Socio-Economic Position, Cancer Incidence and Stage at Diagnosis: A Nationwide Cohort Study in Belgium

Breast cancer incidence, stage distribution, and treatment shifts during the 2020 COVID-19 pandemic: a nationwide population-level study

BACKGROUND

The first COVID-19 wave in 2020 necessitated temporary suspension of non-essential medical services including organized cancer screening programs in Belgium. This study assessed the impact of the pandemic on breast cancer (BC) incidence, stage at diagnosis, and management in Belgium in 2020.

METHODS

All Belgian residents diagnosed with in situ or invasive BC in 2015-2020 in the nationwide, population-based cancer registry database were included. Incidence trends for 2015-2019 were extrapolated to predict incidence and stage distribution for 2020 and compared with the observed values. National healthcare reimbursement data were used to examine treatment strategies. Exact tumor diameter and nodal involvement, extracted from pathology reports, were analyzed for 2019 and 2020.

RESULTS

74,975 tumors were selected for analysis of incidence and clinical stage. Invasive BC incidence declined by -5.0% in 2020, with a drop during the first COVID-19 wave (Mar-Jun; -23%) followed by a rebound (Jul-Dec; +7%). Predicted and observed incidence (in situ + invasive) was not different in patients < 50 years. In the 50-69 and 70 + age groups, significant declines of -4.1% and - 8.4% respectively were found. Excess declines were seen in clinical stage 0 and I in Mar-Jun, without excess increases in clinical stage II-IV tumors in Jul-Dec. There was no increase in average tumor diameter or nodal involvement in 2020. Patients diagnosed in Mar-Jun received significantly more neoadjuvant therapy, particularly neoadjuvant hormonal therapy for patients with clinical stage I-II BC.

CONCLUSIONS

BC incidence decline in 2020 in Belgium was largely restricted to very early-stage BC and patients aged 50 and over. Delayed diagnosis did not result in an overall progression to higher stage at diagnosis in 2020. Observed treatment adaptations in Belgium were successful in prioritizing patients for surgery while preventing tumor progression in those with surgical delay. Continuation of monitoring BC incidence and stage in the future is crucial.

Survey of Danish Head and Neck Cancer Patients' Positions on Personalized Medicine, Gene Tests, and Personalized Follow-Up

The field of personalized medicine (PM) has grown rapidly because of the "omics revolution", but PM may be difficult for patients to comprehend. This study sought to explore head and neck cancer (HNC) patients' positions and knowledge of PM, gene tests, and follow-up and to compare HNC patients' positions to a sample from a national Danish questionnaire. To do this, patients with prior HNC were invited to participate in a questionnaire. Initial interviews revealed a heterogenic understanding of PM between patients. A total of 226 patients were included in the survey and 177 patients with complete data were included for analysis. Most patients were more positive than negative towards gene tests and gene research (83% and 93%, respectively), but 72% had little or no knowledge of the subject. Almost all patients, 98%, were satisfied with their follow-up. Significantly more patients with HNC were positive towards gene research compared to a sample from a national Danish questionnaire (p < 0.001). Patients with HNC were positive towards gene tests and PM, but patients may not understand or comprehend the information given, and it is important to inform and educate patients and health professionals to establish common ground in PM.

Socio-demographic inequalities in stage at diagnosis of lung cancer: A French population-based study

BACKGROUND

Diagnosing patients at a non-advanced stage has become a mainstay of lung cancer prevention and control strategies. Understanding socio-demographic inequalities in stage at diagnosis may improve the targeting of interventions on patients at higher risk. This study aimed to identify these socio-demographic determinants in a large-scale French population-based cancer registry.

METHODS

All incident lung cancers diagnosed between 2008 and 2019 identified from the Poitou-Charentes Cancer Registry (south-west France) were included. Stage at diagnosis was categorised as advanced/non-advanced (TNM III/IV vs I/II) according to the 8th TNM edition, the objective being to ensure a consistent level of prognosis over time. Socio-demographic variables included age, sex, the French European Deprivation Index (EDI) and patient's place of residence. Their impact on stage at diagnosis was quantified by multivariate logistic regression models with subgroup analyses by histological subtype.

