Social class and cancer patient survival in Finland

Disparities in Overall Survival Rates for Cancers across Income Levels in the Republic of Korea

BACKGROUND

The overall survival rates among cancer patients have been improving. However, the increase in survival is not uniform across socioeconomic status. Thus, we investigated income disparities in the 5-year survival rate (5YSR) in cancer patients and the temporal trends.

METHODS

This study used a national cancer cohort from 2002 to 2018 that was established by linking the Korea Central Cancer Registry and the National Health Insurance Service (NHIS) claim database to calculate the cancer survival rate by income level in the Republic of Korea. Survival data were available from 2002 onward, and the analysis was based on the actuarial method. We compared the survival of the earliest available 5-year period of 2002-2006 and the latest available 5-year period of 2014-2018, observing until 31 December 2021. Income level was classified into six categories: Medical Aid beneficiaries and five NHIS subtypes according to insurance premium. The slope index of inequality (SII) and relative index of inequality were used to measure absolute and relative differences in 5YSR by income, respectively.

RESULTS

The 5YSR between the 2002-2006 and 2014-2018 periods for all cancers improved. A significant improvement in 5-year survival rates (5YSR) over the study period was observed in lung, liver, and stomach cancer. The SII of survival rates for lung (17.5, 95% confidence interval (CI) 7.0-28.1), liver (15.1, 95% CI 10.9-19.2), stomach (13.9, 95% CI 3.2-24.7), colorectal (11.4, 95% CI 0.9-22.0), and prostate (10.7, 95% CI 2.5-18.8) cancer was significantly higher, implying higher survival rates as income levels increased. The SII for lung, liver, and stomach cancer increased, while that of thyroid, breast, cervical, prostate, and colorectal cancer decreased over the study period.

CONCLUSIONS

Although substantial improvement in the 5YSR was observed across cancer types and income levels from 2002 to 2018, this increase was not uniformly distributed across income levels. Our study revealed persistent income disparities in the survival of cancer patients, particularly for lung and liver cancer.

The association of socioeconomic deprivation with access and survival after hematopoietic stem cell transplantation in New Zealand

BACKGROUND

Socioeconomic deprivation (SED) is a risk factor for reduced survival of hematopoietic stem cell transplant (HSCT) recipients. This study aimed to evaluate access and long-term survival of HSCT recipients.

METHODS

This was a hospital HSCT Registry-based retrospective cohort study. Patients who underwent HSCT from January 2010 to June 2020 were identified. HSCT recipients younger than 16 years of age, patients who reported their residential address as a post office box or the Department of Corrections, and those who left the country after HSCT were excluded from the study. HSCT recipients with the 2018 New Zealand deprivation index (NZDep2018) deciles 8, 9, and 10 were assigned to the higher SED group and those with NZDep2018 deciles from 1 to 7 were allocated to the lower SED group. The total number of New Zealanders in the higher and lower SED strata was obtained from the 2018 Census.

RESULTS

Eight hundred fifty-one HSCT recipients met the eligibility criteria. HSCT recipients from the higher and lower SED strata of the New Zealand population had similar access to HSCT (odds ratio = .9; 95% confidence interval (CI): .77-1.04; p = .155). Mortality in the higher and lower SED groups of HSCT recipients was 9.6/100 person-years (95% CI: 7.7-12/100 person-years) and 8.1/100 person-years (95% CI: 6.9-9.4/100 person-years), respectively. The mortality ratio was 1.2 (95% CI: .9-1.6), p = .098. Both groups had similar survival.

CONCLUSION

New Zealand residents from the higher and lower SED strata have similar access to HSCT. SED is not associated with reduced survival in adult HSCT recipients.

Living alone as a risk factor for cancer incidence, case-fatality and all-cause mortality: A nationwide registry study

Lack of social contacts has been associated with an increased risk of cancer mortality, but it is not known whether living alone increases the risk of cancer incidence or case fatality. We examined the association between living alone with cancer incidence, case-fatality and all-cause mortality in eight most common cancers. All patients with their first cancer diagnosis in 2000–2017 were identified from the nationwide Finnish Cancer Registry. Information on living arrangements was derived from Statistics Finland. The incidence analyses were conducted using Poisson regression. The total Finnish population served as the population at risk. Fine-Gray model was used to estimate case-fatality and Cox proportional regression model all-cause mortality. In men, we found an association between history of living alone and excess lung cancer incidence but living alone seemed to be associated with lower incidence of prostate cancer and skin melanoma. In women, living alone was more consistently associated with higher incidence of all studied cancers. Cancer patients living alone had an 11%–80% statistically significantly increased case-fatality and all-cause mortality in all studied cancers in men and in breast, colorectal and lung cancer in women. Living alone is consistently associated with increased cancer incidence risk in women but only in some cancers in men. Both men and women living alone had an increased risk of all-cause mortality after cancer diagnosis.

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We studied the effect of living alone on cancer incidence and mortality in total Finnish population.

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Excess cancer incidence risk was only found consistently in women.

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We found persistent excess cancer-specific mortality in cancer patients living alone.

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Cancer patients living alone had also a higher all-cause mortality risk.

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Further studies should study pathways to care among socially isolated individuals.

Socioeconomic inequality: Accessibility and outcomes after renal transplantation in New Zealand

BACKGROUND

Socioeconomic deprivation (SED) is a risk factor for worse outcomes after renal transplantation (RTx). This study aimed to evaluate access to RTx in different SED strata of the New Zealand population. We also assessed patient survival, acute cellular allograft rejection (AR) and allograft loss.

METHODS

This was an Australian and New Zealand Dialysis and Transplantation and Organ Donation Registries-based retrospective cohort study. Patients who underwent RTx in New Zealand from 2008 to 2018 were identified. Patients younger than 16 years of age and those who left the country after RTx were excluded.

RESULTS

In the higher SED stratum of New Zealanders, the rate of RTx was 53% greater than in the lower SED stratum (odds ratio = 1.53; 95% confidence interval: 1.33-1.76; p < 0.00005).

RESULTS

One hundred and thirteen (23%) patients from the lower SED group and 51 (14.8%) patients from the higher SED group underwent living unrelated RTx, p = 0.0033. In 233 (67.5%) patients from the higher SED group and 265 (53.9%) patients from the lower SED group, transplanted kidneys were from deceased donors RTx, p = 0.0001. The incidence of allograft loss and patient survival were similar in these groups.

CONCLUSION

Our data demonstrated a lower overall survival in the more socioeconomically deprived patients than in the lower SED group however this was not statistically significant after adjustment for covariates. A larger study is required to determine whether SED is associated with reduced survival.

Occupational disparities in survival in Korean women with cancer: a nationwide registry linkage study

OBJECTIVES

We sought to examine occupational disparities in survival among Korean women diagnosed with cancer.

DESIGN

Population-based, registry-linkage study.

SETTING

South Korea.

