Small-area analysis on socioeconomic inequalities in cancer survival for 25 cancer sites in Germany.

Socioeconomic inequalities in cancer survival have been reported in various countries but it is uncertain to what extent they persist in countries with relatively comprehensive health insurance coverage such as Germany. We investigated the association between area-based socioeconomic deprivation on municipality level and cancer survival for 25 cancer sites in Germany. We used data from seven population-based cancer registries (covering 32 million inhabitants). Patients diagnosed in 1998 to 2014 with one of 25 most common cancer sites were included. Area-based socioeconomic deprivation was assessed using the categorized German Index of Multiple Deprivation (GIMD) on municipality level. We estimated 3-month, 1-year, 5-year and 5-year conditional on 1-year age-standardized relative survival using period approach for 2012 to 2014. Trend analyses were conducted for periods between 2003-2005 and 2012-2014. Model-based period analysis was used to calculate relative excess risks (RER) adjusted for age and stage. In total, 2 333 547 cases were included. For all cancers combined, 5-year survival rates by GIMD quintile were 61.6% in Q1 (least deprived), 61.2% in Q2, 60.4% in Q3, 59.9% in Q4 and 59.0% in Q5 (most deprived). For most cancer sites, the most deprived quintile had lower 5-year survival compared to the least deprived quintile even after adjusting for stage (all cancer sites combined, RER 1.16, 95% confidence interval 1.14-1.19). For some cancer sites, this association was stronger during short-term follow-up. Trend analyses showed improved survival from earlier to recent periods but persisting deprivation differences. The underlying reasons for these persisting survival inequalities and strategies to overcome them should be further investigated.

Area-Based Socioeconomic Inequalities in Colorectal Cancer Survival in Germany: Investigation Based on Population-Based Clinical Cancer Registration.

Background: Socioeconomic inequalities in colorectal cancer survival have been observed in many countries. To overcome these inequalities, the underlying reasons must be disclosed. Methods: Using data from three population-based clinical cancer registries in Germany, we investigated whether associations between area-based socioeconomic deprivation and survival after colorectal cancer depended on patient-, tumor- or treatment-related factors. Patients with a diagnosis of colorectal cancer in 2000-2015 were assigned to one of five deprivation groups according to the municipality of the place of residence using the German Index of Multiple Deprivation. Cox proportional hazards regression models with various levels of adjustment and stratifications were applied. Results: Among 38,130 patients, overall 5-year survival was 4.8% units lower in the most compared to the least deprived areas. Survival disparities were strongest in younger patients, in rectal cancer patients, in stage I cancer, in the latest period, and with longer follow-up. Disparities persisted after adjustment for stage, utilization of surgery and screening colonoscopy uptake rates. They were mostly still present when restricting to patients receiving treatment according to guidelines. Conclusion: We observed socioeconomic inequalities in colorectal cancer survival in Germany. Further studies accounting for potential differences in non-cancer mortality and exploring treatment patterns in detail are needed.

Socioeconomic differences and lung cancer survival in Germany: Investigation based on population-based clinical cancer registration.

OBJECTIVES: Studies from several countries reported socioeconomic inequalities in lung cancer survival. Hypothesized reasons are differences in cancer care or tumor characteristics. We investigated associations of small-area deprivation and lung cancer survival in Germany and the possible impact of differences in patient, tumor or treatment factors. MATERIALS AND METHODS: Patients registered with a primary tumor of the lung between 2000-2015 in three German population-based clinical cancer registries were included. Area-based socioeconomic deprivation on municipality level was measured with the categorized German Index of Multiple Deprivation. Association of deprivation with overall survival was investigated with Cox regression models. RESULTS: Overall, 22,905 patients were included. Five-year overall survival from the least to the most deprived quintile were 17.2%, 15.9%, 16.7%, 15.7%, and 14.4%. After adjustment for patient and tumor factors, the most deprived group had a lower survival compared to the least deprived group (Hazard Ratio (HR) 1.06, 95% confidence interval (CI) 1.01-1.11). Subgroup analyses revealed lower survival in the most deprived compared to the least deprived quintile in patients with stage I-III [HR: 1.14, 95% CI: 1.06-1.22]. The association persisted when restricting to patients receiving surgery but was attenuated for subgroups receiving either chemotherapy or radiotherapy. CONCLUSION: Our results indicate differences in lung cancer survival according to area deprivation in Germany, which were more pronounced in patients with I-III stage cancer. Future research should address in more detail the underlying reasons for the observed inequalities and possible approaches to overcome them.

Healthy lifestyle behaviors and decreased risk of mortality in a large prospective study of U.S. women and men.

Adiposity, insufficient physical activity, cigarette smoking, and poor diet have all been related independently to increased chronic disease risk, but their joint impact on overall health remains unclear. In a cohort of 170,672 women and men aged 51-71 years at baseline in 1996/1997 and followed-up through 2009, we investigated the individual and joint impact of four low-risk lifestyle factors: abdominal leanness (waist circumference <88 cm in women and <102 cm in men); recommended physical activity level (30 min or more of moderate exercise at least 5 times per week or 20 min or more of vigorous exercise at least 3 times per week); long-term non-smoking (never-smoker or quit smoking more than 10 years ago); and healthy diet (Mediterranean diet score within the upper two sex-specific quintiles). During 2,126,089 person-years of follow-up, 20,903 participants died. In multivariate Cox models, statistically significant decreased risks of mortality were observed for the low-risk factors abdominal leanness (relative risk (RR) = 0.86; 95 % confidence interval (CI) = 0.83-0.89), physical activity (RR = 0.86; 95 % CI = 0.84-0.89), non-smoking (RR = 0.43; 95 % CI = 0.42-0.45), and healthy diet (RR = 0.86; 95 % CI = 0.83-0.88). The larger the number of low-risk lifestyle factors, the lower was the mortality risk. The RR comparing adherence to all versus none of the factors was 0.27 (95 % CI = 0.25-0.29). We estimate that 33 % (95 % CI = 30-35 %) of deaths in our cohort were premature and could have been avoided if all study participants had adhered to all low-risk factors.