RESULTS

Out of the 15,487 included patients, 75% were diagnosed at an advanced stage (66% to 95% depending on the histological subtype), 17% at a non-advanced stage and 10% at a non-specified stage. Multivariate analysis showed different patterns according to histological subtypes. In patients with adenocarcinoma, a higher risk of advanced stage was found for younger and older patients (u-shape), those most deprived, and those living in rural areas. The same effect of age was reported for squamous cell carcinomas, while no association was found for small-cell lung carcinomas.

CONCLUSIONS

This study highlighted substantial socio-demographic inequalities in stage at diagnosis, specifically for adenocarcinoma patients. Diagnosis strategies could be refined and strengthened in the non-smoker population, in which adenocarcinomas are mainly reported.

Socioeconomic and geographic disparities of breast cancer incidence according to stage at diagnosis in France

PURPOSE

Low socioeconomic background (SB) has been associated with lower breast cancer (BC) incidence and higher BC mortality. One explanation of this paradox is the higher frequency of advanced BC observed in deprived women. However, it is still unclear if SB affects similarly BC incidence. This study investigated the link between SB and early/advanced BC incidence from Loire-Atlantique/Vendee Cancer registry data (France).

MATERIALS AND METHODS

Fourteen thousand three hundred fifty three women living in the geographic area covered by the registry and diagnosed with a primary BC in 2008-2015 were included. SB was approached by a combination of two ecological indexes (French European Deprivation Index and urban/rural residence place). Mixed effects logistic and Poisson regressions were used, respectively, to estimate the odds of advanced (stage ≥ II) BC and the ratio of incidence rates of early (stage 0-I) and advanced BC according to SB, overall and by age group (< 50, 50-74, ≥ 75).

RESULTS

Compared to women living in affluent-urban areas, women living in deprived-urban and deprived-rural areas had a higher proportion of advanced BC [respectively, OR = 1.11 (1.01-1.22), OR = 1.60 (1.25-2.06)] and lower overall (from - 6 to - 15%) and early (from - 9 to - 31%) BC incidences rates Advanced BC incidence rates were not influenced by SB. These patterns were similar in women under 75 years, especially in women living in deprived-rural areas. In the elderly, no association between SB and BC frequency/incidence rates by stage was found.

CONCLUSION

Although advanced BC was more frequent in women living in deprived and rural areas, SB did not influence advanced BC incidence. Therefore, differences observed in overall BC incidence according to SB were only due to higher incidence of early BC in affluent and urban areas. Future research should confirm these results in other French areas.

Exploring the association of PM2.5 with lung cancer incidence under different climate zones and socioeconomic conditions from 2006 to 2016 in China

Air pollution generated by urbanization and industrialization poses a significant negative impact on public health. Particularly, fine particulate matter (PM2.5) has become one of the leading causes of lung cancer mortality worldwide. The relationship between air pollutants and lung cancer has aroused global widespread concerns. Currently, the spatial agglomeration dynamic of lung cancer incidence (LCI) has been seldom discussed, and the spatial heterogeneity of lung cancer's influential factors has been ignored. Moreover, it is still unclear whether different socioeconomic levels and climate zones exhibit modification effects on the relationship between PM2.5 and LCI. In the present work, spatial autocorrelation was adopted to reveal the spatial aggregation dynamic of LCI, the emerging hot spot analysis was introduced to indicate the hot spot changes of LCI, and the geographically and temporally weighted regression (GTWR) model was used to determine the affecting factors of LCI and their spatial heterogeneity. Then, the modification effects of PM2.5 on the LCI under different socioeconomic levels and climatic zones were explored. Some findings were obtained. The LCI demonstrated a significant spatial autocorrelation, and the hot spots of LCI were mainly concentrated in eastern China. The affecting factors of LCI revealed an obvious spatial heterogeneity. PM2.5 concentration, nighttime light data, 2 m temperature, and 10 m u-component of wind represented significant positive effects on LCI, while education-related POI exhibited significant negative effects on LCI. The LCI in areas with low urbanization rates, low education levels, and extreme climate conditions was more easily affected by PM2.5 than in other areas. The results can provide a scientific basis for the prevention and control of lung cancer and related epidemics.

