Socioeconomic Inequalities In Cancer Survival Research Articles

Socio-economic inequalities in cancer survival: how do they translate into Number of Life-Years Lost?

BackgroundWe aimed to investigate the impact of socio-economic inequalities in cancer survival in England on the Number of Life-Years Lost (NLYL) due to cancer.MethodsWe analysed 1.2 million patients diagnosed with one of the 23 most common cancers (92.3% of all incident cancers in England) between 2010 and 2014. Socio-economic deprivation of patients was based on the income domain of the English Index of Deprivation. We estimated the NLYL due to cancer within 3 years since diagnosis for each cancer and stratified by sex, age and deprivation, using a non-parametric approach. The relative survival framework enables us to disentangle death from cancer and death from other causes without the information on the cause of death.ResultsThe largest socio-economic inequalities were seen mostly in adults <45 years with poor-prognosis cancers. In this age group, the most deprived patients with lung, pancreatic and oesophageal cancer lost up to 6 additional months within 3 years since diagnosis than the least deprived. For most moderate/good prognosis cancers, the socio-economic inequalities widened with age.ConclusionsMore deprived patients and particularly the young with more lethal cancers, lose systematically more life-years than the less deprived. To reduce these inequalities, cancer policies should systematically encompass the inequities component.

Small-area analysis on socioeconomic inequalities in cancer survival for 25 cancer sites in Germany.

Socioeconomic inequalities in cancer survival have been reported in various countries but it is uncertain to what extent they persist in countries with relatively comprehensive health insurance coverage such as Germany. We investigated the association between area-based socioeconomic deprivation on municipality level and cancer survival for 25 cancer sites in Germany. We used data from seven population-based cancer registries (covering 32 million inhabitants). Patients diagnosed in 1998 to 2014 with one of 25 most common cancer sites were included. Area-based socioeconomic deprivation was assessed using the categorized German Index of Multiple Deprivation (GIMD) on municipality level. We estimated 3-month, 1-year, 5-year and 5-year conditional on 1-year age-standardized relative survival using period approach for 2012 to 2014. Trend analyses were conducted for periods between 2003-2005 and 2012-2014. Model-based period analysis was used to calculate relative excess risks (RER) adjusted for age and stage. In total, 2 333 547 cases were included. For all cancers combined, 5-year survival rates by GIMD quintile were 61.6% in Q1 (least deprived), 61.2% in Q2, 60.4% in Q3, 59.9% in Q4 and 59.0% in Q5 (most deprived). For most cancer sites, the most deprived quintile had lower 5-year survival compared to the least deprived quintile even after adjusting for stage (all cancer sites combined, RER 1.16, 95% confidence interval 1.14-1.19). For some cancer sites, this association was stronger during short-term follow-up. Trend analyses showed improved survival from earlier to recent periods but persisting deprivation differences. The underlying reasons for these persisting survival inequalities and strategies to overcome them should be further investigated.

Socioeconomic deprivation and cancer survival in a metropolitan area: An analysis of cancer registry data from Hamburg, Germany.

BackgroundFew studies have investigated socioeconomic inequalities within cities. Yet, such analyses are particularly important given the increasing international trend to urbanization. Here we investigated area-based socioeconomic inequalities in cancer survival in Hamburg, a port city in the North of Germany (population: 1.84 million people).MethodsPatients with a diagnosis of colorectal, lung, female breast, and prostate cancer in 2004–2018 (follow-up until 31.12.2018) and registered in the Hamburg cancer registry were included. Area-based socioeconomic deprivation on urban district level was assigned to the patients and grouped in five quintiles. Relative survival in 2014–2018 was calculated using the period approach. Trend analyses between 2004 and 2018 were conducted. Relative excess risks adjusted for age and stage were computed with model-based period analyses.FindingsFor the 73,106 included patients, age-standardized 5-year relative survival in 2014–2018 decreased with increasing deprivation with significant differences between the most and least deprived group of 14·7 (prostate), 10·8 (colorectal), 8·0 (breast), and 2·5 (lung) percent units. Standardization by cancer stage decreased the difference for prostate cancer to 8·5 percent units and for breast cancer to 3·6 percent units but had only a minor effect for colorectal and lung cancer. Similar socioeconomic inequalities were already present in 2004–08.InterpretationStrong socioeconomic inequalities in cancer survival were observed in Hamburg, which could be partly explained by differences in the stage distribution. Further research including information on screening participation as well as information on cancer care are important to further understand and finally overcome these inequalities.Funding10.13039/501100005972German Cancer Aid.

