Inequalities In Survival Research Articles

The socioeconomic determinants of cancer.

This paper provides a synthesis on socioeconomic inequalities in cancer incidence, mortality and survival across countries and within countries, with particular focus on the Italian context; the paper also describes the underlying mechanisms documented for cancer incidence, and reports some remarks on policies to tackle inequalities.From a worldwide perspective, the burden of cancer appears to be particularly increasing in developing countries, where many cancers with a poor prognosis (liver, stomach and oesophagus) are much more common than in richer countries. As in the case of incidence and mortality, also in cancer survival we observe a great variability across countries. Different studies have suggested a possible impact of health care on the social gradients in cancer survival, even in countries with a National Health System providing equitable access to care.In developed countries, there is increasing awareness of social inequalities as an important public health issue; as a consequence, there is a variety of strategies and policies being implemented throughout Europe. However, recent reviews emphasize that present knowledge on effectiveness of policies and interventions on health inequalities is not sufficient to offer a robust and evidence-based guide to the choice and design of interventions, and that more evaluation studies are needed.The large disparities in health that we can measure within and between countries represent a challenge to the world; social health inequalities are avoidable, and their reduction therefore represents an achievable goal and an ethical imperative.

Inequalities in under-5 mortality in Nigeria: do ethnicity and socioeconomic position matter?

BackgroundEach ethnic group has its own cultural values and practices that widen inequalities in child health and survival among ethnic groups. This study seeks to examine the mediatory effects of ethnicity and socioeconomic position on under-5 mortality in Nigeria.MethodsUsing multilevel logistic regression analysis of a nationally representative sample drawn from 7620 females age 15 to 49 years in the 2003 Nigeria Demographic and Health Survey, the risk of death in children younger than 5 years (under-5 deaths) was estimated using odds ratios with 95% confidence intervals for 6029 children nested within 2735 mothers who were in turn nested within 365 communities.ResultsThe prevalence of under-5 death was highest among children of Hausa/Fulani/Kanuri mothers and lowest among children of Yoruba mothers. The risk of under-5 death was significantly lower among children of mothers from the Igbo and other ethnic groups, as compared with children of Hausa/Fulani/Kanuri mothers, after adjustment for individual- and community-level factors. Much of the disparity in under-5 mortality with respect to maternal ethnicity was explained by differences in physician-provided community prenatal care.ConclusionsEthnic differences in the risk of under-5 death were attributed to differences among ethnic groups in socioeconomic characteristics (maternal education and to differences in the maternal childbearing age and short birth-spacing practices. These findings emphasize the need for community-based initiatives aimed at increasing maternal education and maternal health care services within communities.

Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK, 1995–2007 (the International Cancer Benchmarking Partnership): an analysis of population-based cancer registry data

SummaryBackgroundCancer survival is a key measure of the effectiveness of health-care systems. Persistent regional and international differences in survival represent many avoidable deaths. Differences in survival have prompted or guided cancer control strategies. This is the first study in a programme to investigate international survival disparities, with the aim of informing health policy to raise standards and reduce inequalities in survival.MethodsData from population-based cancer registries in 12 jurisdictions in six countries were provided for 2·4 million adults diagnosed with primary colorectal, lung, breast (women), or ovarian cancer during 1995–2007, with follow-up to Dec 31, 2007. Data quality control and analyses were done centrally with a common protocol, overseen by external experts. We estimated 1-year and 5-year relative survival, constructing 252 complete life tables to control for background mortality by age, sex, and calendar year. We report age-specific and age-standardised relative survival at 1 and 5 years, and 5-year survival conditional on survival to the first anniversary of diagnosis. We also examined incidence and mortality trends during 1985–2005.FindingsRelative survival improved during 1995–2007 for all four cancers in all jurisdictions. Survival was persistently higher in Australia, Canada, and Sweden, intermediate in Norway, and lower in Denmark, England, Northern Ireland, and Wales, particularly in the first year after diagnosis and for patients aged 65 years and older. International differences narrowed at all ages for breast cancer, from about 9% to 5% at 1 year and from about 14% to 8% at 5 years, but less or not at all for the other cancers. For colorectal cancer, the international range narrowed only for patients aged 65 years and older, by 2–6% at 1 year and by 2–3% at 5 years.InterpretationUp-to-date survival trends show increases but persistent differences between countries. Trends in cancer incidence and mortality are broadly consistent with these trends in survival. Data quality and changes in classification are not likely explanations. The patterns are consistent with later diagnosis or differences in treatment, particularly in Denmark and the UK, and in patients aged 65 years and older.FundingDepartment of Health, England; and Cancer Research UK.

