Aarts, M.J.

Educational inequalities in cancer survival: A role for comorbidities and health behaviours? (Article)

2013-01-01T00:00:00Z

Aim: To describe educational inequalities in cancer survival and to what extent these can be explained by comorbidity and health behaviours (smoking, physical activity and alcohol consumption). Methods: The GLOBE study sent postal questionnaires to individuals in The Netherlands in 1991 resulting in 18 973 respondents (response 70%). Questions were asked on education, health and health-related behaviours. Participants were linked for cancer diagnosis (1991-2008), comorbidity and survival (up to 2010) with the population-based Eindhoven Cancer Registry; 1127 tumours were included in the analyses. Results: 5-year crude survival was best in highly educated patients as compared with low educated patients for all cancers combined: 49% versus 32% in male subjects (log rank: p<0.0001), 65% versus 49% in female subjects (p=0.0001). Compared with highly educated, low educated prostate cancer patients had an increased risk of death (HR 2.9 (95% CI 1.7 to 5.1), adjusted for age, stage and year). No or inconsistent associations between educational level and risk of death were seen in multivariable analyses for breast, colon and non-small cell lung cancer. Although survival in prostate cancer patients was affected by comorbidities (HR2_vs_0_comorbidities: 2.6 (1.5 to 4.4)), physical activity (HRno/little_vs__moderate_physical__activity: 2.0 (1.2 to 3.4)) and smoking (HRcurrent_vs_never_smokers: 2.6 (1.0-6.8)), these did not contribute to educational inequalities in prostate cancer survival (HRlow_vs_high_education: 3.1 (1.6 to 5.8) with adjustment for comorbidity and lifestyle). Conclusions: Compared with low educated, highly educated prostate cancer patients had better survival. Although presence of comorbidities, physical activity levels and smoking status affected survival from prostate cancer, these did not contribute to educational inequalities in survival. The role of other factors for inequalities in cancer survival needs to be explored.

Socioeconomic determinants of cancer risk, detection, and outcome in the Netherlands since 1990 (Doctoral Thesis)

2012-06-19T00:00:00Z

The subject of this thesis is the association between socioeconomic status (SES) and cancer detection and outcome in the Netherlands. Both a description of and explanation for variation in incidence, detection, staging, treatment, survival and health-related quality of life of cancer by SES are given. The studies reported in this thesis can be placed both within the broader framework of research on socioeconomic inequalities in health as well as within the narrower framework of research on socioeconomic inequalities in cancer. The methods and study settings are described, followed by the aims of this thesis.

An increased utilisation rate and better compliance to guidelines for primary radiotherapy for breast cancer from 1997 till 2008: A population-based study in the Netherlands (Article)

2011-08-01T00:00:00Z

Only scarce data are available on the utilisation rate of primary radiotherapy (RT) for patients with breast cancer. In this study, we compared the use of primary RT for patients with stages I-III breast cancer in 4 of the 9 Dutch Comprehensive Cancer Centres, focussing specifically on time trends as well as age effects. From the population-based cancer registries, we selected all females diagnosed with breast cancer between 1997 and 2008 (N = 65,966, about 50% of all Dutch breast cancer patients in this period). We observed an overall increase in the use of primary RT for breast cancer patients ranging from 55-61% in 1997 to 58-68% in 2008. This can be explained by a higher rate of breast-conserving surgery (BCS), which was followed by RT in 87-99% of cases, and a reduced rate of total mastectomy (TM) which was followed by RT in 26-47% of cases. Increasing age was associated with a reduced use of RT, especially for those above 75. Finally, we observed a decrease in time of observed regional variances in the use of RT after BCS as well as after TM (for stage III disease). These findings can be attributed to the development and implementation of the Dutch nationwide guidelines for treatment of breast cancer.

