Do geodemographic typologies explain variations in uptake in colorectal cancer screening? An assessment using routine screening data in the south of England

High polygenic risk score is a risk factor associated with colorectal cancer based on data from the UK Biobank

Colorectal cancer (CRC) is a common cancer among both men and women and is one of the leading causes of cancer death worldwide. It is important to identify risk factors that may be used to help reduce morbidity and mortality of the disease. We used a case-control study design to explore the association between CRC, polygenic risk scores (PRS), and other factors. We extracted data about 2,585 CRC cases and 9,362 controls from the UK Biobank, calculated the PRS for these cases and controls based on 140 single nucleotide polymorphisms, and performed logistic regression analyses for the 11,947 cases and controls, for an older group (ages 50+), and for a younger group (younger than 50). Five significant risk factors were identified when all 11,947 cases and controls were considered. These factors were, in descending order of the values of the adjusted odds ratios (aOR), high PRS (aOR: 2.70, CI: 2.27-3.19), male sex (aOR: 1.52, CI: 1.39-1.66), unemployment (aOR: 1.47, CI: 1.17-1.85), family history of CRC (aOR: 1.44, CI: 1.28-1.62), and age (aOR: 1.01, CI: 1.01-1.02). These five risk factors also remained significant in the older group. For the younger group, only high PRS (aOR: 2.87, CI: 1.65-5.00) and family history of CRC (aOR: 1.73, CI: 1.12-2.67) were significant risk factors. These findings indicate that genetic risk for the disease is a significant risk factor for CRC even after adjusting for family history. Additional studies are needed to examine this association using larger samples and different population groups.

Urban density differences in colorectal cancer screening participation and screening yield in The Netherlands

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Low socioeconomic status has been associated with lower CRC screening participation.

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Effective strategies to target these differences have not been proven effective.

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Sparse data exists on the influence of urban density on screening participation.

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Participation in the Dutch CRC screening programme is lower in urban areas.

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Differences in participation by urban density exceed those by socioeconomic status.

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Strategies to increase uptake should focus on regional hot spots of low participation.

Lower socioeconomic status has been associated with higher colorectal cancer incidence and lower participation in population-based screening with faecal immunochemical testing (FIT) but regional variations in participation may also exist. We analysed differences in participation and yield in colorectal cancer screening by urban density level.

Data of all invitees to the Dutch colorectal cancer screening programme in 2014–2015 were included. Primary outcomes were participation (returning FIT), FIT positive predictive value, and screening yield (advanced neoplasia detected in invitees). Differences were explored across five levels of urban density.

In total 1,873,639 screening invitees were included. FIT participation was 77.3% in the lowest versus 62.8% in the highest urban areas (RR 1.23; 95%CI 1.23–1.24). FIT positive predictive value was 58.6% in the lowest versus 55.2% in the highest urban areas (RR 1.06; 95% CI 1.04–1.09). Screening yield was also higher in the lowest (2.1%-2.3%) compared to the highest urban areas (1.8%). Compared to socioeconomic status, differences in urban density were associated with larger differences in screening participation.

In conclusion, participation is lower and fewer cases of advanced neoplasia are detected in areas with a high urban density in the Dutch colorectal cancer screening programme. Differences in urban density could be used in tailoring regional strategies to target barriers in colorectal cancer screening.

Does geodemographic segmentation explain differences in route of cancer diagnosis above and beyond person-level sociodemographic variables?

BACKGROUND

Emergency diagnosis of cancer is associated with poorer short-term survival and may reflect delayed help-seeking. Optimal targeting of interventions to raise awareness of cancer symptoms is therefore needed.

METHODS

We examined the risk of emergency presentation of lung and colorectal cancer (diagnosed in 2016 in England). By cancer site, we used logistic regression (outcome emergency/non-emergency presentation) adjusting for patient-level variables (age, sex, deprivation and ethnicity) with/without adjustment for geodemographic segmentation (Mosaic) group.

RESULTS

Analysis included 36 194 and 32 984 patients with lung and colorectal cancer. Greater levels of deprivation were strongly associated with greater odds of emergency presentation, even after adjustment for Mosaic group, which nonetheless attenuated associations (odds ratio [OR] most/least deprived group = 1.67 adjusted [model excluding Mosaic], 1.28 adjusted [model including Mosaic], P < 0.001 for both, for colorectal; respective OR values of 1.42 and 1.18 for lung, P < 0.001 for both). Similar findings were observed for increasing age. There was large variation in risk of emergency presentation between Mosaic groups (crude OR for highest/lowest risk group = 2.30, adjusted OR = 1.89, for colorectal; respective values of 1.59 and1.66 for lung).