Stage shift and relative survival for head and neck cancer during the 2020 COVID-19 pandemic: a population-based study of temporal trends

Objective

During the first wave of the COVID-19 pandemic in 2020, non-essential health services were suspended in Belgium, and the public was ordered to socially isolate. Underdiagnosis of cancer during this period was reported worldwide. Certain risk factors for head and neck cancer (HNC) overlap with those for COVID-19 incidence and mortality, making underdiagnosis and subsequent stage shift of this potentially rapidly progressing cancer a major concern. We aimed to analyze incidence, clinical stage at presentation, and survival of patients diagnosed with HNC in 2020 in Belgium, considering recent temporal trends.

Methods

Using population-based data from the Belgian Cancer Registry (BCR), we extrapolated 2017-2019 trends in incidence, clinical stage, and 1-year relative survival (1yRS) of HNC to create an expected value for 2020 and compared this to the observed value.

Results

There were 9.5% fewer HNCs diagnosed in 2020, compared to the predicted incidence. Underdiagnosis was larger for males (-11.8%), patients aged 50-64 (-11.2%) and 65-79 (-11.1%), and for oral cavity cancer (-17.6%). Shifts to more advanced stages were observed in larynx and oropharynx tumors and for (male) patients aged 80+. A 2.4 percentage point decline in 1yRS was observed, relative to the increasing trends in 1yRS (2017-2019).

Conclusion

The COVID-19 pandemic led to underdiagnosis of HNC, resulting in shifts to more advanced stage at presentation in certain subgroups. A stage shift can be expected for the 9.5% of tumors not yet diagnosed at the end of 2020. HNC patients diagnosed in 2020 suffered higher than expected mortality.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Racial/Ethnic Disparities in Cervical Cancer Stage at Diagnosis: Mediating Effects of Neighborhood-level Socioeconomic Deprivation

BACKGROUND

Mortality from cervical cancer has declined steadily in the United States over the past several decades due to widespread screening for precancerous and early-stage cervical cancer (ECC), which are significantly easier to treat compared with late-stage cervical cancer (LCC). Unequal screening access continues to cause significant racial/ethnic disparities in cervical cancer diagnosis stage. This study examined the underlying role of neighborhood-level socioeconomic disadvantage as a potential mediator of the association between race/ethnicity and cervical cancer diagnosis stage.

METHODS

We analyzed Texas Cancer Registry data for cervical cancer cases diagnosed among women ages 18 or older from 2010 to 2018. We performed causal mediation analyses of the association between race/ethnicity and cervical cancer stage at diagnosis mediated by neighborhood-level socioeconomic disadvantage.

RESULTS

Of the 9,192 women with cervical cancer, 4,720 (51.3%) had LCC at diagnosis. Compared with non-Hispanic white (NHW) women (106.13, standard deviation (SD) = 13.32), non-Hispanic Black (NHB; 111.46, SD = 9.55) and Hispanic (112.32, SD = 9.42) women had higher area deprivation index (ADI) and had greater odds of LCC diagnosis [total effects: adjusted odds ratios (AOR) = 1.29 (95% CI, 1.11-1.46) and AOR 1.14 (95% CI, 1.03-1.25), respectively]. Approximately 34.7% and 71.6% of the disparity in LCC diagnosis were attributable to higher neighborhood socioeconomic disadvantage among NHB and Hispanic women, respectively.

