Access to primary care and mortality in excess for patients with cancer in France: Results from 21 French Cancer Registries.

BACKGROUND: The impact of geographical accessibility on cancer survival has been investigated in few studies, with most research focusing on access to reference care centers, using overall mortality and limited to specific cancer sites. This study aims to examine the association of access to primary care with mortality in excess of patients with the 10 most frequent cancers in France, while controlling for socioeconomic deprivation. METHODS: This study included a total of 151,984 cases diagnosed with the 10 most common cancer sites in 21 French cancer registries between 2013 and 2015. Access to primary care was estimated using two indexes: the Accessibilité Potentielle Localisée index (access to general practitioners) and the Scale index (access to a range of primary care clinicians). Mortality in excess was modelized using an additive framework based on expected mortality based on lifetables and observed mortality. FINDINGS: Patients living in areas with less access to primary care had a greater mortality in excess for some very common cancer sites like breast (women), lung (men), liver (men and women), and colorectal cancer (men), representing 46% of patients diagnosed in our sample. The maximum effect was found for breast cancer; the excess hazard ratio was estimated to be 1.69 (95% CI, 1.20-2.38) 1 year after diagnosis and 2.26 (95% CI, 1.07-4.80) 5 years after diagnosis. INTERPRETATION: This study revealed that this differential access to primary care was associated with mortality in excess for patients with cancer and should become a priority for health policymakers to reduce these inequalities in health care accessibility.

Estimation of the general population and children under five years of age in France exposed to magnetic field from high or very high voltage power line using geographic information system and extrapolated field data.

BACKGROUND: The effects of extremely low-frequency magnetic fields, especially their long-term health effects, including childhood leukaemia, remain elusive. The International Agency for Research on Cancer has classified the exposure to magnetic fields >0.4 µT as 'possibly carcinogenic to humans (group 2 B)' for childhood leukaemia. However, the number of exposed individuals, particularly children, remains poorly documented in international literature. The objective of this study was to estimate the number of individuals living near a high or very high voltage line in France (≥63 kV), among the general population and children under the age of five years. METHODS: The estimate considered different exposure scenarios depending on the line voltage and the distance of the housing from it, and whether the line is overhead or underground. The exposure scenarios were obtained using a multilevel linear model created from a measurement database published by "Réseau de transport d'électricité", the operator of the French electricity transmission network. RESULTS: Between 0.11% (n = 67,893) and 1.01% (n = 647,569) of the French population and between 0.10% (n = 4712) and 1.03% (n = 46,950) of children under five years of age were estimated to be living in an area potentially exposed to a magnetic field, depending on the exposure scenario (>0.4 µT and >0.1 µT, respectively). CONCLUSIONS: By making it possible to estimate the total number of residents, schools, and health institutions near high-voltage power lines, the proposed methodology can help identify potential co-exposures near high-voltage power lines, which are regularly cited as a possible explanation for contradictory results from epidemiological studies.

Water and Soil Pollution: Ecological Environmental Study Methodologies Useful for Public Health Projects. A Literature Review.

Health risks at population level may be investigated with different types of environmental studies depending on access to data and funds. Options include ecological studies, case-control studies with individual interviews and human sample analysis, risk assessment or cohort studies. Most public health projects use data and methodologies already available due to the cost of ad-hoc data collection. The aim of the article is to perform a literature review of environmental exposure and health outcomes with main focus on methodologies for assessing an association between water and/or soil pollutants and cancer. A systematic literature search was performed in May 2019 using PubMed. Articles were assessed by four independent reviewers. Forty articles were identified and divided into four groups, according to the data and methods they used, i.e.: (1) regression models with data by geographical area; (2) regression models with data at individual level; (3) exposure intensity threshold values for evaluating health outcome trends; (4) analyses of distance between source of pollutant and health outcome clusters. The issue of exposure assessment has been investigated for over 40 years and the most important innovations regard technologies developed to measure pollutants, statistical methodologies to assess exposure, and software development. Thanks to these changes, it has been possible to develop and apply geo-coding and statistical methods to reduce the ecological bias when considering the relationship between humans, geographic areas, pollutants, and health outcomes. The results of the present review may contribute to optimize the use of public health resources.