PARTICIPANTS

Our study population comprised female workers registered in the Korean national employment insurance programme during 1995-2000 and diagnosed with cancer between 1995 and 2008. A total of 61 110 women with cancer diagnoses was included in analysis. The occupation was categorised into four groups: (1) managers, professionals and technical workers, (2) clerks, (3) service/sales workers and (4) blue-collar workers.

PRIMARY AND SECONDARY OUTCOME MEASURE

Study population were linked to the national death registry until 2009. HRs for mortality adjusting for age and year of diagnosis were calculated in the study sample and subgroups with 10 specific cancer sites including thyroid, breast, stomach, cervix, colon or lung cancer using managers, professionals and technical workers as the reference.

RESULTS

Women in service/sales (HR 1.25, 95% CI 1.15 to 1.35) and blue-collar occupations (HR 1.34, 95% CI 1.25 to 1.44) had poorer survival for all cancer sites combined, while blue-collar workers showed poorer survival for lung (HR 1.41, 95% CI 1.14 to 1.77), breast (HR 1.28, 95% CI 1.06 to 1.54), cervical cancer (HR 1.42, 95% CI 1.02 to 2.06) and non-Hodgkin's lymphoma (HR 1.69, 95% CI 1.09 to 2.77) compared with women in professional and managerial positions.

CONCLUSION

We found substantial and significant inequalities in overall survival by the occupational group among Korean women with cancer, even in the context of universal access to cancer screening and treatment.

Occupational disparities in bladder cancer survival: A population-based cancer registry study in Japan

Background

Little is known about occupational disparities in bladder cancer survival.

Methods

Using data from a population‐based cancer registry (1970‐2016), we identified 3593 patients with incident bladder cancer diagnosed during 1970‐2011 who completed occupational information. The patients were followed for 5 years (median follow‐up time 5.0 years). Their longest‐held occupations at incident bladder cancer diagnosis were classified according to a national standardized classification. Hazard ratios (HRs) and 95% confidence intervals (CIs) for overall death were estimated by Cox proportional hazard model, adjusted for age, sex, and year of diagnosis. Clerical workers served as the reference group.

Results

Overall prognosis was fair in this population (5‐year overall survival, 61.9%). Compared with patients in clerical jobs, survival was poorer for those in professional and managerial jobs (mortality HR 1.36; 95% CI 1.09‐1.69), sales and service jobs (HR 1.25, 95% CI 1.01‐1.56), construction jobs (HR 1.83, 95% CI 1.40‐2.38), and manufacturing jobs (HR 1.32, 95% CI 1.05‐1.66), as well as those not actively employed (HR 1.27, 95% CI 1.02‐1.58). A similar pattern was observed in the subgroup analyses restricted to male patients as well as additional analyses adjusted for potential prognostic variables (eg, stage) with multiple imputation.

Conclusion

We documented occupational disparities in bladder cancer survival in Japan. However, the pattern of disparity did not favor highest occupational groups.

The effect of time from diagnosis to surgery on oncological outcomes in patients undergoing surgery for colon cancer: A systematic review

Many countries have implemented cancer pathways with strict time limits dictating the pace of diagnostic testing and treatment. There are concerns that prehabilitation may worsen long-term oncological outcomes if surgery is delayed. We aimed to systematically review the literature investigating the association between increased time between diagnosis of colon cancer and surgical treatment, with special focus on survival outcomes.

METHODS

Through a systematic search and analysis of the databases PubMed (1966-2017), EMBASE (1974-2017), CINHAL (1981-2017), and The Cochrane Library performed on June 7th, 2017, the effect of treatment delays on overall survival in colon cancer patients was reviewed. Treatment delay was defined as time from diagnosis to initiation of surgical treatment. All patients included were diagnosed with colon cancer and treated with elective curative surgery without neoadjuvant chemotherapy. This review was prospectively registered on the PROSPERO database of systematic review protocols with registration number CRD42017059774.

RESULTS

Five observational studies including 13,514 patients were included. The treatment delay intervals ranged from 1 to ≥56 days. Four of the five studies found no association between time elapsed from diagnosis to surgery and reduced overall survival. One study found a clinically insignificant association between longer treatment delays and overall survival. Three studies investigated the effect on disease specific survival and found no negative associations.

CONCLUSION

The available data showed no association between treatment delay and reduced overall survival in colon cancer patients.

Nordic Cancer Registries - an overview of their procedures and data comparability

BACKGROUND

The Nordic Cancer Registries are among the oldest population-based registries in the world, with more than 60 years of complete coverage of what is now a combined population of 26 million. However, despite being the source of a substantial number of studies, there is no published paper comparing the different registries. Therefore, we did a systematic review to identify similarities and dissimilarities of the Nordic Cancer Registries, which could possibly explain some of the differences in cancer incidence rates across these countries.

METHODS

We describe and compare here the core characteristics of each of the Nordic Cancer Registries: (i) data sources; (ii) registered disease entities and deviations from IARC multiple cancer coding rules; (iii) variables and related coding systems. Major changes over time are described and discussed.

RESULTS

All Nordic Cancer Registries represent a high quality standard in terms of completeness and accuracy of the registered data.

CONCLUSIONS

Even though the information in the Nordic Cancer Registries in general can be considered more similar than any other collection of data from five different countries, there are numerous differences in registration routines, classification systems and inclusion of some tumors. These differences are important to be aware of when comparing time trends in the Nordic countries.

Explaining time elapsed prior to cancer diagnosis: patients' perspectives

Background

Cancer is the leading cause of death in Canada. Early cancer diagnosis could improve patients’ prognosis and quality of life. This study aimed to analyze the factors influencing elapsed time between the first help-seeking trigger and cancer diagnosis with respect to the three most common and deadliest cancer types: lung, breast, and colorectal.

Methods

This paper presents the qualitative component of a larger project based on a sequential explanatory design. Twenty-two patients diagnosed were interviewed, between 2011 to 2013, in oncology clinics of four hospitals in the two most populous regions in Quebec (Canada). Transcripts were analyzed using the Model of Pathways to Treatment.

Results

Pre-diagnosis elapsed time and phases are difficult to appraise precisely and vary according to cancer sites and symptoms specificity. This observation makes the Model of Pathways to Treatment challenging to use to analyze patients’ experiences. Analyses identified factors contributing to elapsed time that are linked to type of cancer, to patients, and to health system organization.

Conclusions

This research allowed us to identify avenues for reducing the intervals between first symptoms and cancer diagnosis. The existence of inequities in access to diagnostic services, even in a universal healthcare system, was highlighted.

