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.

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.

Is there sex disparity in vascular access at dialysis initiation in France? A mediation analysis using data from the Renal Epidemiology and Information Network registry.

Background: This study was conducted to estimate the direct effect of sex on the proportion of hemodialysis (HD) catheters used at dialysis initiation and to investigate whether predialysis care or socioeconomic status acted as a mediator of the sex effect. Methods: Patients who started dialysis between January 1, 2017, and June 30, 2018, in France were included using the data of the Renal Epidemiology and Information Network (REIN) registry. We performed logistic regression to study the association between sex and the proportion of HD catheters used. A mediation analysis with a counterfactual approach was carried out to evaluate whether there was an indirect effect of sex through the proxies of predialysis care {hemoglobin, albumin levels, glomerular filtration rate [GFR] at dialysis initiation} and socioeconomic status. Because an interaction between sex and social deprivation has been identified, we performed a subgroup analysis on deprived and nondeprived patients. Results: The study included 16 032 patients, and the sex ratio (male to female) was 10 405:5627. In the multivariable analysis, women were associated with a greater risk of starting dialysis with a catheter {odds ratio [OR], 1.32 [95% confidence interval (CI): 1.23-1.42]}. There was an indirect effect of sex on the proportion of HD catheters through proxies for predialysis care {albuminemia <30 g/L [OR, 1.08 (95% CI: 1.05-1.10)], hemoglobin <11 g/dL [OR, 1.03 (95% CI: 1.02-1.04)], glomerular filtration rate <7 mL/min [OR, 1.05 (95% CI: 1.04-1.07)]}. Among deprived patients, there was no direct effect of sex on catheter proportion. Conclusions: Women were associated with a higher risk of starting dialysis through an HD catheter. The effect of sex was mediated by predialysis care, particularly for deprived patients.

Evaluation of a mobile mammography unit: concepts and randomized cluster trial protocol of a population health intervention research to reduce breast cancer screening inequalities.

BACKGROUND: Breast cancer is the leading cancer in women in France both in incidence and mortality. Organized breast cancer screening (OBCS) has been implemented nationwide since 2004, but the participation rate remains low (48%) and inequalities in participation have been reported. Facilities such as mobile mammography units could be effective to increase participation in OBCS and reduce inequalities, especially areas underserved in screening. Our main objective is to evaluate the impact of a mobile unit and to establish how it could be used to tackle territorial inequalities in OBCS participation. METHODS: A collaborative project will be conducted as a randomized controlled cluster trial in 2022-2024 in remote areas of four French departments. Small geographic areas were constructed by clustering women eligible to OBCS, according to distance to the nearest radiology centre, until an expected sample of eligible women was attained, as determined by logistic and financial constraints. Intervention areas were then selected by randomization in parallel groups. The main intervention is to propose an appointment at the mobile unit in addition to current OBCS in these remote areas according to the principle of proportionate universalism. A few weeks before the intervention, OBCS will be promoted with a specific information campaign and corresponding tools, applying the principle of multilevel, intersectoral and community empowerment to tackle inequalities. DISCUSSION: This randomized controlled trial will provide a high level of evidence in assessing the effects of mobile unit on participation and inequalities. Contextual factors impacting the intervention will be a key focus in this evaluation. Quantitative analyses will be complemented by qualitative analyses to investigate the causal mechanisms affecting the effectiveness of the intervention and to establish how the findings can be applied at national level. TRIAL REGISTRATION: Registered on ClinicalTrials.gov, December 21, 2021: NCT05164874 .

Evolution of socioeconomic inequalities in cancer incidence between 2006 and 2016 in France: a population-based study.

OBJECTIVE: The existence of socioeconomic inequalities in cancer incidence is now well established and their reduction is a priority in many countries. This study aimed to measure the evolution of socioeconomic inequalities in the incidence of the most common cancers in France, over an 11-year period. METHODS: The study focused on 19 cancer entities (16 solid tumors and 3 hematological malignancies). Data are obtained from the French Network of Cancer Registries, representing 604 205 cancer cases. Each patient address was geolocalized and assigned to an IRIS, the smallest geographic unit in France. The French version of the European Deprivation Index was used to measure the level of deprivation in each IRIS. A generalized linear mixed model was used to account for the longitudinal nature of the data and to assess the evolution of socioeconomic inequalities. RESULTS: A significant evolution of the social gradient of incidence over time was highlighted for five cancer entities and all entities combined. For lung cancer for both sexes and bladder cancer in men, more frequent in deprived areas, the social gradient in incidence tended to decrease over time. For breast cancer in women and lymphocytic leukemia in men, more frequent in affluent areas, the gap continues to widen. CONCLUSION: Cancer entities with large disparities continued to present social inequalities in incidence without exacerbation with time. The few temporal evolutions observed do not show a worsening of the social gradient of incidence to the disadvantage of the most deprived areas, but rather an increase in incidence that is greater in the most affluent areas.