Estimation of the Potentially Avoidable Excess Deaths Associated with Socioeconomic Inequalities in Cancer Survival in Germany.

Simple SummaryIn this study, we estimate the number of avoidable deaths attributable to socioeconomic inequalities in cancer survival in Germany. We used data from epidemiological cancer registries. The German Index of Multiple Deprivation (GIMD) 2010 was used to assess deprivation on a municipality level. Results show that summed over the 25 cancer sites, 4100 annual excess deaths (3.0% of all excess deaths) could have been avoided each year in Germany during the period 2013–2016 if relative survival were in all regions comparable with the least deprived regions. Colorectal, oral and pharynx, prostate, and bladder cancer contributed the largest numbers of avoidable excess deaths. We also observed that cancer incidence was generally higher in more deprived areas. Our analyses demonstrate the importance of cancer prevention and of survival improvements in more deprived regions.Many countries have reported survival inequalities due to regional socioeconomic deprivation. To quantify the potential gain from eliminating cancer survival disadvantages associated with area-based deprivation in Germany, we calculated the number of avoidable excess deaths. We used population-based cancer registry data from 11 of 16 German federal states. Patients aged ≥15 years diagnosed with an invasive malignant tumor between 2008 and 2017 were included. Area-based socioeconomic deprivation was assessed using the quintiles of the German Index of Multiple Deprivation (GIMD) 2010 on a municipality level nationwide. Five-year age-standardized relative survival for 25 most common cancer sites and for total cancer were calculated using period analysis. Incidence and number of avoidable excess deaths in Germany in 2013–2016 were estimated. Summed over the 25 cancer sites, 4100 annual excess deaths (3.0% of all excess deaths) could have been avoided each year in Germany during the period 2013–2016 if relative survival were in all regions comparable with the least deprived regions. Colorectal, oral and pharynx, prostate, and bladder cancer contributed the largest numbers of avoidable excess deaths. Our results provide a good basis to estimate the potential of intervention programs for reducing socioeconomic inequalities in cancer burden in Germany.

Factors Explaining Socio-Economic Inequalities in Cancer Survival: A Systematic Review.

Background:There is strong and well-documented evidence that socio-economic inequality in cancer survival exists within and between countries, but the underlying causes of these differences are not well understood.Methods:We systematically searched the Ovid Medline, EMBASE, and CINAHL databases up to 31 May 2020. Observational studies exploring pathways by which socio-economic position (SEP) might causally influence cancer survival were included.Results:We found 74 eligible articles published between 2005 and 2020. Cancer stage, other tumor characteristics, health-related lifestyle behaviors, co-morbidities and treatment were reported as key contributing factors, although the potential mediating effect of these factors varied across cancer sites. For common cancers such as breast and prostate cancer, stage of disease was generally cited as the primary explanatory factor, while co-morbid conditions and treatment were also reported to contribute to lower survival for more disadvantaged cases. In contrast, for colorectal cancer, most studies found that stage did not explain the observed differences in survival by SEP. For lung cancer, inequalities in survival appear to be partly explained by receipt of treatment and co-morbidities.Conclusions:Most studies compared regression models with and without adjusting for potential mediators; this method has several limitations in the presence of multiple mediators that could result in biased estimates of mediating effects and invalid conclusions. It is therefore essential that future studies apply modern methods of causal mediation analysis to accurately estimate the contribution of potential explanatory factors for these inequalities, which may translate into effective interventions to improve survival for disadvantaged cancer patients.

Socioeconomic Inequalities in Colorectal Cancer Survival in Southern Spain: A Multilevel Population-Based Cohort Study.