Multidisciplinary team meetings: are all patients presented and does it impact quality of care and survival - a registry-based study.

BACKGROUND: Multidisciplinary team meetings (MDTMs) are part of the standard cancer care process in many European countries. In France, they are a mandatory condition in the authorization system for cancer care administration, with the goal to ensure that all new patients diagnosed with cancer are presented in MDTMs. AIM: Identify the factors associated with non-presentation or unknown presentation in MDTMs, and study the impact of presentation in MDTMs on quality of care and survival in patients diagnosed with colorectal cancer (CRC). METHODS: 3999 CRC patients diagnosed between 2005 and 2014 in the area covered by the "Calvados Registry of Digestive Tumours" were included. Multivariate multinomial logistic regression was used to assess the factors associated with presentation in MDTMs. Univariate analyses were performed to study the impact of MDTMs on quality of care. Multivariate Cox model and the Log-Rank test were used to assess the impact of MDTMs on survival. RESULTS: Non-presentation or unknown presentation in MDTMs were associated with higher age at diagnosis, dying within 3 months after diagnosis, unknown metastatic status, non-metastatic cancer and colon cancer. Non-presentation was associated with a diagnosis after 2010. Unknown presentation was associated with a diagnosis before 2007 and a longer travel time to the reference care centres. Presentation in MDTMs was associated with more chemotherapy administration for patients with metastatic cancer and more adjuvant chemotherapy for patients with stage III colon cancer. After excluding poor prognosis patients, lower survival was significantly associated with higher age at diagnosis, unknown metastatic status or metastatic cancer, presence of comorbidities, rectal cancer and non-presentation in MDTMs (HR = 1.5 [1.1-2.0], p < 0.001). CONCLUSIONS: Elderly and poor prognosis patients were less presented in MDTMs. Geriatric assessments before presentation in MDTMs were shown to improve care plan establishment. The 100% objective is not coherent if MDTMs are only to discuss diagnosis and curative cares. They could also be a place to discuss therapeutic limitations. MDTMs were associated with better treatment and longer survival. We must ensure that there is no inequity in presentation in MDTMs that could lead to a loss of chance for patients.

Is self-care dialysis associated with social deprivation in a universal health care system? A cohort study with data from the Renal Epidemiology and Information Network Registry.

BACKGROUND: Socioeconomic status is associated with dialysis modality in developed countries. The main objective of this study was to investigate whether social deprivation, estimated by the European Deprivation Index (EDI), was associated with self-care dialysis in France. METHODS: The EDI was calculated for patients who started dialysis in 2017. The event of interest was self-care dialysis 3 months after dialysis initiation [self-care peritoneal dialysis (PD) or satellite haemodialysis (HD)]. A logistic model was used for the statistical analysis, and a counterfactual approach was used for the causal mediation analysis. RESULTS: Among the 9588 patients included, 2894 (30%) were in the most deprived quintile of the EDI. A total of 1402 patients were treated with self-care dialysis. In the multivariable analysis with the EDI in quintiles, there was no association between social deprivation and self-care dialysis. Compared with the other EDI quintiles, patients from Quintile 5 (most deprived quintile) were less likely to be on self-care dialysis (odds ratio 0.81, 95% confidence interval 0.71-0.93). Age, sex, emergency start, cardiovascular disease, chronic respiratory disease, cancer, severe disability, serum albumin and registration on the waiting list were associated with self-care dialysis. The EDI was not associated with self-care dialysis in either the HD or in the PD subgroups. CONCLUSIONS: In France, social deprivation estimated by the EDI is associated with self-care dialysis in end-stage renal disease patients undergoing replacement therapy.

Socioeconomic environment and disparities in cancer survival for 19 solid tumor sites: An analysis of the French Network of Cancer Registries (FRANCIM) data.