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 disparities in mortality after diffuse large B-cell lymphoma in the modern treatment era

Despite advances in treatment, including the introduction of rituximab, survival after diffuse large B-cell lymphoma (DLBCL) remains heterogeneous. However, no studies have considered the association between neighborhood socioeconomic status (SES) and race/ethnicity on DLBCL mortality before (1988-2000) and after (2001-2009) the introduction of rituximab. We studied all 33,032 DLBCL patients diagnosed between 1988-2009 in California for vital status through December 31, 2010. Patients diagnosed from 2001 to 2009 vs 1988 to 2000 had significantly decreased overall and DLBCL-specific mortality. However, those living in lower SES neighborhoods had 34% (95% confidence interval [CI], 27%-40%) and 24% (95% CI, 16%-32%) higher mortality rate from all causes and lymphoma, respectively, than patients in higher SES neighborhoods. The magnitude of mortality disparities by neighborhood SES was more marked in younger (<65 years) than in older patients (≥65 years), in married than nonmarried patients, and after 2000. We concluded that patients living in low SES neighborhoods had substantially worse survival after DLBCL, and this disparity was striking in younger (ie, not eligible for Medicare-aged) patients, married patients, and after the introduction of rituximab. These disparities suggest there are barriers, including inadequate insurance coverage with additional financial burden, to effective treatment among socioeconomically disadvantaged patients.

Mortality from cancer and other causes in commercial airline crews: a joint analysis of cohorts from 10 countries

BACKGROUND

Commercial airline crew is one of the occupational groups with the highest exposures to ionising radiation. Crew members are also exposed to other physical risk factors and subject to potential disruption of circadian rhythms.

METHODS

This study analyses mortality in a pooled cohort of 93 771 crew members from 10 countries. The cohort was followed for a mean of 21.7 years (2.0 million person-years), during which 5508 deaths occurred.

RESULTS

The overall mortality was strongly reduced in male cockpit (SMR 0.56) and female cabin crews (SMR 0.73). The mortality from radiation-related cancers was also reduced in male cockpit crew (SMR 0.73), but not in female or male cabin crews (SMR 1.01 and 1.00, respectively). The mortality from female breast cancer (SMR 1.06), leukaemia and brain cancer was similar to that of the general population. The mortality from malignant melanoma was elevated, and significantly so in male cockpit crew (SMR 1.57). The mortality from cardiovascular diseases was strongly reduced (SMR 0.46). On the other hand, the mortality from aircraft accidents was exceedingly high (SMR 33.9), as was that from AIDS in male cabin crew (SMR 14.0).

CONCLUSIONS

This large study with highly complete follow-up shows a reduced overall mortality in male cockpit and female cabin crews, an increased mortality of aircraft accidents and an increased mortality in malignant skin melanoma in cockpit crew. Further analysis after longer follow-up is recommended.

Disparities in bladder cancer

Among men, bladder cancer is the fourth most common malignancy and ninth leading cause of death from cancer in the United States. In contrast, it is the 11th most common malignancy and 12th leading cause of death from cancer among women. The successful management of bladder cancer largely depends on its timely diagnosis and treatment. Unfortunately, barriers disproportionately delay detection and treatment for individuals with social, economic, and community disadvantages. This imbalance creates health disparities (i.e., differences in health outcomes that are closely linked to these disadvantages), which negatively affect vulnerable populations, such as racial and ethnic minority groups, those from lower socioeconomic classes, and the uninsured. To obtain a better understanding of this issue, we review the current state of bladder cancer disparities research.

Biobanks and registers in epidemiologic research on cancer

The Nordic countries have a long tradition of register-based epidemiologic studies. Numerous population-based specialized registers offer high-quality data from individuals, and the extensive use of register data further improves the quality of the registers. Unique personal identity codes given to every resident and used in all registers guarantee easy and accurate record linkage. A legislation that makes the use of the existing data possible for purposes that benefit both registered individuals and the society - instead of forcing researchers to use their energy in repeated questionnaire studies, disturbing individuals' privacy and leading to response and recall biases - is a prerequisite for effective epidemiologic research. Biobanks can be considered an additional type of registers. They may offer data from individuals that cannot be reliably collected via questionnaire surveys. In turn, other types of registers are crucial in biobank-based studies (1) in defining for how long the persons in biobank cohorts are at risk of getting the diseases, (2) to get information on cofactors that may modify the relative risk measured by the biomarkers, and (3) to get information on the long-term outcome events. This chapter describes the possibilities of register use mainly in Finland - a typical representative of the Nordic "paradise of register-based epidemiological research" - in research of cancer etiology. The ongoing Nordic research project Changing work life and cancer risk in the Nordic countries (NOCCA) will be described as an example of a massive register use, including both direct linkages on an individual level and indirect group level linkages.

Education, survival and avoidable deaths in cancer patients in Finland

BACKGROUND

Relative survival after cancer in Finland is at the highest level observed in Europe and has, in general, been on a steady increase. The aim of this study is to assess whether the high survival is equally shared by different population subgroups and to estimate the possible gains that might be achieved if equity prevailed.

MATERIALS AND METHOD

The educational level and occupation before the cancer diagnosis of patients diagnosed in Finland in 1971-2005 was derived from an antecedent population census. The cancers were divided into 27 site categories. Cancer (cause)-specific 5-year survival proportions were calculated for three patient categories based on the educational level and for an occupational group of potentially health-conscious patients (physicians, nurses, teachers etc.). Proportions of avoidable deaths were derived by assuming that the patients from the two lower education categories would have the same mortality owing to cancer, as those from the highest educational category. Estimates were also made by additionally assuming that even the mortalities owing to other causes of death were all equal to those in the highest category.

RESULTS

For almost all the sites considered, survival was consistently highest for patients with the highest education and lowest for those with only basic education. The potentially health-conscious patients had an even higher survival. The differences were, in part, attributable to less favourable distributions of tumour stages in the lower education categories. In 1996-2005, 4-7% of the deaths in Finnish cancer patients could have potentially been avoided during the first 5-year period after diagnosis, if all the patients had the same cancer mortality as the patients with the highest educational background. The proportion would have also been much higher, 8-11%, if, in addition, the mortality from other causes had been the same as that in the highest educational category.

INTERPRETATION

Even in a potentially equitable society with high health care standards, marked inequalities persist in cancer survival. Earlier cancer diagnosis and the ability to cope within the health care system may be a partly relevant explanation, but personal habits and lifestyles also have a role, particularly for the cancer patients' mortality from other causes of death than cancer.

The influence of socioeconomic deprivation on outcomes following renal transplantation in the United kingdom

Socio-economic deprivation is an important determinant of poor health and is associated with a higher incidence of end-stage renal disease, higher mortality for dialysis patients and lower chance of being listed for transplantation. The influence of deprivation on outcomes following renal transplantation has not previously been reported in the United Kingdom. The Welsh Index of Multiple Deprivation was used to assess the influence of socio-economic deprivation on outcomes for 621 consecutive renal transplant recipients from a single centre in the United Kingdom transplanted between 1997 and 2005. Outcomes measured were rate of acute rejection and graft survival. Patients from the most deprived areas were significantly more likely to experience an episode of acute rejection requiring treatment (36% vs. 27%, p=0.01) and increasing overall deprivation correlated with increasing rates of rejection (p=0.03). Income deprivation was significantly and independently associated with graft survival (HR 1.484, p=0.046). Among patients who experienced acute rejection 5-year graft survival was 79% for those from the most deprived areas compared with 90% for patients from the least deprived areas (p = 0.018). Overall socio-economic deprivation is associated with higher rate of acute rejection following renal transplantation and income deprivation is a significant and independent predictor of graft survival.

