Area-Based Socio-Economic Inequalities in Mortality from Lung Cancer and Respiratory Diseases

Socio-economic inequalities in lung cancer mortality in Spain: a nation-wide study using area-based deprivation

BACKGROUND

Lung cancer is the main cause of cancer mortality worldwide and in Spain. Several previous studies have documented socio-economic inequalities in lung cancer mortality but these have focused on specific provinces or cities. The goal of this study was to describe lung cancer mortality in Spain by sex as a function of socio-economic deprivation.

METHODS

We analysed all registered deaths from lung cancer during the period 2011-2017 in Spain. Mortality data was obtained from the National Institute of Statistics, and socio-economic level was measured with the small-area deprivation index developed by the Spanish Society of Epidemiology, with the census tract of residence at the time of death as the unit of analysis. We computed crude and age-standardized rates per 100,000 inhabitants by sex, deprivation quintile, and type of municipality (rural, semi-rural, urban) considering the 2013 European standard population (ASR-E). We further calculated ASR-E ratios between the most deprived (Q5) and the least deprived (Q1) areas and mapped census tract smoothed standardized lung cancer mortality ratios by sex.

RESULTS

We observed 148,425 lung cancer deaths (80.7% in men), with 73.5 deaths per 100,000 men and 17.1 deaths per 100,000 women. Deaths from lung cancer in men were five times more frequent than in women (ASR-E ratio = 5.3). Women residing in the least deprived areas had higher mortality from lung cancer (ASR-E = 22.2), compared to women residing in the most deprived areas (ASR-E = 13.2), with a clear gradient among the quintiles of deprivation. For men, this pattern was reversed, with the highest mortality occurring in areas of lower socio-economic level (ASR-E = 99.0 in Q5 vs. ASR-E = 86.6 in Q1). These socio-economic inequalities remained fairly stable over time and across urban and rural areas.

CONCLUSIONS

Socio-economic status is strongly related to lung cancer mortality, showing opposite patterns in men and women, such that mortality is highest in women residing in the least deprived areas and men residing in the most deprived areas. Systematic surveillance of lung cancer mortality by socio-economic status may facilitate the assessment of public health interventions aimed at mitigating cancer inequalities in Spain.

Mutual Associations of Healthy Behaviours and Socioeconomic Status with Respiratory Diseases Mortality: A Large Prospective Cohort Study

Little cohort evidence is available on the effect of healthy behaviours and socioeconomic status (SES) on respiratory disease mortality. We included 372,845 participants from a UK biobank (2006-2021). SES was derived by latent class analysis. A healthy behaviours index was constructed. Participants were categorized into nine groups on the basis of combinations of them. The Cox proportional hazards model was used. There were 1447 deaths from respiratory diseases during 12.47 median follow-up years. The hazard ratios (HRs, 95% CIs) for the low SES (vs. high SES) and the four or five healthy behaviours (vs. no or one healthy behaviour) were 4.48 (3.45, 5.82) and 0.44 (0.36, 0.55), respectively. Participants with both low SES and no or one healthy behaviour had a higher risk of respiratory disease mortality (aHR = 8.32; 95% CI: 4.23, 16.35) compared with those in both high SES and four or five healthy behaviours groups. The joint associations were stronger in men than in women, and in younger than older adults. Low SES and less healthy behaviours were both associated with an increased risk of respiratory disease mortality, which augmented when both presented together, especially for young man.

Is area-level socioeconomic deprivation associated with mortality due to circulatory system diseases in Poland?

BACKGROUND

Socioeconomic deprivation (SED) is known to influence cardiovascular health. However, studies analyzing the relationship between deprivation and circulatory system diseases (CSD) in Central and Eastern Europe are limited. This study aimed to assess the relationship between SED and mortality due to CSD at a population level in 66 sub-regions of Poland.

METHODS

The 2010-2014 data regarding mortality and SED components were obtained from the Central Statistical Office. An area-based SED index was calculated based on the higher education rates, employment structure, wages, unemployment, and poverty. The dynamics of changes in mortality due to CSD was expressed by the number of deaths prevented or postponed (DPP) in terciles of the SED index. The associations between the mortality from CSD and SED index were analyzed using multivariate Poisson regression models and generalized estimating equations.

