Social Inequalities In Survival Research Articles

Inequalities in survival and care across social determinants of health in a cohort of advanced lung cancer patients in Quebec (Canada): A high-resolution population-level analysis.

Advanced lung cancer patients exposed to breakthrough therapies like EGFR tyrosine kinase inhibitors (EGFR-TKI) may experience social inequalities in survival, partly from differences in care. This study examined survival by neighborhood-level socioeconomic and sociodemographic status, and geographical location of advanced lung cancer patients who received gefitinib, an EGFR-TKI, as first-line palliative treatment. Differences in the use and delay of EGFR-TKI treatment were also examined. Lung cancer patients receiving gefitinib from 2001 to 2019 were identified from Quebec's health administrative databases. Accounting for age and sex, estimates were obtained for the median survival time from treatment to death, the probability of receiving osimertinib as a second EGFR-TKI, and the median time from biopsy to receiving first-line gefitinib. Among 457 patients who received first-line treatment with gefitinib, those living in the most materially deprived areas had the shortest median survival time (ratio, high vs. low deprivation: 0.69; 95% CI: 0.47-1.04). The probability of receiving osimertinib as a second EGFR-TKI was highest for patients from immigrant-dense areas (ratio, high vs. lowdensity: 1.95; 95% CI: 1.26-3.36) or from Montreal (ratio, other urban areas vs. Montreal: 0.39; 95% CI: 0.16-0.71). The median wait time for gefitinib was 1.27 times longer in regions with health centers peripheral to large centers in Quebec or Montreal in comparison to regions with university-affiliated centers (95% CI: 1.09-1.54; n = 353). This study shows that real-world variations in survival and treatment exist among advanced lung cancer patients in the era of breakthrough therapies and that future research on inequalities should also focus on this population.

Are there social gradients in the occurrence of lung cancer and in the survival of lung cancer patients? Findings from an observational study using German claims data of Lower Saxony

ObjectivesOnly a few studies on health inequalities in terms of lung cancer are available. We examined whether social inequalities are present for the occurrence of lung cancer. Confining the analyses to patients, it was also examined whether survival over the observation period and over a standardised period of 18 months differed by occupational position and income.MethodsOur findings are based on claims data from a German statutory health insurance covering 2005–2016. The database comprised N=3 163 211 women (50.7%) and men (49.3%) aged 18 years and older. Diagnoses (International Statistical Classification of Diseases and Related Health Problems 10th Revision: C34.0 to C34.9) were hospital-based, and income and occupational position were used as indicators of socioeconomic position. Analyses on social gradients were performed for employed and retired insured, but only for employed insured information on occupation and on income were available, for retired women and men only income was available. Analyses were performed by means of proportional hazard regression.ResultsIn employed women, social gradients for the occurrence emerged for occupational position, but not for income. In men, social differences were found for both indicators. For retired insured, income gradients were found in men. Looking at overall survival, neither in women nor in men social gradients emerged.ConclusionsThe reported social inequalities in the occurrence of lung cancer are pointing towards social differences in smoking behaviour, exposition to hazardous occupation-related substances and differences in preventive strategies. The absence of social inequalities in survival after lung cancer suggests equality in medical treatment of the disease.

Social inequalities in cancer survival: A population-based study using the Costa Rican Cancer Registry

BackgroundSocial inequalities in survival after cancer diagnosis have been described in several high-income countries, all cancer sites combined and for several specific cancer sites. The objective of this study was to analyze 5-year net survival after cancer diagnosis in a middle-income country (Costa Rica), according to the characteristics at the district level. MethodsCosta Rican Cancer Registry is a national population-based registry. All cases diagnosed between January 1, 2011 and December 31, 2015 were included (N = 46,904). Deaths that occurred before December 31, 2018 were identified. An ecological study was implemented. The 477 districts were described using the 2011 Census. Urbanity and wealth was assessed. Socioeconomic inequalities in cancer survival were measured using multivariable flexible parametric models. Life tables by socio-economic status were used. Results5-year net survival ranged from 9% for liver cancer to 98 % for in situ cervical cancer. Patients living in socioeconomically disadvantaged districts experienced poorer cancer survival at 5 years, after taking into account the inequalities in survival in the general population (HR = 1.23, p < 0.01). This result was robust and was found at 1, 2 and 5 years, in all-cancer combined, and in low-, medium- and high-lethality cancers. There was no difference according to the area, except for low-lethality cancers at 1 year. DiscussionDespite its universal and solidarity-based health system, Costa Rica is experiencing social inequalities in survival after cancer diagnosis.

