Abstract
PurposeDespite recent improvements in cancer treatment in Germany, a marked difference in cancer survival based on socioeconomic factors persists. We aim to quantify the effect of socioeconomic inequality on head and neck cancer (HNC) survival.MethodsInformation on 20,821 HNC patients diagnosed in 2009–2013 was routinely collected by German population-based cancer registries. Socioeconomic inequality was defined by the German Index of Socioeconomic Deprivation. The Cox proportional regression and relative survival analysis measured the survival disparity according to level of socioeconomic deprivation with respective confidence intervals (CI). A causal mediation analysis was conducted to quantify the effect of socioeconomic deprivation mediated through medical care, stage at diagnosis, and treatment on HNC survival.ResultsThe most socioeconomically deprived patients were found to have the highest hazard of dying when compared to the most affluent (Hazard Ratio: 1.25, 95% CI 1.17–1.34). The most deprived patients also had the worst 5-year age-adjusted relative survival (50.8%, 95% CI 48.5–53.0). Our mediation analysis showed that most of the effect of deprivation on survival was mediated through differential stage at diagnosis during the first 6 months after HNC diagnosis. As follow-up time increased, medical care, stage at diagnosis, and treatment played no role in mediating the effect of deprivation on survival.ConclusionThis study confirms the survival disparity between affluent and deprived HNC patients in Germany. Considering data limitations, our results suggest that, within six months after HNC diagnosis, the elimination of differences in stage at diagnosis could reduce survival inequalities.
Highlights
Head and neck cancer (HNC) accounts for approximately 3% of all new malignancies in Germany, and is ranked the seventh most common cancer worldwide (Global Burden of Disease Cancer et al, 2017)
While the effect of socioeconomic factors (SES) on head and neck cancer (HNC) survival has been documented in past literature (Boing et al 2011; Choi et al 2016; Johnson et al 2008), recent studies have started to investigate the effect of area-based socioeconomic deprivation on cancer survival in general (Chang et al 2012; Rachet et al 2010; Singh and Jemal 2017), and HNC in particular (Bryere et al 2017; Chang et al 2013; Hagedoorn et al 2016; Megwalu 2017)
We aimed to (1) measure the survival gap according to socioeconomic deprivation level and (2) to decompose the total effect of deprivation on HNC survival into direct effect and indirect effect mediated through other possible factors
Summary
Head and neck cancer (HNC) accounts for approximately 3% of all new malignancies in Germany, and is ranked the seventh most common cancer worldwide (Global Burden of Disease Cancer et al , 2017). In Germany, studies investigating socioeconomic disparity are scarce and are often limited to certain regions Jansen et al published the only large-scale study from Germany that aimed to measure social inequalities in cancer survival in 2014 (Jansen et al 2014). This study found the 5‐year age‐ standardized relative survival of the most deprived patients diagnosed with cancer of the mouth/pharynx to be 45.2% versus 49.3% for the most affluent patients. It is essential to understand the mechanism by which social disparity affects cancer survival and to identify modifiable risk factors
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