequalities in cancer survival differ when using individual-based ('person') compared with area-based ('place') measures of deprivation for three socioeconomic dimensions: income, deprivation and occupation.

DESIGN

Cohort study.

SETTING

Data from the Office for National Statistics Longitudinal Study of England and Wales, UK, linked to the National Cancer Registration Database.

PARTICIPANTS

Patients diagnosed with cancers of the colorectum, breast, prostate, bladder or with non-Hodgkin's lymphoma during the period 2008-2016.

PRIMARY AND SECONDARY OUTCOME MEASURES

Differentials in net survival between groups defined by individual wage, occupation and education compared with those obtained from corresponding area-level metrics using the English and Welsh Indices of Multiple Deprivation.

RESULTS

Survival was negatively associated with area-based deprivation irrespective of the type analysed, although a trend from least to most deprived was not always observed. Socioeconomic differences were present according to individually-measured socioeconomic groups although there was an absence of a consistent 'gradient' in survival. The magnitude of differentials was similar for area-based and individually-derived measures of deprivation, which was unexpected.

CONCLUSION

These unique data suggest that the socioeconomic influence of 'person' is different to that of 'place' with respect to cancer outcomes. This has implications for health policy aimed at reducing inequalities. Further research could consider the separate and additional influence of area-based deprivation over individual-level characteristics (contextual effects) as well as investigate the geographic, socioeconomic and healthcare-related characteristics of areas with poor outcomes in order to inform policy intervention.

Socio-economic inequalities in cancer survival: how do they translate into Number of Life-Years Lost?

BACKGROUND

We aimed to investigate the impact of socio-economic inequalities in cancer survival in England on the Number of Life-Years Lost (NLYL) due to cancer.

METHODS

We analysed 1.2 million patients diagnosed with one of the 23 most common cancers (92.3% of all incident cancers in England) between 2010 and 2014. Socio-economic deprivation of patients was based on the income domain of the English Index of Deprivation. We estimated the NLYL due to cancer within 3 years since diagnosis for each cancer and stratified by sex, age and deprivation, using a non-parametric approach. The relative survival framework enables us to disentangle death from cancer and death from other causes without the information on the cause of death.

RESULTS

The largest socio-economic inequalities were seen mostly in adults <45 years with poor-prognosis cancers. In this age group, the most deprived patients with lung, pancreatic and oesophageal cancer lost up to 6 additional months within 3 years since diagnosis than the least deprived. For most moderate/good prognosis cancers, the socio-economic inequalities widened with age.

CONCLUSIONS

More deprived patients and particularly the young with more lethal cancers, lose systematically more life-years than the less deprived. To reduce these inequalities, cancer policies should systematically encompass the inequities component.

Colorectal Cancer Screening in Castilla La Mancha, Spain: The Influence of Social, Economic, Demographic and Geographic Factors

Colorectal cancer (CRC) is a health problem with a significant social impact, accounting for 700,000 deaths a year globally. CRC survival rates are increasing as a result of early detection and improvements in society and labor conditions. Differences in CRC have been found depending on place of residence (urban or rural), socioeconomic situation and unemployment, although studies in this regard are limited. The aims of the present study were to determine whether differences exist in diagnostic delay according to place of residence, to analyze the association between socioeconomic level and colonoscopy results and to evaluate CRC risk according to place of residence, income level and unemployment. Retrospective, descriptive and observational study based on colonoscopies performed between May 2015 and November 2018, analyzing relationships between colonoscopy findings of a population screening program and various socioeconomic and demographic variables included in the study (sex, age, place of residence, average annual income, unemployment rate, etc.), and determining any association between such factors and related increases in adenocarcinoma risk. A total of 1422 patients were included in the study. The difference in participation according to sex was greater in rural population (63,4% men/36,6% women in rural areas, 58% men/42% women in urban areas). The mean delayed diagnosis was 59,26 days in both groups. Adenocarcinoma risk was 1.216 times higher in rural population. High-grade dysplasic lesions and adenocarcinoma were more common in municipalities with income < 9000€. However, advanced stage adenocarcinoma was higher in municipalities with income > 9000€. Adenocarcinoma risk was 1,088 times higher in municipalities with an unemployment rate of > 10%. Living in rural areas is not a barrier to access to health care, with no disadvantages identified regarding diagnosis and treatment, thanks to public health policies and the large number of small municipalities near the referral hospital in Cuenca.

