Abstract
BackgroundPeople living in more deprived areas of high-income countries have lower cancer survival than those in less deprived areas. However, associations between individual-level socio-economic circumstances and cancer survival are relatively poorly understood. Moreover, few studies have addressed contextual effects, where associations between individual-level socio-economic status and cancer survival vary depending on area-based deprivation.MethodsUsing 9276 individual-level observations from a longitudinal study in England and Wales, we examined the association with cancer survival of area-level deprivation and individual-level occupation, education, and income, for colorectal, prostate and breast cancer patients aged 20–99 at diagnosis. With flexible parametric excess hazard models, we estimated excess mortality across individual-level and area-level socio-economic variables and investigated contextual effects.ResultsFor colorectal cancers, we found evidence of an association between education and cancer survival in men with Excess Hazard Ratio (EHR) = 0.80, 95% Confidence Interval (CI) = 0.60;1.08 comparing “degree-level qualification and higher” to “no qualification” and EHR = 0.74 [0.56;0.97] comparing “apprenticeships and vocational qualification” to “no qualification”, adjusted on occupation and income; and between occupation and cancer survival for women with EHR = 0.77 [0.54;1.10] comparing “managerial/professional occupations” to “manual/technical,” and EHR = 0.81 [0.63;1.06] comparing “intermediate” to “manual/technical”, adjusted on education and income. For breast cancer in women, we found evidence of an association with income (EHR = 0.52 [0.29;0.95] for the highest income quintile compared to the lowest, adjusted on education and occupation), while for prostate cancer, all three individual-level socio-economic variables were associated to some extent with cancer survival. We found contextual effects of area-level deprivation on survival inequalities between occupation types for breast and prostate cancers, suggesting wider individual-level inequalities in more deprived areas compared to least deprived areas. Individual-level income inequalities for breast cancer were more evident than an area-level differential, suggesting that area-level deprivation might not be the most effective measure of inequality for this cancer. For colorectal cancer in both sexes, we found evidence suggesting area- and individual-level inequalities, but no evidence of contextual effects.ConclusionsFindings highlight that both individual and contextual effects contribute to inequalities in cancer outcomes. These insights provide potential avenues for more effective policy and practice.
Highlights
People living in more deprived areas of high-income countries have lower cancer survival than those in less deprived areas
A preliminary model fitted with only age and the area-based deprivation variable showed that those living in less deprived areas experienced lower excess hazard than those in more deprived areas for prostate (EHR = 0.80 [95% confidence interval, Confidence Interval (CI):0.72–0.90]), breast (EHR = 0.89 [0.82–0.96]), and colorectal cancers
For prostate and breast cancers, the disadvantageous effect of area-based deprivation was substantially reduced by adjustment for individual-level effects, whereas the opposite was true for colorectal cancer
Summary
People living in more deprived areas of high-income countries have lower cancer survival than those in less deprived areas. There is a need to explore the potential for area-level and individual-level factors to interact with one another, such that individual-level health inequalities could differ depending on the deprivation context of the area an individual lives in In this way, data that describes area-level, or group-level, characteristics such as overall level of deprivation or access to services could have differing effects on individual outcomes according to personal characteristics such as education level or type of occupation. Data that describes area-level, or group-level, characteristics such as overall level of deprivation or access to services could have differing effects on individual outcomes according to personal characteristics such as education level or type of occupation These ‘contextual effects’ could be important given recent evidence that the area-level deprivation where an individual lives is not necessarily a good indicator of their individual socio-economic circumstances [12, 13]. There is a risk that area-level differentials are interpreted principally at an individual level and the influence of the area itself is not acknowledged
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