BackgroundColorectal cancer (CRC) is the most frequently diagnosed cancer in Spain. Socioeconomic inequalities in cancer survival are not documented in Spain. We aim to study the association of socioeconomic inequalities with overall mortality and survival among CRC patients in southern Spain.MethodsWe conducted a multilevel population-based cohort study, including CRC cases for the period 2011–2013. The study time-to-event outcome was death, and the primary exposure was CRC patients’ socioeconomic status assessed by the Spanish deprivation index at the census tract level. We used a mixed-effects flexible hazard model, including census tract as a random intercept, to derive overall survival estimates by deprivation.ResultsAmong 3589 CRC patients and 12,148 person-years at risk (pyr), 964 patients died before the end of the follow-up. Mortality by deprivation showed the highest mortality rate for the most deprived group (96.2 per 1000 pyr, 95% CI: 84.0–110.2). After adjusting for sex, age, cancer stage, and the area of residence, the most deprived had a 60% higher excess mortality risk than the less deprived group (excess mortality risk ratio: 1.6, 95% CI: 1.1–2.3).ConclusionsWe found a consistent association between deprivation and CRC excess mortality and survival. The reasons behind these inequalities need further investigation in order to improve equality cancer outcomes in all social groups.

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.

Impact of national cancer policies on cancer survival trends and socioeconomic inequalities in England, 1996-2013: population based study

ObjectiveTo assess the effectiveness of the NHS Cancer Plan (2000) and subsequent national cancer policy initiatives in improving cancer survival and reducing socioeconomic inequalities in survival in England.DesignPopulation based cohort...

The impact of geographic unit of analysis on socioeconomic inequalities in cancer survival and distant summary stage – a population‐based study

Objective:When using area‐level disadvantage measures, size of geographic unit can have major effects on recorded socioeconomic cancer disparities. This study examined the extent of changes in recorded socioeconomic inequalities in cancer survival and distant stage when the measure of socioeconomic disadvantage was based on smaller Census Collection Districts (CDs) instead of Statistical Local Areas (SLAs). Methods:Population‐based New South Wales Cancer Registry data were used to identify cases diagnosed with primary invasive cancer in 2000–2008 (n=264,236). Logistic regression and competing risk regression modelling were performed to examine socioeconomic differences in odds of distant stage and hazard of cancer death for all sites combined and separately for breast, prostate, colorectal and lung cancers. Results:For all sites collectively, associations between socioeconomic disadvantage and cancer survival and distant stage were stronger when the CD‐based socioeconomic disadvantage measure was used compared with the SLA‐based measure. The CD‐based measure showed a more consistent socioeconomic gradient with a linear upward trend of risk of cancer death/distant stage with increasing socioeconomic disadvantage. Site‐specific analyses provided similar findings for the risk of death but less consistent results for the likelihood of distant stage. Conclusions:The use of socioeconomic disadvantage measure based on the smallest available spatial unit should be encouraged in the future. Implications for public health:Disadvantage measures based on small spatial units can more accurately identify socioeconomic cancer disparities to inform priority settings in service planning.

Barriers to cancer symptom presentation among people from low socioeconomic groups: a qualitative study.

BackgroundSocioeconomic inequalities in cancer survival can in part be explained by long patient intervals among people from deprived groups; however, the reasons for this are unclear. This qualitative study explores the actual and anticipated barriers to cancer symptom presentation in the context of socioeconomic deprivation.MethodsThirty participants were recruited through the International Cancer Benchmarking Partnership Welsh database (n = 20), snowball sampling (n = 8) and community partners (n = 2). Semi-structured qualitative interviews were conducted with symptomatic and asymptomatic adults over the age of 50 years, who were identified as being from a low socioeconomic group based on multiple individual and group level indicators. Transcripts were analysed using a Framework approach based on the COM-B model (Capability, Opportunity, Motivation-Behaviour).ResultsThere was evidence of poor awareness of non-specific cancer symptoms (Capability), fearful and fatalistic beliefs about cancer (Motivation), and various barriers to accessing an appointment with the family physician (Opportunity) and full disclosure of symptoms (Capability). These in combination were associated with a lengthened patient interval among participants. Social networks (Opportunity) were influential on the formation of knowledge and beliefs about cancer. Participants’ behavioural and normative beliefs were usually formed and reinforced by people they knew with cancer, and such beliefs were considered to lengthen the patient interval. Discussing symptoms with a family member or friend before a visit to the family physician was the norm, and could act as a barrier or facilitator depending on the quality of advice given (Opportunity). Economic hardship meant fulfilling basic day-to-day needs such as finding money for food were prioritised over medical help seeking (Opportunity).ConclusionsThe complex interaction between individual characteristics and socio-environmental factors is important for understanding cancer symptom presentation behaviour, especially in the context of socioeconomic deprivation. Interventions targeted at deprived communities should take into account the wider social influences on symptom presentation behaviour.