Social inequalities are concerning along the cancer continuum. In France, social gradient in health is particularly marked but little is known about social gradient in cancer survival. We aimed to investigate the influence of socioeconomic environment on cancer survival, for all cancers reported in the French Network of Cancer Registries. We analyzed 189,657 solid tumors diagnosed between 2006 and 2009, recorded in 18 registries. The European Deprivation Index (EDI), an ecological index measuring relative poverty in small geographic areas, assessed social environment. The EDI was categorized into quintiles of the national distribution. One- and five-year age-standardized net survival (ASNS) were estimated for each solid tumor site and deprivation quintile, among men and among women. We found that 5-year ASNS was lower among patients living in the most deprived areas compared to those living in the least deprived ones for 14/16 cancers among men and 16/18 cancers among women. The extent of cancer survival disparities according to deprivation varied substantially across the cancer sites. The reduction in ASNS between the least and the most deprived quintile reached 34% for liver cancer among men and 59% for bile duct cancer among women. For pancreas, stomach and esophagus cancer (among men), and ovary and stomach cancer (among women), deprivation gaps were larger at 1-year than 5-year survival. In conclusion, survival was worse in the most deprived areas for almost all cancers. Our results from population-based cancer registries data highlight the need for implementing actions to reduce social inequalities in cancer survival in France.

Social deprivation is associated with poor kidney transplantation outcome in children.

Socioeconomic status is an important determinant of health. Its impact on kidney transplantation outcome has been studied among adults but data in children are scarce, especially in Europe. Here, we investigate the association between the level of social deprivation (determined by the continuous score European Deprivation Index) and graft failure risk in pediatric kidney transplant recipients. All patients listed under 18 years of age who received a first kidney transplant between 2002 and 2014 in France were included. Of 1050 kidney transplant recipients (males 59%, median age at transplantation 13.2 years, preemptive transplantation 23%), 211 graft failures occurred within a median followup of 5.9 years. Thirty-seven percent of these patients belong to the most deprived quintile, suggesting that deprivation is more frequent in pediatric patients with end-stage kidney disease (ESKD) than in the general population. Five- and ten-year graft survival were 85% and 69%, respectively, in the most deprived quintile vs. 90% and 83%, respectively, in the least deprived quintile. At any time after transplantation, patients in the most deprived quintile had almost a two-fold higher hazard of graft failure compared with the least deprived quintile, after adjustment for age at renal replacement therapy, duration of dialysis, primary kidney disease, and rural/urban living environment (hazard ratio 1.99; 95% confidence interval 1.20-3.28). The hazard of graft failure did not differ significantly between girls and boys. Thus, our findings suggest a lower socioeconomic status is independently associated with poor graft outcome in pediatric kidney transplantation.

Cost-Effectiveness Analysis of a Mobile Mammography Unit for Breast Cancer Screening to Reduce Geographic and Social Health Inequalities.

BACKGROUND: Breast cancer is the leading cancer in terms of incidence and mortality among women in France. Effective organized screening does exist, however, the participation rate is low, and negatively associated with a low socioeconomic status and remoteness. OBJECTIVES: To determine the cost-effectiveness of a mobile mammography (MM) program to increase participation in breast cancer screening and reduce geographic and social inequalities. METHODS: A cost-effectiveness analysis from retrospective data was conducted from the payer perspective, comparing an invitation to a mobile mammography unit (MMU) or to a radiologist's office (MM or RO group) with an invitation to a radiologist's office only (RO group) (n = 37 461). Medical and nonmedical direct costs were estimated. Outcome was screening participation. The mean incremental cost and effect, the incremental cost-effectiveness ratio, and the cost-effectiveness acceptability curve were estimated. RESULTS: The mean incremental cost for invitation to MM or RO was estimated to be €23.21 (95% CI, 22.64-23.78) compared with RO only, and with a point of participation gain of 3.8% (95% CI, 2.8-4.8), resulting in an incremental cost per additional screen of €610.69 (95% CI, 492.11-821.01). The gain of participation was more important in women living in deprived areas and for distances exceeding 15 km from an RO. CONCLUSION: Screening involving a MMU can increase participation in breast cancer screening and reduce geographic and social inequalities while being more cost-effective in remote areas and in deprived areas. Because of the retrospective design, further research is needed to provide more evidence of the effectiveness and cost-effectiveness of using a MMU for organized breast cancer screening and to determine the optimal conditions for implementing it.