CONCLUSIONS

LCC disparity varied by race/ethnicity and was partly attributable to neighborhood disadvantage. The disparity among Hispanic women due to neighborhood deprivation was twice as high among NHB women.

IMPACT

Findings may be used to develop targeted race- and place-specific interventions to improve cancer care equity.

Long-term exposure to residential green spaces and site-specific cancer mortality in urban Belgium: A 13-year follow-up cohort study

BACKGROUND

Residing in greener areas may decrease the burden of chronic diseases, but the association with cancer is unclear. We studied the associations between residential green spaces and site-specific cancer mortality in urban Belgium.

METHODOLOGY

We linked the 2001 Belgian census, register mortality data for 2001-2014, and environmental information (green spaces and air pollution) at baseline residence (2001). We included residents from the largest Belgian urban areas aged ≥ 30 years at baseline. Exposure to residential green spaces was assessed using the Normalized Difference Vegetation Index (NDVI), Urban Atlas, and perceived neighbourhood greenness (from the census). We used Cox proportional hazards models to obtain hazard ratios (HR) and their 95 % confidence intervals (95 %CI) of the mortality risk from lung, colorectal, breast (in women) and prostate cancer (in men) per interquartile range increment in residential green spaces. We further analyzed the role of outdoor air pollution and effect modification by age and socioeconomic position (SEP) in main associations.

RESULTS

2,441,566 individuals were included at baseline. During follow-up, 1.2 % died from lung cancer, 0.6 % from colorectal cancer, 0.8 % from breast cancer, and 0.6 % from prostate cancer. After adjustment, higher exposure to green spaces was associated with a reduced mortality risk from lung cancer and breast cancer [e.g., for NDVI within 300 m, HR:0.946 (95 %CI:0.924,0.970), and HR:0.927 (95 %CI:0.892,0.963), respectively], but not with colorectal or prostate cancer mortality. For the latter, a suggestive hazardous effect of green spaces was found. Air pollution seemed to have only a marginal role. Beneficial effects of greenspace were generally stronger in < 65-year-old, but no clear trend by SEP was found.

CONCLUSIONS

Our findings suggest that residing in green areas could decrease mortality risk from lung and breast cancer, potentially independent from air pollution. Future studies should consider different indicators of greenspace exposure and investigate potential pathways underlying the associations.

The association between sociodemographic factors and time to diagnosis for colorectal cancer in northern Sweden

OBJECTIVES

This study examined whether sociodemographic factors, including distance to hospital, were associated with differences in the diagnostic interval and the treatment interval for colorectal cancer in northern Sweden.

METHODS

Data were retrieved from the Swedish cancer register on patients (n = 446) diagnosed in three northern regions during 2017-2018, then linked to data from Statistics Sweden and medical records. Also, Google maps was used to map the distance between patients' place of residence and nearest hospital. The different time intervals were analysed using Mann-Whitney U-test and Cox regression.

RESULTS

Differences in time to diagnosis were found between groups for income and distance to hospital, favouring those with higher income and shorter distance. The unadjusted regression analysis showed higher income to be associated with more rapid diagnosis (HR 1.004, CI 1.001-1.007). This association remained in the fully adjusted model for income (HR 1.004, CI 1.000-1.008), but not for distance. No differences between sociodemographic groups were found in the treatment interval.

CONCLUSION

Higher income and shorter distance to hospital were in the unadjusted models associated with shorter time to diagnosis for patients with CRC in northern Sweden. The association remained for income when adjusting for other variables even though the difference was small.

Temporal trends and factors associated with the cancer diagnosed at stage IV in patients included in the integrated hospital-based cancer registry system in Brazil in two decades

BACKGROUND

In several countries, such as Brazil, the oncological diagnosis usually occurs at an advanced stage of the disease. Thus, the aim of this study was to investigate temporal trends and factors associated with the cancer diagnosed at stage IV in Brazil in two decades.