Socioeconomic status and changing inequalities in colorectal cancer? A review of the associations with risk, treatment and outcome

BACKGROUND

Upcoming mass screening for colorectal cancer (CRC) makes a review of recent literature on the association with socioeconomic status (SES) relevant, because of marked and contradictory associations with risk, treatment and outcome.

METHODS

The Pubmed database using the MeSH terms 'Neoplasms' or 'Colorectal Neoplasms' and 'Socioeconomic Factors' for articles added between 1995 and 1st October 2009 led to 62 articles.

RESULTS

Low SES groups exhibited a higher incidence compared with high SES groups in the US and Canada (range risk ratio (RR) 1.0-1.5), but mostly lower in Europe (RR 0.3-0.9). Treatment, survival and mortality all showed less favourable results for people with a lower socioeconomic status: Patients with a low SES received less often (neo)adjuvant therapy (RR ranging from 0.4 to 0.99), had worse survival rates (hazard ratio (HR) 1.3-1.8) and exhibited generally the highest mortality rates up to 1.6 for colon cancer in Europe and up to 3.1 for rectal cancer.

CONCLUSIONS

A quite consistent trend was observed favouring individuals with a high SES compared to those with a low SES that still remains in terms of treatment, survival and thus also mortality. We did not find evidence that the low/high SES gradients for treatment chosen and outcome are decreasing. To meet increasing inequalities in mortality from CRC in Europe for people with a low SES and to make mass screening successful, a high participation rate needs to be realised of low SES people in the soon starting screening program.

Social differences in breast cancer survival in relation to patient management within a National Health Care System (Sweden)

Epidemiologic studies have shown that cancer survival is poorer in low compared with high socioeconomic groups. We investigated whether these differences were associated with disparities in tumour characteristics and management. This cohort study was based on 9,908 women aged 20-79 years at diagnosis with primary breast cancer identified in a Swedish population-based clinical register. Information on socioeconomic standing was obtained from a social database. The 5-year cause-specific survival (CSS) and mortality hazard ratios (HR) were estimated by Cox proportional hazard models to assess differences in survival between socioeconomic groups while adjusting for diagnostic intensity, tumour characteristics and treatment. Following adjustment for age, year and stage at diagnosis, the risk of dying of breast cancer was 35% lower among women with high education compared with that of low education (HR = 0.65, 95% CI 0.53-0.80). When compared with women with high education, a lower percentage of women with low education had been investigated for proliferation (84 vs. 76%) or hormone receptor status (89 vs. 81%), had tumours <or=20 mm (68 vs. 64%), were treated at a main hospital (75 vs. 68%) and had received radiation treatment (80 vs. 67%) or chemotherapy (31 vs. 18%). However, these proportional differences could not explain the observed social gradient in survival. To minimize social differences in breast cancer survival, further research should address not only factors leading to inequities in management but also focus on patient factors such as health awareness, comorbidity burden and compliance to adjuvant treatment.

Mortality in Danish patients with nonmelanoma skin cancer, 1978-2001

BACKGROUND

Nonmelanoma skin cancer (NMSC) is a growing public health problem among Caucasians, thus mortality data that may provide insight into the clinical course and foster our understanding of NMSC are important.

OBJECTIVES

We examined total and cause-specific mortality among patients with NMSC registered in the Danish Cancer Registry from 1978 to 2001.

METHODS

A total of 82 837 patients with basal cell carcinoma (BCC) and 13 453 patients with squamous cell carcinoma (SCC) were followed through the National Death Registry for specific causes of death. Standardized mortality ratios (SMRs) were computed based on mortality rates in the general population.

RESULTS

Among patients with BCC, we found a slightly reduced total mortality [SMR 0.97, 95% confidence interval (CI) 0.96-0.98] with decreased SMRs seen for chronic obstructive pulmonary disease (COPD), cardiovascular disease (CVD) and diabetes mellitus. The SMR for suicide was increased. Among patients with SCC, we found an increased total mortality (SMR 1.30, 95% CI 1.26-1.33) due primarily to excess deaths from cancers, COPD, CVD and infectious diseases.

CONCLUSIONS

We found markedly different mortality patterns among patients with BCC and those with SCC, suggesting important differences in the clinical course of these patients.

Long-term inequalities in breast cancer survival--a ten year follow-up study of patients managed within a National Health Care System (Sweden)

INTRODUCTION

Converging epidemiological evidence based on studies of different designs in a variety of populations and settings show that cancer survival tends to be poorer in low compared to high socioeconomic groups. In an extension of an earlier register-based study, we examined the influence of socioeconomic factors on long-term survival in women with a first diagnosis of invasive breast cancer in 1993 in Sweden, a country with a policy of providing equal access to health care to all at nominal cost within a National Health Care System.

MATERIAL AND METHODS

The study was based on data set generated by record linkages between the Swedish Cancer Register, Census databases and the Cause of Death Register. Four different categorical variables were used as indicators of socioeconomic standing. Cox proportional hazard regression models were used to estimate the effects of socioeconomic status on risk of death.

RESULTS

Of 4 645 eligible women with breast cancer, 1 016 had died from breast cancer at the end of follow-up on December 31, 2003. After adjustment for tumour size and age at diagnosis, risk of death was 19% lower among women belonging to a household of high compared to low socioeconomic status (HR high versus low 0.81; 95% CI: 0.67-0.97).

DISCUSSION

These findings indicate that social inequalities in breast cancer survival persist at least up to ten years after an initial diagnosis. While social gradients detected shortly after diagnosis may mainly reflect an influence of socioeconomic differences in overall health status and frailty, differentials persisting beyond five years rather point to a long-term influence of disparities in management of both primary tumours and recurrences. Further studies are needed to explore whether the present findings reflect amendable inequalities in access to state-of-the-art treatment. For all calendar periods, observed survival in the most privileged groups sets the goal for what is achievable for all breast cancer patients.

Relationship of diagnostic and therapeutic delay with survival in colorectal cancer: a review

BACKGROUND

Early diagnosis of colorectal cancer before the onset of symptoms improves survival. Once symptoms have occurred, however, the effect of delay on survival is unclear. We review here evidence on the relationship of diagnostic and therapeutic delay with survival in colorectal cancer.

METHODS

We conducted a systematic of Medline, Embase, Cancerlit and the Cochrane Database of Systematic Reviews to identify publications published between 1962 and 2006 dealing with delay, survival and colon cancer. A meta-analysis was performed based on the calculation of the relative risk (RR) and on a model of random effects.

