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Education, survival and avoidable deaths in cancer patients in Finland.

Pokhrel A, Martikainen P, Pukkala E, Rautalahti M, Seppä K, Hakulinen T - Br. J. Cancer (2010)

Bottom Line: For almost all the sites considered, survival was consistently highest for patients with the highest education and lowest for those with only basic education.The differences were, in part, attributable to less favourable distributions of tumour stages in the lower education categories.The proportion would have also been much higher, 8-11%, if, in addition, the mortality from other causes had been the same as that in the highest educational category.

View Article: PubMed Central - PubMed

Affiliation: Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Pieni Roobertinkatu 9, FI-00130, Helsinki, Finland. arun.pokhrel@cancer.fi

ABSTRACT

Background: Relative survival after cancer in Finland is at the highest level observed in Europe and has, in general, been on a steady increase. The aim of this study is to assess whether the high survival is equally shared by different population subgroups and to estimate the possible gains that might be achieved if equity prevailed.

Materials and method: The educational level and occupation before the cancer diagnosis of patients diagnosed in Finland in 1971-2005 was derived from an antecedent population census. The cancers were divided into 27 site categories. Cancer (cause)-specific 5-year survival proportions were calculated for three patient categories based on the educational level and for an occupational group of potentially health-conscious patients (physicians, nurses, teachers etc.). Proportions of avoidable deaths were derived by assuming that the patients from the two lower education categories would have the same mortality owing to cancer, as those from the highest educational category. Estimates were also made by additionally assuming that even the mortalities owing to other causes of death were all equal to those in the highest category.

Results: For almost all the sites considered, survival was consistently highest for patients with the highest education and lowest for those with only basic education. The potentially health-conscious patients had an even higher survival. The differences were, in part, attributable to less favourable distributions of tumour stages in the lower education categories. In 1996-2005, 4-7% of the deaths in Finnish cancer patients could have potentially been avoided during the first 5-year period after diagnosis, if all the patients had the same cancer mortality as the patients with the highest educational background. The proportion would have also been much higher, 8-11%, if, in addition, the mortality from other causes had been the same as that in the highest educational category.

Interpretation: Even in a potentially equitable society with high health care standards, marked inequalities persist in cancer survival. Earlier cancer diagnosis and the ability to cope within the health care system may be a partly relevant explanation, but personal habits and lifestyles also have a role, particularly for the cancer patients' mortality from other causes of death than cancer.

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Risk ratios for cancer death of patients diagnosed in 1971–2005 (high vs basic education) without and with accounting for stage, by site (sites: OE=oesophagus; ST=stomach; CO=colon; RE=rectum; LI=liver; GB=gallbladder; PA=pancreas; LU=lung; ME=skin, melanoma; NM=skin, non-melanoma; BR=breast; CE=cervix uteri; CU=corpus uteri; OV=ovary; PR=prostate; KI=kidney; UB=urinary bladder; TH=thyroid; HL=Hodgkin's lymphoma; NHL=non-Hodgkin's lymphoma; OTH=other cancers as specified in Table 1). The model accounts for gender where applicable. The diagonal indicates equality of the two RRs. Results are shown for sites with model convergence only.
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fig1: Risk ratios for cancer death of patients diagnosed in 1971–2005 (high vs basic education) without and with accounting for stage, by site (sites: OE=oesophagus; ST=stomach; CO=colon; RE=rectum; LI=liver; GB=gallbladder; PA=pancreas; LU=lung; ME=skin, melanoma; NM=skin, non-melanoma; BR=breast; CE=cervix uteri; CU=corpus uteri; OV=ovary; PR=prostate; KI=kidney; UB=urinary bladder; TH=thyroid; HL=Hodgkin's lymphoma; NHL=non-Hodgkin's lymphoma; OTH=other cancers as specified in Table 1). The model accounts for gender where applicable. The diagonal indicates equality of the two RRs. Results are shown for sites with model convergence only.

Mentions: The group with a high educational level had a higher age-standardised cancer-specific 5-year survival than that with basic educational level, almost without exception (Table 1). The age-specific and, thereby, also the age-standardised 5-year cancer-specific survival proportions and their differences could not be estimated for every educational group in 1996–2005 for five sites in males and four sites in females. Statistical modelling showed that the higher survival among the highly educated had persisted over calendar time. Differences in RRs of cancer-specific mortality between the educational categories were larger when the stage was not included in the model, and existed only when that RR was under 0.85 (Figure 1). In other words, when there was a larger mortality difference related to educational level, it was partly accounted for by differences in stage distribution, almost regardless of the site. The attenuation of the relative differences varied strongly but was, with the exception of testicular and kidney cancers, quite modest. The health-conscious occupational group still clearly had a more favourable cancer-specific survival than the rest of the high education category (Figure 2). The RRs of this group were also somewhat attenuated when the stage was adjusted for by the model compared with the results derived without adjusting for the stage.


