Compression, expansion, or maybe both? Growing inequalities in lung cancer in Germany

[How has life expectancy without functional limitations developed in Germany? An analysis with data from the German Ageing Survey (DEAS)]

INTRODUCTION

The long-term increase in life expectancy raises the question of whether the increased life expectancy is accompanied by an extension of years without health limitations. The study analyzes how life expectancy without functional and mobility limitations from the ages of 46 and 65 and their proportions of remaining life expectancy have changed since 2008.

METHODS

We analyze data from the German Ageing Survey of the 2008, 2014, and 2020/21 waves. Life expectancy without functional limitations (disability-free life expectancy-DFLE) was calculated using the Sullivan method. Severe functional limitations (using the Global Activity Limitation Indicator-GALI) and mobility limitations (climbing stairs, walking more than 1 km) were examined.

RESULTS

Compression of morbidity in the GALI has been observed in 46- and 65-year-old men since 2014, but not in women of the same age. In terms of mobility, 46- and 65-year-old men show trends towards compression when climbing stairs and 46-year-old men when walking more than 1 km since 2014. The values for women have stagnated for the first two indicators mentioned, but not for 46-year-old women since 2014 when walking more than 1 km.

DISCUSSION

Our analyses show different trends in DFLE depending on the indicator, age, and gender and do not allow a clear answer to the question of morbidity compression or expansion. We tend to see morbidity compression in men, whereas trends of stagnation or expansion tend to be seen in women. These results signal challenges in maintaining functional health, especially in women, and point to the need for targeted interventions to improve quality of life and healthy life expectancy.

Time trends in limited lung function among German middle-aged and older adults

Limited lung function represents a serious health impairment. However, studies investigating changes in limited lung function over time are rare. Thus, the current study investigates time-related changes in limited lung function and potential social inequalities. Data from the 2008 and 2017 waves of the population-based German Aging Survey were used in a repeated cross-sectional study design (N = 8778), including participants aged 40 years and older. Lung function was assessed by the peak flow test. Socio-economic indicators included educational attainment, income and occupational group. Additionally, smoking history, occupational exposure to fumes and gases, and physical exercise were used as potentially explanatory variables for the observed changes. We found that the prevalence of limited lung function decreased strongly over time on a descriptive level from 9.0 to 5.4%. In line with these results, a decreasing trend emerged (OR = 0.48) when controlling for age and gender differences. When additionally controlling for changes in socio-economic indicators and explanatory variables there were still significant decreases over time, but the decline was slightly reduced (OR = 0.57). Moreover, similar significant relative decreases over time occurred for middle-aged and older participants, female and male participants, and those belonging to the different socio-economic groups. Thus, limited lung function generally decreased over time. This decrease could partially be explained by beneficial developments in socio-economic indicators, smoking, occupational exposures, and physical exercise. Future studies might investigate how changes in medicinal treatment and prevention efforts have contributed to the observed beneficial trends in lung health.

Widening area-based socioeconomic inequalities in cancer mortality in Germany between 2003 and 2019

Cancer mortality has declined in recent decades, but-due to a lack of national individual-level data-it remains unclear whether this applies equally to all socioeconomic groups in Germany. Using an area-based approach, this study investigated socioeconomic inequalities in cancer mortality and their secular trends on a German nationwide scale for the first time. Official cause-of-death data from 2003 to 2019 were linked to the district-level German Index of Socioeconomic Deprivation. Age-standardised mortality rates for all cancers combined and the most common site-specific cancers were calculated according to the level of regional socioeconomic deprivation. To quantify the extent of area-based socioeconomic inequalities in cancer mortality, absolute (SII) and relative (RII) indices of inequality were estimated using multilevel Poisson models. On average, cancer mortality was 50% (women) and 80% (men) higher in Germany's most deprived than least deprived districts (absolute difference: 84 deaths per 100,000 in women and 185 deaths per 100,000 in men). As declines in cancer mortality were larger in less deprived districts, the socioeconomic gap in cancer mortality widened over time. This trend was observed for various common cancers. Exceptions were cancers of the lung in women and of the pancreas in both sexes, for which mortality rates increased over time, especially in highly deprived districts. Our study provides first evidence on increasing socioeconomic inequalities in cancer mortality on a nationwide scale for Germany. Area-based linkage allows to examine socioeconomic inequalities in cancer mortality across Germany and identify regions with high needs for cancer prevention and control.