RESULTS

We identified 40 studies, representing 20,440 patients. Fourteen studies were excluded due to excessively restricted samples (e.g. exclusion of patients with intestinal obstruction, with tumours at stage C or D at the time of diagnosis, or who died 1-3 months after surgery); or because they studied only a portion of the delay. Of the 26 remaining studies, 20 showed no association between delay and survival. In contrast, four studies showed that delay was a factor contributing to better prognosis, and two showed that it contributed to poorer prognosis. There was no association between delay and survival when the colon and rectum were considered separately, when a multivariate analysis was performed, and when the effects of tumour stage and degree of differentiation were taken into account. To perform a meta-analysis, 18 additional studies were excluded, since the published articles did not specify the absolute numbers. In the remaining eight studies, the combined relative risk (RR) of delay was 0.92 (confidence interval (CI) 95%: 0.87-0.97).

CONCLUSIONS

The results of the review suggest that there is no association between diagnostic and therapeutic delay and survival in colorectal cancer patients. Colon and rectum should be assessed separately, and it is necessary to adjust for other relevant variables such as tumour stage.

Influence of socio-economic deprivation on outcomes for patients diagnosed with oesophageal cancer

OBJECTIVE

To determine the influence of deprivation on outcomes for patients with oesophageal cancer.

MATERIAL AND METHODS

A total of 1196 consecutive patients with oesophageal carcinoma presenting to a regional multidisciplinary team between 1 January 1998 and 31 August 2005 were studied prospectively and deprivation scores calculated using the Indices of Multiple Deprivation (IMD) of the National Assembly for Wales. The patients were subdivided into quintiles for analysis.

RESULTS

Inhabitants of the most deprived areas (quintile 5) were younger at presentation (median age 67 years versus 70 years, p = 0.01) and were more likely to have squamous cell carcinomas (SCCs) (p = 0.002) in comparison with patients from the least deprived areas (quintile 1). Stage of disease and morbidity did not correlate with deprivation quintile, but operative mortality was greater in quintile 1 versus 5 (1.9% versus 5.8%, p = 0.281). Overall 5-year survival for those patients undergoing oesophagectomy was unrelated to deprivation quintile (1 versus 5, 24% versus 33%, p = 0.8246), but was lower following definitive chemoradiotherapy (dCRT) for the least deprived quintiles (1, 2 & 3 versus 4 & 5, 35% versus 16%, p = 0.0272).

CONCLUSIONS

Although deprivation was associated with younger age, SCC and a trend towards higher operative mortality, survival after diagnosis and oesophagectomy were unrelated to deprivation.

Socioeconomic inequalities in alcohol related cancer mortality among men: to what extent do they differ between Western European populations?

We aim to study socioeconomic inequalities in alcohol related cancers mortality [upper aerodigestive tract (UADT) (oral cavity, pharynx, larynx, oesophagus and liver)] in men and to investigate whether the contribution of these cancers to socioeconomic inequalities in cancer mortality differs within Western Europe. We used longitudinal mortality datasets, including causes of death. Data were collected during the 1990s among men aged 30-74 years in 13 European populations [Madrid, the Basque region, Barcelona, Turin, Switzerland (German and Latin part), France, Belgium (Walloon and Flemish part, Brussels), Norway, Sweden, Finland]. Socioeconomic status was measured using the educational level declared at the census at the beginning of the follow-up period. We conducted Poisson regression analyses and used both relative [Relative index of inequality (RII)] and absolute (mortality rates difference) measures of inequality. For UADT cancers, the RII's were above 3.5 in France, Switzerland (both parts) and Turin whereas for liver cancer they were the highest (around 2.5) in Madrid, France and Turin. The contribution of alcohol related cancer to socioeconomic inequalities in cancer mortality was 29-36% in France and the Spanish populations, 17-23% in Switzerland and Turin, and 5-15% in Belgium and the Nordic countries. We did not observe any correlation between mortality rates differences for lung and UADT cancers, confirming that the pattern found for UADT cancers is not only due to smoking. This study suggests that alcohol use substantially influences socioeconomic inequalities in male cancer mortality in France, Spain and Switzerland but not in the Nordic countries and nor in Belgium.

Changes in socioeconomic inequalities in cancer mortality rates among French men between 1968 and 1996

OBJECTIVES

We investigated changes in socioeconomic inequalities in cancer mortality rates among men in France between 1968 and 1996.

METHODS

We used a representative sample of 1% of the French population and studied 4 periods (1968-1974, 1975-1981, 1982-1988, and 1990-1996). Causes of death were obtained by direct linkage with the French national death registry. The socioeconomic position of men aged 35 to 59 years was measured by using the occupational class reported at the time of the census at the beginning of each period. Analyses were conducted for all cancers and specifically for lung, upper aerodigestive tract, esophageal, colorectal, and other cancers.

RESULTS

In all analyses, we observed socioeconomic inequalities during the 4 periods considered; the inequalities increased between the first and the last period. Most of the total increase occurred between 1968 and 1981, and inequalities remained stable thereafter. Inequalities were larger when men out of the labor force were included in the analysis. The strongest increase in socioeconomic inequalities over time was observed for upper aerodigestive tract cancer.

CONCLUSIONS

Although cancer mortality rates have decreased, substantial socioeconomic inequalities in cancer mortality among men remain.

Socioeconomic gradients in clinical stage at presentation and survival among breast cancer patients in the Stockholm area 1977-1997

A program to ensure an equivalent standard of care for all patients with breast cancer was initiated in the Stockholm area in the mid 1970s. As part of an evaluation of this program, social gradients in clinical stage at presentation and survival were analyzed among patients diagnosed during 1977 through 1997. The patients (n = 15,021) were selected from a database covering about 88% of all diagnosed breast cancer cases in the region. Putative associations were analyzed between clinical stage, survival and different socioeconomic indicators (level of education, income and occupation). There were significant social differences (p < 0.01) in distribution of clinical stage as well as in total and stage-specific survival. High income, more skilled work and a high level of education were all associated with clinically less advanced tumors and hence better survival. However, stage-specific survival differences were mostly generated by differences in nonbreast cancer mortality. The results indicate social inequalities regarding awareness of the disease and/or access to early detection. Social gradients in nonbreast cancer mortality were also found to influence observed survival. In contrast, we observed no significant social differences in stage-specific breast cancer mortality.

