Socioeconomic status and site-specific cancer incidence, a Bayesian approach in a French Cancer Registries Network study

International audienceThe aim of this study was to identify and compare cancer sites whose incidence is influenced by social deprivation. The study population comprised 189 144 cases of cancer diagnosed between 2006 and 2009, recorded in member registries of the French Network of Cancer Registries. Social environment was assessed at an aggregate level using the European Deprivation Index. The association between incidence and socioeconomic status was assessed by a geographical Bayesian Poisson model enabling a reduction of the overall variability and smoothing of the relative risks by sharing information provided by multiple geographic units. For cancers of the stomach, liver, lips-mouth-pharynx, and lung, a higher incidence in deprived populations was found for both sexes as well as for cancers of the larynx, esophagus, pancreas, and bladder in men and cervical cancer in women. For melanoma, prostate, testis, ovarian, and breast cancer, a higher incidence was observed in affluent populations. The highest relative risks of the lowest social class compared with the highest social class were found for larynx [relative risk (RR) = 1.67 (1.43-1.95)], lips-mouth-pharynx [RR = 1.89 (1.72-2.07)], and lung cancer [RR = 1.59 (1.50-1.68)] in men and for cervix [RR = 1.62 (1.40-1.88)] and lips-mouth-pharynx [RR = 1.56 (1.30-1.86)] cancer in women. By estimating the burden of social deprivation on cancer incidence throughout France, this study enables us to measure the gains that could be achieved by implementing targeted prevention efforts

Can an Ecological Index of Deprivation Be Used at the Country Level? The Case of the French Version of the European Deprivation Index (F-EDI)

Most ecological indices of deprivation are constructed from census data at the national level, which raises questions about the relevance of their use, and their comparability across a country. We aimed to determine whether a national index can account for deprivation regardless of location characteristics. In Metropolitan France, 43,853 residential census block groups (IRIS) were divided into eight area types based on quality of life. We calculated score deprivation for each IRIS using the French version of the European Deprivation Index (F-EDI). We decomposed the score by calculating the contribution of each of its components by area type, and we assessed the impact of removing each component and recalculating the weights on the identification of deprived IRIS. The set of components most contributing to the score changed according to the area type, but the identification of deprived IRIS remained stable regardless of the component removed for recalculating the score. Not all components of the F-EDI are markers of deprivation according to location characteristics, but the multidimensional nature of the index ensures its robustness. Further research is needed to examine the limitations of using these indices depending on the purpose of the study, particularly in relation to the geographical grid used to calculate deprivation scores

Incidence trends for potentially human papillomavirus-related and -unrelated head and neck cancers in France using population-based cancer registries data: 1980-2012.

Human papillomavirus (HPV) has been recently recognised as a carcinogenic factor for a subset of head and neck cancers (HNC). In Europe, France has one of the highest incidence rates of HNC. The aim of this study is to explore changes in HNC incidence in France, potentially in relation with infection by HPV. HNC were classified into two anatomical groups: potentially HPV-related and HPV-unrelated. Trends over the period 1980-2012 were analysed by an age-period-cohort model based on data from eleven French cancer registries. Among men, the age-standardised incidence rate (ASR) of HNC decreased in both groups, but less so for HPV-related sites as compared to unrelated sites, especially in recent years (annual percentage change [APC] over the period 2005-2012: -3.5% vs. -5.4%). Among women, the ASR increased in both groups, but more rapidly for HPV-related as compared to unrelated sites (APC over the period 2005-2012: +1.9% vs. -0.4%). This preferential growth of HPV-related versus unrelated HNC was observed in the cohorts born from 1930 to 1935. The differences in trends between possible HPV-related and HPV-unrelated sites suggest an increasing incidence of HNC due to HPV infection. The difference was less marked in men as compared to women, most likely because of a higher contamination in the HPV-related group by cancers due to tobacco or alcohol consumption. The pattern observed is consistent with observations made in other countries, with studies of HPV prevalence in HNC and the evolution of sexual behaviour in France

Slovenian Version of The European Deprivation Index at Municipal Level

Introduction: Ecological deprivation indices belong to essential instruments for monitoring and understanding health inequalities. Our aim was to develop the SI-EDI, a newly derived European Deprivation Index for Slovenia. We intend to provide researchers and policy-makers in our country with a relevant tool for measuring and reducing the socioeconomic inequalities in health, and even at a broader level. Methods: Data from the European survey on Income and Living Conditions and Slovenian national census for the year 2011 were used in the SI-EDI construction. The concept of relative deprivation was used where deprivation refers to unmet need(s), which is caused by lack of all kinds of resources, not only material. The SI-EDI was constructed for 210 Slovenian municipalities. Its geographical distribution was compared to the distribution of two existing deprivation scores previously applied in health inequality research in Slovenia. Results: There were 36% of adults recognized as deprived in Slovenia in 2011. SI-EDI was calculated using 10 census variables that were associated with individual deprivation. A clear east-to-west gradient was detected with the most deprived municipalities in the eastern part of the country. The two existing deprivation scores correlate significantly with the SI-EDI. Conclusions: A new deprivation index, the SI-EDI, is grounded on the internationally established scientific concept, can be replicated over time and, crucially, provides an account of the socioeconomic and cultural particularities of the Slovenian population. The SI-EDI could be used by the stakeholders and the governmental and nongovernmental sectors in Slovenia, with the goal of better understanding health inequalities in Slovenia

Describing the association between socioeconomic inequalities and cancer survival: methodological guidelines and illustration with population-based data.