Socioeconomic inequalities in attending the mass screening for breast cancer in the south of the Netherlands-associations with stage at diagnosis and survival (Article)

2011-07-01T00:00:00Z

The associations of socioeconomic status (SES) and participation in the breast cancer screening program, as well as consequences for stage of disease and prognosis were studied in the Netherlands, where no financial barriers for participating or health care use exist. From 1998 to 2005, 1,067,952 invitations for biennial mammography were sent to women aged 50-75 in the region covered by the Eindhoven Cancer Registry. Screening attendance rates according to SES were calculated. Tumor stage and survival were studied according to SES group for patients diagnosed with breast cancer between 1998 and 2006, whether screen-detected, interval carcinoma or not attended screening at all. Attendance rates were rather high: 79, 85 and 87% in women with low, intermediate and high SES (p < 0.001), respectively. Compared to the low SES group, odds ratios for attendance were 1.5 (95%CI:1.5-1.6) for the intermediate SES group and 1.8 (95%CI:1.7-1.8) for the high SES group. Moreover, women with low SES had an unfavorable tumor-node-metastasis stage compared to those with high SES. This was seen in non-attendees, among women with interval cancers and with screen-detected cancers. Among non-attendees and interval cancers, the socioeconomic survival disparities were largely explained by stage distribution (48 and 35%) and to a lesser degree by therapy (16 and 16%). Comorbidity explained most survival inequalities among screen-detected patients (23%). Despite the absence of financial barriers for participation in the Dutch mass-screening program, socioeconomic inequalities in attendance rates exist, and women with low SES had a significantly worse tumor stage and lower survival rate.

A population-based study on the utilisation rate of primary radiotherapy for prostate cancer in 4 regions in the Netherlands, 1997-2008 (Article)

2011-05-01T00:00:00Z

Aim: The purpose was to study variations in utilisation rates of external beam radiotherapy (EBRT) and brachytherapy (BT) for prostate cancer patients. Materials and methods: We calculated the proportion and number of EBRT and BT given or planned within 6 months of diagnosis in 4 Dutch regions, according to stage and age in a population-based setting including 47,259 prostate cancer patients diagnosed from 1997 until 2008. Results: During this study period, the overall utilisation rate of EBRT remained stable at around 25%, while the rate of BT for non-metastasized patients increased from 1% (95% CI:0-1%) to 12% (11-13%) in 2006 and slightly decreased towards 10% (9-11%) in 2008. From 2001 on, the overall utilisation rate of EBRT decreased significantly in one region (p < 0.05). In this region, a sharp rise in the utilisation rate of BT for non-metastatic patients was noted to 17% (14-20%) in 2008 after a peak of 24% (21-27%) in 2006. For localised disease, BT was used more often at the expense of EBRT while for locally advanced disease the utilisation rate of EBRT increased. In the multivariate analysis, regional differences in the utilisation rate of EBRT persisted with odds ratios ranging from 0.7 to 0.9 compared to the reference region. Moreover, low rates of EBRT were associated with high BT rates. The regional differences could not be explained by differences in risk profiles. Conclusions: The utilisation rate of EBRT remained stable with limited variation between regions while BT was used increasingly with clear regional differences. To cope with this and in view of the increasing incidence of prostate cancer, adequate resources have to be planned for the optimal care of these patients.

Breast and stomach cancer incidence and survival in migrants in the Netherlands, 1996-2006 (Article)

2011-05-01T00:00:00Z

Migrant populations experience a health transition that influences their cancer risk, determined by environmental changes and acculturation processes. In this retrospective cohort study, we investigated differences in breast and stomach cancer risk and survival in migrants to the Netherlands. Invasive breast and stomach cancer cases diagnosed between 1996 and 2006 were selected from the Netherlands Cancer Registry. Standardized incidence ratios (SIR) were computed as the ratio of observed and expected cancers. Differences in the survival were expressed as hazard ratio (HR) using Cox regression and relative survival rates (RSR). All migrant women exhibited a significantly lower risk for breast cancer compared with Dutch natives. However, 5-year RSR was lower in all migrants (range 68-73%) compared with Dutch natives (85%). Death rates were increased in Moroccan [HR=1.2 (1.0-1.5)] and reduced in Indonesian [HR=0.8 (0.8-0.9)] patients with breast cancer. The incidence of noncardia stomach cancer was significantly elevated in all migrants, being highest in Turkish males [SIR=1.9 (1.6-2.3)]. Cardia stomach cancer was less frequent in all migrants, being lowest in Surinamese males [SIR=0.3 (0.2-0.6)]. Death rates for stomach cancer were lower in patients from Morocco [HR=0.6 (0.4-0.9)], whereas 1-year RSR for stomach cancer was better in all migrant groups. Both lower breast cancer rates and higher stomach cancer rates point to a strong link between environmental exposures, behavioural patterns and cancer risk during the life course. Favourable risks in migrants should be sustained as long as possible whereas survival disparities require careful monitoring and counteraction with preventive means as well as improved access to healthcare.