Effect of social deprivation on peritoneal dialysis uptake: A mediation analysis with the data of the REIN registry.

BACKGROUND: Social deprivation could act as a barrier to peritoneal dialysis (PD). The objective of this study was to assess the association between social deprivation estimated by the European deprivation index (EDI) and PD uptake and to explore the potential mediators of this association. METHODS: From the Renal Epidemiology and Information Network registry, patients who started dialysis in 2017 were included. The EDI was calculated based on the patient's address. The event of interest was the proportion of PD 3 months after dialysis initiation. A mediation analysis with a counterfactual approach was carried out to evaluate the direct and indirect effect of the EDI on the proportion of PD. RESULTS: Among the 9588 patients included, 1116 patients were on PD; 2894 (30.2%) patients belonged to the most deprived quintile (Q5). PD was associated with age >70 years (odds ratio (OR) 0.79 [95% confidence interval (CI): 0.69-0.91]), male gender (0.85 [95% CI: 0.74-0.97]), cardiovascular disease (OR 0.86 [95% CI: 0.86-1.00]), chronic heart failure (OR 1.34 [95% CI: 1.13-1.58]), active cancer (OR 0.67 [95% CI: 0.53-0.85]) and obesity (OR 0.75 [95% CI: 0.63-0.89]). In the mediation analysis, Q5 had a direct effect on PD proportion OR 0.84 [95% CI: 0.73-0.96]. The effect of Q5 on the proportion of PD was mediated by haemoglobin level at dialysis initiation (OR 0.96 [95% CI: 0.94-0.98]) and emergency start (OR 0.98 [95% CI: 0.96-0.99]). CONCLUSION: Social deprivation, estimated by the EDI, was associated with a lower PD uptake. The effect of social deprivation was mediated by haemoglobin level, a proxy of predialysis care and emergency start.

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.

Socio-Territorial Inequities in the French National Breast Cancer Screening Programme-A Cross-Sectional Multilevel Study.

BACKGROUND: France implemented in 2004 the French National Breast Cancer Screening Programme (FNBCSP). Despite national recommendations, this programme coexists with non-negligible opportunistic screening practices. AIM: Analyse socio-territorial inequities in the 2013-2014 FNBCSP campaign in a large sample of the eligible population. METHOD: Analyses were performed using three-level hierarchical generalized linear model. Level one was a 10% random sample of the eligible population in each département (n = 397,598). For each woman, age and travel time to the nearest accredited radiology centre were computed. These observations were nested within 22,250 residential areas called "Îlots Regroupés pour l'Information Statistique" (IRIS), for which the European Deprivation Index (EDI) is defined. IRIS were nested within 41 départements, for which opportunistic screening rates and gross domestic product based on purchasing power parity were available, deprivation and the number of radiology centres for 100,000 eligible women were computed. RESULTS: Organized screening uptake increased with age (OR1SD = 1.05 [1.04-1.06]) and decreased with travel time (OR1SD = 0.94 [0.93-0.95]) and EDI (OR1SD = 0.84 [0.83-0.85]). Between départements, organized screening uptake decreased with opportunistic screening rate (OR1SD = 0.84 [0.79-0.87]) and départements deprivation (OR1SD = 0.91 [0.88-0.96]). Association between EDI and organized screening uptake was weaker as opportunistic screening rates and as département deprivation increased. Heterogeneity in FNBCSP participation decreased between IRIS by 36% and between départements by 82%. CONCLUSION: FNBCSP does not erase socio-territorial inequities. The population the most at risk of dying from breast cancer is thus the less participating. More efforts are needed to improve equity.

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.

Socioeconomic Deprivation Does Not Impact Liver Transplantation Outcome for HCC: A Survival Analysis From a National Database.