No inequalities in survival from colorectal cancer by education and socioeconomic deprivation - a population-based study in the North Region of Portugal, 2000-2002.

BackgroundAssociation between cancer survival and socioeconomic status has been reported in various countries but it has never been studied in Portugal. We aimed here to study the role of education and socioeconomic deprivation level on survival from colorectal cancer in the North Region of Portugal using a population-based cancer registry dataset.MethodsWe analysed a cohort of patients aged 15–84 years, diagnosed with a colorectal cancer in the North Region of Portugal between 2000 and 2002. Education and socioeconomic deprivation level was assigned to each patient based on their area of residence. We measured socioeconomic deprivation using the recently developed European Deprivation Index. Net survival was estimated using Pohar-Perme estimator and age-adjusted excess hazard ratios were estimated using parametric flexible models. Since no deprivation-specific life tables were available, we performed a sensitivity analysis to test the robustness of the results to life tables adjusted for education and socioeconomic deprivation level.ResultsA total of 4,105 cases were included in the analysis. In male patients (56.3 %), a pattern of worse 5- and 10-year net survival in the less educated (survival gap between extreme education groups: -7 % and -10 % at 5 and 10 years, respectively) and more deprived groups (survival gap between extreme EDI groups: -5 % both at 5 and 10 years) was observed when using general life tables. No such clear pattern was found among female patients. In both sexes, when likely differences in background mortality by education or deprivation were accounted for in the sensitivity analysis, any differences in net survival between education or deprivation groups vanished.ConclusionsOur study shows that observed differences in survival by education and EDI level are most likely attributable to inequalities in background survival. Also, it confirms the importance of using the relevant life tables and of performing sensitivity analysis when evaluating socioeconomic inequalities in cancer survival. Comparison studies of different healthcare systems organization should be performed to better understand its influence on cancer survival inequalities.Electronic supplementary materialThe online version of this article (doi:10.1186/s12885-016-2639-9) contains supplementary material, which is available to authorized users.

How much do tumor stage and treatment explain socioeconomic inequalities in breast cancer survival? Applying causal mediation analysis to population-based data.

Substantial socioeconomic inequalities in breast cancer survival persist in England, possibly due to more advanced cancer at diagnosis and differential access to treatment. We aim to disentangle the contributions of differential stage at diagnosis and differential treatment to the socioeconomic inequalities in cancer survival. Information on 36,793 women diagnosed with breast cancer during 2000–2007 was routinely collected by an English population-based cancer registry. Deprivation was determined for each patient according to her area of residence at the time of diagnosis. A parametric implementation of the mediation formula using Monte Carlo simulation was used to estimate the proportion of the effect of deprivation on survival mediated by stage and by treatment. One-third (35 % [23–48 %]) of the higher mortality experienced by most deprived patients at 6 months after diagnosis, and one tenth (14 % [−3 to 31 %]) at 5 years, was mediated by adverse stage distribution. We initially found no evidence of mediation via differential surgical treatment. However, sensitivity analyses testing some of our study limitations showed in particular that up to thirty per cent of the higher mortality in most deprived patients could be mediated by differential surgical treatment. This study illustrates the importance of using causal inference methods with routine medical data and the need for testing key assumptions through sensitivity analyses. Our results suggest that, although effort for earlier diagnosis is important, this would reduce the cancer survival inequalities only by a third. Because of data limitations, role of differential surgical treatment may have been under-estimated.Electronic supplementary materialThe online version of this article (doi:10.1007/s10654-016-0155-5) contains supplementary material, which is available to authorized users.