RESULTS

Among men, the percentage of DPP in 2014 was 13.1% for CSD, 23.4% for ischemic heart disease (IHD), and 21.4% for cerebrovascular diseases (CeVD). In the case of women, the proportion of DPP was 12.8, 25.6, and 21.6%, respectively. More deprived sub-regions experienced a greater decrease in CSD-related mortality than less deprived sub-regions. The disparity in mortality reduction between more deprived and less deprived sub-regions was even more pronounced for women. After adjusting for smoking prevalence, average BMI, population density, and changes in mortality over time, it was found that the SED index over the 2010-2014 time period was significantly associated with CSD- and IHD-related mortality for men (respectively 5.3 and 19.5% expected mortality increase per 1-unit increase of SED index), and with IHD- and CeVD-related mortality for women (respectively 30.3 and 23.0% expected mortality increase per 1-unit increase of SED index).

CONCLUSIONS

Significant differences in mortality changes due to CSD in Poland could be observed in relation to socioeconomic deprivation, resulting in reduced health inequalities. To reduce CSD mortality, more comprehensive preventive measures, including approaches addressing the socioeconomic factors, mainly poverty, education and employment, are needed, particularly in less urbanized areas.

Mendelian randomization to explore the direct or mediating associations between socioeconomic status and lung cancer

Objective

The purpose of this study was to verify whether there are direct or mediated causal associations between socioeconomic status and lung cancer.

Methods

Pooled statistics were obtained from corresponding genome-wide association studies. The inverse-variance weighted, weighted median, MR-Egger, MR-PRESSO and contamination-mixture methods were used as supplements to Mendelian randomization (MR) statistical analysis. Cochrane's Q value and the MR-Egger intercept were used for sensitivity analysis.

Results

In the univariate MR analysis, household income and education had protective effects on overall lung cancer (income: P = 5.46×10^-4; education: P = 4.79×10^-7) and squamous cell lung cancer (income: P = 2.67×10^-3; education: P = 1.42×10^-10). Smoking and BMI had adverse effects on overall lung cancer (smoking: P = 2.10×10^-7; BMI: P = 5.67×10^-4) and squamous cell lung cancer (smoking: P = 5.02×10^-6; BMI: P = 2.03×10^-7). Multivariate MR analysis found that smoking and education were independent risk factors for overall lung cancer (smoking: P = 1.96×10^-7; education: P = 3.11×10^-3), while smoking was an independent risk factor for squamous cell lung cancer (P = 2.35×10^-6). Smoking, education, and household income mediate the effect of BMI on overall lung cancer (smoking 50.0%, education 49.2%, income 25.3%) and squamous cell lung cancer (smoking 34.8%, education 30.8%, income 21.2%). Smoking, education, and BMI mediate the effect of income on overall lung cancer (smoking 13.9%, education 54.8%, BMI 9.4%) and squamous cell lung cancer (smoking 12.6%, education 63.3%, BMI 11.6%). Smoking, BMI, and income mediate the effect of education on squamous cell lung cancer (smoking 24.0%, BMI 6.2%, income 19.4%).

Conclusion

Income, education, BMI, and smoking are causally associated with both overall lung cancer and squamous cell lung cancer. Smoking and education are independent association factors for overall lung cancer, while smoking is an independent association factor for squamous cell lung cancer. Smoking and education also play important mediating roles in overall lung cancer and squamous cell lung cancer. No causal relationship was found between multiple risk factors associated with socioeconomic status and lung adenocarcinoma.

Effects of Demographic and Socio-Economic Factors on Investigation Time of Lung Cancer Patients in Denmark: A Retrospective Cohort Study

Background

Lung cancer is one of the most common cancer types worldwide. The significance of the individual socio-economic position on the delay in lung cancer diagnosis has not been properly investigated. The purpose of this nationwide population-based study is to examine the association between position and the length of the primary investigation for lung cancer.

Materials and Methods

This register study was based on all lung cancer patients in Denmark who were diagnosed in 2012 to 2017, in total 28,431 patients. We used a multivariate logistic regression model and multivariate zero-inflated negative binomial model to estimate the effect of education level, family income, difficulty of transport, and cohabitation status on the length of the primary investigation.