BACKGROUND: To investigate the value of European deprivation index (EDI) and hepatocellular carcinoma (HCC) characteristics and their relationships with outcome after liver transplantation (LT). METHODS: Patients undergoing LT for HCC were included from a national database (from "Agence de la Biomédecine" between 2006 and 2016. Characteristics of the patients were blindly extracted from the database. Thus, EDI was calculated in 5 quintiles and prognosis factors of survival were determined according to a Cox model. RESULTS: Among the 3865 included patients, 33.9% were in the fifth quintile (quintile 1, N = 562 [14.5%]; quintile 2, N = 647 [16.7%]; quintile 3, N = 654 [16.9%]; quintile 4, N = 688 [17.8%]). Patients in each quintile were comparable regarding HCC history, especially median size of HCC, number of nodules of HCC and alpha-fetoprotein score. In the univariate analysis of the crude survival, having >2 nodules of HCC before LT and time on waiting list were associated with a higher risk of death (P < 0.0001 and P = 0.03, respectively). EDI, size of HCC, model for end-stage liver disease score, Child-Pugh score were not statistically significant in the crude and net survival. In both survival, time on waiting list and number of HCC ≥2 were independent factor of mortality after LT for HCC (P = 0.009 and 0.001, respectively, and P = 0.03 and 0.02, respectively). CONCLUSIONS: EDI does not impact overall survival after LT for HCC. Number of HCC and time on waiting list are independent prognostic factors of survival after LT for HCC.

The association between cervical cancer screening participation and the deprivation index of the location of the family doctor's office.

BACKGROUND: Cervical cancer screening rates are known to be strongly associated with socioeconomic status. Our objective was to assess whether the rate is also associated with an aggregated deprivation marker, defined by the location of family doctors' offices. METHODS: To access this association, we 1) collected data from the claim database of the French Health Insurance Fund about the registered family doctors and their enlisted female patients eligible for cervical screening; 2) carried out a telephone survey with all registered doctors to establish if they were carrying out Pap-smears in their practices; 3) geotracked all the doctors' offices in the smallest existing blocks of socioeconomic homogenous populations (IRIS census units) that were assigned a census derived marker of deprivation, the European Deprivation Index (EDI), and a binary variable of urbanization; and 4) we used a multivariable linear mixed model with IRIS as a random effect. RESULTS: Of 348 eligible doctors, 343 responded to the telephone survey (98.6%) and were included in the analysis, encompassing 88,152 female enlisted patients aged 25-65 years old. In the multivariable analysis (adjusted by the gender of the family doctor, the practice of Pap-smears by the doctor and the urbanization of the office location), the EDI of the doctor's office was strongly associated with the cervical cancer screening participation rate of eligible patients (p<0.001). CONCLUSION: The EDI linked to the location of the family doctor's office seems to be a robust marker to predict female patients' participation in cervical cancer screening.

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.

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.

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.

No effect of comorbidities on the association between social deprivation and geographical access to the reference care center in the management of colon cancer.

BACKGOUND: Patients with colon cancer in France exhibit one of the steepest socioeconomic survival gradients in Europe. Among the putative causes for this situation, comorbidities are frequently incriminated but evidence of this is lacking. AIMS: Measure the influence of social deprivation and geographical access to the reference care center for the management of colon cancer, and the putative role of associated comorbidities. MATERIALS AND METHODS: The study population comprised all 1383 resected colon cancer cases diagnosed between 2005 and 2010 in the area covered by the "Calvados Registry of Digestive Tumors". Social environment was assessed by using the European Deprivation Index and travel time to the reference care center and comorbidities by using Charlson's comorbidity index. RESULTS: Our results confirm the existence of socioeconomic or geographical inequalities at each step of colon cancer management, but without any role of associated comorbidities. The effect of deprivation is mainly explained by age at diagnosis, while travel time to the reference care center is an independent predictor of cancer management. CONCLUSION: We found no effect of comorbidities on the association between socioeconomic factors and the management of colon cancer in this French department.

Socioeconomic status and site-specific cancer incidence, a Bayesian approach in a French Cancer Registries Network study.

