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

Abstract

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.T here is strong evidence that patients from higher socioeconomic groups have better survival across a wide range of cancers, including malignant melanoma, 1 breast cancer, 2 and cancers of the colon, rectum, and cervix. 3 Reduction of such inequalities would contribute to improving cancer survival, yet the reasons underlying them remain poorly understood. Moreover, lessening inequalities in health and promoting equity in access to health care are central to the health policy of the UK government, 4 and a restructuring of cancer services in England and Wales is presently underway, with the aim of reducing regional variations in treatment and outcome for cancer patients. 5Inequalities in colorectal cancer survival have been clearly demonstrated, with a 3%-5% difference in five year survival between the most affluent and deprived quintiles of the population.6 This is of considerable importance as this is the second commonest cause of death from cancer affecting both men (after lung cancer) and women (after breast cancer) in the UK. It accou...

Dying in the Margins: Understanding Palliative Care and Socioeconomic Deprivation in the Developed World

“…The limited resources available for the socioeconomically deprived highlights the potential burden of a terminal diagnosis for this group. Evidence supports the notion that the healthcare needs of the socioeconomically deprived are greater than those of the general healthcare population [4][5][6]. Recognizing socioeconomic disadvantage as a significant factor in influencing health outcomes, underscores the importance of focusing of the distinctive characteristics that the illness and death experience has for this group.…”

Socioeconomic inequalities in cancer survival in Scotland 1986–2000

“…Socioeconomic gradients in colorectal cancer survival may be explained by differences in treatment (Faivre-Finn et al, 2002;Guyot et al, 2005;Yu et al, 2005), stage at diagnosis (Singh et al, 2003) or comorbidity (Schrijvers et al, 1995a;Wrigley et al, 2005), although such differences are not consistent (Ionescu et al, 1998;Brewster et al, 2001;Wrigley et al, 2005). In Scotland, deprived and affluent patients diagnosed during 1991 -1994 had similar curative resection rates, but survival was lower among deprived patients, even after adjusting for stage at diagnosis and type of operation (Hole and McArdle, 2002).…”

Trends in colorectal cancer mortality by ethnicity and socio‐economic position in New Zealand, 1981‐99: one country, many stories

“…Socio-economic differences in survival have been found in other countries, 49,50 and lower socio-economic groups in New Zealand have more unmet need in terms of health care services generally. 51 One theory to understand these survival differences is the inverse equity theory, which suggests that as mortality declines due to technological advances, relative inequality will increase as individuals with higher SEP claim the benefits of new technologies or interventions prior to those with lower SEP. 52 As CRC treatments steadily improve over time, it is not implausible that higher socio-economic groups are initially more advantaged.…”