Results

We found that the patients' income, difficulty of transport, and cohabitation status were associated with the length of the primary investigation. The chance of carrying out the investigation process within 24 days is higher for patients with a high income (adjusted OR = 0.86 with 95% CI (0.81; 0.91)), lower for patients with troublesome transport (adjusted OR = 0.67 with 95% CI (0.61; 0.72)), and lower for patients living alone (adjusted OR = 0.93 with 95% CI (0.88; 0.99)).

Conclusion

Several socio-economic factors are associated with the length of the primary lung cancer investigation. To ensure that all patients receive the most appropriate health care and to avoid extra investigation time, clinicians may pay extra attention to patients who are less fortunate due to low income, troublesome transport to the hospital, or living alone.

Effects of Environmental and Socioeconomic Inequalities on Health Outcomes: A Multi-Region Time-Series Study

The gradual increase in temperatures and changes in relative humidity, added to the aging and socioeconomic conditions of the population, may represent problems for public health, given that future projections predict even more noticeable changes in the climate and the age pyramid, which require analyses at an appropriate spatial scale. To our knowledge, an analysis of the synergic effects of several climatic and socioeconomic conditions on hospital admissions and deaths by cardiorespiratory and mental disorders has not yet been performed in Brazil. Statistical analyses were performed using public time series (1996-2015) of daily health and meteorological data from 16 metropolitan regions (in a subtropical climate zone in South America). Health data were stratified into six groups according to gender and age ranges (40-59; 60-79; and ≥80 years old) for each region. For the regression analysis, two distributions (Poisson and binomial negative) were tested with and without zero adjustments for the complete series and percentiles. Finally, the relative risks were calculated, and the effects based on exposure-response curves were evaluated and compared among regions. The negative binomial distribution fit the data best. High temperatures and low relative humidity were the most relevant risk factors for hospitalizations for cardiovascular diseases (lag = 0), while minimum temperatures were important for respiratory diseases (lag = 2 or 3 days). Temperature extremes, both high and low, were the most important risk factors for mental illnesses at lag 0. Groups with people over 60 years old presented higher risks for cardiovascular and respiratory diseases, while this was observed for the adult group (40-59 years old) in relation to mental disorders. In general, no major differences were found in the results between men and women. However, regions with higher urbanization levels presented risks, mainly for respiratory diseases, while the same was observed for cardiovascular diseases for regions with lower levels of urbanization. The Municipal Human Development Index is an important factor for the occurrence of diseases and deaths for all regions, depending on the evaluated group, representing high risks for health outcomes (the value for hospitalization for cardiovascular diseases was 1.6713 for the female adult group in the metropolitan region Palmas, and the value for hospitalization for respiratory diseases was 1.7274 for the female adult group in the metropolitan region Campo Mourão). In general, less developed regions have less access to adequate health care and better living conditions.

A Population-Based Study on the Prognostic factors and Efficacy of Adjuvant Chemotherapy in the Postoperative Stage for Patients with Stage IIA Non-Small Cell Lung Cancer

Objective

This study aimed to design a nomogram survival prediction by means of the figures retrieved from the Surveillance, Epidemiology, and End Results (SEER) source bank, and to predict the overall survival (OS) of patients with stage IIA non-small cell lung cancer (NSCLC) after surgery.

Methods

Data for 4511 patients who had been diagnosed with postoperative stage IIA NSCLC were collected from the SEER databank, while information on 528 patients was acquired from the Chongqing University Cancer Hospital for the external validation cohort. The independent risk factors that affected the prognosis were identified using a multivariate Cox proportional hazards regression model (also used to conduct a nomogram). A survival analysis between the low- and the high-risk groups was performed using the Kaplan-Meier method. Furthermore, a subgroup analysis was conducted of the two groups using the Kaplan-Meier method to determine whether the patients had received adjuvant chemotherapy.