METHODS

Secondary-based study, with time series analysis for trend assessment and cross-sectional of factors associated with diagnosis of female breast, prostate, cervix uteri, colorectal, lung, stomach, lip and oral cavity, thyroid, esophagus or corpus uteri at stage IV.

RESULTS

1,218,322 cases were evaluated. The types of cancer with the highest proportion of stage IV at diagnosis in men and women, respectively, were: lung (53.7% and 57.4%), stomach (48.4% and 45.0%) and lip/oral cavity (53.5% and 43.4%). Most showed an increasing trend of annual percent change of cancer diagnosed at stage IV, being more pronounced in corpus uteri cancer (2013-2019: +7.4%, p < 0.001). The odds of cancer diagnosed at stage IV were associated with different factors, according to primary tumor site, but marked by the inverse association with female sex [odds ratio (OR) ranging from 0.42 to 0.91, p < 0.001] and direct association in cases with < 7 years of study (OR ranging from 1.08 to 1.81, p < 0.001), living without a partner (OR ranging from 1.06, p < 0.050 to1.27, p < 0.001), living in the South and Southeast regions (OR ranging from 1.04 to 1.13, p < 0.001), with more than one tumor (OR ranging from 1.19, p < 0.050 to 1.54, p < 0.001) and treated in Centers of High Complexity in Oncology (OR ranging from 1.03, p < 0.050 to1.24, p < 0.001).

CONCLUSION

There was a high frequency of cancer diagnosed at stage IV and an increasing trend in different cancer types, which were associated with distinct sociodemographic, lifestyle, and clinical factors.

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.

Real-World Estimation of First- and Second-Line Treatments for Diffuse Large B-Cell Lymphoma Using Health Insurance Data: A Belgian Population-Based Study

We determined first- and second-line regimens, including hematopoietic stem cell transplantations, in all diffuse large B cell lymphoma (DLBCL) patients aged ≥20 yr (n = 1,888), registered at the Belgian Cancer Registry (2013–2015). Treatments were inferred from reimbursed drugs, and procedures registered in national health insurance databases. This real-world population-based study allows to assess patients usually excluded from clinical trials such as those with comorbidities, other malignancies (12%), and advanced age (28% are ≥80 yr old). Our data show that the majority of older patients are still started on first-line regimens with curative intent and a substantial proportion of them benefit from this approach. First-line treatments included full R-CHOP (44%), “incomplete” (R-)CHOP (18%), other anthracycline (14%), non-anthracycline (9%), only radiotherapy (3%), and no chemo-/radiotherapy (13%), with significant variation between age groups. The 5-year overall survival (OS) of all patients was 56% with a clear influence of age (78% [20–59 yr] versus 16% [≥85 yr]) and of the type of first-line treatments: full R-CHOP (72%), other anthracycline (58%), “incomplete” (R-)CHOP (47%), non-anthracycline (30%), only radiotherapy (30%), and no chemo-/radiotherapy (9%). Second-line therapy, presumed for refractory (7%) or relapsed disease (9%), was initiated in 252 patients (16%) and was predominantly (71%) platinum-based. The 5-year OS after second-line treatment without autologous stem cell transplantation (ASCT) was generally poor (11% in ≥70 yr versus 17% in <70 yr). An ASCT was performed in 5% of treated patients (n = 82). The 5-year OS after first- or second-line ASCT was similar (69% versus 66%). After adjustment, multivariable OS analyses indicated a significant hazard ratio (HR) for, among others, age (HR 1.81 to 5.95 for increasing age), performance status (PS) (HR 4.56 for PS >1 within 3 months from incidence), subsequent malignancies (HR 2.50), prior malignancies (HR 1.34), respiratory and diabetic comorbidity (HR 1.41 and 1.24), gender (HR 1.25 for males), and first-line treatment with full R-CHOP (HR 0.41) or other anthracycline-containing regimens (HR 0.72). Despite inherent limitations, patterns of care in DLBCL could be determined using an innovative approach based on Belgian health insurance data.