Age-related and socioeconomic inequalities in timeliness of referral and start of treatment in colorectal cancer: a population-based analysis

Inequalities in the evolution of the COVID-19 pandemic: an ecological study of inequalities in mortality in the first wave and the effects of the first national lockdown in England

OBJECTIVES

To examine how ecological inequalities in COVID-19 mortality rates evolved in England, and whether the first national lockdown impacted them. This analysis aimed to provide evidence for important lessons to inform public health planning to reduce inequalities in any future pandemics.

DESIGN

Longitudinal ecological study.

SETTING

307 lower-tier local authorities in England.

PRIMARY OUTCOME MEASURE

Age-standardised COVID-19 mortality rates by local authority, regressed on Index of Multiple Deprivation (IMD) and relevant epidemic dynamics.

RESULTS

Local authorities that started recording COVID-19 deaths earlier were more deprived, and more deprived authorities saw faster increases in their death rates. By 6 April 2020 (week 15, the earliest time that the 23 March lockdown could have begun affecting death rates) the cumulative death rate in local authorities in the two most deprived deciles of IMD was 54% higher than the rate in the two least deprived deciles. By 4 July 2020 (week 27), this gap had narrowed to 29%. Thus, inequalities in mortality rates by decile of deprivation persisted throughout the first wave, but reduced during the lockdown.

CONCLUSIONS

This study found significant differences in the dynamics of COVID-19 mortality at the local authority level, resulting in inequalities in cumulative mortality rates during the first wave of the pandemic. The first lockdown in England was fairly strict-and the study found that it particularly benefited those living in more deprived local authorities. Care should be taken to implement lockdowns early enough, in the right places-and at a sufficiently strict level-to maximally benefit all communities, and reduce inequalities.

Concordance with urgent referral guidelines in patients presenting with any of six 'alarm' features of possible cancer: a retrospective cohort study using linked primary care records

BACKGROUND

Clinical guidelines advise GPs in England which patients warrant an urgent referral for suspected cancer. This study assessed how often GPs follow the guidelines, whether certain patients are less likely to be referred, and how many patients were diagnosed with cancer within 1 year of non-referral.

METHODS

We used linked primary care (Clinical Practice Research Datalink), secondary care (Hospital Episode Statistics) and cancer registration data. Patients presenting with haematuria, breast lump, dysphagia, iron-deficiency anaemia, post-menopausal or rectal bleeding for the first time during 2014-2015 were included (for ages where guidelines recommend urgent referral). Logistic regression was used to investigate whether receiving a referral was associated with feature type and patient characteristics. Cancer incidence (based on recorded diagnoses in cancer registry data within 1 year of presentation) was compared between those receiving and those not receiving referrals.

RESULTS

48 715 patients were included, of which 40% (n=19 670) received an urgent referral within 14 days of presentation, varying by feature from 17% (dysphagia) to 68% (breast lump). Young patients (18-24 vs 55-64 years; adjusted OR 0.20, 95% CI 0.10 to 0.42, p<0.001) and those with comorbidities (4 vs 0 comorbidities; adjusted OR 0.87, 95% CI 0.80 to 0.94, p<0.001) were less likely to receive a referral. Associations between patient characteristics and referrals differed across features: among patients presenting with anaemia, breast lump or haematuria, those with multi-morbidity, and additionally for breast lump, more deprived patients were less likely to receive a referral. Of 29 045 patients not receiving a referral, 3.6% (1047) were diagnosed with cancer within 1 year, ranging from 2.8% for rectal bleeding to 9.5% for anaemia.

CONCLUSIONS

Guideline recommendations for action are not followed for the majority of patients presenting with common possible cancer features. A significant number of these patients developed cancer within 1 year of their consultation, indicating scope for improvement in the diagnostic process.

Administrative data deficiencies plague understanding of the magnitude of rape-related crimes in Indian women and girls

Background

This paper investigates trends in rape-related crimes against women and girls reported in the Indian administrative data from 2001 to 2018 to assess the burden of crime, describe sub-national variations, and highlight data gaps to address sexual violence effectively in India.

Methods

Data on five rape-related crimes were extracted from the annual reports of National Crimes Record Bureau (NCRB), and included assault with the intent to outrage modesty of woman, rape, insult to the modesty of women, attempt to commit rape, and murder with rape/gang-rape. Rates for all categories combined, and for each crime were estimated for women and girls for India and its states. Trends for type of offender for rape, mean number of people arrested, and legal status of the cases was also assessed.