Disparities in quality of life, social distress and employment outcomes in Australian cancer survivors

PURPOSE

To examine how socio-demographic, comorbidities and information needs influence quality of life (QoL) outcomes of survivors of breast, colorectal, or prostate cancer, non-Hodgkin lymphoma or melanoma.

METHODS

Cross-sectional postal survey with eligible participants identified through a population-based cancer registry. QoL outcomes were assessed by EQ-5D-5L, social difficulties index (SDI) and, for those employed at diagnosis, current employment. Regression analyses explored associations between outcome variables and cancer type, age, time since diagnosis, residential location, socio-economic disadvantage, comorbidities and unmet information needs. Mediation analyses examined whether comorbidities and information needs explained relationships between outcome variables and socio-economic disadvantage.

RESULTS

2115 survivors participated. Mean EQ-5D-5L scores (mean = 0.84) were similar to population averages and SDI scores were low for the entire sample (mean = 3.80). In multivariate analyses, being aged over 80, greater socio-economic disadvantage, comorbidities and unmet information needs decreased EQ-5D-5L scores. Higher SDI scores were associated with socio-economic disadvantage, comorbidities and unmet information needs. Not being employed was associated with being aged over 50, more comorbidities and socio-economic disadvantage. Comorbidities but not information needs partially mediated the impact of socio-economic disadvantage on EQ-5D-5L and SDI accounting for 17% and 14% of the total effect of socio-economic disadvantage respectively. Neither comorbidities nor information needs mediated the association between socio-economic disadvantage and employment outcomes.

CONCLUSIONS

To improve quality of life, survivorship care should be better tailored to address the needs of individuals given their overall health and impact of comorbidities, their age and type of cancer and not simply time since diagnosis.

Rural residence is related to shorter survival in epithelial ovarian cancer patients

OBJECTIVE

Rural residence has been related to health disparities and greater mortality risk in cancer patients, including gynecologic cancer patients. Lower survival rates for rural cancer survivors have been attributed to limited access to specialized healthcare, including surgery. Here, we examined whether a rural/urban survival gap existed in ovarian cancer patients receiving surgery at tertiary-care facilities, and potential causes for this gap, including educational attainment.

METHODS

Rural and urban patients with high grade invasive ovarian cancer (n = 342) seeking treatment at two midwestern tertiary-care university hospitals were recruited pre-surgery and followed until death or censoring date. Rural/urban residence was categorized using the USDA Rural-Urban Continuum Codes. Stratified Cox proportional hazards regression analyses, with clinical site as strata, adjusting for clinical and demographic covariates, were used to examine the effect of rurality on survival.

RESULTS

Despite specialized surgical care, rural cancer survivors showed a higher likelihood of death compared to their urban counterparts, HR = 1.39 (95% CI: 1.04, 1.85) p = 0.026, adjusted for covariates. A rurality by education interaction was observed (p = 0.027), indicating significantly poorer survival in rural vs. urban patients among those with trade school/some college education, adjusted HR = 2.49 (95% CI: 1.44, 4.30), p = 0.001; there was no rurality survival disparity for the other 2 levels of education.

CONCLUSIONS

Differences in ovarian cancer survival are impacted by rurality, which is moderated by educational attainment even in patients receiving initial care in tertiary settings. Clinicians should be aware of rurality and education as potential risk factors for adverse outcomes and develop approaches to address these possible risks.