Inequalities in cancer survival: Spearhead Primary Care Trusts are appropriate geographic units of analyses

Cancer survival in Spearhead Primary Care trusts (PCTs) is lower than in the rest of England for most common cancers, but differences are smaller than the more substantial survival gradients between deprived and affluent populations using small-area measures of deprivation. The way in which Spearhead PCTs were designated may give an unduly favourable image of inequalities in cancer survival. Five-year age-standardised relative survival for 10 common cancers was estimated separately for patients resident in Spearhead local authorities (LAs), Spearhead PCTs, and the rest of England. Differences in survival between Spearhead and other LAs and the corresponding differences between Spearhead and other PCTs were compared. Cancer survival was consistently lower for patients resident in Spearhead areas than in the rest of England for the majority of cancers, regardless of the geographic unit used. Survival was lower in Spearhead LAs than Spearhead PCTs for 11 of the 16 cancer-sex combinations examined. As a consequence, the survival gap between the Spearhead areas and the rest of England was slightly wider when the definition of Spearhead was based on LAs rather than PCTs, but the two contrasts provide a very similar picture. Small differences were found between using Spearhead LAs and Spearhead PCTs in the estimation of cancer survival, but results were inconsistent. Although the overlap between the two geographies is imperfect, Spearhead PCTs are appropriate geographic units for monitoring inequalities in cancer survival. However, given the instability of NHS geographical boundaries, Spearhead LAs could be a suitable alternative geographic unit.

Ethnic inequity in neonatal survival: a case‐referent study in northern Vietnam

In this study from Quang Ninh province in northern Vietnam (sub-study of the trial Neonatal Health - Knowledge into Practice, NeoKIP, ISRCTN 44599712), we investigated determinants of neonatal mortality through a case-referent design, with special emphasis on socio-economic factors and health system utilization. From July 2008 until December 2009, we included 183 neonatal mortality cases and 599 referents and their mothers were interviewed. Ethnicity was the main socio-economic determinant for neonatal mortality (OR 2.08, 95% CI 1.39-3.10, adjusted for mothers' education and household economic status). Health system utilization before and at delivery could partly explain the risk elevation, with an increased risk of neonatal mortality for mothers who did not attend antenatal care and who delivered at home (OR 4.79, 95% CI 2.98-7.71). However, even if mothers of an ethnic minority attended antenatal care or delivered at a health facility, the increased risk for this group was sustained. Our study demonstrates inequity in neonatal survival that is related to ethnicity rather than family economy or education level of the mother and highlights the need to include the ethnic dimension in the efforts to reduce neonatal mortality.

Health Inequalities, Deprivation, Immigration and Aboriginality in Canada: A Geographic Perspective

This study explores the contribution of deprivation, immigration and Aboriginal status to survival in various parts of Canada. It is hypothesized that differences in the magnitude of survival inequalities according to deprivation across Canada are attenuated when immigration and Aboriginal status are accounted for. The study is based on a file linking the 1991 census and a follow-up of mortality from 1991 to 2001. Geographic areas are the Canadian regions, the census metropolitan areas (CMAs) of Montréal, Toronto and Vancouver as well as the metropolitan-influenced zones. Deprivation is measured through a Canadian deprivation index. Immigration is based on declared place of birth and Aboriginal status on ethnic origin, registered treaty Indian status and Band or First Nation membership. Survival is modelized through Cox regression and two sets of models are produced for every geographic area. Survival is associated with deprivation, immigration and Aboriginal status in most parts of Canada. After accounting for immigration and Aboriginal status, differences in the magnitude of survival inequalities related to deprivation across Canada are attenuated. Such inequalities are highly reduced in the Prairies and remote hinterland and slightly increased in the CMA of Toronto. Nevertheless, high survival inequalities related to deprivation remain in Canada, namely in the Prairies and, to a lesser degree, in British Columbia and the CMA of Vancouver. After accounting for immigration and Aboriginal status, differences in the magnitude of survival inequalities according to deprivation across Canada are attenuated but not completely eliminated.