A 50% higher prevalence of life-shortening chronic conditions among cancer patients with low socioeconomic status (Article)

2010-11-23T00:00:00Z

Background: Comorbidity and socioeconomic status (SES) may be related among cancer patients. Method : Population-based cancer registry study among 72 153 patients diagnosed during 1997-2006. Results : Low SES patients had 50% higher risk of serious comorbidity than those with high SES. Prevalence was increased for each cancer site. Low SES cancer patients had significantly higher risk of also having cardiovascular disease, chronic obstructive pulmonary diseases, diabetes mellitus, cerebrovascular disease, tuberculosis, dementia, and gastrointestinal disease. One-year survival was significantly worse in lowest vs highest SES, partly explained by comorbidity. Conclusion : This illustrates the enormous heterogeneity of cancer patients and stresses the need for optimal treatment of cancer patients with a variety of concomitant chronic conditions.

Long-term prostate cancer survivors with low socioeconomic status reported worse mental healthrelated quality of life in a population-based study (Article)

2010-11-01T00:00:00Z

Objective: To explore whether socioeconomic status (SES) was associated with health-related quality of life (HRQL) and health care use among long-term prostate cancer survivors. Patients and Methods: Through urologists in the Comprehensive Cancer Center South, all 5- to 10-year prostate cancer survivors known in the Eindhoven Cancer Registry without disease progression were invited to complete the 36-item Short Form Health Survey (SF-36), the Expanded Prostate Cancer Index, and the Dutch sexual activities module. Multivariate linear regression assessed the effect of SES (based on home value and household income) on HRQL and health care use. Results: Five-hundred eighty-four patients (response rate 81%) were included. Survivors with a low SES exhibited lower mental SF-36 scores (616 points on a 0100 scale), independent of sociodemographic and clinical characteristics (P <.05), and hardly any differences in physical SF-36 subscales, sexual function, and urinary and bowel function and bother. Presence of serious comorbidity had a stronger predictive value for HRQL than SES. Health care use did not seem to be associated with SES. Conclusions: Prostate cancer survivors with a low SES exhibited a worse mental but not physical HRQL than those with a higher SES. Long-term health outcomes of patients with low SES may be maximized by paying extra attention to comorbid conditions.

Socioeconomic status and changing inequalities in colorectal cancer? A review of the associations with risk, treatment and outcome (Article)

2010-10-01T00:00:00Z

Background: Upcoming mass screening for colorectal cancer (CRC) makes a review of recent literature on the association with socioeconomic status (SES) relevant, because of marked and contradictory associations with risk, treatment and outcome. Methods: The Pubmed database using the MeSH terms 'Neoplasms' or 'Colorectal Neoplasms' and 'Socioeconomic Factors' for articles added between 1995 and 1st October 2009 led to 62 articles. Results: Low SES groups exhibited a higher incidence compared with high SES groups in the US and Canada (range risk ratio (RR) 1.0-1.5), but mostly lower in Europe (RR 0.3-0.9). Treatment, survival and mortality all showed less favourable results for people with a lower socioeconomic status: Patients with a low SES received less often (neo)adjuvant therapy (RR ranging from 0.4 to 0.99), had worse survival rates (hazard ratio (HR) 1.3-1.8) and exhibited generally the highest mortality rates up to 1.6 for colon cancer in Europe and up to 3.1 for rectal cancer. Conclusions: A quite consistent trend was observed favouring individuals with a high SES compared to those with a low SES that still remains in terms of treatment, survival and thus also mortality. We did not find evidence that the low/high SES gradients for treatment chosen and outcome are decreasing. To meet increasing inequalities in mortality from CRC in Europe for people with a low SES and to make mass screening successful, a high participation rate needs to be realised of low SES people in the soon starting screening program.