CONCLUSION

Variation in risk of emergency presentation in cancer patients can be explained by geodemography, additional to deprivation group and age. The findings support proof of concept for public health interventions targeting all the examined attributes, including geodemography.

Enabling and constraining successful reablement: Individual and neighbourhood factors

Using multilevel logistic regression to analyse management data of reablement episodes collected by Essex County Council, a UK local authority, this article identifies constraining and enabling factors for successful reablement. Overall, 59.5% of reablement clients were classed as able to care for themselves when assessed after 13 weeks following the reablement intervention (N = 8,118). Several age-related, disability, referral, and social factors were found to constrain reablement, but some of the largest constraining effects were neighbourhood deprivation as measured through the Index of Multiple Deprivation and, particularly, unfavourable geodemographic profiles as measured through Experian Mosaic consumer classifications. The results suggest that in order to optimise reablement, programmes should consider broader social and environmental influences on reablement rather than only individual and organisational aspects. Reablement might also be better tailored and intensified for client groups with particular underlying disabilities and for those displaying specific geodemographic characteristics.

Geodemographic Area Classification and Association with Mortality: An Ecological Study of Small Areas of Cyprus

Geographical investigations are a core function of public health monitoring, providing the foundation for resource allocation and policies for reducing health inequalities. The aim of this study was to develop geodemographic area classification based on several area-level indicators and to explore the extent of geographical inequalities in mortality. A series of 19 area-level socioeconomic indicators were used from the 2011 national population census. After normalization and standardization of the geographically smoothed indicators, the k-means cluster algorithm was implemented to classify communities into groups based on similar characteristics. The association between geodemographic area classification and the spatial distribution of mortality was estimated in Poisson log-linear spatial models. The k-means algorithm resulted in four distinct clusters of areas. The most characteristic distinction was between the ageing, socially isolated, and resource-scarce rural communities versus metropolitan areas with younger population, higher educational attainment, and professional occupations. By comparison to metropolitan areas, premature mortality appeared to be 44% (95% Credible Intervals [CrI] of Rate Ratio (RR): 1.06-1.91) higher in traditional rural areas and 36% (95% CrI of RR: 1.13-1.62) higher in young semi-rural areas. These findings warrant future epidemiological studies investigating various causes of the urban-rural differences in premature mortality and implementation policies to reduce the mortality gap between urban and rural areas.

The utility of geodemographic indicators in small area estimates of limiting long-term illness

Small area health data are not always available on a consistent and robust routine basis across nations, necessitating the employment of small area estimation methods to generate local-scale data or the use of proxy measures. Geodemographic indicators are widely marketed as a potential proxy for many health indicators. This paper tests the extent to which the inclusion of geodemographic indicators in small area estimation methodology can enhance small area estimates of limiting long-term illness (LLTI). The paper contributes to international debates on small area estimation methodologies in health research and the relevance of geodemographic indicators to the identification of health care needs. We employ a multilevel methodology to estimate small area LLTI prevalence in England, Scotland and Wales. The estimates were created with a standard geographically-based model and with a cross-classified model of individuals nested separately in both spatial groupings and non-spatial geodemographic clusters. LLTI prevalence was estimated as a function of age, sex and deprivation. Estimates from the cross-classified model additionally incorporated residuals relating to the geodemographic classification. Both sets of estimates were compared against direct estimates from the 2011 Census. Geodemographic clusters remain relevant to understanding LLTI even after controlling for age, sex and deprivation. Incorporating a geodemographic indicator significantly improves concordance between the small area estimates and the Census. Small area estimates are however consistently below the equivalent Census measures, with the LLTI prevalence in urban areas characterised as 'blue collar' and 'struggling families' being markedly lower. We conclude that the inclusion of a geodemographic indicator in small area estimation can improve estimate quality and enhance understanding of health inequalities. We recommend the inclusion of geodemographic indicators in public releases of survey data to facilitate better small area estimation but caution against assumptions that geodemographic indicators can, on their own, provide a proxy measure of health status.

A cross-sectional ecological analysis of international and sub-national health inequalities in commercial geospatial resource availability

BACKGROUND

Commercial geospatial data resources are frequently used to understand healthcare utilisation. Although there is widespread evidence of a digital divide for other digital resources and infra-structure, it is unclear how commercial geospatial data resources are distributed relative to health need.