Health Inequalities, Deprivation, Immigration and Aboriginality in Canada: A Geographic Perspective

Objective: This study explores the contribution of deprivation, immigration and Aboriginal status to survival in various parts of Canada. It is hypothesized that differences in the magnitude of survival inequalities according to deprivation across Canada are attenuated when immigration and Aboriginal status are accounted for. Methods: The study is based on a file linking the 1991 census and a follow-up of mortality from 1991 to 2001. Geographic areas are the Canadian regions, the census metropolitan areas (CMAs) of Montréal, Toronto and Vancouver as well as the metropolitan-influenced zones. Deprivation is measured through a Canadian deprivation index. Immigration is based on declared place of birth and Aboriginal status on ethnic origin, registered treaty Indian status and Band or First Nation membership. Survival is modelized through Cox regression and two sets of models are produced for every geographic area. Results: Survival is associated with deprivation, immigration and Aboriginal status in most parts of Canada. After accounting for immigration and Aboriginal status, differences in the magnitude of survival inequalities related to deprivation across Canada are attenuated. Such inequalities are highly reduced in the Prairies and remote hinterland and slightly increased in the CMA of Toronto. Nevertheless, high survival inequalities related to deprivation remain in Canada, namely in the Prairies and, to a lesser degree, in British Columbia and the CMA of Vancouver. Conclusion: After accounting for immigration and Aboriginal status, differences in the magnitude of survival inequalities according to deprivation across Canada are attenuated but not completely eliminated.

Abstract A93: Investigating reasons for ethnic disparities in breast cancer survival in New Zealand

Abstract Background: In New Zealand the burden of breast cancer is not shared equally among ethnic groups. Although incidence is similar for indigenous Maori women and Pacific women compared with non-Maori/non-Pacific women, Maori and Pacific women are more likely to die from breast cancer. This suggests much of the breast cancer mortality disparities are due to inequalities in survival rather than incidence. We investigated the role that demographic and tumor factors play in explaining ethnic disparities in breast cancer survival. Methods: Breast cancer cases notified to the New Zealand Cancer Registry (NZCR) from April 2005 to April 2007 were followed up to April 2009. Maori, Pacific and non-Maori/non-Pacific women were categorized according to ethnicity on the NZCR. Deprivation was analyzed as quintiles of the New Zealand area-based index of socioeconomic position. Relative survival rates were estimated using ethnic-specific life tables. Missing values were imputed and excess mortality modeling was used to estimate the contribution of demographic and tumor factors to ethnic inequalities in survival. Results: There were 2,968 breast cancer cases (76.5% non-Maori/non-Pacific, 17% Maori, and 6.5% Pacific) included and 433 recorded deaths. Relative survival rates at 4 years were 91.45% (CI 89.68 to 92.93) for non-Maori/non-Pacific, 86.15 (CI 80.33 to 90.36) for Maori, and 79.56% (CI 68.17 to 87.24) for Pacific women. Using non-Maori/non-Pacific as the reference group, the age-adjusted hazard ratio (HR) dropped for Maori from 1.76 (CI 1.22 to 2.48) to 1.43 (CI 0.97 to 2.10) when further adjusted by deprivation. For Pacific the HR dropped from 2.49 (CI 1.57 to 3.94) to 1.94 (CI 1.20 to 3.13). Inequalities persisted after adjustment for subtype variables (ER/PR/HER2), but adjusting for access to care variables (stage/size) eliminated the ethnic inequalities in excess mortality. Conclusion: Ethnic disparities in breast cancer survival in New Zealand can be attributed to differential access to health care rather than differences in breast cancer subtypes. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):A93.