Reduction of socioeconomic inequality in cancer incidence in the South of the Netherlands during 1996-2008 (Article)

2010-09-01T00:00:00Z

Background: Cancer incidence varies according to socioeconomic status (SES) and time trends. SES category may thus point to differential effects of lifestyle changes but early detection may also affect this. Patients and methods: We studied patients diagnosed in 1996-2008 and registered in the South Netherlands Cancer registry. Incidence rates and estimated annual percentage changes were calculated according to SES category, age group (25-44, 45-64 and ≥65) and sex. Results: People with a low SES exhibited elevated incidence rates of cancer of the head and neck, upper airways (both sexes), gastro-intestinal tract, squamous cell skin cancer, breast (≥65) and all female genital, bladder, kidney and mature B-cells (all in females only), whereas prostate cancer, basal cell skin cancer (BCC) and melanoma (both except in older females) were most common among those with a high SES. Due to the greater increase in prostate cancer and melanoma in high SES males and the larger reduction of lung cancer in low SES males, incidence of all cancers combined became more elevated among males of ≥45 years with a high and intermediate SES, and approached rates for low SES men aged 45-64. In spite of more marked increases in the incidence of colon, rectal and lung cancer in high SES women, the incidence of all cancers combined remained highest for low SES women of ≥45 years. However, at age 25-44 years, the highest incidence of cancer of the breast and melanoma was observed among high SES females. During 1996-2008 inequalities increased unfavourably among higher SES people for prostate cancer, BCC (except in older women) and melanoma (at middle age), while decreasing favourably among low SES people for cancers of the oesophagus, stomach, pancreas and kidney (both in females only), breast (≥65 years), corpus uteri and ovary. Conclusions: Although those with a low SES exhibited the highest incidence rates of the most common cancers, higher risks were observed among those with high SES for melanoma and BCC (both except older females) and for prostate and breast (young females) cancer. Altogether this might also have contributed to the recent higher cancer awareness in Dutch society which is usually promoted more by patients of high SES and those who know or surround them.

Increase in basal cell carcinoma incidence steepest in individuals with high socioeconomic status: Results of a cancer registry study in the Netherlands (Article)

2009-10-01T00:00:00Z

Background Development of both basal cell carcinoma (BCC) and cutaneous malignant melanoma (MM) is associated with acute and intermittent sun exposure. In contrast to MM, the association between socioeconomic status (SES) and BCC is not well documented. Objectives To investigate the incidence of BCC according to SES, stratifying by age and tumour localization in a large population-based cohort. To assess changes over time in the distribution of the patients with BCC across the SES categories. Methods All patients with a histologically confirmed first primary BCC (n = 27027) diagnosed between 1988 and 2005 in the Southeast of the Netherlands were stratified by sex, age (25-44, 45-64 and ≥ 65 years), period of diagnosis, SES category (based on income and value of housing) and localization of the BCC. Age-standardized BCC incidence rates were calculated for the year 2004 by SES category and localization. Ordinal regression was used to assess changes over time in the proportion of patients with BCC by sex, age and SES. Results For men in all age groups higher BCC incidence in the highest SES category was observed, which remained significant after stratification for tumour localization. For women a consistent relationship was found only in younger women (< 65 years) for truncal BCCs, which occurred more frequently in high SES groups. Between 1990 and 2004, the proportion of BCC patients with high SES increased (+6%) and the proportion with low SES decreased (-7%). Conclusions High SES is associated with increased incidence of BCC among men. Our data suggest that BCC is changing from a disease of the poor to a disease of the rich.