METHODS

To examine the distribution of commercial geospatial data resources relative to health needs, we assembled coverage and quality metrics for commercial geocoding, neighbourhood characterisation, and travel time calculation resources for 183 countries. We developed a country-level, composite index of commercial geospatial data quality/availability and examined its distribution relative to age-standardised all-cause and cause specific (for three main causes of death) mortality using two inequality metrics, the slope index of inequality and relative concentration index. In two sub-national case studies, we also examined geocoding success rates versus area deprivation by district in Eastern Region, Ghana and Lagos State, Nigeria.

RESULTS

Internationally, commercial geospatial data resources were inversely related to all-cause mortality. This relationship was more pronounced when examining mortality due to communicable diseases. Commercial geospatial data resources for calculating patient travel times were more equitably distributed relative to health need than resources for characterising neighbourhoods or geocoding patient addresses. Countries such as South Africa have comparatively high commercial geospatial data availability despite high mortality, whilst countries such as South Korea have comparatively low data availability and low mortality. Sub-nationally, evidence was mixed as to whether geocoding success was lowest in more deprived districts.

CONCLUSIONS

To our knowledge, this is the first global analysis of commercial geospatial data resources in relation to health outcomes. In countries such as South Africa where there is high mortality but also comparatively rich commercial geospatial data, these data resources are a potential resource for examining healthcare utilisation that requires further evaluation. In countries such as Sierra Leone where there is high mortality but minimal commercial geospatial data, alternative approaches such as open data use are needed in quantifying patient travel times, geocoding patient addresses, and characterising patients' neighbourhoods.

Socioeconomic and ethnic inequities within organised colorectal cancer screening programmes worldwide

OBJECTIVE

Colorectal cancer (CRC) screening programmes can reduce CRC mortality. However, the implementation of a screening programme may create or exacerbate socioeconomic and ethnic health inequities if participation varies by subgroup. We determined which organised programmes characterise participation inequities by socioeconomic and ethnic subgroups, and assessed the variation in subgroup participation among programmes collecting group-specific data.

DESIGN

Employing a literature review and survey among leaders of national or regional screening programmes, this study identified published and unpublished data on participation by socioeconomic status and ethnicity. We assessed programmes offering faecal occult blood tests (FOBT) for screening. Primary outcome was screening participation rate.

RESULTS

Across 24 organised FOBT-screening programmes meeting the inclusion criteria, participation rates ranged from 21% to 73%. Most programmes (13/24, 54%) did not collect data on participation by socioeconomic status and ethnicity. Among the 11 programmes with data on participation by socioeconomic status, 90% (28/31 publications) reported lower participation among lower socioeconomic groups. Differences across socioeconomic gradients were moderate (66% vs 71%) to severe (35% vs 61%). Only six programmes reported participation results by ethnicity. Ethnic differences were moderate, though only limited data were available for evaluation.

CONCLUSIONS

Across organised CRC screening programmes worldwide, variation in participation by socioeconomic status and ethnicity is often not assessed. However, when measured, marked disparities in participation by socioeconomic status have been observed. Limited data were available to assess inequities by ethnicity. To avoid exacerbating health inequities, screening programmes should systematically monitor participation by socioeconomic status and ethnicity, and investigate and address determinants of low participation.

Understanding frailty: meanings and beliefs about screening and prevention across key stakeholder groups in Europe

Innovative methods to manage frailty are critical to managing the needs of an ageing population. Evidence suggests there are opportunities to reverse or prevent frailty through early intervention. However, little is known about older adults’, families’ and practitioners’ beliefs about the malleability of frailty. This study examined European stakeholders’ accounts of the acceptability and feasibility of frailty screening and prevention to inform future intervention development. Semi-structured focus groups and individual interviews were conducted in three European Union countries (Italy, Poland and the United Kingdom) with key stakeholders – frail and non-frail older adults, family care-givers, and health and social care professionals. Thematic analysis identified four themes: synchronicity between the physical and the psychological in frailty, living with frailty in the social world, the need for a new kind of care, and screening for and preventing frailty. Findings emphasised the need for a holistic approach to frailty care and early intervention. Integrated care services and advocacy were important in the organisation of care. Central to all stakeholders was the significance of the psychological and social alongside the physical elements of frailty and frailty prevention. Support and care for older adults and their family care-givers needs to be accessible and co-ordinated. Interventions to prevent frailty must encompass a social dimension to help older adults maintain a sense of self while building physical and psychological resilience.

