Pandemic, crisis and perspectives: spatial and territorial insights on the CoViD-19

The emerging pathogen responsible for the CoViD-19 outbreak was first notified in the Wuhan area (China) in December 2019. It turned into a pandemic in less than three months. It led to the lockdown of half of the world’s population in order to limit its spread and reduce the pressure on health care systems This pandemic has many geographical dimensions 1) in terms of diffusion 2) in the crisis management (economic, social, etc.) 3) in the set up of policies (before, during and after the lock..

Pandémie, crises et perspectives : lectures territoriales de la Covid-19

L’agent pathogène émergent responsable de l’épidémie de Covid-19 a été notifié dans la région de Wuhan (Chine) en décembre 2019 et s’est diffusé en moins de trois mois à l’ensemble de la planète. Son apparition a conduit au confinement de la moitié de la population mondiale dans le but de limiter son expansion et de réduire les effets sur les systèmes de soins. Cette pandémie comporte bien des dimensions géographiques 1) dans les modalités de sa propagation (dans un monde globalisé), comme in..

Le territoire, générateur d’inégalités face aux cancers

Agir efficacement contre les inégalités géographiques face aux cancers implique une meilleure compréhension du processus aboutissant à ces inégalités. Une méthodologie interdisciplinaire, traitant conjointement les multiples dimensions par lesquelles le territoire impacte la santé et retraçant l’évolution pronostique des patients, permettrait de répondre à ce besoin. La cohorte EMS, retraçant la prise en charge de patients atteints de sarcomes (cancers rares) en Rhône-Alpes, a été analysée suivant ces principes méthodologiques. L’analyse de 15 variables géographiques ayant une influence sur la santé a permis de distinguer six types de territoires rhônalpins. Cette typologie a ensuite été croisée avec les données de la cohorte EMS pour étudier les pertes de chances propres à chaque type de territoire. La surmortalité des pôles urbains est liée à l’incidence plus importante des sarcomes, quand celle des quartiers populaires et des espaces ruraux s’expliquent davantage par des pertes de chances de survie au cours de la prise en charge.Cancers inequalities in France are among the highest in developed countries and these gaps seem to be growing in the last decades. Territorial inequalities of cancers are analyzed by mapping, which showed higher mortality rates in the North-East Regions of France. At the local scale, standardized mortality rates are two times higher in some areas in the North as other areas in the South-East. Epidemiological studies, mostly based on multilevel analysis, evidence the impact of physical environment, deprivation or health care access on health outcomes. But to identify contextual effects are not sufficient to understand how cancer inequalities are built and how patient’s life context contributes to this process. As epidemiological approach is splitting contextual effects according to health outcomes, geographical approach may have to explain how these contextual effects lead to cancer inequalities, by using territorial typology to summarize these contextual effects. Comparing health outcomes according to this territorial classification may help to understand territory’s ability to generate health inequalities. Several stages across the cancer continuum are implied in the building of the cancer inequalities. This medical process has to be reconstructed to determine whether mortality inequalities are generated by a higher incidence or a lower survival. Moreover, lower survival may be linked to the worse prognosis of patients at diagnosis or to the lower quality of management according to cancer care facilities. Evolution of patients’ prognosis may be reconstructed, thanks to clinical data, in order to identify the most influent steps during this medical process. As a result, to understand the way geographical inequalities of cancers are building requires a multidisciplinary methodology, considering the territory’s contribution as a whole and using longitudinal clinical data. But to reconstitute this medical process is quite difficult actually because few longitudinal and exhaustive data are available. The EMS cohort represents an opportunity to test and discuss this methodological approach. This cohort includes all sarcoma (rare cancer) patients diagnosed in 2005 and 2006, in the Rhône-Alpes Region, and collects clinical data from the diagnosis to the patient follow-up. For this geographical analysis of the EMS cohort, we used a territorial typology generated thanks to multivariate analysis of 15 geographical variables known for their impact on health. Strong differences are noticed in terms of environment exposures, deprivation and health care access between the six types of territory (metropolitan neighborhoods, working-class neighborhoods, urban districts, residential areas, periurban areas, rural areas). This typology seems to be relevant to study geographical inequalities because it enables to distinguish populations which are not exposed to the same risks through their life context. A logistic regression including stage, age and histological subtype, as clinical factors influencing prognosis, estimates the patients’ prognosis at diagnosis. This prognosis score seems to be quite predictive because only 7% of “good prognosis” patients will be dead five years later, whereas this five years death rate raises to 80% for the worse prognosis patients. Analysis of geographical inequalities for sarcoma patients in the Rhône-Alpes Region shows the diversity of situations leading to inequalities of mortality. Indeed, the higher mortality in three types of territories has to be attributed to three different processes. In the case of the urban hub, this high mortality is linked to the higher incidence of sarcoma, as survival rate for patients of these districts is very close to the regional average. As incidence and prognosis risk in the working-class neighborhoods are quite similar to the regional average, higher mortality is due to the loss of survival odds in the course of treatments, probably because of a less optimal management. Despite the second lower incidence among the six types of territories, the worse prognosis of patients (more late-stage diagnosis) and the loss of survival odds during cancer management explained the high mortality rated in the rural areas. Thanks to the EMS cohort’s analysis, we assess the potential of a multidisciplinary methodology studying the territory’s ability to generate geographical inequalities of cancers. Territorial typology, produced without health outcomes data, may be used for every health studies as a synthetic index of the territory and also evidence strong inequalities of health according to people’s life contexts. As public policies struggle to be successful on this issue, to identify key events in the medical process leading to cancer inequalities may improve the territorialization and the efficiency of these policies. Territories with high risk before diagnosis would be focused on prevention and early diagnosis, whereas those more disadvantage during the management would lean towards cancer care quality, access to hospitals and cancer expertise and patient compliance