Results

The following five variables were integrated into the nomogram: sex (female: HR 1.73, 95% CI 0.64-0.83), age (≥60: HR 1.61, 95% CI 1.39-1.87), differentiation grade (grade II: HR 2.19, 95% CI 1.66-2.88; grade III: HR 2.65, 95% CI 2.00-3.51; grade IV: HR 3.17, 95% CI 1.99-5.03), surgery (lobectomy: HR 0.72, 95% CI 0.59-0.86), and lymph node resection (>12: HR 0.82, 95% CI 0.70-0.96). Furthermore, the patients selected were categorized into high- and low-risk groups. The OS rate was significantly lower in the high-risk group than in the low-risk group (P < 0.001). Finally, adjuvant chemotherapy was highly correlated with OS in the high-risk set (P = 0.035); however, adjuvant chemotherapy was not related to OS in the low-risk set.

Conclusion

A nomogram was created as a reliable, convenient scheme that could predict OS, and it was determined that the high-risk feature patients identified by the nomogram gained benefits from adjuvant chemotherapy.

Association of Allostatic Load With Overall Mortality Among Patients With Metastatic Non-Small Cell Lung Cancer

Importance

Adverse social determinants of health (SDHs) (eg, poverty) are associated with poor oncologic outcomes among patients with lung cancer. However, no studies have evaluated biological correlates of adverse SDHs, operationalized as allostatic load (AL), with mortality due to lung cancer.

Objective

To examine the association among AL, SDHs, and mortality among patients with metastatic non-small cell lung cancer (NSCLC).

Design, Setting, and Participants

This cross-sectional study of an observational cohort was performed at a National Cancer Institute-designated comprehensive cancer center with data accrued from June 1, 2017, to August 31, 2019. Patients with metastatic (stage IV) NSCLC enrolled at diagnosis into a prospective observational cohort study were included in the present analysis if they had all the biomarkers to calculate an AL score (N = 143). Follow-up was completed on August 31, 2021, and data were analyzed from July 1 to September 30, 2021.

Exposures

Social determinants of health.

Main Outcomes and Measures

Overall mortality and AL.

Results

A total of 143 patients met the study criteria with a median age of 63 (IQR, 55-71) years (89 men [62.2%] and 54 women [37.8%]). In terms of race and ethnicity, 1 patient (0.7%) was Asian, 7 (4.9%) were Black, 117 (81.8%) were White, 17 (11.9%) were of multiple races, and 1 (0.7%) was of other race or ethnicity. The mean (SD) AL was 2.90 (1.37). Elevated AL covaried with lower educational level (r = -0.26; P = .002), male sex (r = 0.19; P = .02), limited mobility (r = 0.19; P = .04), worsening self-care (r = 0.30; P < .001), problems engaging in usual activities (r = 0.21; P = .01), depressive symptoms (r = 0.23; P = .005), and a high number of stressful life events (r = 0.30; P < .001). Multivariable analysis found only increasing difficulty with mobility (r = 0.37 [95% CI, 0.13-0.60]; P = .002) and male sex (r = 0.63 [95% CI, 0.19-1.08]; P = .005) associated with higher AL. On adjusted analysis, elevated AL (hazard ratio, 1.43 [95% CI, 1.16-1.79]; P = .001) and low educational level (hazard ratio, 2.11 [95% CI, 1.03-4.34]; P = .04) were associated with worse overall mortality.

Conclusions and Relevance

The findings of this cross-sectional study suggest that higher AL was associated with adverse SDHs and worse overall mortality among patients with advanced NSCLC. These results provide a framework for replication and further studies of AL as a biological correlate for SDH and future prognostic marker.

Significant Regional Differences in Lung Cancer Incidence in Hungary: Epidemiological Study Between 2011 and 2016

Objective: Hungary has one of the highest incidences and mortality rates of lung cancer (LC), therefore the objective of this study was to analyse and compare LC incidence and mortality rates between the main Hungarian regions.

Methods: This nationwide, retrospective study used data from the National Health Insurance Fund and included patients aged ≥20 years who were diagnosed with lung cancer (ICD-10 C34) between Jan 1, 2011 and Dec 31, 2016. Age-standardized incidence and mortality rates were calculated and compared for the main regions.