WS10-1 Social inequalities in survival in cystic fibrosis: a joint modelling study using UK Registry data

WS10-1 Social inequalities in survival in cystic fibrosis: a joint modelling study using UK Registry data

Acute myocardial infarction: Does survival depend on geographical location and social background?

This study described the interplay between geographical and social inequalities in survival after incident acute myocardial infarction (AMI) and examined whether geographical variation in survival exists when accounting for sociodemographic characteristics of the patients and their neighbourhood. Ringmap visualization and generalized linear models were performed to study post-AMI mortality. Three individual-level analyses were conducted: immediate case fatality, mortality between days 1 and 28 after admission and 365-day survival among patients who survived 28 days after admission. In total, 99,013 incident AMI cases were registered between 2005 and 2014 in Denmark. Survival after AMI tended to correlate with sociodemographic indicators at the municipality level. In individual-level models, geographical inequality in immediate case fatality was observed with high mortality in northern parts of Jutland after accounting for sociodemographic characteristics. In contrast, no geographical variation in survival was observed among patients who survived 28 days. In all three analyses, odds and rates of mortality were higher among patients with low educational level (odds ratio (OR) (95% credible intervals) of 1.20 (1.12-1.29), OR of 1.12 (1.01-1.24) and mortality rate ratio of 1.45 (1.30-1.61)) and low income (OR of 1.24 (1.15-1.33), OR of 1.33 (1.20-1.48) and mortality rate ratio of 1.25 (1.13-1.38)). Marked geographical inequality was observed in immediate case fatality. However, no geographically unequal distribution of survival was found among patients who survived 28 days after AMI. Results additionally showed social inequality in survival following AMI.

Social Inequalities Along the Childhood Cancer Continuum: An Overview of Evidence and a Conceptual Framework to Identify Underlying Mechanisms and Pathways.

Inequalities in health according to social conditions are regarded as unnecessary and unjust. There is a large body of evidence on inequalities in adult cancer, observable throughout the societies on a national level as well as on a global scale. Socioeconomic influences on health matter at all ages including childhood, for which childhood cancer is the leading cause of disease related death in high-income countries (HICs). Substantial differences in the reported incidence of childhood cancers have been observed globally by socioeconomic development of a population. This is reflected in the higher incidence rates reported for HICs, particularly for acute lymphoblastic leukemia, and for cancer in infants (below 1 year), compared to low- and middle-income countries (LMICs). Considerable inequalities between populations and degree of socioeconomic development are also noted for survival from childhood cancer, with substantially lower survival rates seen in most LMICs compared to HICs. With respect to inequalities by socioeconomic position (SEP) within countries, findings of an association between SEP and childhood cancer risk are diverse and limited to studies from HICs. On the contrary, observations on social inequalities in survival within countries are accumulating and indicate that survival inequalities do not only concern resource-poor countries but also high-income populations including European countries. In turn, a childhood cancer diagnosis in itself may have implications on the parents' socioeconomic situation as well as on the later socioeconomic life after having survived the disease. The underlying mechanisms and causal pathways of these empirically demonstrated social inequalities are poorly understood, although it is of significant public health relevance for any actions or strategies to reduce childhood cancer-related inequity. We propose a conceptual framework on potential underlying mechanism and pathways specifically addressing social inequalities in childhood cancer and after childhood cancer to (i) illustrate potential pathways by which social determinants may create health inequities at different points of the childhood cancer continuum; (ii) illustrate potential pathways by which a childhood cancer diagnosis may impact the socioeconomic situation of the concerned family or the later life of a childhood survivor; and (iii) point out how major determinants may relate to each other.