036 Socio-economic inequalities in cancer survival in England after the NHS cancer plan

ObjectivesSocio-economic inequalities in survival have been reported for most adult cancers in England. The NHS Cancer Plan (2000) aimed to improve cancer patient survival, and tackle inequalities in survival between...

039 Regional disparities in cancer survival following the NHS National Cancer Plan for England: an analysis by cancer network

ObjectiveReducing geographic inequalities in survival from cancer in England was a key aim of the Calman-Hine Report (1995) and the NHS Cancer Plan (2000). In this paper we assess whether...

Investigating reasons for socioeconomic inequalities in breast cancer survival in New Zealand

Background: This study investigated the role that demographic and tumour factors play in explaining socioeconomic inequalities in breast cancer survival. Methods: Breast cancer cases notified to the New Zealand Cancer Registry (NZCR) from April 2005 to April 2007 were followed up to April 2009. The New Zealand area-based deprivation index (NZDep) was used as a measure of socioeconomic position. Relative survival rates were estimated using sex-, deprivation- and ethnic-specific life tables. Multiple imputation was used to impute missing data. Excess mortality modelling was used to estimate the contribution of demographic and tumour factors to inequalities in survival. Results: There were 2968 breast cancer cases included and 433 recorded deaths. Relative survival rates at 4 years varied across deprivation groups. Using NZDep deciles 1–4 (least deprived) as the reference group, the age- and ethnicity-adjusted hazard ratio (HR) for NZDep deciles 7–8 was 2.03 (CI 1.36–3.04) and for NZDep deciles 9–10 was 1.93 (CI 1.28–2.92). In the fully adjusted model there remained 50% excess mortality for the two most deprived groups compared to the most affluent. Variables which measured timely access to care (extent/size) accounted for more of the survival disparity than breast cancer subtype variables (ER/PR/HER2). Conclusion: Women from deprived areas in New Zealand who are diagnosed with breast cancer are less likely to survive as long as those from affluent areas. A substantial proportion of these socioeconomic disparities can be attributed to differential access to health care although other factors, currently unknown, are also likely to play an important role.

Inequalities in cancer survival and the NHS cancer plan: evidence of progress?

Inequalities in cancer survival and the NHS cancer plan: evidence of progress?

Decomposition of socio-economic differences in life expectancy at birth by age and cause of death among 4 million South Korean public servants and their dependents

Differences in life expectancy at birth across social classes can be more easily interpreted as a measure of absolute inequalities in survival. This study quantified age- and cause-specific contributions to life expectancy differences by income among 4 million public servants and their dependents in South Korea (9.1% of the total Korean population). Using 9-year mortality follow-up data (208,612 deaths) on 4,055,150 men and women aged 0-94 years, with national health insurance premiums imposed proportionally based on monthly salary as a measure of income, differences in life expectancy at birth by income were estimated by age- and cause-specific mortality differences using Arriaga's decomposition method. Life expectancy at birth gradually increased with income. Differences in life expectancy at birth between the highest and the lowest income quartile were 6.22 years in men and 1.74 years in women. Mortality differentials by income among those aged ≥50 years contributed most substantially (80.4% in men and 85.6% in women) to the socio-economic differences in life expectancy at birth. In men, cancers (stomach, liver and lung), cardiovascular diseases (stroke), digestive diseases (liver cirrhosis) and external causes (transport accidents and suicide) were important contributors to the life expectancy differences. In women, the contribution of ill-defined causes was most important. Cardiovascular diseases (stroke and hypertensive disease) and external causes (transport accidents and suicide) also contributed to the life expectancy differences in women while the contributions of cancers and digestive diseases were minimal. Reductions in socio-economic differentials in mortality from stroke and external causes (transport accidents and suicide) among middle-aged and older men and women would significantly contribute to equalizing life expectancy among income groups. Policy efforts to reduce mortality differentials in major cancers (stomach, liver and lung) and liver cirrhosis are also important for eliminating Korean men's socio-economic inequalities in life expectancy.