Social class is an important and independent prognostic factor of breast cancer mortality

Reasons of the important impact of socioeconomic status on breast cancer prognosis are far from established. This study aims to evaluate and explain the social disparities in breast cancer survival in the Swiss canton of Geneva, where healthcare costs and life expectancy are among the highest in the world. This population-based study included all 3,920 female residents of Geneva, who were diagnosed with invasive breast cancer before the age of 70 years between 1980 and 2000. Patients were divided into 4 socioeconomic groups, according to the woman's last occupation. We used Cox multivariate regression analysis to identify reasons for the socioeconomic inequalities in breast cancer survival. Compared to patients of high social class, those of low social class had an increased risk (unadjusted hazard ratio [HR] 2.4, 95% CI: 1.6-3.5) of dying as a result of breast cancer. These women were more often foreigners, less frequently had screen-detected cancer and were at more advanced stage at diagnosis. They less frequently underwent breast-conserving surgery, hormonal therapy, and chemotherapy, in particular, in case of axillary lymph node involvement. When adjusting for all these factors, patients of low social class still had a significantly increased risk of dying of breast cancer (HR 1.8, 95% CI: 1.2-2.6). Overmortality linked to low SES is only partly explained by delayed diagnosis, unfavorable tumor characteristics and suboptimal treatments. Other factors, not measured in this study, also could play a role. While waiting for the outcome of other researches, we should consider socioeconomic status as an independent prognostic factor and provide intensified support and surveillance to women of low social class.

Cervical and corpus cancer survival disparities by socioeconomic status in a metropolitan area of Japan

The purpose of this study was to analyze socioeconomic differences in cervical and corpus cancer survival, and to investigate if the differences are due to differences in age, cancer stage, histology and treatment. A total of 14,055 cases with cervical cancer and 3,113 cases with corpus cancer were obtained from the Osaka Cancer Registry. Municipality-based SES measurements were obtained from the System of Social and Demographic Statistics. Survival analysis was carried out with Kaplan-Meier survival curves. Three types of Cox proportional hazards regression models were tested to assess survival differences among groups and effects of SES on survival, controlling for clinical factors. SES was related to age and cancer stage for cervical and corpus cancer patients, and histology for cervical cancer patients. Differences were observed in cumulative 5-year survival for cervical cancer patients among low, middle and high unemployment municipalities (68.9%, 64.3% and 50.9%, respectively, P<0.0001). Differences in cumulative 5-year survival for cervical cancer patients were also observed among high, middle and low education municipalities (65.1%, 62.2% and 56.1%, respectively, P<0.0001). Similar patterns in 5-year survival were also found for corpus cancer patients. After adjusting for age, cancer stage, histology and treatment, survival differences between patients from high and low SES areas still remained. In conclusion, our population-based analysis of a metropolitan representative sample in Japan has demonstrated, for the first time in Japan, SES differences in survival following cervical and corpus cancer.

Night work and breast cancer risk: a systematic review and meta-analysis

The association between occupations that involve night shift work (a surrogate for exposure to light at night with subsequent melatonin suppression) and breast cancer risk is uncertain. We therefore conducted a systematic review and meta-analysis of observational studies to assess the effects of night work on breast cancer risk. Data sources were MEDLINE from January 1960 to January 2005, experts in the field, bibliographies, and abstracts. Search terms included night work terms, flight personnel terms, cancer terms, and risk terms. Independent data extraction by two authors using standardised forms was performed. The method of DerSimonian and Laird was used to derive combined estimates and Egger's; and Begg and Mazumdar's tests for publication bias were conducted. Based on 13 studies, including seven studies of airline cabin crew and six studies of other night shift workers, the aggregate estimate for all studies combined was 1.48 (95% CI, 1.36-1.61), with a similar significant elevation of breast cancer risk among female airline cabin crew (standardised incidence ratio (SIR), 1.44; 95% CI, 1.26-1.65), and female night workers (relative risk (RR), 1.51; 95% CI, 1.36-1.68) separately. We found some evidence suggesting confounding due to incomplete adjustment for breast cancer risk factors, with smaller effects in the studies that more completely adjusted for reproductive history and other confounding factors. Egger's and Begg and Mazumdar's tests for publication bias showed no significant asymmetry (P>0.05). Studies on night shift work and breast cancer risk collectively show an increased breast cancer risk among women. Publication bias is unlikely to have influenced the results.

Influence of socio-economic deprivation on outcomes for patients diagnosed with gastric cancer

OBJECTIVE

Socio-economic deprivation has an influence on the outcome for patients diagnosed with breast, colorectal and bronchial cancer, but there are few data on its association with gastric cancer. The aim of this study was to determine the influence of socio-economic deprivation on outcomes for patients with gastric cancer.

MATERIAL AND METHODS

Three hundred and thirty consecutive patients with gastric adenocarcinoma presenting to a single hospital between 1 October 1995 and 30 June 2004 were studied prospectively and deprivation scores calculated using the National Assembly for Wales Indices of Multiple Deprivation. The patients were subdivided into quintiles for analysis.

RESULTS

Inhabitants of the most deprived areas (quintile 5) were younger at presentation (median 70 years versus 74 years, p=0.007), and experienced longer delays in diagnosis (18 weeks versus 9 weeks, p=0.02) when compared with patients from the least deprived areas (quintile 1). Operative mortality was 3-fold higher for patients from the most deprived areas when compared with patients from less deprived areas (15% versus 5%, p=0.03). There was no correlation between stage of disease and socio-economic deprivation. For patients undergoing potentially curative surgery, the 5-year survival for patients from the most deprived areas was 32%, compared with 66% for patients from the least deprived areas (p=0.03).

CONCLUSIONS

Socio-economic deprivation was associated with younger age at diagnosis, longer diagnostic delay, greater operative mortality and a shorter duration of survival following R0 gastrectomy. These poorer outcomes were not explained by the stage of disease at diagnosis.

Socio-economic factors and breast cancer survival – a population-based cohort study (Sweden)

OBJECTIVE

To assess the influence of socio-economic factors on breast cancer survival in Sweden, a country with population-based mammography screening and a uniform health care system aiming to provide care to all on equal terms.

METHODS

All women with a first diagnosis of invasive breast cancer in Sweden in 1993 were identified in the Swedish Cancer Register. Their sociodemographic characteristics were determined by record linkages to the 1970, 1980, 1985 and 1990 Census databases, and a nationwide Fertility Register. Information on tumor characteristics at diagnosis was obtained from five Swedish Regional Cancer Registers. Survival status on 31 December 1998, was assessed through follow-up in the Swedish Cause of Death Register.

RESULTS

Of totally 4645 eligible women diagnosed with breast cancer in 1993, 772 had died from breast cancer through 1998. After adjustment for tumor characteristics and age, risk of death was 37 higher among women of low compared to high socio-economic status (HR high vs. low 0.73; 95 CI: 0.54-0.99). This difference was most pronounced in women less than 50 years at diagnosis.

CONCLUSIONS

These results show that socio-economic disparities in breast cancer survival prevail even in this relatively homogenous society, offering outreach mammography and standardised treatment regimens in a tax-funded health care system.

The impact of education and occupation on the employment status of cancer survivors

We explored the effect of a diagnosis of cancer on employment according to cancer type, education, occupation, age, gender, mother tongue (Swedish or Finnish), calendar time and hospital district. All 12,542 new cancer cases diagnosed in 1987-1988 and 1992-1993, aged 15-60 years at the time of the diagnosis were identified from the Finnish Cancer Registry. The employment rate of the cancer survivors 2-3 years after the diagnosis was only 9% lower than their gender- and age-matched referents. However, we found that education and occupation modified the effect of cancer on the employment; the difference between cancer survivors and their referents in the probability of being employed was greater in the lower than in the higher educational groups. A modifying effect of education on the probability of employment was found among people with cancer of the lung, stomach, rectum and cervix uteri and those with cancers of the nervous system.