Preferences and acceptance of colorectal cancer screening in Thailand

Colorectal cancer (CRC) is now common in Thailand with an increase in incidence over time. Health authorities are planning to implement a nationwide CRC screening program using fecal immunochemical test (FIT) as a primary screening tool. This study aimed to estimate preferences and acceptance of FIT and colonoscopy, explore factors influencing the acceptance, and investigate reasons behind choosing and rejecting to screen before the program was implemented. Patients aged 50-69, visiting the primary care unit during the study period, were invited to join this study. Patients with a history of cancer or past CRC screening were excluded. Face-to-face interviews were conducted. Subjects were informed about CRC and the screening tests: FIT and colonoscopy. Then, they were asked for their opinions regarding the screening. The total number of subjects was 437 (86.7% response rate). Fifty-eight percent were females. The median age was 58 years. FIT was accepted by 74.1% of subjects compared to 55.6% for colonoscopy. The acceptance of colonoscopy was associated with perceived susceptibility to CRC and family history of cancer. No symptoms, unwilling to screen, healthy, too busy and anxious about diagnosis were reasons for refusing to screen. FIT was preferred for its simplicity and non-invasiveness compared with colonoscopy. Those rejecting FIT expressed a strong preference for colonoscopy. Subjects chose colonoscopy because of its accuracy; it was refused for the process and complications. If the screening program is implemented for the entire target population in Thailand, we estimate that 106,546 will have a positive FIT, between 8,618 and 12,749 identified with advanced adenoma and between 2,645 and 3,912 identified with CRC in the first round of the program.

Socioeconomic status influences the likelihood but not the outcome of liver resection for colorectal liver metastasis

BACKGROUND

The aim of this study was to compare the socioeconomic profile of patients undergoing liver resection for colorectal liver metastasis (CLM) in a regional hepatopancreatobiliary unit with that of the local population. A further aim was to determine if degree of deprivation is associated with tumour recurrence after resection.

METHODS

A retrospective analysis of patients undergoing liver resection for CLM was performed. Geodemographic segmentation was used to divide the population into five categories of socioeconomic status (SES).

RESULTS

During a 7-year period, 303 patients underwent resection for CLM. The proportion of these patients in the two least deprived categories of SES was greater than that of the local population (50.2% versus 40.2%) and the proportion in the two most deprived categories was lower (18.3% versus 30.1%) (P < 0.001). There was no difference in recurrence rate (P = 0.867) or disease-free survival among categories of SES (P = 0.913). Multivariate analysis demonstrated no association between SES and tumour recurrence (P = 0.700).

CONCLUSIONS

Liver resection for CLM is performed more commonly among the least socioeconomically deprived population than among the most deprived. However, degree of deprivation was not associated with tumour recurrence after resection.

A neighbourhood level mortality classification of England and Wales, 2006-2009

The paper provides an overview of a neighbourhood level classification of mortality for England and Wales (2006-2009). Standardised mortality ratios for 63 causes of death were calculated for middle super output areas (weighted by prevalence). A k-means partitional method was used to classify the data. An eight cluster solution was found to best segment mortality patterns. Clusters mostly differentiated in terms of prevalence, however the importance of neurodegenerative diseases and causes related to unhealthy behaviours were important. The results describe a neighbourhood classification that can be an important tool to help inform policy development, resource allocation and targeting of services.

Social deprivation does not affect lung cancer stage at presentation or disease outcome

INTRODUCTION

Lung cancer mortality rates are higher in more deprived populations. This may simply reflect higher incidence of the disease, or additionally delayed presentation and worse outcomes amongst more deprived patients. Low socio-economic status (SES) has also been linked to cancer fatalism which might account for such differences. We determined the interaction between SES, patient's characteristics at presentation with lung cancer, and disease outcome at a large UK teaching hospital.

METHODS

Stage, PS at presentation, treatment and survival data, index of multiple deprivation score and ACORN group (geo-demographic segmentation tool) were analysed for 1432 patients.

RESULTS

There were no significant differences in stage or PS distribution by IMD quintile or ACORN group. When patients with stage I/II disease were considered, there were no differences in IMD or ACORN group for those undergoing or not undergoing surgical resection. Similarly when the whole cohort was considered, there were no differences in these parameters between those receiving and not receiving any anti-cancer therapy. There was a non-significant trend to lower IMD score (i.e. less deprivation) in the stage IIIb/IV patients receiving palliative chemotherapy compared to those not receiving chemotherapy. There was no significant difference in median survival or one-year survival according to IMD quintile or ACORN group.

CONCLUSION

In our patient cohort, deprivation does not appear to affect stage or performance status at presentation, nor survival from lung cancer. If cancer fatalism is more prevalent in deprived populations, this does not appear to lead to later diagnosis nor worse disease outcome.