Trends in ethnic and socioeconomic inequalities in cancer survival, New Zealand, 1991–2004

Improvements in cancer survival may be distributed inequitably throughout populations and across time. We assessed trends in cancer survival inequalities in New Zealand by ethnic and income group. 126,477 people diagnosed with cancer between 1991 and 2004, followed-up to 2006, were included. First, inequalities pooled over time were measured with excess mortality rate ratios (EMRRs). Second, interpretation of changes in inequalities over time can differ depending on whether one uses EMRRs, excess mortality rate differences (EMRD) or absolute differences in relative survival risks (RSRD); we estimated all three by cancer-site and (for EMRRs only) pooled across all sites. We found that pooled over time and all sites, Māori had an EMRR of 1.29 (95% CI, 1.24–1.34) compared to non-Māori. The low compared to high-income EMRR was 1.12 (95% CI, 1.09–1.15). Pooled over cancers, there was no change in the ethnic EMRR over time but the income EMRR increased by 9% per decade (1–17%). Changes over time in site-specific inequalities were imprecisely measured, but the direction of change was usually consistent across EMRRs, EMRDs and RSRDs. There were persistent ethnic inequalities in cancer survival over time, and slower improvements for low-income people.

The impact of age at diagnosis on socioeconomic inequalities in adult cancer survival in England

BackgroundUnderstanding the age at which persistent socioeconomic inequalities in cancer survival become apparent may help motivate and support targeting of cancer site-specific interventions, and tailoring guidelines to patients at higher risk. Patients and methodsWe analysed data on more than 40,000 patients diagnosed in England with one of three common cancers in men and women, breast, colon and lung, 2001–2005 with follow-up to the end of 2011. We estimated net survival for each of the five deprivation categories (affluent, 2, 3, 4, deprived), cancer site, sex and age group (15–44, 45–54, 55–64, and 65–74 and 75–99 years). ResultsThe magnitude and pattern of the age specific socioeconomic inequalities in survival was different for breast, colon and lung. For breast cancer the deprivation gap in 1-year survival widened with increasing age at diagnosis, whereas the opposite was true for lung cancer, with colon cancer having an intermediate pattern. The ‘deprivation gap’ in 1-year breast cancer survival widened steadily from −0.8% for women diagnosed at 15–44 years to −4.8% for women diagnosed at 75–99 years, and was the widest for women diagnosed at 65−74 years for 5- and 10-year survival. For colon cancer in men, the gap was widest in patients diagnosed aged 55–64 for 1-, 5- and 10-year survival. For lung cancer, the ‘deprivation gap’ in survival in patients diagnoses aged 15–44 years was more than 10% for 1-year survival in men and for 1- and 5-year survival in women. ConclusionOur findings suggest that reduction of socioeconomic inequalities in survival will require updating of current guidelines to ensure the availability of optimal treatment and appropriate management of lung cancer patients in all age groups and older patients in deprived groups with breast or colon cancer.

P0115 Effect of differential stage or treatment on socioeconomic inequalities in survival from non-small-cell lung carcinoma (NSCLC): Mediation analysis using Osaka population-based cancer registry data in Japan

Background Wide socioeconomic inequalities in cancer survival were observed in Osaka, Japan. Both 1-year and 5-year survival from non-small-cell lung carcinoma (NSCLC) differed by about 5% between the most affluent and most deprived patients. We aimed to estimate the part played by differential stage distribution and surgical treatment in such inequalities. Methods We did an observational study using population-based cancer registry data. The final analysis included 30,528 patients diagnosed with a NSCLC in Osaka Prefecture in 1993–2004, who were followed up for at least 5 years. 11% were excluded because of missing information on tumour stage. Mediation analyses using Monte Carlo simulation were used to estimate the proportion of the socioeconomic effect mediated by tumour stage on (i) cancer survival and (ii) receiving surgical treatment of curative intent. Findings Compared with the highest socioeconomic patients, higher 1-year mortality in lower socioeconomic groups was mediated by adverse stage distribution in nearly half of cases. Stage explained none of the higher conditional 5-year mortality among lower socioeconomic patients. Lower socioeconomic levels were also associated with decreasing proportions of surgery with curative intent, but this association was mediated by stage only in the lowest socioeconomic group: the lower proportion of treatment was explained by adverse stage distribution in nearly 80% of cases. Interpretation Access to earlier diagnosis should be deployed in low socioeconomic populations. Suboptimal management observed among the poorest NSCLC patients needs to be further investigated. This is crucial in an equitable society with a universal health-care system.