Could mobile mammography reduce social and geographic inequalities in breast cancer screening participation?

Evaluation of mobile mammography for reducing social and geographic inequalities in breast cancer screening participation. We examined the responses to first invitations to undergo breast cancer screening from 2003 to 2012 in Orne, a French department. Half of the participants could choose between screening in a radiologist's office or a mobile mammography (MM) unit. We calculated the participation rate and individual participation model according to age group, deprivation quintile and distance. Among participants receiving an MM invitation, the preference was for MM. This was especially the case in the age group >70years and increased with deprivation quintile and remoteness. There were no significant participation trends with regard to deprivation or remoteness. In the general population, the influence of deprivation and remoteness was markedly diminished. After adjustment, MM invitation was associated with a significant increase in individual participation (odds ratio=2.9). MM can target underserved and remote communities, allowing greater participation and decreasing social and geographic inequalities in the general population. Proportionate universalism is an effective principle for public health policy in reducing health inequalities.

Assessment of the ecological bias of seven aggregate social deprivation indices.

BACKGROUND: In aggregate studies, ecological indices are used to study the influence of socioeconomic status on health. Their main limitation is ecological bias. This study assesses the misclassification of individual socioeconomic status in seven ecological indices. METHODS: Individual socioeconomic data for a random sample of 10,000 persons came from periodic health examinations conducted in 2006 in 11 French departments. Geographical data came from the 2007 census at the lowest geographical level available in France. The Receiver Operating Characteristics (ROC) curves, the areas under the curves (AUC) for each individual variable, and the distribution of deprived and non-deprived persons in quintiles of each aggregate score were analyzed. RESULTS: The aggregate indices studied are quite good "proxies" for individual deprivation (AUC close to 0.7), and they have similar performance. The indices are more efficient at measuring individual income than education or occupational category and are suitable for measuring of deprivation but not affluence. CONCLUSIONS: The study inventoried the aggregate indices available in France and evaluated their assessment of individual SES.

Health professionals and the early detection of head and neck cancers: a population-based study in a high incidence area.

BACKGROUND: In the context of early detection of head and neck cancers (HNC), the aim of this study was to describe how people sought medical consultation during the year prior to diagnosis and the impact on the stage of the cancer. METHODS: Patients over 20 years old with a diagnosis of HNC in 2010 were included from four French cancer registries. The medical data were matched with data regarding uptake of healthcare issued from French National Health Insurance General Regime. RESULTS: In 86.0 % of cases, patients had consulted a general practitioner (GP) and 21.1 % a dentist. Consulting a GP at least once during the year preceding diagnosis was unrelated to Charlson index, age, sex, département, quintile of deprivation of place of residence. Patients from the 'quite privileged', 'quite underprivileged' and 'underprivileged' quintiles consulted a dentist more frequently than those from the 'very underprivileged' quintile (p = 0.007). The stage was less advanced for patients who had consulted a GP (OR = 0.42 [0.18-0.99]) - with a dose-response effect. CONCLUSIONS: In view of the frequency of consultations, the existence of a significant association between consultations and a localised stage at diagnosis and the absence of a socio-economic association, early detection of HNC by GPs would seem to be the most appropriate way.

What are the real waiting times for therapeutic management of head and neck cancer: a study in the general population in the north-west of France.

Head and neck cancers (HNC) have a poor prognosis and a long treatment delay may have a negative impact on this. Some studies have investigated the determinants of this delay but not in the general population and rarely taking into account socio-economic factors. A high-resolution population-based study about cancer management was conducted, using registries in the north-west of France, on HNC diagnosed between 2008 and 2010. The median time between diagnosis and multidisciplinary team meeting (DMI) (N = 1631) was 14 days (Q1: 7 to Q3: 26). The median time between diagnosis and first treatment (DTI) (N = 1519) was 35 days (Q1: 21 to Q3: 54). When the first treatment was radiotherapy, the interval was 54.5 days (Q1: 40 to Q3: 71). In multivariate analysis, DTI was associated with the type of first treatment and place of treatment. For advanced stage HNC, DTI was associated with comorbidities, topography of the cancer and socio-economic status, underprivileged patients being treated later than privileged ones. Given the French governmental cancer plans which set out to coordinate care pathways via nursing coordinators and to improve the availability of radiotherapy, the waiting times observed in this study still seem long. The optimal care pathway should include adapted social management but the DTI was still longer for underprivileged patients.