Determinants of the access to remote specialised services provided by national sarcoma reference centres

BACKGROUND: Spatial inequalities in cancer management have been evidenced by studies reporting lower quality of care or/and lower survival for patients living in remote or socially deprived areas. NETSARC+ is a national reference network implemented to improve the outcome of sarcoma patients in France since 2010, providing remote access to specialized diagnosis and Multidisciplinary Tumour Board (MTB). The IGéAS research program aims to assess the potential of this innovative organization, with remote management of cancers including rare tumours, to go through geographical barriers usually impeding the optimal management of cancer patients. METHODS: Using the nationwide NETSARC+ databases, the individual, clinical and geographical determinants of the access to sarcoma-specialized diagnosis and MTB were analysed. The IGéAS cohort (n = 20,590) includes all patients living in France with first sarcoma diagnosis between 2011 and 2014. Early access was defined as specialised review performed before 30 days of sampling and as first sarcoma MTB discussion performed before the first surgery. RESULTS: Some clinical populations are at highest risk of initial management without access to sarcoma specialized services, such as patients with non-GIST visceral sarcoma for diagnosis [OR 1.96, 95% CI 1.78 to 2.15] and MTB discussion [OR 3.56, 95% CI 3.16 to 4.01]. Social deprivation of the municipality is not associated with early access on NETSARC+ remote services. The quintile of patients furthest away from reference centres have lower chances of early access to specialized diagnosis [OR 1.18, 95% CI 1.06 to 1.31] and MTB discussion [OR 1.24, 95% CI 1.10 to 1.40] but this influence of the distance is slight in comparison with clinical factors and previous studies on the access to cancer-specialized facilities. CONCLUSIONS: In the context of national organization driven by reference network, distance to reference centres slightly alters the early access to sarcoma specialized services and social deprivation has no impact on it. The reference networks' organization, designed to improve the access to specialized services and the quality of cancer management, can be considered as an interesting device to reduce social and spatial inequalities in cancer management. The potential of this organization must be confirmed by further studies, including survival analysis

Territories towards rare cancers. Creation of a territorial quality typology for the study of geographical inequalities of cancers

La progression des inégalités géographiques face aux cancers souligne notre difficulté à comprendre comment elles se construisent et agir efficacement sur ce processus médical géographiquement différencié, reflétant la diverse qualité des territoires à protéger leurs habitants des risques de santé. Comprendre la construction de ces inégalités implique donc de reconstituer le processus médical aboutissant à ces inégalités, tout en montrant l’impact de la qualité territoriale sur l’issue de ce processus médical.Les cohortes de patients atteints de cancers rares (cancers de l’adolescent et adulte jeune - sarcomes) en Rhône-Alpes, développées par l’équipe EMS du Centre Léon Bérard, permettent justement de reconstituer ce processus médical, depuis la phase de diagnostic jusqu’au suivi post-thérapeutique. Un indicateur de qualité territoriale (IndiQuaTerr), regroupant 15 variables géographiques, caractérise la qualité de l’environnement physique, social et médical des IRIS (échelle infra-communale) de Rhône-Alpes. L’analyse multi-variée de l’IndiQuaTerr établit une typologie de six types de territoires (Quartiers métropolitains, Quartiers populaires, Pôles urbains, Zones résidentielles, Espaces Périurbains, Espaces ruraux). Cette typologie permet d’observer l’importance des inégalités géographiques pour les adolescents et jeunes adultes, avec notamment un taux de rechute significativement plus élevé pour les patients des espaces ruraux. Elle montre aussi la construction complexe de ces inégalités dans le cas des sarcomes, en identifiant, pour chaque type de territoire, les facteurs à l’origine de ces inégalités.Ces analyses montrent les possibilités d’une méthodologie interdisciplinaire, observant l’évolution médicale des patients en fonction de leur contexte de vie, afin de comprendre précisément la construction des inégalités géographiques face aux cancers. Cette précision pourrait améliorer l’efficacité des politiques publiques, en ciblant directement les facteurs et les mécanismes responsables de ces inégalités.The progression of geographical inequalities of cancers underlines our difficulty to understand the way they build up and to act efficiently on this medical process geographically differentiated which reflects the diverse territory quality to protect their inhabitants from health risks. Understanding the construction of these inequalities involves reconstructing the medical process leading to these inequalities, while showing the impact of territorial quality on this medical process.Cohorts of patients with rare cancers (adolescent and young adult cancers – sarcomas) in the Rhône-Alpes region, developed by the EMS Team in the Centre Léon Bérard precisely reconstruct this medical process, from diagnosis to follow-up aftercare. A territorial quality index (IndiQuaTerr), gathering 15 geographical variables, characterizes the quality of the physical, social and medical environment of the Rhône-Alpes IRIS.The multivariate analysis of IndiQuaTerr establishes six types of territories (metropolitan area, popular area, urban hub, residential area, periurban spaces, rural spaces). This typology highlights the importance of geographical inequalities for adolescents and young adults, especially with a significant higher rate of progression for patients from rural spaces. It shows as well the complex construction of these inequalities, in the case of sarcomas, in identifying, for each territory type, factors leading to these inequalities.These analysis show the ability of this interdisciplinary methodology, relating the patients’ medical evolution according to their life context, in order to understand precisely the construction of geographical inequalities of cancers. This precision could improve the efficiency of public policies, in targeting directly factors and mechanisms responsible for these inequalities