BACKGROUND: Describing the relationship between socioeconomic inequalities and cancer survival is important but methodologically challenging. We propose guidelines for addressing these challenges and illustrate their implementation on French population-based data. METHODS: We analyzed 17 cancers. Socioeconomic deprivation was measured by an ecological measure, the European Deprivation Index (EDI). The Excess Mortality Hazard (EMH), ie, the mortality hazard among cancer patients after accounting for other causes of death, was modeled using a flexible parametric model, allowing for nonlinear and/or time-dependent association between the EDI and the EMH. The model included a cluster-specific random effect to deal with the hierarchical structure of the data. RESULTS: We reported the conventional age-standardized net survival (ASNS) and described the changes of the EMH over the time since diagnosis at different levels of deprivation. We illustrated nonlinear and/or time-dependent associations between the EDI and the EMH by plotting the excess hazard ratio according to EDI values at different times after diagnosis. The median excess hazard ratio quantified the general contextual effect. Lip-oral cavity-pharynx cancer in men showed the widest deprivation gap, with 5-year ASNS at 41% and 29% for deprivation quintiles 1 and 5, respectively, and we found a nonlinear association between the EDI and the EMH. The EDI accounted for a substantial part of the general contextual effect on the EMH. The association between the EDI and the EMH was time dependent in stomach and pancreas cancers in men and in cervix cancer. CONCLUSION: The methodological guidelines proved efficient in describing the way socioeconomic inequalities influence cancer survival. Their use would allow comparisons between different health care systems

Functional forms of socio-territorial inequities in breast cancer screening - A French cross-sectional study using hierarchical generalised additive models

To reduce the breast cancer burden, the French National Organised Breast Cancer Screening Programme (FNOBCSP) was implemented in 2004. The recommended participation rate has never been achieved and socio-territorial inequities in participation have been reported on several occasions. We investigated the functional forms and consistency of the relationships between neighbourhood deprivation, travel time to the nearest accredited radiology centre and screening uptake. We used two-level hierarchical generalised additive models in 8 types of territories classified by socio-demographic and economic factors. The first level was 368,201 women aged 50-72 invited to the 2013-2014 screening campaign in metropolitan France. They were nested in 41 départements, the level of organisation of the FNOBCSP. The effect of travel time showed two main patterns: it was either linear (with participation decreasing as travel time increased) or participation first increased with increasing travel time to a peak around 5-15 min and decreased afterward. In nearly all types and départements, the probability of participation decreased linearly with increasing deprivation. Territorial inequities in participation were more context-dependent and complex than social inequities. Inequities in participation represent a loss of opportunity for individuals who already have the worst cancer outcomes. Evidence-based public health policies are needed to increase the effectiveness and equity of breast cancer screening

Development of a cross-cultural deprivation index in five European countries.

BACKGROUND: Despite a concerted policy effort in Europe, social inequalities in health are a persistent problem. Developing a standardised measure of socioeconomic level across Europe will improve the understanding of the underlying mechanisms and causes of inequalities. This will facilitate developing, implementing and assessing new and more effective policies, and will improve the comparability and reproducibility of health inequality studies among countries. This paper presents the extension of the European Deprivation Index (EDI), a standardised measure first developed in France, to four other European countries-Italy, Portugal, Spain and England, using available 2001 and 1999 national census data. METHODS AND RESULTS: The method previously tested and validated to construct the French EDI was used: first, an individual indicator for relative deprivation was constructed, defined by the minimal number of unmet fundamental needs associated with both objective (income) poverty and subjective poverty. Second, variables available at both individual (European survey) and aggregate (census) levels were identified. Third, an ecological deprivation index was constructed by selecting the set of weighted variables from the second step that best correlated with the individual deprivation indicator. CONCLUSIONS: For each country, the EDI is a weighted combination of aggregated variables from the national census that are most highly correlated with a country-specific individual deprivation indicator. This tool will improve both the historical and international comparability of studies, our understanding of the mechanisms underlying social inequalities in health and implementation of intervention to tackle social inequalities in health

Is the Social Gradient in Net Survival Observed in France the Result of Inequalities in Cancer-Specific Mortality or Inequalities in General Mortality?

BACKGROUND: In cancer net survival analyses, if life tables (LT) are not stratified based on socio-demographic characteristics, then the social gradient in mortality in the general population is ignored. Consequently, the social gradient estimated on cancer-related excess mortality might be inaccurate. We aimed to evaluate whether the social gradient in cancer net survival observed in France could be attributable to inaccurate LT. METHODS: Deprivation-specific LT were simulated, applying the social gradient in the background mortality due to external sources to the original French LT. Cancer registries' data from a previous French study were re-analyzed using the simulated LT. Deprivation was assessed according to the European Deprivation Index (EDI). Net survival was estimated by the Pohar-Perme method and flexible excess mortality hazard models by using multidimensional penalized splines. RESULTS: A reduction in net survival among patients living in the most-deprived areas was attenuated with simulated LT, but trends in the social gradient remained, except for prostate cancer, for which the social gradient reversed. Flexible modelling additionally showed a loss of effect of EDI upon the excess mortality hazard of esophagus, bladder and kidney cancers in men and bladder cancer in women using simulated LT. CONCLUSIONS: For most cancers the results were similar using simulated LT. However, inconsistent results, particularly for prostate cancer, highlight the need for deprivation-specific LT in order to produce accurate results