Socioeconomic environment and cancer incidence: a French population-based study in Normandy.

BACKGROUND: The struggle against social inequalities is a priority for many international organizations. The objective of the study was to quantify the cancer burden related to social deprivation by identifying the cancer sites linked to socioeconomic status and measuring the proportion of cases associated with social deprivation. METHODS: The study population comprised 68 967 cases of cancer diagnosed between 1997 and 2009 in Normandy and collected by the local registries. The social environment was assessed at an aggregated level using the European Deprivation Index (EDI). The association between incidence and socioeconomic status was assessed by a Bayesian Poisson model and the excess of cases was calculated with the Population Attributable Fraction (PAF). RESULTS: For lung, lips-mouth-pharynx and unknown primary sites, a higher incidence in deprived was observed for both sexes. The same trend was observed in males for bladder, liver, esophagus, larynx, central nervous system and gall-bladder and in females for cervix uteri. The largest part of the incidence associated with deprivation was found for cancer of gall-bladder (30.1%), lips-mouth-pharynx (26.0%), larynx (23.2%) and esophagus (19.6%) in males and for unknown primary sites (18.0%) and lips-mouth-pharynx (12.7%) in females. For prostate cancer and melanoma in males, the sites where incidence increased with affluence, the part associated with affluence was respectively 9.6% and 14.0%. CONCLUSIONS: Beyond identifying cancer sites the most associated with social deprivation, this kind of study points to health care policies that could be undertaken to reduce social inequalities.

Spatial Accessibility to Primary Care in Metropolitan France: Results Using the SCALE Spatial Accessibility Index for All Regions.

Accessibility to care is a major public health issue. Various tools to assess it are available, but they do not solve the problem of scale. Moreover, accessibility is a multidimensional concept that is not taken into account with current tools. The SCALE index aims to overcome these two limitations by proposing a synthetic measure on a more precise scale than the administrative unit or the sub-municipal scale. Under the assumption of access to care facilities for all and access to the nearest facilities, the potential accessibility distance was calculated for each couple (residential area, accessible facilities). This was defined as the average distance by road that the population has to travel to access care. To take the availability of resources into account, these distances were weighted by the theoretical pressure on the facilities. The SCALE index was then calculated using a linear combination of the distances of potential accessibility to care facilities It highlights differences in accessibility at the national and regional scale. Using this index, it was possible to provide maps for all French regions and the major cities in a story-map. The major conurbation around Paris and the main urban centers has high accessibility. Low accessibility forms a "Y" shape. In conclusion, the SCALE index measures accessibility at the scale of a small geographic unit taking the proximity and the availability of health professionals into account. It is also possible to take into account the diversity of accessibility in a given territory.

Environmental and social inequities in continental France: an analysis of exposure to heat, air pollution, and lack of vegetation.

BACKGROUND: Cumulative environmental exposures and social deprivation increase health vulnerability and limit the capacity of populations to adapt to climate change. OBJECTIVE: Our study aimed at providing a fine-scale characterization of exposure to heat, air pollution, and lack of vegetation in continental France between 2000 and 2018, describing spatiotemporal trends and environmental hotspots (i.e., areas that cumulate the highest levels of overexposure), and exploring any associations with social deprivation. METHODS: The European (EDI) and French (FDep) social deprivation indices, the normalized difference vegetation index, daily ambient temperatures, particulate matter (PM2.5 and PM10), nitrogen dioxide, and ozone (O3) concentrations were estimated for 48,185 French census districts. Reference values were chosen to characterize (over-)exposure. Hotspots were defined as the areas cumulating the highest overexposure to temperature, air pollution, and lack of vegetation. Associations between heat overexposure or hotspots and social deprivation were assessed using logistic regressions. RESULTS: Overexposure to heat was higher in 2015-2018 compared with 2000-2014. Exposure to all air pollutants except for O3 decreased during the study period. In 2018, more than 79% of the urban census districts exceeded the 2021 WHO air quality guidelines. The evolution of vegetation density between 2000 and 2018 was heterogeneous across continental France. In urban areas, the most deprived census districts were at a higher risk of being hotspots (odds ratio (OR): 10.86, 95% CI: 9.87-11.98 using EDI and OR: 1.07, 95% CI: 1.04-1.11 using FDep). IMPACT STATEMENT: We studied cumulative environmental exposures and social deprivation in French census districts. The 2015-2018 period showed the highest overexposure to heat between 2000 and 2018. In 2018, the air quality did not meet the 2021 WHO guidelines in most census districts and 8.6 million people lived in environmental hotspots. Highly socially deprived urban areas had a higher risk of being in a hotspot. This study proposes for the first time, a methodology to identify hotspots of exposure to heat, air pollution, and lack of vegetation and their associations with social deprivation at a national level.