Education, survival and avoidable deaths in cancer patients in Finland.

Pokhrel A, Martikainen P, Pukkala E, Rautalahti M, Seppä K, Hakulinen T - Br. J. Cancer (2010)

Risk ratios for cancer death of patients diagnosed in 1971–2005 (high vs basic education) without and with accounting for stage, by site (sites: OE=oesophagus; ST=stomach; CO=colon; RE=rectum; LI=liver; GB=gallbladder; PA=pancreas; LU=lung; ME=skin, melanoma; NM=skin, non-melanoma; BR=breast; CE=cervix uteri; CU=corpus uteri; OV=ovary; PR=prostate; KI=kidney; UB=urinary bladder; TH=thyroid; HL=Hodgkin's lymphoma; NHL=non-Hodgkin's lymphoma; OTH=other cancers as specified in Table 1). The model accounts for gender where applicable. The diagonal indicates equality of the two RRs. Results are shown for sites with model convergence only.
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Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2965870&req=5

fig1: Risk ratios for cancer death of patients diagnosed in 1971–2005 (high vs basic education) without and with accounting for stage, by site (sites: OE=oesophagus; ST=stomach; CO=colon; RE=rectum; LI=liver; GB=gallbladder; PA=pancreas; LU=lung; ME=skin, melanoma; NM=skin, non-melanoma; BR=breast; CE=cervix uteri; CU=corpus uteri; OV=ovary; PR=prostate; KI=kidney; UB=urinary bladder; TH=thyroid; HL=Hodgkin's lymphoma; NHL=non-Hodgkin's lymphoma; OTH=other cancers as specified in Table 1). The model accounts for gender where applicable. The diagonal indicates equality of the two RRs. Results are shown for sites with model convergence only.
Mentions: The group with a high educational level had a higher age-standardised cancer-specific 5-year survival than that with basic educational level, almost without exception (Table 1). The age-specific and, thereby, also the age-standardised 5-year cancer-specific survival proportions and their differences could not be estimated for every educational group in 1996–2005 for five sites in males and four sites in females. Statistical modelling showed that the higher survival among the highly educated had persisted over calendar time. Differences in RRs of cancer-specific mortality between the educational categories were larger when the stage was not included in the model, and existed only when that RR was under 0.85 (Figure 1). In other words, when there was a larger mortality difference related to educational level, it was partly accounted for by differences in stage distribution, almost regardless of the site. The attenuation of the relative differences varied strongly but was, with the exception of testicular and kidney cancers, quite modest. The health-conscious occupational group still clearly had a more favourable cancer-specific survival than the rest of the high education category (Figure 2). The RRs of this group were also somewhat attenuated when the stage was adjusted for by the model compared with the results derived without adjusting for the stage.

Bottom Line: For almost all the sites considered, survival was consistently highest for patients with the highest education and lowest for those with only basic education.The differences were, in part, attributable to less favourable distributions of tumour stages in the lower education categories.The proportion would have also been much higher, 8-11%, if, in addition, the mortality from other causes had been the same as that in the highest educational category.

View Article: PubMed Central - PubMed

Affiliation: Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Pieni Roobertinkatu 9, FI-00130, Helsinki, Finland. arun.pokhrel@cancer.fi

ABSTRACT

Background: Relative survival after cancer in Finland is at the highest level observed in Europe and has, in general, been on a steady increase. The aim of this study is to assess whether the high survival is equally shared by different population subgroups and to estimate the possible gains that might be achieved if equity prevailed.

Materials and method: The educational level and occupation before the cancer diagnosis of patients diagnosed in Finland in 1971-2005 was derived from an antecedent population census. The cancers were divided into 27 site categories. Cancer (cause)-specific 5-year survival proportions were calculated for three patient categories based on the educational level and for an occupational group of potentially health-conscious patients (physicians, nurses, teachers etc.). Proportions of avoidable deaths were derived by assuming that the patients from the two lower education categories would have the same mortality owing to cancer, as those from the highest educational category. Estimates were also made by additionally assuming that even the mortalities owing to other causes of death were all equal to those in the highest category.

Results: For almost all the sites considered, survival was consistently highest for patients with the highest education and lowest for those with only basic education. The potentially health-conscious patients had an even higher survival. The differences were, in part, attributable to less favourable distributions of tumour stages in the lower education categories. In 1996-2005, 4-7% of the deaths in Finnish cancer patients could have potentially been avoided during the first 5-year period after diagnosis, if all the patients had the same cancer mortality as the patients with the highest educational background. The proportion would have also been much higher, 8-11%, if, in addition, the mortality from other causes had been the same as that in the highest educational category.

Interpretation: Even in a potentially equitable society with high health care standards, marked inequalities persist in cancer survival. Earlier cancer diagnosis and the ability to cope within the health care system may be a partly relevant explanation, but personal habits and lifestyles also have a role, particularly for the cancer patients' mortality from other causes of death than cancer.

Show MeSH
Related in: MedlinePlus