Geographical Accessibility of the Sarcoma Referral Networks in France. Intermediate Results from the IGéAS Research Program

Rare cancer patients face lower survival and experience delays in diagnosis and therapeutic mismanagement. Considering the specificities of rare cancers, referral networks have been implemented in France to improve the management and survival of patients. The IGéAS research program aims to assess the networks’ ability to reduce inequalities. Data analysis of the IGéAS cohort (n = 20,590, sarcoma diagnosed between 2011 and 2014) by gathering medical data and geographical index will identify risk factors associated with the belated access to expertise or with no access to expertise. Intermediate results show that referral networks give sarcoma patients access to sarcoma expertise despite the remoteness of some of them. Regional expert centers mostly receive requests from within their area while national referral centers receive requests from the whole country. Delays in the access to expertise may be reduced by making outside practitioners more sensitive to the issues of rare cancers. The perception and involvement of outside practitioners in this device will be assessed using a qualitative survey. All the results are discussed and will contribute to design guidelines to improve early access to expertise and reduce inequalities. Results of the IGéAS research program may contribute to the assessment of referral sarcoma networks and provide some useful lessons to improve cancer care management

Place of integrative approaches in the study of spatial dimension of health outcomes

International audienceAs the concept of exposome is nowadays emphasized for its integrative virtues, this holistic vision of pathogenesis was already shared by some illustrious and ancient figures of medicine. The question is not so much whether this holistic and integrative vision of the exposome represents a real novelty in the field of environmental health studies, but rather to determine the extent to which this concept and the techniques associated with it are really contributing to the set up of a more integrative and holistic knowledge of the environmental determinants of health. In this chapter, we propose to go back over the epistemological and methodological paths in the study of spatial dimension of health. With regards to these historical and scientific contexts, the exposome seems to extend a holistic and integrative scientific dynamic that already exists, for various reasons, in the field of spatial analyses in health. The development of exposomic studies represents a significant opportunity for better integration of environmental measures into health studies with high level of precision, thanks to molecular data. But the exhaustive measure of environmental factors potentially contributing to health status and inequalities is still limited by technical and financial constraints which questions the representativeness of the studies and their ability to address all public health issues, usually reported by studies in epidemiology and health geography. This should lead us to qualify not the scientific interest of the exposome but its claim to provide objective knowledge to support policies addressing public health issues, such as socio-spatial inequalities in health

Distance et vécu de la prise en charge chez les patients atteints de cancers. Entretiens rétrospectifs auprès de patients du Centre Léon Bérard (Lyon)

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Integrative approaches in environmental health and exposome research: Epistemological and practical issues

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Integrative Approaches in Environmental Health and Exposome Research

International audienceResearch on the relationship between health and the environment in a postgenomic context is increasingly aimed at understanding the various exposures as a whole, simultaneously taking into account data pertaining to the biology of organisms and the physical and social environment. Exposome research is a paradigmatic case of this new trend in environmental health studies.This book takes a multidisciplinary approach focusing on the conceptual, epistemological, and sociological reflections in the latest research on environmental and social determinants of health and disease. It offers a combination of theoretical and practical approaches and the authors are scholars from a multidisciplinary background (epidemiology, geography, philosophy of medicine and biology, sociology). Crucially, the book balances the benefit and cost of the integration of biological and social factors when modelling aetiology of disease