Geographical and social inequalities in survival after incident acute myocardial infarction in Denmark: A spatial epidemiological cohort study based on nationwide register data

Introduction Survival after acute myocardial infarction (AMI) is associated with receiving adequate and often time-dependent treatment as well as sociodemographic characteristics of the patient. Access to adequate AMI treatment might depend on where you live as distance to the nearest hospital differs substantially across the country. Moreover, where you live is to some degree influenced by your socioeconomic position and economical resources. The interplay between the geographical and social inequalities in survival after an AMI is not clearly understood and it remains unclear whether geographical patterns in survival can be explained by sociodemographic factors. This study aimed to examine whether the geographical patterns in survival after incident AMI can be explained by individual- and neighborhood-level sociodemographic characteristics. Methods The study population consisted of patients (≥ 30 years) with an incident AMI between 1 January 2005 and 31 December 2014 registered in the National Patient Register or the Danish Register of Causes of Death. The population was followed for a maximum of 365 days or until emigration, study end or death, whichever came first. The year 2005 was used as run-in period to ensure adequate results estimates across calendar years. Hence, the study period was 1 January 2006 to 31 December 2014. Poisson regression of incidence rates of all-cause mortality with a geographical component as a random effect was performed in R by use of the Bayesian Integrated Nested Laplace Approximations (INLA) method. The analysis included the individual-level variables age, sex, ethnicity, calendar year, cohabitation status, disposable household income, and educational level and the neighborhood-level variables population density, socioeconomic position, and ethnical composition of the neighborhood. Results The study population consisted of 95,274 patients with incident AMI contributing with 62,8210 person-years at-risk between 2006 and 2014. During the study period 28,194 deaths occurred within 365 days. Crude mortality rates varied substantially across the country as well as across neighborhood and individual-level characteristics, e.g., 53.2/100 person-years died within 365 days after an AMI in neighborhoods with low socioeconomic position, whereas this number was 36.7/100 person-years in high socioeconomic position neighborhoods. Results from the model only including calendar year and the geographically structured random effect component showed clear geographical patterns in survival after an AMI with especially the northern part of Jutland being a high-risk area. After additionally including sociodemographic characteristics of the population and neighborhood in the model the variation in survival after an AMI decreased across the country, but high-risk areas were still observed. Results on fixed effects from the adjusted model showed that persons with low educational level, low-income level and persons living in neighborhoods with low socioeconomic position had an increased incidence rate ratio (IRR) of dying within 365 days after AMI compared to the most educated and affluent population groups [IRRs (95% confidence intervals) of 1.29 (1.23–1.36), 1.26 (1.20–1.32) and 1.11 (1.05–1.17), respectively]. Furthermore, risk of dying within 365 days after an AMI decreased throughout the study period. Results from sensitivity analyses showed that the geographical patterns were more pronounced in out-of-hospital than in-hospital deaths. Conclusions Evident geographical and social inequalities in survival after an incident AMI exist in Denmark. Sociodemographic characteristics at the individual- and neighborhood-level explained part of the geographical variation in survival after an AMI; however, marked geographical patterns in survival after AMI persisted. Further studies are needed to explain the remaining geographical inequalities in survival after an AMI, especially with focus on out-of-hospital deaths.

Does stage of cancer, comorbidity or lifestyle factors explain educational differences in survival after endometrial cancer? A cohort study among Danish women diagnosed 2005–2009

Background: Several studies have documented an association between socioeconomic position and survival from gynaecological cancer, but the mechanisms are unclear. Objective: The aim of this study was to examine the association between level of education and survival after endometrial cancer among Danish women; and whether differences in stage at diagnosis and comorbidity contribute to the educational differences in survival. Methods: Women with endometrial cancer diagnosed between 2005 and 2009 were identified in the Danish Gynaecological Cancer Database, with information on clinical characteristics, surgery, body mass index (BMI) and smoking status. Information on highest attained education, cohabitation and comorbidity was obtained from nationwide administrative registries. Logistic regression models were used to determine the association between level of education and cancer stage and Cox proportional hazards model for analyses of overall survival. Results: Of the 3638 patients identified during the study period, 787 had died by the end of 2011. The group of patients with short education had a higher odds ratio (OR) for advanced stage at diagnosis, but this was not statistically significant (adjusted OR 1.20; 95% CI 0.97–1.49). The age-adjusted hazard ratio (HR) for dying of patients with short education was 1.47 (CI 95% 1.17–1.80). Adjustment for cohabitation status, BMI, smoking and comorbidity did not change HRs, but further adjustment for cancer stage yielded a HR of 1.36 (1.11–1.67). Conclusion: Early detection in all educational groups might reduce social inequalities in survival, however, the unexplained increased risk for death after adjustment for prognostic factors, warrants increased attention to patients with short education in all age groups throughout treatment and rehabilitation.