Socioeconomic inequalities in cancer survival: A population-based study of adult patients diagnosed in Osaka, Japan, during the period 1993–2004

Background. Long-term recession of the Japanese economy during the 1990s led to growing social inequalities whilst health inequalities also appeared. The 2007 National Cancer Control Program of Japan targeted “equalisation of cancer medical services”, but the system to monitor health inequalities was still inadequate. We aimed to measure socioeconomic inequalities in cancer survival in Japan.Material and methods. We analysed 13 common invasive, primary, malignant tumours diagnosed from 1993 to 2004 and registered by the population-based Cancer Registry of Osaka Prefecture. An ecological socioeconomic deprivation index based on small area statistics, divided into quintile groups, was linked to patients according to their area of residence at the time of diagnosis. We estimated one-, five-year and conditional five-year net survival by sex, period of diagnosis (1993–1996/1997–2000/2001–2004) and deprivation group. Changes in survival over time, deprivation gap in survival, and change in deprivation gap were estimated at one and five years after diagnosis using variance-weighted least square regression.Results. The deprivation gap in one-year net survival was narrower than in five-year net survival and conditional five-year survival. During the study period, there was no change in deprivation gap, except for reductions for pancreas (men) and stomach (women), and an increase for lung (men) in one-year survival. We observed a linear association between level of survival and deprivation gap at five years and conditional five years, but no association at one-year survival.Conclusion. A wide deprivation gap in survival was observed in most of the adult, solid, malignant tumours, within the universal healthcare system in Japan. Overall, cancer survival improved in Osaka without any widening of inequalities in cancer survival in 1993–2004, shortly after the long-term economic recession and deep modifications in the social and work environments in Japan. The longer term impact of the recession on inequalities in cancer survival needs to be monitored using population-based cancer registry data.

Socioeconomic deprivation and cancer survival in Germany: An ecological analysis in 200 districts in Germany

Although socioeconomic inequalities in cancer survival have been demonstrated both within and between countries, evidence on the variation of the inequalities over time past diagnosis is sparse. Furthermore, no comprehensive analysis of socioeconomic differences in cancer survival in Germany has been conducted. Therefore, we analyzed variations in cancer survival for patients diagnosed with one of the 25 most common cancer sites in 1997-2006 in ten population-based cancer registries in Germany (covering 32 million inhabitants). Patients were assigned a socioeconomic status according to the district of residence at diagnosis. Period analysis was used to derive 3-month, 5-year and conditional 1-year and 5-year age-standardized relative survival for 2002-2006 for each deprivation quintile in Germany. Relative survival of patients living in the most deprived district was compared to survival of patients living in all other districts by model-based period analysis. For 21 of 25 cancer sites, 5-year relative survival was lower in the most deprived districts than in all other districts combined. The median relative excess risk of death over the 25 cancer sites decreased from 1.24 in the first 3 months to 1.16 in the following 9 months to 1.08 in the following 4 years. Inequalities persisted after adjustment for stage. These major regional socioeconomic inequalities indicate a potential for improving cancer care and survival in Germany. Studies on individual-level patient data with access to treatment information should be conducted to examine the reasons for these socioeconomic inequalities in cancer survival in more detail.