Socioeconomic inequalities in cancer survival in England after the NHS cancer plan

Background:Socioeconomic inequalities in survival were observed for many cancers in England during 1981–1999. The NHS Cancer Plan (2000) aimed to improve survival and reduce these inequalities. This study examines trends in the deprivation gap in cancer survival after implementation of the Plan.Materials and method:We examined relative survival among adults diagnosed with 1 of 21 common cancers in England during 1996–2006, followed up to 31 December 2007. Three periods were defined: 1996–2000 (before the Cancer Plan), 2001–2003 (initialisation) and 2004–2006 (implementation). We estimated the difference in survival between the most deprived and most affluent groups (deprivation gap) at 1 and 3 years after diagnosis, and the change in the deprivation gap both within and between these periods.Results:Survival improved for most cancers, but inequalities in survival were still wide for many cancers in 2006. Only the deprivation gap in 1-year survival narrowed slightly over time. A majority of the socioeconomic disparities in survival occurred soon after a cancer diagnosis, regardless of the cancer prognosis.Conclusion:The recently observed reduction in the deprivation gap was minor and limited to 1-year survival, suggesting that, so far, the Cancer Plan has little effect on those inequalities. Our findings highlight that earlier diagnosis and rapid access to optimal treatment should be ensured for all socioeconomic groups.

Socio-economic inequalities in child survival in India: A decomposition analysis

This paper provides a first time assessment of the decomposed contributions of socio-economic determinants of under2 child mortality in India and its states using the recent National Family Health Survey (NFHS-3, 2005-06) data. In the first stage analysis, concentration indices of under2 mortality were generated as measures of socio-economic inequalities. The concentration indices were then decomposed into their determining factors. Decomposition results reveal that poor household economic status (46%), mother's illiteracy (35%) and rural residence (15%) contribute to 96% of total socio-economic inequalities in child survival at the national level. The contribution of economic status is relatively smaller in 5 states that are advanced in health transition. The varying pattern of evidence across the states from decomposition analysis suggests the need for unique health intervention strategies for different states in accordance with the evidence of major contributions to total child health inequalities arising from poverty, illiteracy and rural residence.

Social inequalities in non-small cell lung cancer management and survival: a population-based study in central Sweden

ObjectivesTo examine possible associations between socioeconomic status, management and survival of patients with non-small cell lung cancer (NSCLC).MethodsIn a population-based cohort study, information was retrieved from the Regional Lung Cancer...

How well does LiST capture mortality by wealth quintile? A comparison of measured versus modelled mortality rates among children under-five in Bangladesh

Background In the absence of planned efforts to target the poor, child survival programs often favour the rich. Further evidence is needed urgently about which interventions and programme approaches are most effective in addressing inequities. The Lives Saved Tool (LiST) is available and can be used to model mortality levels across economic groups based on coverage levels for child survival interventions.Methods We used LiST to model neonatal and under-5 mortality levels among the highest and the lowest wealth quintiles in Bangladesh based on national and wealth-quintile-specific coverage of child survival interventions. The cause-of-death structure among children under-5 was also modelled using the coverage levels. Modelled rates were compared to the rates measured directly from the 2004 Bangladesh Demographic and Health Survey and associated verbal autopsies.Results Modelled estimates of mortality within wealth quintiles fell within the 95% confidence intervals of measured mortality for both neonatal and post-neonatal mortality. LiST also performed well in predicting the cause-of-death structure for these two age groups for the poorest quintile of the population, but less well for the richest quintile.Conclusions LiST holds promise as a useful tool for assessing socio-economic inequities in child survival in low-income countries.