Socioeconomic position and survival after lung cancer: Influence of stage, treatment and comorbidity among Danish patients with lung cancer diagnosed in 2004–2010

Background. To address social inequality in survival after lung cancer, it is important to consider how socioeconomic position (SEP) influences prognosis. We investigated whether SEP influenced receipt of first-line treatment and whether socioeconomic differences in survival could be explained by differences in stage, treatment and comorbidity.Material and methods. In the Danish Lung Cancer Register, we identified 13 045 patients with lung cancer diagnosed in 2004–2010, with information on stage, histology, performance status and first-line treatment. We obtained age, gender, vital status, comorbid conditions and socioeconomic information (education, income and cohabitation status) from nationwide population-based registers. Associations between SEP and receipt of first-line treatment were analysed in multivariate logistic regression models and those with overall mortality in Cox regression models with stepwise inclusion of possible mediators.Results. For both low- and high-stage lung cancer, adjusted ORs for first-line treatment were reduced in patients with short education and low income, although the OR for education did not reach statistical significance in men with high-stage disease. Patients with high-stage disease who lived alone were less likely to receive first-line treatment. The socioeconomic difference in overall survival was partly explained by differences in stage, treatment and comorbidity, although some differences remained after adjustment. Among patients with high-stage disease, the hazard ratio (HR) for death of those with low income was 1.12 (95% CI 1.05–1.19) in comparison with those with high income. Among patients with low-stage disease, those who lived alone had a 14% higher risk for dying (95% CI 1.05–1.25) than those who lived with a partner. The differences in risk for death by SEP were greatest in the first six months after diagnosis.Conclusion. Socioeconomic differences in survival after lung cancer are partly explained by social inequality in stage, first-line treatment and comorbidity. Efforts should be made to improve early diagnosis and adherence to first-line treatment recommendations among disadvantaged lung cancer patients.

Influence of metabolic indicators, smoking, alcohol and socioeconomic position on mortality after breast cancer

Background. Factors differently distributed among social groups like obesity, metabolic syndrome, diabetes, smoking, and alcohol intake predict survival after breast cancer diagnosis and therefore might mediate part of the observed social inequality in survival.Material and methods. We conducted a cohort study among 1250 postmenopausal breast cancer patients identified among 29 875 women in the Danish Diet, Cancer and Health Study. Participants completed questionnaires and anthropometric measurements were made at enrollment. Information on survival, socioeconomic position, and comorbidity was obtained by linkage to national Danish registries. Clinical information was obtained from the nationwide Danish Breast Cancer Database. Selected information was obtained from hospital records at time of diagnosis. All analyses were based on Cox proportional hazard models, using death from all causes as outcome.Results. Median follow-up was 9.6 years [interquartile range (IQR), 2.2–17.0 years]. The hazard ratio (HR) for death from all causes increased with lower education (p for trend, 0.01). Adjustment for disease-related prognostic factors, comorbidity and metabolic indicators measured as BMI, waist circumference and diabetes, and smoking and alcohol affected but did not explain the social gradient.Conclusion. The findings indicate that these factors explain some but not all the social inequality in survival after breast cancer and that improvement of lifestyle to some extent would improve survival among women with low socioeconomic position.

Social inequality in survival after lung cancer: The attribution of stage at diagnosis, receipt of treatment, and comorbidity in a Danish nationwide clinical database study.