Results

The rate of all rape-related crime increased from 11.6 in 2001 to 19.8 in 2018 per 100,000 women and girls. Most of the 70.7% increase in rate between 2001 and 2018 was post 2012 following a gang-rape and murder case in India’s capital. The largest proportion of crimes was recorded as assault with the intent to outrage modesty of the woman, followed by rape. The cited offender in rape cases was for the majority a close known person (44·3%) or other known person (43·1%). By the end of 2018, only 9·6% of the cases had completed trials, with acquittals in 73% cases.

Conclusions

The wide variations in the yearly crime rates at state-level highlighted significant issues in data quality including under-reporting, non-comparability, possible bias in data reporting in NCRB, definition of rape-related crime in India, and access in reporting of crimes. Addressing barriers to reporting, improving quality and scope of administrative data recorded on sexual violence is urgently needed for India to meet SDG targets of eliminating all forms of violence against women and girls.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13182-0.

Socioeconomic differences in help-seeking experiences in primary care for symptoms related to colorectal cancer during COVID-19: A UK-wide qualitative interview study

Background

COVID-19 has led to rapid changes in healthcare delivery, raising concern that these changes may exacerbate existing inequalities in patient outcomes.

Aim

To understand how patients’ help-seeking experiences in primary care for colorectal cancer symptoms during COVID-19 were affected by their socioeconomic status (SES).

Design and setting

Qualitative semi-structured interviews with males and females across the UK, recruited using purposive sampling by SES.

Method

Interviews were carried out with 39 participants (20 higher SES; 19 lower SES) who contacted primary care about possible symptoms of colorectal cancer during COVID-19. Data were analysed using framework analysis followed by comparative thematic analysis to explore differences between groups.

Results

Three themes were identified with differences between SES groups: 1) how people decided to seek medical help through appraisal of symptoms; 2) how people navigated services; and 3) impact of COVID-19 on how patients interacted with healthcare professionals. The lower SES group expressed uncertainty appraising symptoms and navigating services (in terms of new processes resulting from COVID-19 and worries about infection). There was also potential for increased disparity in diagnosis and management, with other methods of getting in touch (for example, email or 111) taken up more readily by higher SES patients.

Conclusion

The findings suggest that COVID-19 exacerbated disparities between higher and lower SES participants. This study raises awareness around challenges in help seeking in the context of the pandemic, which are likely to persist (post-COVID-19) as healthcare systems settle on new models of care (for example, digital). Recommendations are provided to reduce inequalities of care.

Are there socio-economic inequalities in utilization of predictive biomarker tests and biological and precision therapies for cancer? A systematic review and meta-analysis

BACKGROUND

Novel biological and precision therapies and their associated predictive biomarker tests offer opportunities for increased tumor response, reduced adverse effects, and improved survival. This systematic review determined if there are socio-economic inequalities in utilization of predictive biomarker tests and/or biological and precision cancer therapies.

METHODS

MEDLINE, Embase, Scopus, CINAHL, Web of Science, PubMed, and PsycINFO were searched for peer-reviewed studies, published in English between January 1998 and December 2019. Observational studies reporting utilization data for predictive biomarker tests and/or cancer biological and precision therapies by a measure of socio-economic status (SES) were eligible. Data was extracted from eligible studies. A modified ISPOR checklist for retrospective database studies was used to assess study quality. Meta-analyses were undertaken using a random-effects model, with sub-group analyses by cancer site and drug class. Unadjusted odds ratios (ORs) and 95% confidence intervals (CIs) were computed for each study. Pooled utilization ORs for low versus high socio-economic groups were calculated for test and therapy receipt.

RESULTS

Among 10,722 citations screened, 62 papers (58 studies; 8 test utilization studies, 37 therapy utilization studies, 3 studies on testing and therapy, 10 studies without denominator populations or which only reported mean socio-economic status) met the inclusion criteria. Studies reported on 7 cancers, 5 predictive biomarkers tests, and 11 biological and precision therapies. Thirty-eight studies (including 1,036,125 patients) were eligible for inclusion in meta-analyses. Low socio-economic status was associated with modestly lower predictive biomarker test utilization (OR 0.86, 95% CI 0.71-1.05; 10 studies) and significantly lower biological and precision therapy utilization (OR 0.83, 95% CI 0.75-0.91; 30 studies). Associations with therapy utilization were stronger in lung cancer (OR 0.71, 95% CI 0.51-1.00; 6 studies), than breast cancer (OR 0.93, 95% CI 0.78-1.10; 8 studies). The mean study quality score was 6.9/10.

CONCLUSIONS

These novel results indicate that there are socio-economic inequalities in predictive biomarker tests and biological and precision therapy utilization. This requires further investigation to prevent differences in outcomes due to inequalities in treatment with biological and precision therapies.