Results: The highest incidence rate in males was recorded in Northern Hungary (146.8/100,000 person-years [PY]), while the lowest rate was found in Western Transdanubia (94.7/100,000 PY in 2011). All rates showed a declining trend between 2011 and 2016, with the largest decrease in the Northern Great Plain (−20.0%; p = 0.008). LC incidence and mortality rates in women both showed a rising tendency in all regions of Hungary, reaching the highest in Central Hungary (59.86/100,000 PY in 2016). Lung cancer incidence and mortality rates in males correlated with the level of education and smoking prevalence (p = 0.006 and p = 0.01, respectively) in the regions. A correlation with GDP per capita and Health Development Index (HDI) index could also be observed in the Hungarian regions, although these associations were not statistically significant. No correlations could be detected between these parameters among females.

Conclusion: This analysis revealed considerable differences in the epidemiology of LC between the 7 main Hungarian regions. LC incidence and mortality rates significantly correlated with smoking and certain socioeconomic factors in men, but not in women. Further research is needed to explain the regional differences.

A Cluster Analysis of Risk Factors for Cancer across EU Countries: Health Policy Recommendations for Prevention

Cancer burden in the European Union (EU) is increasing and has stimulated the European Commission (EC) to develop strategies for cancer control. A common “one size fits all” prevention policy may not be effective in reducing cancer morbidity and mortality. The goal of this paper is to show that EU member states are not homogenous in terms of their exposure to risk factors for cancer (i.e., lifestyle, socio-economic status (SES), air pollution, and vaccination). Data from a variety of sources including Eurostat, the UNESCO Institute for Statistics, the European Health Interview Survey, Eurobarometer, and the European Environment Agency were merged across years 2013–2015 and used to develop a cluster analysis. This work identified four patterns of cancer prevention behaviors in the EU thus making it possible to group EU members states into four distinct country clusters including: sports-engaged countries, tobacco and pollutant exposed nations, unhealthy lifestyle countries, and a stimulant-enjoying cluster of countries. This paper finds that there is a need for closer collaboration among EU countries belonging to the same cluster in order to share best practices regarding health policy measures that might improve cancer control interventions locally and across the EU.

Recent trends in premature mortality and health disparities attributable to ambient PM2.5 exposure in China: 2005-2017

In the past decade, particulate matter with aerodynamic diameter less than 2.5 μm (PM_2.5) has reached unprecedented levels in China and posed a significant threat to public health. Exploring the long-term trajectory of the PM_2.5 attributable health burden and corresponding disparities across populations in China yields insights for policymakers regarding the effectiveness of efforts to reduce air pollution exposure. Therefore, we examine how the magnitude and equity of the PM_2.5-related public health burden has changed nationally, and between provinces, as economic growth and pollution levels varied during 2005-2017. We derive long-term PM_2.5 exposures in China from satellite-based observations and chemical transport models, and estimate attributable premature mortality using the Global Exposure Mortality Model (GEMM). We characterize national and interprovincial inequality in health outcomes using environmental Lorenz curves and Gini coefficients over the study period. PM_2.5 exposure is linked to 1.8 (95% CI: 1.6, 2.0) million premature deaths over China in 2017, increasing by 31% from 2005. Approximately 70% of PM_2.5 attributable deaths were caused by stroke and IHD (ischemic heart disease), though COPD (chronic obstructive pulmonary disease) and LRI (lower respiratory infection) disproportionately affected poorer provinces. While most economic gains and PM_2.5-related deaths were concentrated in a few provinces, both gains and deaths became more equitably distributed across provinces over time. As a nation, however, trends toward equality were more recent and less clear cut across causes of death. The rise in premature mortality is due primarily to population growth and baseline risks of stroke and IHD. This rising health burden could be alleviated through policies to prevent pollution, exposure, and disease. More targeted programs may be warranted for poorer provinces with a disproportionate share of PM_2.5-related premature deaths due to COPD and LRI.