Trends in cancer-free working life expectancy based on health insurance data from Germany-Is the increase as strong as in working life expectancy?

BACKGROUND

Against the backdrop of population ageing, governments are facing the need to raise the statutory retirement age. In this context, the question arises whether these extra years added to working life would be spent in good health. As cancer represents a main contributor to premature retirement this study focuses on time trends and educational inequalities in cancer-free working life expectancy (WLE).

METHODS

The analyses are based on the data of a large German health insurer covering annually about 2 million individuals. Cancer-free WLE is calculated based on multistate life tables and reported for three periods: 2006-2008, 2011-2013, and 2016-2018. Educational inequalities in 2011-2013 were assessed by two educational levels (8 to 11 years and 12 to 13 years of schooling).

RESULTS

While labour force participation increased, cancer incidence rates decreased over time. Cancer-free WLE at age 18 increased by 2.5 years in men and 6.3 years in women (age 50: 1.3 years in men, 2.4 years in women) between the first and third period while increases in WLE after a cancer diagnosis remained limited. Furthermore, educational inequalities are substantial, with lower groups having lower cancer-free WLE. The proportion of cancer-free WLE in total WLE remained constant in women and younger men, while it decreased in men at higher working age.

CONCLUSION

The increase in WLE is accompanied by an increase in cancer-free WLE. However, the subgroups considered have not benefitted equally from this positive development. Among men at higher working age, WLE increased at a faster pace than cancer-free WLE. Particular attention should be paid to individuals with lower education and older men, as the general level and time trends in cancer-free WLE are less favourable.

German Index of Socioeconomic Deprivation (GISD): Revision, update and applications

Background

Regional deprivation indices enable researchers to analyse associations between socioeconomic disadvantages and health outcomes even if the health data of interest does not include information on the individuals' socioeconomic position. This article introduces the recent revision of the German Index of Socioeconomic Deprivation (GISD) and presents associations with life expectancy as well as age-standardised cardiovascular mortality rates and cancer incidences as applications.

Methods

The GISD measures the level of socioeconomic deprivation using administrative data of education, employment, and income situations at the district and municipality level from the INKAR database. The indicators are weighted via principal component analyses. The regional distribution is depicted cartographically, regional level associations with health outcomes are presented.

Results

The principal component analysis indicates medium to high correlations of the indicators with the index subdimensions. Correlation analyses show that in districts with the lowest deprivation, the average life expectancy of men is approximately six years longer (up to three years longer for women) than for those from districts with the highest deprivation. A similar social gradient is observed for cardiovascular mortality and lung cancer incidence.

Conclusions

The GISD provides a valuable tool to analyse socioeconomic inequalities in health conditions, diseases, and their determinants at the regional level.

Compression and Expansion of Morbidity

BACKGROUND

Morbidity is said to be compressed when the interval from the onset of a disease or disability to death becomes shorter over time, or when the incidence of the disease or disability declines over time. In the reverse situation, morbidity is said to be expanded.

METHODS

This review is based on national and international studies retrieved by a selective literature search on secular trends in morbidity and mortality. The findings were derived from data from surveys and registries, and from the routine data of health insurance carriers.

RESULTS

Three different types of secular trends in morbidity were seen. For some diseases (e.g., lung cancer, stroke, and dementia), morbidity among the elderly was compressed over time. On the other hand, for multimorbidity and type 2 diabetes including comorbidities, morbidity expanded over time. Unexpectedly, a double development was seen in certain other conditions, with both compression among the elderly and expansion among the middle-aged: this was particularly so for myo - cardial infarction, grip strength, and indicators of general health.