6570 Background: Survival after lung cancer depends on stage, treatment, and patient-specific factors as comorbidity. These factors are potentially influenced by social position (SEP). We previously reported a lower risk for advanced-stage lung cancer among persons with higher SEP and we investigate the association between SEP (education, income and cohabiting status) on receipt of 1stline treatment and overall survival in a population-based cohort of lung cancer patients in Denmark. Methods: This registry-based cohort study links data on prognostic factors and treatment from the Danish Lung Cancer Registry to individual socioeconomic information in Statistics Denmark and comorbidity from the National Hospital Discharge Registry for 13,659 persons diagnosed with lung cancer 2004-2011. Results: ORs for receipt of 1stline treatment were higher with longer education and higher income and for patients living with a partner in both men and women with low (T1-3N0M0; T0-3N1M0) and advanced-stage (T0-3N2-3M0; T4N0-3M0; TxNxM1) lung cancer although not statistically significant for all estimates. Among low-stage patients all-cause mortality was 15% higher in patients with short vs higher education, 26% higher for low vs high income and 23% higher for living alone vs living with a partner. In advanced-stage patients, differences in all-cause mortality was 11%, 14% and 8% for education, income and cohabitation status. Stage, treatment, Charlson Comorbidity Score and Performance Score attenuated associations but did not eliminate the association between low income (HR, 1.12; 95% CI, 1.05-1.19) and living alone (HR, 1.15; 95 CI, 1.06-1.25) in low stage lung cancer patients while no social differences in adjusted HR remained in advanced-stage patients. Conclusions: We show that even in a country with free and equal access to health care disparities exist in access to lung cancer treatment both of curative and of palliative intent. Differences in stage, treatment and presence of comorbidity by social position explained most of the social inequality in lung cancer survival although differences remained in the short term for low-stage patients.

Do patient characteristics, disease, or treatment explain social inequality in survival from colorectal cancer?

This paper investigates the association between individually measured socioeconomic status (SES) and all-cause survival in colorectal cancer patients, and explores whether factors related to the patient, the disease, or the surgical treatment mediate the observed social gradient. The data were derived from a nationwide clinical database of all adenocarcinomas of the colon or rectum diagnosed in Denmark between 2001 and 2004 (inclusive). These data were linked to those from several central registries providing information on income, education, and housing status, as well as to data on comorbidity from previous hospitalizations and use of medication. Only patients with colorectal cancer as their first primary tumour and those born after 1920 were included. A total of 8763 patients were included in the study. Cox proportional hazard regression models revealed a positive social gradient in survival for increasing levels of education and income, and in owners versus renters of housing. A series of regression analyses were used to test potential mediators of the association between the socioeconomic indicators and survival by stepwise inclusion of lifestyle factors (smoking, alcohol intake, body mass index), comorbidity, stage of disease, mode of admission, type of operation, specialization of the surgeon, and curative versus palliative resection. A causal diagram guided the analyses. Inclusion of comorbidity, and to a lesser extent lifestyle, reduced the variation associated with SES, while no evidence of a mediating effect was found for disease or surgical treatment factors. This indicates that the difference in survival among colorectal cancer patients from different social groups was probably not caused by unintentional differences in treatment factors related to surgery, and suggests that primary prevention of chronic diseases among the socially deprived might be one way to reduce social differences in prognosis.

Influence of socioeconomic factors on survival after breast cancer—A nationwide cohort study of women diagnosed with breast cancer in Denmark 1983–1999

The reasons for social inequality in breast cancer survival are far from established. Our study aims to study the importance of a range of socioeconomic factors and comorbid disorders on survival after breast cancer surgery in Denmark where the health care system is tax-funded and uniform. All 25,897 Danish women who underwent protocol-based treatment for breast cancer in 1983-1999 were identified in a clinical database and information on socioeconomic variables and both somatic and psychiatric comorbid disorders was obtained from population-based registries. We used Cox proportional hazards models to estimate the association between socioeconomic position and overall survival and further to analyse breast cancer specific deaths in a competing risk set-up regarding all other causes of death as competing risks. The adjusted hazard ratio (HR) for death was reduced in women with higher education (HR, 0.91; 95% confidence interval (CI), 0.85-0.98), with higher income (HR, 0.93; 95% CI, 0.87-0.98) and with larger dwellings (HR, 0.90; 95% CI, 0.85-0.96 for women living in houses larger than 150 m(2)). Presence of comorbid disorders increased the HR. An interaction between income and comorbid disorders resulting in a 15% lower survival 10 year after primary surgery in poor women with low-risk breast cancer having comorbid conditions ( approximately 65%) compared to rich women with similar breast cancer prognosis and comorbid conditions ( approximately 80%) suggests that part of the explanation for the social inequality in survival after breast cancer surgery in Denmark lies in the access to and/or compliance with management of comorbid conditions in poorer women.