Social Deprivation and Incidence of Pediatric Kidney Failure in France.

Introduction: Approximately 8 per million children and young adults aged < 20 years initiate kidney replacement therapy (KRT) per year in France. We hypothesize that social deprivation could be a determinant of childhood-onset kidney failure. The objective of this study was to estimate the incidence of pediatric KRT in France according to the level of social deprivation. Methods: All patients < 20 years who initiated KRT from 2010 to 2015 in metropolitan France were included. Data were collected from the comprehensive French registry of KRT French Renal Epidemiology and Information network (REIN). We used a validated ecological index to assess social deprivation, the 2011 French version of the European Deprivation Index (EDI). We estimated the age standardized incidence rates according to the quintiles of EDI using direct standardization and incidence rate ratio using Poisson regression. Results: We included 672 children with kidney failure (58.6% males, 30.7% with glomerular or vascular disease, 43.3% starting KRT between 11 and 17 years). 38.8% were from the most deprived areas (quintile 5 of EDI). The age standardized incidence rate increased with quintile of EDI, from 5.45 (95% confidence interval [CI] = 4.25-6.64) per million children per year in the least deprived quintile to 8.46 (95% CI = 7.41-9.51) in the most deprived quintile of EDI (incidence rates ratio Q5 vs. Q1 1.53-fold; 95% CI = 1.18-2.01). Conclusion: This study showed that even in a country with a universal health care system, there is a strong association between the incidence of pediatric KRT and social deprivation showing that social health inequalities appear from KRT initiation. This study highlights the need to look further into social inequalities in the earliest stage of chronic kidney disease (CKD).

Area-based social inequalities in adult mortality: construction of French deprivation-specific life tables for the period 2016-2018.

Background: In order to tackle social inequalities in mortality, it is crucial to quantify them. We produced French deprivation-specific life tables for the period 2016-2018 to measure the social gradient in adult all-cause mortality. Methods: Data from the Permanent Demographic Sample (EDP) were used to provide population and death counts by age, sex and deprivation quintile. The European Deprivation Index (EDI), applied at a sub-municipal geographical level, was used as an ecological measure of deprivation. Smoothed mortality rates were calculated using a one-dimensional Poisson counts smoothing method with P-Splines. We calculated life expectancies by age, sex and deprivation quintile as well as interquartile mortality rate ratios (MRR). Results: At the age of 30, the difference in life expectancy between the most and least deprived groups amounted to 3.9 years in males and 2.2 years in females. In terms of relative mortality inequalities, the largest gaps between extreme deprivation groups were around age 55 for males (MRR = 2.22 [2.0; 2.46] at age 55), around age 50 in females (MRR = 1.77 [1.48; 2.1] at age 47), and there was a decrease or disappearance of the gaps in the very older adults. Conclusions: There is a strong social gradient in all-cause mortality in France for males and females. The methodology for building these deprivation-specific life tables is reproducible and could be used to monitor its development. The tables produced should contribute to improving studies on net survival inequalities for specific diseases by taking into account the pre-existing social gradient in all-cause mortality.

Cancer Survival and Travel Time to Nearest Reference Care Center for 10 Cancer Sites: An Analysis of 21 French Cancer Registries.