The aim of this study was to identify and compare cancer sites whose incidence is influenced by social deprivation. The study population comprised 189 144 cases of cancer diagnosed between 2006 and 2009, recorded in member registries of the French Network of Cancer Registries. Social environment was assessed at an aggregate level using the European Deprivation Index. The association between incidence and socioeconomic status was assessed by a geographical Bayesian Poisson model enabling a reduction of the overall variability and smoothing of the relative risks by sharing information provided by multiple geographic units. For cancers of the stomach, liver, lips-mouth-pharynx, and lung, a higher incidence in deprived populations was found for both sexes as well as for cancers of the larynx, esophagus, pancreas, and bladder in men and cervical cancer in women. For melanoma, prostate, testis, ovarian, and breast cancer, a higher incidence was observed in affluent populations. The highest relative risks of the lowest social class compared with the highest social class were found for larynx [relative risk (RR)=1.67 (1.43-1.95)], lips-mouth-pharynx [RR=1.89 (1.72-2.07)], and lung cancer [RR=1.59 (1.50-1.68)] in men and for cervix [RR=1.62 (1.40-1.88)] and lips-mouth-pharynx [RR=1.56 (1.30-1.86)] cancer in women. By estimating the burden of social deprivation on cancer incidence throughout France, this study enables us to measure the gains that could be achieved by implementing targeted prevention efforts.

Is atmospheric pollution exposure during pregnancy associated with individual and contextual characteristics? A nationwide study in France.

BACKGROUND: Exposure to atmospheric pollutants is a danger for the health of pregnant mother and children. Our objective was to identify individual (socioeconomic and behavioural) and contextual factors associated with atmospheric pollution pregnancy exposure at the nationwide level. METHOD: Among 14 921 women from the French nationwide ELFE (French Longitudinal Study of Children) mother-child cohort recruited in 2011, outdoor exposure levels of PM2.5, PM10 (particulate matter <2.5 µm and <10 µm in diameter) and NO2 (nitrogen dioxide) were estimated at the pregnancy home address from a dispersion model with 1 km resolution. We used classification and regression trees (CART) and linear regression to characterise the association of atmospheric pollutants with individual (maternal age, body mass index, parity, education level, relationship status, smoking status) and contextual (European Deprivation Index, urbanisation level) factors. RESULTS: Patterns of associations were globally similar across pollutants. For the CART approach, the highest tertile of exposure included mainly women not in a relationship living in urban and socially deprived areas, with lower education level. Linear regression models identified different determinants of atmospheric pollutants exposure according to the residential urbanisation level. In urban areas, atmospheric pollutants exposure increased with social deprivation, while in rural areas a U-shaped relationship was observed. CONCLUSION: We highlighted social inequalities in atmospheric pollutants exposure according to contextual characteristics such as urbanisation level and social deprivation and also according to individual characteristics such as education, being in a relationship and smoking status. In French urban areas, pregnant women from the most deprived neighbourhoods were those most exposed to health-threatening atmospheric pollutants.

Neighborhood deprivation and risk of head and neck cancer: A multilevel analysis from France.

BACKGROUND: While it is known that cancer risk is related to area-level socioeconomic status, the extent to which these inequalities are explained by contextual effects is poorly documented especially for head and neck cancer. METHODS: A case-control study, ICARE, included 2415 head and neck cancer cases and 3555 controls recruited between 2001 and 2007 from 10 French regions retrieved from a general cancer registry. Individual socioeconomic status was assessed using marital status, highest educational level and occupational social class. Area-level socioeconomic status was assessed using the French version of the European Deprivation Index (EDI). The relationship between both individual and area-based socioeconomic level and the risk of head and neck cancer was assessed by multilevel analyses. RESULTS: A higher risk for head and neck cancer was found in divorced compared with married individuals (OR=2.14, 95% CI=1.78-2.57), for individuals with a basic school-leaving qualification compared with those with higher education (OR=4.55 95% CI=3.72-5.57), for manual workers compared with managers (OR=4.91, 95% CI=3.92-6.15) and for individuals living in the most deprived areas compared with those living in the most affluent ones (OR=1.98, 95% CI=1.64-2.41). The influence of area-level socioeconomic status measured by EDI remained after controlling for individual socioeconomic characteristics (OR=1.51; 95% confidence interval: 1.23-1.85, p-value=0.0003). CONCLUSIONS: The role of individual socioeconomic status in the risk of head and neck cancer is undeniable, although contextual effects of deprived areas also increase the susceptibility of individuals developing the disease.