Factors Explaining Socio-Economic Inequalities in Survival from Colon Cancer: A Causal Mediation Analysis

BACKGROUND

Socio-economic inequalities in colon cancer survival exist in high-income countries, but the reasons are unclear. We assessed the mediating effects of stage at diagnosis, comorbidities, and treatment (surgery and intravenous chemotherapy) on survival from colon cancer.

METHODS

We identified 2,203 people aged 15 to 79 years with first primary colon cancer diagnosed in Victoria, Australia, between 2008 and 2011. Colon cancer cases were identified through the Victorian Cancer Registry (VCR), and clinical information was obtained from hospital records. Deaths till December 31, 2016 (n = 807), were identified from Victorian and national death registries. Socio-economic disadvantage was based on residential address at diagnosis. For stage III disease, we decomposed its total effect into direct and indirect effects using interventional mediation analysis.

RESULTS

Socio-economic inequalities in colon cancer survival were not explained by stage and were greater for men than women. For men with stage III disease, there were 161 [95% confidence interval (CI), 67-256] additional deaths per 1,000 cases in the 5 years following diagnosis for the most disadvantaged compared with the least disadvantaged. The indirect effects through comorbidities and intravenous chemotherapy explained 6 (95% CI, -10-21) and 15 (95% CI, -14-44) per 1,000 of these additional deaths, respectively. Surgery did not explain the observed gap in survival.

CONCLUSIONS

Disadvantaged men have lower survival from stage III colon cancer that is only modestly explained by having comorbidities or not receiving chemotherapy after surgery.

IMPACT

Future studies should investigate the potential mediating role of factors occurring beyond the first year following diagnosis, such as compliance with surveillance for recurrence and supportive care services.

Trends of incidence, mortality and survival of multiple myeloma in Spain. A twenty-three-year population-based study

BACKGROUND

Despite major advances, multiple myeloma remains an incurable disease. Epidemiological data from high-quality population-based registries are needed to understand the heterogeneous landscape of the disease.

METHODS

Incidence, mortality and survival in multiple myeloma were comprehensively analyzed in the Girona and Granada population-based cancer registries, over a 23-year study (1994-2016), divided into three periods (1994-2001, 2002-2009 and 2010-2016). Joinpoint regression analysis was used to estimate the annual percentage change in incidence and mortality. Age-standardized net survival was calculated with the Pohar-Perme method.

RESULTS

1957 myeloma patients were included in the study, with a median age of 72 years. Age-standardized incidence and mortality rates decreased over time in both sexes and both rates were higher in males. Five-year age-standardized net survival by period was 27.4% (1994-2001), 38.8% (2002-2009), and 47.4% (2010-2016). Survival improved for all age groups: 32.4%, 74.1% and 78.5% for patients aged 15-49; 27.5%, 44.6%, and 58.5% for those aged 50-69; finally, 24.8%, 25.5%, and 26.3% for the older group.

CONCLUSION

Incidence remained overall stable throughout the study, with only a small increase for men. Mortality was progressively decreasing in both sexes. Both incidence and mortality were higher in men. Age plays a critical role in survival, with impressive improvement in patients younger than 70 years, but only a minor benefit in those older than 70.

Socioeconomic Status is Globally a Prognostic Factor for Overall Survival of Multiple Myeloma Patients: Synthesis of Studies and Review of the Literature

Background

Socioeconomic status (SES) is reflecting differences in sociodemographic factors affecting cancer survivorship. Deprived, low SES populations have a higher prevalence of multiple myeloma and worst survival, a condition which widens over time.

Methods

We performed a meta-analysis of 16 studies (registries and cohorts) reporting myeloma patients’ survival data according to SES. Ten studies reported Hazzard Ratio (H.R.) (95 % CI), and 16 studies reported p values. We combined the H.R. from 10 studies, and by using the Mosteller-Bush formula, we performed a synthesis of p values according to the area of the globe.