CONCLUSION

The notion of morbidity being reduced by compression seems less tenable in view of the double development just mentioned. The findings suggest that the observed secular trend toward better health among the elderly has not persisted among the more recently born cohorts. This can have negative effects on social security systems, particularly with respect to retirement ages being deferred or made more flexible, as well as the cost of health care.

Evolution of socioeconomic inequalities in cancer incidence between 2006 and 2016 in France: a population-based study

OBJECTIVE

The existence of socioeconomic inequalities in cancer incidence is now well established and their reduction is a priority in many countries. This study aimed to measure the evolution of socioeconomic inequalities in the incidence of the most common cancers in France, over an 11-year period.

METHODS

The study focused on 19 cancer entities (16 solid tumors and 3 hematological malignancies). Data are obtained from the French Network of Cancer Registries, representing 604 205 cancer cases. Each patient address was geolocalized and assigned to an IRIS, the smallest geographic unit in France. The French version of the European Deprivation Index was used to measure the level of deprivation in each IRIS. A generalized linear mixed model was used to account for the longitudinal nature of the data and to assess the evolution of socioeconomic inequalities.

RESULTS

A significant evolution of the social gradient of incidence over time was highlighted for five cancer entities and all entities combined. For lung cancer for both sexes and bladder cancer in men, more frequent in deprived areas, the social gradient in incidence tended to decrease over time. For breast cancer in women and lymphocytic leukemia in men, more frequent in affluent areas, the gap continues to widen.

CONCLUSION

Cancer entities with large disparities continued to present social inequalities in incidence without exacerbation with time. The few temporal evolutions observed do not show a worsening of the social gradient of incidence to the disadvantage of the most deprived areas, but rather an increase in incidence that is greater in the most affluent areas.

Living longer, working longer: analysing time trends in working life expectancy in Germany from a health perspective between 2002 and 2018

Population ageing poses growing challenges to social security systems, in particular to public pension funds. The study analyses how Working Life Expectancy (WLE) and Healthy Working Life Expectancy (HWLE) in terms of three health indicators developed in Germany. Based on the German Socio-Economic Panel (GSOEP) from 2002 to 2018 (n = 211,141), time trends in labour force rates, mental and physical Health-Related Quality of Life (HRQoL), self-rated health (SRH) and the respective combinations (health indicator*labour force) were analysed for all respondents aged 18-74. WLE and HWLE were calculated using the Sullivan method. WLE and HWLE in men and women at age 18 and 50 clearly increased over time. These increases in HWLE were found in terms of all three health indicators. This development was mainly driven by the clear increase of the labour force rates, since the shares of individuals with good and satisfactory SRH or average and good HRQoL remained largely stable over time. The results show that from a health perspective there have been potentials for increases in WLE during the past two decades and that increasingly more healthy life years are spent economically active. However, life years in the labour force but in poor health have increased, too. The absence of clear improvements in health emphasises the importance of current and future preventive measures to maintain health, especially among the middle-aged and older labour force.

Time Trends and Income Inequalities in Cancer Incidence and Cancer-Free Life Expectancy - a Cancer Site-Specific Analysis of German Health Insurance Data