Health Care Resources and 24,910 Deaths Due to Traffic Accidents: An Ecological Mortality Study in Poland

Background: Deaths due to traffic accidents are preventable and the access to health care is an important determinant of traffic accident case fatality. This study aimed to assess the relation between mortality due to traffic accidents and health care resources (HCR), at the population level, in 66 sub-regions of Poland. Methods: An area-based HCR index was delivered from the rates of physicians, nurses, and hospital beds. Associations between mortality from traffic accidents and the HCR index were tested using multivariate Poisson regression models. Results: In the sub-regions studied, the average mortality from traffic accidents was 11.7 in 2010 and 9.3/100.000 in 2015. After adjusting for sex, age and over time trends in mortality, out-of-hospital deaths were more frequently compared to hospitalized fatal cases (incidence rate ratio (IRR) = 1.68, 95% CI 1.45–1.93). Compared to sub-regions with high HCR, mortality from traffic accidents was higher in sub-regions with low and moderate HCR (IRR = 1.25, 95% CI 1.11–1.42 and IRR = 1.19, 95% CI 1.02–1.38, respectively), which reflected the differences in out-of-hospital mortality most pronounced in car accidents. Conclusions: Poor HCR is an important factor that explains the territorial differentiation of mortality due to traffic accidents in Poland. The high percentage of out-of-hospital deaths indicates the importance of preventive measures and the need for improvement in access to health care to reduce mortality due to traffic accidents.

Lower Respiratory Tract Infection Trends in East and South-East Asia: In the Light of Economic and Health Care Development

This study explored to what degree economic development and improvement of healthcare are associated with lower respiratory tract infection (LRTI) mortality. A correlation analysis between LRTI mortality and Gross Domestic Product (GDP) per capita, and the Health Access and Quality Index (HAQI), respectively was conducted for 15 countries in East and South-East Asia. The results revealed a dramatic decrease in LRTI mortality in total populations for lower-middle income (LMI) countries but at the same time an increase in upper-middle income (UMI) and high-income (HI) countries. A highly significant (P < .001) growth-dependent relationship between LRTI mortality and economic growth was observed. Improvements in HAQI were significantly associated with a decrease in LRTI mortality in LMI countries, but an increase in UMI and HI countries. The decline of LRTI mortality amongst children in LMI countries is an encouraging trend and efforts against LRTI must be continued, though not at the expense of preparing health systems for the growing burden.

Primary and Secondary Prevention of Lung Cancer: Tobacco Treatment

Tobacco dependence is the most consequential target to reduce the burden of lung cancer worldwide. Quitting after a cancer diagnosis can improve cancer prognosis, overall health, and quality of life. Several oncology professional organizations have issued guidelines stressing the importance of tobacco treatment for patients with cancer. Providing tobacco treatment in the context of lung cancer screening is another opportunity to further reduce death from lung cancer. In this review, the authors describe the current state of tobacco dependence treatment focusing on new paradigms and approaches and their particular relevance for persons at risk or on treatment for lung cancer.

Lifestyle and Sociodemographic and Economic Characteristics of Patients with Lung Cancer in Morocco

Background

Lifestyle maintenance is a crucial condition before and after lung cancer disease. According to the previous research in the scientific databases, the effect of the interaction between socioeconomic and demographic factors on the lifestyle of lung cancer patients in Southern Morocco regions remains unexamined. Accordingly, this study was designed to examine the relationship between socioeconomic factors, demographic factors, and the lifestyle of lung cancer patients.

Methods

A total of 133 patients with lung cancer were divided into 103 men and 30 women with a sex ratio of 3.43 and ages varying between 28 and 82 years, and they served as informants for the study and filled in a questionnaire to provide information on their sociodemographic background, various economic characteristics, and their lifestyle. These patients have also been submitted to an anthropometric examination following the standardized procedure recommended by the World Health Organization. The survey was conducted from July 2013 to March 2015 at the Oncology and Radiotherapy Department, at Mohammed VI Hospital Center in Marrakech, Morocco.

Results

The preliminary results showed that the average age of patients was 59 ± 9 years. A proportion of 81% lived in the Marrakech-Safi region and 19% lived in four other southern regions. Among the patients, 6% were smokers, while 14% were nonsmokers and 80% were ex smokers. Following the discovery of the disease, 26% revealed that they had sleep disorders and 98% were reported to have a lack of appetite. Obesity, normal weight, and underweight were also taken as criteria to categorize the patients; thus, obese informants represented 23% of the total number, those having normal weight reached 67% and the patients having underweight represented 10%.

Conclusion

Sociodemographic variables and various economic characteristics were shown to have a negative impact on the lifestyle of lung cancer patients.