BACKGROUND: The impact of several non-clinical factors on cancer survival is poorly understood. The aim of this study was to investigate the influence of travel time to the nearest referral center on survival of patients with cancer. PATIENTS AND METHODS: The study used data from the French Network of Cancer Registries that combines all the French population-based cancer registries. For this study, we included the 10 most common solid invasive cancer sites in France between 1 January 2013 and 31 December 2015, representing 160,634 cases. Net survival was measured and estimated using flexible parametric survival models. Flexible excess mortality modelling was performed to investigate the association between travel time to the nearest referral center and patient survival. To allow the most flexible effects, restricted cubic splines were used to investigate the influence of travel times to the nearest cancer center on excess hazard ratio. RESULTS: Among the 1-year and 5-year net survival results, lower survival was observed for patients residing farthest from the referral center for half of the included cancer types. The remoteness gap in survival was estimated to be up to 10% at 5 years for skin melanoma in men and 7% for lung cancer in women. The pattern of the effect of travel time was highly different according to tumor type, being either linear, reverse U-shape, non-significant, or better for more remote patients. For some sites restricted cubic splines of the effect of travel time on excess mortality were observed with a higher excess risk ratio as travel time increased. CONCLUSIONS: For numerous cancer sites, our results reveal geographical inequalities, with remote patients experiencing a worse prognosis, aside from the notable exception of prostate cancer. Future studies should evaluate the remoteness gap in more detail with more explanatory factors.

Is the Social Gradient in Net Survival Observed in France the Result of Inequalities in Cancer-Specific Mortality or Inequalities in General Mortality?

BACKGROUND: In cancer net survival analyses, if life tables (LT) are not stratified based on socio-demographic characteristics, then the social gradient in mortality in the general population is ignored. Consequently, the social gradient estimated on cancer-related excess mortality might be inaccurate. We aimed to evaluate whether the social gradient in cancer net survival observed in France could be attributable to inaccurate LT. METHODS: Deprivation-specific LT were simulated, applying the social gradient in the background mortality due to external sources to the original French LT. Cancer registries' data from a previous French study were re-analyzed using the simulated LT. Deprivation was assessed according to the European Deprivation Index (EDI). Net survival was estimated by the Pohar-Perme method and flexible excess mortality hazard models by using multidimensional penalized splines. RESULTS: A reduction in net survival among patients living in the most-deprived areas was attenuated with simulated LT, but trends in the social gradient remained, except for prostate cancer, for which the social gradient reversed. Flexible modelling additionally showed a loss of effect of EDI upon the excess mortality hazard of esophagus, bladder and kidney cancers in men and bladder cancer in women using simulated LT. CONCLUSIONS: For most cancers the results were similar using simulated LT. However, inconsistent results, particularly for prostate cancer, highlight the need for deprivation-specific LT in order to produce accurate results.

Social deprivation reduced registration for kidney transplantation through markers of nephrological care: a mediation analysis.

OBJECTIVES: We assessed the direct and indirect effect of social deprivation mediated by modifiable markers of nephrological follow-up on registration on the renal transplantation waiting-list. STUDY DESIGN AND SETTINGS: From the Renal Epidemiology and Information Network, we included French incident dialysis patients eligible for a registration evaluation between January 2017 and June 2018. Mediation analyses were conducted to assess effects of social deprivation estimated by quintile 5 (Q5) of the European Deprivation Index on registration defined as wait-listing at dialysis start or within the first 6 months. RESULTS: Among the 11,655 included patients, 2,410 were registered. The Q5 had a direct effect on registration (odds ratio [OR]: 0.82 [0.80-0.84]) and an indirect effect mediated by emergency start dialysis (OR: 0.97 [0.97-0.98]), hemoglobin <11 g/dL and/or lack of erythropoietin (OR 0.96 [0.96-0.96]) and albumin <30 g/L (OR: 0.98 [0.98-0.99]). CONCLUSION: Social deprivation was directly associated with a lower registration on the renal transplantation waiting-list but its effect was also mediated by markers of nephrological care, suggesting that improving the follow-up of the most deprived patients should help to reduce disparities in access to transplantation.