The state of the art of cancer control in 30 European countries in 2008

Inequalities in cancer incidence, mortality and survival represent a major challenge for public health. Addressing this challenge requires complex and multidisciplinary approaches. Sharing successful experiences from across Europe may therefore be of benefit. We describe the state of the art of cancer control structures in the 27 European Union countries, plus Iceland, Norway and Switzerland, at the beginning of 2008. Information on cancer plans, cancer registries, cancer screening, Human Papillomavirus (HPV) vaccination and smoking restrictions in each country was identified through PubMed, the official websites of national and international organizations and Google searches. Experts and/or health authorities from each country completed and validated the information. Sixteen countries had implemented national cancer plans in 2008. Twenty four countries had population-based cancer registries with 100% coverage. The exceptions were Greece and Luxembourg (no population-based registry yet), France, Italy and Spain (<50%), and Switzerland (62%). In 9 countries, population coverage of breast cancer screening was 100% with participation ranging from 26 to 87%; 8 countries did not have organized programmes. Seven countries had cervical cancer screening programmes with 100% coverage with participation ranging from 10 to 80%; 8 countries had no organized programme. Nine countries had announced national HPV vaccination policies by early 2008. Six countries had organized colorectal cancer screening programmes. Five countries had complete bans on smoking in public places. There is wide international heterogeneity in cancer control structures in Europe. This provides considerable scope and motivation for cooperation and sharing of experience.

A multilevel study of the determinants of area-level inequalities in colorectal cancer survival

BackgroundIn Australia, associations between geographic remoteness, socioeconomic disadvantage, and colorectal cancer (CRC) survival show that survival rates are lowest among residents of geographically remote regions and those living in disadvantaged areas. At present we know very little about the reasons for these inequalities, hence our capacity to intervene to reduce the inequalities is limited.Methods/DesignThis study, the first of its type in Australia, examines the association between CRC survival and key area- and individual-level factors. Specifically, we will use a multilevel framework to investigate the possible determinants of area- and individual-level inequalities in CRC survival and quantify the relative contribution of geographic remoteness, socioeconomic and demographic factors, disease stage, and access to diagnostic and treatment services, to these inequalities. The multilevel analysis will be based on survival data relating to people diagnosed with CRC in Queensland between 1996 and 2005 (n = 22,723) from the Queensland Cancer Registry (QCR), area-level data from other data custodians such as the Australian Bureau of Statistics, and individual-level data from the QCR (including extracting stage from pathology records) and Queensland Hospitals. For a subset of this period (2003 and 2004) we will utilise more detailed, individual-level data (n = 1,966) covering a greater range of risk factors from a concurrent research study. Geo-coding and spatial technology will be used to calculate road travel distances from patients' residence to treatment centres. The analyses will be conducted using a multilevel Cox proportional hazards model with Level 1 comprising individual-level factors (e.g. occupation) and level 2 area-level indicators of remoteness and area socioeconomic disadvantage.DiscussionThis study focuses on the health inequalities for rural and disadvantaged populations that have often been documented but poorly understood, hence limiting our capacity to intervene. This study utilises and develops emerging statistical and spatial technologies that can then be applied to other cancers and health outcomes. The findings of this study will have direct implications for the targeting and resourcing of cancer control programs designed to reduce the burden of colorectal cancer, and for the provision of diagnostic and treatment services.

Ethnic disparities in child health in Nigeria: a multilevel analysis of individual and contextual factors

Each ethnic group has its own peculiar cultural practices that may widen inequalities in child health and survival among ethnic groups. This study estimated ethnic disparities in mortality of under‐five‐year‐olds, controlling for individual and community level characteristics. Using multilevel multivariable regression analysis on a nationally representative sample drawn from 7,864 households in the 2003 Nigeria Demographic and Health Survey, we estimated the risks of deaths under‐five‐year‐olds for 6,029 children nested within 2,735 mothers aged 15‐49 years old, who were in turn nested within 365 communities. Results were expressed as odds ratios with 95% confidence intervals. The observed risk of under‐five death was highest among children of Hausa/Fulani/Kanuri mothers and lowest among children of Yoruba mothers. The mother's affiliation to the Yoruba ethnic group, compared to Hausa/Fulani/Kanuri, was still significantly associated with decreased under‐five mortality (OR = 0.66, 95% CI = 0.45 ‐ 0.96) after adjustment for individual and community level factors. Under‐five mortality was significantly related to socio‐economic and demographic factors (birth order/birth interval, mother's age, and mother's education), which explained much but not all of the ethnic disparities. Findings underscore the need for measures aimed at improving female education and the socio‐economic standard of women, changing short birth spacing norms and reducing inequitable distribution of maternal and child health services.