Cancer represents a major burden of morbidity and mortality globally. So far, however, little is known on time trends and inequalities in the lengths of life spent free of any cancer. This study steps into this gap by analyzing time trends and income inequalities in cancer-free life expectancy (CFLE). For this retrospective cohort study, data of a large German health insurer were used (N = 3,405,673individuals, 2006-2018). Income inequalities were assessed using individual income (<60% of German average income (GAI) and ≥60% of GAI). Trends in incidence risks were analysed employing proportional-hazard regression models by splitting the observation time into three periods of 52 months. Trends in CFLE in total and for the most common site-specific cancers were calculated based on multiple decrement life tables. Incidence rates declined in almost all cancers and CFLE increased substantially over time (49.1 (95% CI 48.8-49.4) to 51.9 (95% CI 51.6-52.2) years for men, 53.1 (95% CI 52.7-53.5) to 55.4 (95% CI 55.1-55.8) years for women at age 20 for total cancer) and income groups. Considerable income inequalities in cancer risks were evident in both sexes, but were more pronounced in men (total cancer HR 0.86 (95% CI 0.85-0.87)), with higher-income individuals having lower risks. The highest income inequalities were found in colon (HR 0.90 (95% CI 0.87-0.93)), stomach (HR 0.78 (95% CI 0.73-0.84)), and lung cancer (HR 0.58 (95% CI 0.56-0.60)) in men. A reverse gradient was found for skin (HR 1.39 (95% CI 1.30-1.47) men; HR 1.27 (95% CI 1.20-1.35) women) and prostate cancer (HR 1.13 (95% CI 1.11-1.15)). The proportion of CFLE in total life expectancy declined for lung, skin and cervical cancer in women, indicating a relative shortening of lifetime spent cancer-free. In contrast, increasing proportions were found in breast and prostate cancer. To our knowledge, this is the first study analysing trends and income inequalities in CFLE. The life span free of cancer increased clearly over time. However, not all cancer types contributed equally to this positive development. Income inequalities persisted or tended to widen, which underlines the need for increased public health efforts in socioeconomically vulnerable groups.

Integration of rapid PCR testing as an adjunct to NGS in diagnostic pathology services within the UK: evidence from a case series of non-squamous, non-small cell lung cancer (NSCLC) patients with follow-up

AIMS

Somatic genetic testing in non-squamous, non-small cell lung carcinoma (NSCLC) patients is required to highlight subgroups eligible for a number of novel oncological therapies. This study aims to determine whether turnaround times for reporting epidermal growth factor receptors (EGFR) by next-generation sequencing (NGS) alone is sufficient to meet the needs of lung cancer patients.

METHODS

We performed a retrospective case series with follow-up. Outcomes of EGFR testing (102 tests) in 96 patients by NGS were compared with a rapid, fully automated PCR-based platform (Idylla) in local histopathology laboratories.

RESULTS

Turnaround time for reporting NGS was 17 calendar days. Reporting using the Idylla EGFR Mutation Test, by contrast, gave a potential turnaround time of 3.8 days from request to authorisation. Three-quarters of patients presenting with stage IV disease had a performance status of 0, 1, or 2 but 18% experienced rapid clinical deterioration (p<0.05). A third of these patients were deceased by the time NGS reports were available.

CONCLUSIONS

We discuss issues around integrating rapid PCR testing alongside NGS in multidisciplinary care pathways and strategies for mitigating against foreseeable difficulties. Dual testing for stage IV non-squamous, NSCLC patients has the potential to improve care and survival outcomes by providing access to the right test at the right time.

Socioeconomic inequalities in lung cancer - a time trend analysis with German health insurance data

BACKGROUND

Lung Cancer (LC) is one of the most prevalent cancer diseases. Due to the lack of databases which allow the combination of information on individual socioeconomic status (SES) and cancer incidence, research on social inequalities in LC among the German population is rare. The aim of the study is to analyse time trends in social inequalities in LC in Germany.

METHODS

The analyses are based on data of a large statutory health insurance provider. The data contain information on diagnoses, occupation and education (working age), and income (full age range) of the insurance population. Trends were analysed for two subpopulations (retirement age and working age) and stratified by sex. The analyses are based on incidence rates and proportional hazard models spanning the periods 2006-2009, 2010-2013 and 2014-2017.

RESULTS

Incidence rates declined in men but increased in women. For men, inequalities were strongest in terms of income and the decline in incidence was most pronounced in middle- and higher-income men. Among women at retirement age, a reversed income gradient was found which disappeared in the second period. The educational gradient among the working-age population decreased over time due to the trend towards increasing incidence among individuals with higher education. Declining gradients were also found for occupational position.

CONCLUSION

The findings reveal considerable inequalities in LC and that trends vary with respect to SES, sex and age. Widening income inequalities were found in the retired population, while educational and occupational inequalities tend to narrow among the working-age population.