The poor are not benefiting as much as the rich from improvements in cancer survival according to a major new study funded by Cancer Research UK and the Office for National Statistics (ONS).
Researchers compared outcome in patients diagnosed with cancer during three successive five-year periods between 1986 and 1999 and followed up to the end of 2001. The results show that cancer survival in England and Wales has improved to record levels almost across the board.
But during the same period the gap in cancer survival between the richest and poorest patients has widened.
The findings – published in the British Journal of Cancer – have far-reaching implications for policy makers, as the statistics cover the period immediately preceding the publication of the Government’s Cancer Plan in September 2000.
Achieving equality in cancer treatment is one of the central aims of the Cancer Plan.
Researchers based at the London School of Hygiene and Tropical Medicine and part-funded by Cancer Research UK measured survival in 2.2 million cancer patients in England and Wales. They included adult patients diagnosed with one of the 20 most common cancers – equivalent to 90 per cent of all malignancies.
Survival had improved for 15 of the 16 cancers examined among men, and for 13 of the 17 cancers examined among women – indicating that new treatments and efforts directed at diagnosing cancer earlier are working.
But when the research team analysed survival by patients’ deprivation status, the picture became more complex. Comparing outcome for patients diagnosed with cancer during 1986-1990 and 1996-1999, the gap in survival between rich and poor had increased for 12 of 16 cancers in men and for 9 of 17 cancers in women over that period.
Professor Michel Coleman, who led the international team based at the London School of Hygiene and Tropical Medicine, says: “Survival from cancer in this country is improving steadily, thanks to developments in early diagnosis and in treatment. But taking a closer look it becomes clear that the poor have increasingly been left behind when it comes to cancer survival.”
“The statistics indicate that improvements in survival and the deprivation gap in survival are closely linked – as survival has increased, the deprivation gap in survival has widened. Our analyses show that cancer survival is likely to continue improving for people being diagnosed with the disease now. But while this is great news we need to take action to ensure everyone benefits equally from advances in the detection and treatment of the disease.”
Bowel cancer – which includes cancer of the colon and rectum – is a striking example.
There was significant overall improvement in survival for bowel cancer during the 1990s. Survival from colon cancer improved by an average of 5.6 per cent every 5 years for both sexes and survival from rectal cancer by 7.4 per cent in men and 8.1 per cent in women every five years.
But the deprivation gap for cancers of the colon and rectum also widened significantly. Survival for rectal cancer in the latest period analysed (1996-1999) was 9.4 per cent higher for the richest patients than the poorest patients in men and 8.3 per cent higher in women. Over three successive five-year periods – 1986-1990, 1991-1995 and 1996-1999 – this gap widened by an average of 2.4 per cent every five years in men and 2.5 per cent in women.
The deprivation gap in survival was also large for colon cancer – 5.7 per cent in men and 7.3 per cent in women in the period 1996-1999. The gap widened by an average of 1.9 per cent in men and 2.2 per cent in women every five years during the three successive five-year periods studied.
Professor John Northover, Director of the Cancer Research UK Colorectal Cancer Unit, says: “These findings tell us that the most deprived patients may not have benefited equally from the medical advances that have led to greatly improved survival from bowel cancer, such as developments in early diagnosis and greater use of specialist rectal cancer surgery and adjuvant chemo- and radiotherapies.
“The positive news is that despite the deprivation gap, the poor diagnosed with rectal cancer in the final five-year period included in the study were doing at least as well as the rich diagnosed in the previous five-year period.
“The task now is to shorten that lag by improving equality of access to the best treatments and ensuring that less affluent patients actually take up new treatment opportunities as they become available. Another lesson from this study is that to make full use of the opportunity of a national screening programme we will have to especially target the deprived in society.”
Results showed that the average widening of the deprivation gap every five-years was statistically significant for cancers of the oesophagus, colon, rectum, larynx and prostate in men and for cancers of the colon, rectum and for myeloma in women. While for other individual cancers the five-yearly increases did not reach statistical significance, the overall pattern provides strong evidence of a widening deprivation gap in cancer survival.
The deprivation gap for prostate cancer widened by an average of 3.2 per cent every five years, and probably reflects greater access to PSA testing in higher socio-economic groups. However, PSA testing for prostate cancer remains controversial as in some men it may diagnose early disease that might never become a clinical problem. Inclusion of these men may therefore lead to a large but potentially misleading statistical increase in survival from the disease.
The deprivation gap narrowed for some cancers. For testicular cancer this reflects a ‘ceiling effect’ as the national average five-year survival estimate for men diagnosed during 1996-1999 was 96 per cent. Any further increase in survival would be expected to affect men in less affluent groups, whose survival had been lower.
Cancer Research UK’s Chief Executive Professor Alex Markham says: “These figures highlight the importance and relevance of the Government’s Cancer Plan and the scale of the task ahead. The patients included in this study were diagnosed in the 14 years just before the introduction of the Cancer Plan in September 2000. Survival from cancer is at a record high, but this study shows that the gap between the richest and poorest patients has also been widening.
“The reasons behind the widening deprivation gap are unclear. But it seems that where healthcare resources are limited, the more affluent members of society have benefited more from medical advances than those from deprived groups.
“Addressing that deprivation gap and providing equal access to treatments for all is an extremely important part of the Government’s Cancer Plan. This study provides us with a good baseline for measuring the outcome of the Plan and whether it manages to tackle the inequalities seen in the late 1990s effectively.”
Each patient included in the study was assigned to one of five categories of socio-economic deprivation – from the most affluent (‘rich’) to the most deprived (‘poor’) – based on their electoral ward of residence at diagnosis (average population 5,500), the smallest geographic unit for which adequate data were available over the entire period 1986-99.
The study authors defined ‘deprivation gap’ in survival as the difference between the relative survival rates for the most affluent and most deprived categories, as derived from the linear regression model used for the study.
The decrease in survival from brain cancer in the least deprived groups may reflect increased diagnosis of worst-prognosis cancers using CT or MRI scanning for more affluent patients. Some of these cancers might previously have been certified on death as strokes.
The Government identified health inequality as a crucial issue for NHS development in the NHS Plan (2000). It stated as two of its core principles that the NHS would “respond to different needs of different populations” and that it would aim to “keep people healthy and work to reduce health inequalities”. In the subsequent NHS Cancer Plan (2000) this theme was repeated with specific reference to cancer, with the Plan aiming “to tackle the inequalities in health that mean unskilled workers are twice as likely to die from cancer as professionals.”
In the three-year report on the progress of the NHS Cancer Plan, ‘Maintaining the Momentum’, the importance of addressing health inequalities was underlined once again. However, unlike other targets for the Plan there was little specific reference to progress in tackling inequality.
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