How much of socioeconomic differences in survival in patients with breast cancer can be explained by differences in stage of diagnosis and treatment? Application of causal mediation analysis to routine data

BackgroundSubstantial socioeconomic inequalities in breast cancer survival exist in England. Late presentation at more advanced stages and differential access to treatment are two main factors that might contribute to the survival differences. We aimed to adapt methods from the causal inference setting to examine what proportions of the differences in survival can be explained by these factors. MethodsInformation for 36 793 women diagnosed with breast cancer between 2000 and 2007 was gathered by the population-based Northern and Yorkshire Cancer Registry. Vital status was ascertained until the end of 2007, at which point 29 009 women were still alive. Information on surgical treatment was retrieved from the Hospital Episode Statistics (HES) dataset. Hierarchical matching was done using a unique identification number, date of birth, postcode, and sex. The OPCS-4 (Office of Population Censuses and Surveys Classification of Interventions and Procedures) codes from HES within 1 month before and 6 months after cancer diagnosis were dichotomised into major versus minor or no procedures using recommendations from a clinical reference group. Deprivation category, based on the indices of multiple deprivation (income domain), was allocated to each patient according to their area of residence at the time of diagnosis. G-computation procedures were used to estimate the proportion of the effect of deprivation on treatment mediated by stage, survival mediated by stage, and survival mediated by treatment. Single stochastic imputation was incorporated in the g-computation procedures to handle missing stage (8%). FindingsNet survival differed between the most affluent and the most deprived patients by 3·6% at 1 year (97·2% vs 93·6%) and 10·0% at 5 years (85·9% vs 75·9%) after diagnosis. Adverse stage distribution was associated with more deprived patients (localised stage 43% [2622 of 6045] in most affluent, 38% [2861 of 7489] in most deprived; distant metastasis 4% [224 of 6045] in most affluent, 6% [484 of 7489] in most deprived; p<0·0001). The more advanced the stage at diagnosis, the less likely the patient received major surgical treatment (p<0·0001). The most deprived patients were 9% (95% CI 1–18) more likely to receive major surgery than the most affluent patients. However, if most deprived patients had the stage distribution of the most affluent, they would be 8% (95% CI 5–13) more likely to receive such treatment. This effect was not noted for the other deprivation categories. The most deprived patients were almost three times more likely to die within 6 months after diagnosis than the most affluent patients (odds ratio 2·77, 95% CI 2·17–3·53); a third of this was mediated by adverse stage distribution (proportion mediated 0·35, 95% CI 0·23–0·48) whereas none was mediated through differential surgical treatment (p>0·5). InterpretationPreliminary results elucidate how much effect different contributory factors have on the differential short-term cancer survival between deprivation groups in patients with breast cancer. Efforts to advance diagnoses are important, but would reduce the socioeconomic inequalities in cancer survival by only a third. These results are based on population-based data—ie, they include virtually all patients diagnosed with a breast cancer in Yorkshire and the northeast of England, including those who were diagnosed with advanced stage and those who did not receive optimum treatment. Our study is nevertheless observational. We used a causal approach in which age, year of diagnosis, and regions of England were adjusted. We did not have reliable information on comorbidity, another potential mediator on the causal pathway. Quantifying the proportions of the deprivation gap mediated via comorbidity, stage, and treatment separately informs us about the parts they played and, ultimately, what could be done to most effectively reduce the deprivation gap in cancer survival. FundingNone.

How many deaths would be avoidable if socioeconomic inequalities in cancer survival in England were eliminated? A national population-based study, 1996–2006

AimInequalities in survival between rich and poor have been reported for most adult cancers in England. This study aims to quantify the public health impact of these inequalities by estimating the number of cancer-related deaths that would be avoidable if all patients were to have the same cancer survival as the most affluent patients. MethodsNational Cancer Registry data for all adults diagnosed with one of 21 common cancers in England were used to estimate relative survival. We estimated the number of excess (cancer-related) deaths that would be avoidable within three years after diagnosis if relative survival for patients in all deprivation groups was as high as the most affluent group. ResultsFor patients diagnosed during 2004–2006, 7122 of the 64,940 excess deaths a year (11%) would have been avoidable if three-year survival for all patients had been as high as in the most affluent group. The annual number of avoidable deaths fell from 8435 (13%) a year for patients diagnosed during 1996–2000. Over 60% of the total number of avoidable deaths occurred within six months after diagnosis and approximately 70% occurred in the two most deprived groups. ConclusionThe downward trend in the annual number of avoidable deaths reflects more an improvement in survival in England overall, rather than a narrowing of the deficit in cancer survival between poor and rich. The lack of any substantial change in the percentage of avoidable excess deaths highlights the persistent nature of the deficit in survival between affluent and deprived groups.

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...