Results

Combination of H.R. from 10 studies including 85198 myeloma patients weighted to sample size of each study and adopting the hypothesis of random effect returned a combined H.R.: 1,26 (1,13–1,31) in favor of high SES patients.

USA: Synthesis of p values coming from 6 studies (n=89807 pts) by using the Mosteller and Bush formula extracted a p-value of <0.0001 favoring high SES patients.

Oceania: Synthesis of p values in two cohorts from Australia and New Zealand (n= 10196 pts) returned a p-value of 0,022 favoring high SES patients.

Europe: The synthesis of p values from the U.K. and Greece studies (n=18533 pts) returned a p-value of <0,0001 favoring high SES patients.

Asia: Synthesis of 2 studies from Asia (n=915 pts) returned a p-value of <0,0001 favoring high SES patients.

Conclusions

Across the globe and widening over decades, the socioeconomic status remains a gap for equality in myeloma care.

Early postoperative complications and 90-day mortality in patients undergoing radical cystectomy

Introduction: The standard treatment method of muscle-invasive bladder cancer is radical cystectomy. This complex procedure consists of removing the urinary bladder with distal ureters and regional lymph nodes. Additionally, the prostate with seminal vesicles in men and uterus with ovaries in women should be excised. Therefore, this demanding oncological surgery is associated with a high occurrence of complications. The aim of this study was to assess the complications after radical cystectomy and identify the factors associated with severe complications and high mortality rate. Materials/Methods: We retrospectively analyzed medical data of 213 patients who underwent a radical cystectomy. Preoperative risk factors were assessed based on American Society of Anesthesiologists classification (ASA) and the Charlson Comorbidity Index (CCI). Clavien-Dindo classification was also included in our analysis. We investigated various factors associated with 30-day and 90-day mortality. Results: Complications after surgery were reported in 38% (n = 81) of patients in the studied group. Excluding perioperative high fever, the complication rate was 18%. The following complications were observed in 30-day postoperative period: wound infection (n = 6), wound dehiscence (n = 4), mechanical bowel obstruction (n = 3), hemorrhage (n = 2), cardiological (n = 8), stroke (n = 3). Observed 30-day mortality was 2.3% (n = 5), while 90-day mortality was 8.9% (n = 19). The mortality rate was associated with the stage of cancer and the type of urinary diversion. Conclusions: Radical cystectomy is a complex and traumatic urological surgery. It is associated with a significant complication rate and mortality, and it negatively affects quality of life. Therefore, all known risk factors should be thoroughly assessed preoperatively to select optimal treatment. Furthermore, the patient should be carefully informed about the risks associated with the surgery.

Deprivation gap in colorectal cancer survival attributable to stage at diagnosis: A population-based study in Spain

OBJECTIVE

Socioeconomic inequalities in colorectal cancer (CRC) survival are a major concern of the Spanish public health system. If these inequalities were mainly due to differences in stage at diagnosis, population-based screening programs might reduce them substantially. We aimed to determine to what extent adverse stage distribution contributed to survival inequalities in a Spanish region before the implementation of a CRC screening program.

METHODS

We analyzed data from a population-based cohort study that included all patients living in a region of southern Spain with CRC diagnosed between 2004 and 2013. The European Deprivation Index was used to assign each patient a socioeconomic level based on their area of residence. The role of tumor stage in survival disparities between socioeconomic groups was assessed using a causal mediation analysis.

RESULTS

A total of 2802 men and 1957 women were included in the study. For men, the adjusted difference in deaths between the most deprived and the most affluent areas was 131 deaths per 1000 person-years by the first year after diagnosis. Of these deaths, 42 (per 1000 person-years) were attributable to differences in stage at diagnosis. No socioeconomic disparities in survival were detected among female patients.

CONCLUSIONS

In this study, we mainly detected socioeconomic disparities in short term survival of male patients. More than two thirds of these inequalities could not be attributed to differences in stage at diagnosis. Our results suggest that in addition to a screening program, other public health interventions are necessary to reduce the deprivation gap in survival.