Socio-economic deprivation and survival in bladder cancer

OBJECTIVES

To investigate the relationship between deprivation, delay and survival from bladder cancer in the West Midlands, as socio-economic deprivation is associated with worse survival in many malignancies, and it has been suggested that treatment differences and delay in seeking care are major contributing causes.

PATIENTS AND METHODS

Data were prospectively collected on 1537 newly diagnosed cases of urothelial cancer presenting in the West Midlands between January 1991 and June 1992. Survival was censored at 31 July 2000, when 785 (51%) patients had died. The influence of deprivation on survival was explored using cause-specific and all-cause mortality.

RESULTS

Patients in less affluent groups had significantly worse survival than patients in more affluent groups when considering deaths from all causes (P = 0.02), which held true when adjusting for independent prognostic factors (age, smoking history, and tumour grade, stage, type and size). Bladder cancer-specific mortality showed no significant difference between socio-economic groups (P = 0.30).

CONCLUSION

Socio-economic deprivation is a significant predictor of survival when death from all causes is considered. However, this does not hold true for bladder cancer-specific death. The perceived differences in treatment and delay between socio-economic groups do not seem to occur for bladder cancer in the West Midlands.

Influences of ethnicity, treatment, and comorbidity on breast cancer survival in Hawaii

The purpose of this study was to examine factors contributing to the ethnic discrepancies in breast cancer survival described previously. Through the use of the Hawaii Tumor Registry and insurance claims data, 1,052 breast cancer patients' survival times were examined in relation to demographics, disease characteristics, comorbidity, and treatment patterns as compared to national guidelines for breast cancer treatment. In stepwise and hierarchical Cox regression models, TNM stage was the strongest predictor of survival and explained all of the ethnic survival differences. In addition, comorbidity and treatment patterns were significant in predicting survival. In this population of health plan members, ethnic differences in survival were not a result of differential treatment, but due to variations in early detection. These results support the hypothesis that pre-existing conditions and treatment patterns are related to breast cancer survival even after controlling for stage at diagnosis indicating the usefulness of insurance claims data in this research field.

Inequalities in survival from colorectal cancer: a comparison of the impact of deprivation, treatment, and host factors on observed and cause specific survival

OBJECTIVE

To investigate whether socioeconomic deprivation is associated with cause specific and all cause survival for colorectal cancer and to what extent this is independent of significant prognostic factors.

DESIGN

Prospective cohort.

SETTING

The former Wessex Health Region, South West England.

PARTICIPANTS

All patients resident in Wessex registered with a diagnosis of colorectal cancer over three years (n=5176). Survival analysis was carried out on those patients with compete data for all factors and a positive survival time (n=4419).

OUTCOMES

Death from colorectal cancer and all cause over five year follow up from initial diagnosis.

MAIN RESULTS

Deprivation was significantly associated with survival for both outcomes in univariate analysis; the unadjusted hazard ratio for dying from colorectal cancer (most deprived compared with most affluent) was 1.12 (95% CI 1.00 to 1.25) and for all cause was 1.18 (1.07 to 1.30). Significant prognostic factors for both outcomes were age, specialisation of surgeon, Dukes's stage, and emergency compared with elective surgery. Comorbidity and gender were only associated with all cause survival. After adjustment for prognostic factors, the effect of deprivation on both cause specific and all cause mortality was reduced, and it was non-significant for colorectal cancer. However, the most deprived group had consistently worse survival than the most affluent.

CONCLUSIONS

Factors associated with survival with colorectal cancer depend on the outcome measure. Socioeconomic deprivation is adversely associated with survival in patients with colorectal cancer. This is strongest for non-colorectal cancer death, partly reflecting higher comorbidity, but it is there for colorectal cancer though not statistically significant. Conclusive evidence of the inequalities by socioeconomic status and underlying reasons needs to come from studies using individual based measures of socioeconomic status and more detail on treatment and host related factors.

Socioeconomic status and breast cancer in Denmark

BACKGROUND

Breast cancer is the most frequent cancer in women and the incidence has increased over time. Our objectives were to study: (1) the socioeconomic differences in breast cancer incidence and mortality in Denmark, (2) how different socioeconomic groups have contributed to the increasing incidence, (3) whether the diverging trend between breast cancer incidence and mortality reflects different socioeconomic distributions of breast cancer cases and breast cancer deaths, and (4) to compare measures of socioeconomic status based on own and spouses' occupation, respectively. We addressed these questions by studying the socioeconomic distribution of breast cancer incidence and breast cancer mortality in Danish women during the last 25 years.

METHODS

In all 1 402 225 women in Denmark were individually followed up for death, emigration, and incident breast cancer in 1970-1995. Of the 1 402 225 women included in the study, 730 549 were economically active in 1970, and 480 379 women were both married and economically active. Socioeconomic status was assessed based on the occupation in 1970.

RESULTS

For all women classified by their own socioeconomic group, the standardized incidence (SIR) and the standardized mortality ratios (SMR) were highest in academics (SIR = 1.39, SMR = 1.29), and lowest in women in agriculture (SIR = 0.77, SMR = 0.75). For married, economically active women classified by their own socioeconomic group the SIR and SMR were highest in academics (SIR = 1.40, SMR = 1.44) and lowest in women in agriculture (SIR = 0.76, SMR = 0.76). Classified by their husbands' socioeconomic group, the SIR and SMR were highest in women married to academics (SIR = 1.21, SMR = 1.16) and lowest in women married to men in agriculture (SIR = 0.79, SMR = 0.79). From 1970 to 1995, the risk of developing breast cancer increased by 38% in women aged 50-64. All social groups contributed to this increase, the increase being 45% in unskilled workers, and 26% in academics.

CONCLUSION

During the last quarter of the 20th century academics had the highest risk of breast cancer in Denmark. The size of the social gradient in breast cancer occurrence depended on the measure used. The time trends in social distribution will result in breast cancer becoming more frequent.

Ethnicity and prognosis in acute myeloid leukemia

Ethnicity has been described as a prognostic factor in breast cancer and in childhood acute lymphocytic leukemia but not in adult acute myeloid leukemia (AML). We reviewed the records of 225 consecutive AML patients who were diagnosed and treated between 1983 and 1995. Data were collected concerning demographic factors, presenting clinical features, and treatment protocols. We categorized ethnicity as follows: European Jews, non-European Jews, and Arabs. We assessed the role of ethnicity controlling for other known prognostic factors on treatment outcome and survival in this population. Older age, high leukocyte count at diagnosis, and high-risk chromosomal aberrations were significantly associated with overall survival in univariate analysis. In multivariate analysis high leukocyte count and high-risk chromosomal aberrations exerted an independent negative effect on survival. European origin was associated with longer event-free survival in univariate analysis (P = 0.024) and longer overall (P < 0.01) and event-free (P < 0.01) survival but not with a higher remission rate in multivariate analysis. For AML patients who achieved remission after induction chemotherapy and survived its complications, European origin is an independent favorable prognostic factor for long-term remission and survival in Israel. These findings may reflect better socioeconomic status, social support, increased compliance with treatment protocols, or better psychological coping mechanisms with malignancy.

Socio-economic differences in incidence rates of cancers of the male genital organs in Finland, 1971-95

We studied social class variation in the incidence of cancers of the prostate, testis, penis and scrotum among 1.1 million Finnish men (45-69 years of age) during 1971-95. The incidence of prostate cancer (6,972 cases) was increasing during the study period; the highest at all the times occurred in Social Class I (highest social class), 40-50% higher than in Social Class IV (lowest). The social class gradient was strongest in localized disease but there was some variation in incidence of non-localized prostate cancer. A total of 174 testicular cancer cases were diagnosed during the study period. In the early 1970s, the incidence of testicular cancer in Social Class I was 5-fold compared to Social Classes III and IV. Thereafter, the incidence rate decreased in Social Class I, but increased in the lower classes. The positive social class gradient was similar for seminomas and non-seminomas. For penile cancer (n = 128), the incidence decreased over time and social class variation was small. Only 6 cases of scrotum cancer were observed. In testicular cancer the strong positive social class association in the early 1970s is disappearing along with converging incidence trend slopes in different social classes. The difference diminished to less than 2-fold in the 1990s. Reasons for this observation remain open.

Cancer-specific survival of patients with multiple cancers: an application to patients with multiple breast cancers

In the analysis of cause-specific survival, the causes of death must be known. For single-cancer patients with a known cause of death, the estimation of the cause-specific survival rate is straightforward. For multiple-cancer patients with two primary cancers, however, the analysis of cause-specific survival rates is more complex, particularly if the cancers are of the same primary site. In these situations, a concept of cancer-specific survival may also be distinguished from cause-specific survival. Cancer-specific survival rates are studied here by introducing two models, the primary one where the death from cancer is attributed to one of the cancers, and an alternative where such an attribution is not necessary. The models are illustrated using data on patients with multiple breast cancers. The model-based survival rates are compared with each other and with the corresponding relative survival rates based on analogous modelling of relative survival. The results show that for the subsequent breast cancer, the cancer-specific survival rates based on the alternative, where the distinction between the cancers as a cause of death was not necessary, tended to be higher than those based on that distinction. It is thus possible that the subsequent cancer was too often coded as a cause of death, particularly when being localized at diagnosis.

Survival of breast cancer patients in Connecticut in relation to socioeconomic and health care access indicators

The purpose of this study of 16,931 black and white Connecticut women diagnosed with invasive breast cancer in 1988-1995 was to examine survival in relation to surrogate or proxy indicators of both socioeconomic status (SES) and access to primary care. Patients were followed through 1998, and the risk of death was elevated for the lowest (vs. highest) SES category independent of stage at diagnosis and other characteristics, especially among patients diagnosed before age 65 years. The health care access indicator was not associated with risk of death when other patient characteristics (including the SES variable and stage at diagnosis) were taken into account. Unexplained elevations, relative to the rest of the state, in risk of death were found for patients diagnosed while living in two of the state's four largest cities.

A cancer survival model that takes sociodemographic variations in "normal" mortality into account: comparison with other models

STUDY OBJECTIVES

Sociodemographic differentials in cancer survival have occasionally been studied by using a relative survival approach, where all cause mortality among persons with a cancer diagnosis is compared with that among similar persons without such a diagnosis ("normal" mortality). One should ideally take into account that this "normal" mortality not only depends on age, sex, and period, but also various other sociodemographic variables. However, this has very rarely been done. A method that permits such variations to be considered is presented here, as an alternative to an existing technique, and is compared with a relative survival model where these variations are disregarded and two other methods that have often been used.

DESIGN, SETTING, AND PARTICIPANTS

The focus is on how education and marital status affect the survival from 12 common cancer types among men and women aged 40-80. Four different types of hazard models are estimated, and differences between effects are compared. The data are from registers and censuses and cover the entire Norwegian population for the years 1960-1991. There are more than 100 000 deaths to cancer patients in this material.

MAIN RESULTS AND CONCLUSIONS

A model for registered cancer mortality among cancer patients gives results that for most, but not all, sites are very similar to those from a relative survival approach where educational or marital variations in "normal" mortality are taken into account. A relative survival approach without consideration of these sociodemographic variations in "normal" mortality gives more different results, the most extreme example being the doubling of the marital differentials in survival from prostate cancer. When neither sufficient data on cause of death nor on variations in "normal" mortality are available, one may well choose the simplest method, which is to model all cause mortality among cancer patients. There is little reason to bother with the estimation of a relative-survival model that does not allow sociodemographic variations in "normal" mortality beyond those related to age, sex, and period. Fortunately, both these less data demanding models perform well for the most aggressive cancers.

Socioeconomic inequalities in cancer survival in England and Wales

BACKGROUND

Cancer survival often has been reported as lower for the poor than the rich, but, to the authors' knowledge, systematic national estimates of deprivation gradients in survival over long periods of time have not been available.

METHODS

The authors estimated national population-based survival rates for almost 3 million people who were diagnosed with 1 of 58 types of cancers (47 in adults, 11 in children) in England and Wales during the 20-year period 1971-1990 and followed through December 31, 1995. Cancer patients were assigned by their address at diagnosis to 1 of 5 categories (quintiles of the national distribution) of material deprivation by using a standard index derived from census data on unemployment, car ownership, household overcrowding, and social class that was available for all 109,000 census tracts in Great Britain. The authors used relative survival rates: the ratio of observed survival among the cancer patients to the survival that would have been expected if they had had the same background mortality as the general population. Background mortality differed widely among socioeconomic categories, and the authors constructed life tables from raw national mortality data by gender, single year of age, calendar period of death, and socioeconomic category to adjust for it. The authors used variance-weighted least squares regression to estimate both time trends in age standardized survival and socioeconomic gradients in survival. The number of avoidable deaths was estimated from the observed mortality excess compared with the expected mortality in each group of patients.

RESULTS

Survival rose steadily for most cancers over 25 years to 1995 in England and Wales, but inequalities in survival between patients living in rich and poor areas were geographically widespread and persistent over this period of time. These patterns existed for 44 of 47 adult cancers examined but not for 11 childhood cancers. These inequalities in survival represented more than 2500 deaths that would have been avoided each year if all cancer patients had had the same chance of surviving up to 5 years after diagnosis as patients in the most affluent group.

CONCLUSIONS

The largest national cancer survival study has provided strong evidence of systematic disadvantage in outcome among patients who lived in poorer districts compared with those who lived in wealthier districts.