Socioeconomic Inequalities in Total and Site-Specific Cancer Incidence in Germany: A Population-Based Registry Study

Abstract

Most chronic diseases follow a socioeconomic gradient with higher rates in lower socioeconomic groups. A growing body of research, however, reveals cancer to be a disease group with very diverse socioeconomic patterning, even demonstrating reverse socioeconomic gradients for certain cancers. To investigate this matter at the German national level for the first time, this study examined socioeconomic inequalities in cancer incidence in Germany, both for all cancers combined as well as for common site-specific cancers. Population-based data on primary cancers newly diagnosed in 2010–2013 was obtained from the German Centre for Cancer Registry Data. Socioeconomic position was assessed at the district level using the German Index of Socioeconomic Deprivation, which is a composite index of area-based socioeconomic indicators. Absolute and relative socioeconomic inequalities in total and site-specific cancer incidence were analyzed using multilevel Poisson regression models with the logarithm of the number of residents as an offset. Among men, socioeconomic inequalities in cancer incidence with higher rates in more deprived districts were found for all cancers combined and various site-specific cancers, most pronounced for cancers of the lung, oral and upper respiratory tract, stomach, kidney, and bladder. Among women, higher rates in more deprived districts were evident for kidney, bladder, stomach, cervical, and liver cancer as well as for lymphoid/hematopoietic neoplasms, but no inequalities were evident for all cancers combined. Reverse gradients with higher rates in less deprived districts were found for malignant melanoma and thyroid cancer in both sexes, and in women additionally for female breast and ovarian cancer. Whereas in men the vast majority of all incident cancers occurred at cancer sites showing higher incidence rates in more deprived districts and cancers with a reverse socioeconomic gradient were in a clear minority, the situation was more balanced for women. This is the first national study from Germany examining socioeconomic inequalities in total and site-specific cancer incidence. The findings demonstrate that the socioeconomic patterning of cancer is diverse and follows different directions depending on the cancer site. The area-based cancer inequalities found suggest potentials for population-based cancer prevention and can help develop local strategies for cancer prevention and control.

Socioeconomic inequalities in cancer incidence in Europe: a comprehensive review of population-based epidemiological studies

“…19 The most studied individual-level SES indicator is education, for which overall RR estimates in men range from 1.5 to 3 and are generally even higher than those found for lung cancer. Effect of area deprivation in men in France 16,17,37 , Germany 18,19 , Spain 38 and Italy 29 was found to be between 1.5 and 2.0, whereas in a Scottish study cancers of the mouth, oropharynx and larynx were each shown to be twice to over 3-times as likely in people from the most deprived compared to the least deprived ar-eas, though they did not stratify by sex. 39 There is convincing evidence that area deprivation has an independent effect on UADT cancer risk, not explained by individual factors.…”

“…13,15,29 Studies relying on area-level SES as a proxy for individual SES (Supplementary table 3) provided RR estimates in the same range. [16][17][18][19][20][21][22] Different individual and area factors when mutually adjusted or unadjusted exhibit comparable strength of association. Aside from unemployment, for which observed RRs were occasionally found to exceed 4 13 (a finding which could result also from reverse causality or significant comorbidity that was not adjusted for), generally, point estimates do not exceed RR of 2.…”

“…Many European studies have shown cancers of the upper aerodigestive tract (UADT) to be strongly associated with lower SES (Supplementary tables 4 and 5). [15][16][17][18][19]27,29,30,32,[36][37][38][39][40][41][42][43][44] As with lung cancer, the association is much stronger for men than women. In Italian 29,30 , Lithuanian 32 and multi-country European 42 studies for example, excess incidence of UADT and head and neck cancers among the lowest educated could only be confirmed for men.…”

The changing relationship between health burden and work disability of Australian cancer survivors, 2003–2017: evidence from a longitudinal survey

“…Some studies have also provided evidence that the magnitude of the cancer burden is negatively associated with socioeconomic status [16,[31][32][33][34]. Furthermore, adverse health outcomes (e.g., worse health status, long and short-term disability and shorter life expectancy) were disproportionately found in poorer people as opposed to those with higher socio-economic status [13,16,31,33,[64][65][66][67][68][69][70][71]. Contribtuing factors to the high rates of long term health impacts among the poorest groups includes higher tobacco rates [16,27], economic burden [35,36], increased mental illness [72], lack of health education and awareness [73], and less access to competent and effective health care services [73].…”

Soziale Ungleichheit und COVID-19: Sozialepidemiologische Perspektiven auf die Pandemie

“…Für viele dieser Erkrankungen ist auch für die in Deutschland lebende Bevölkerung nachgewiesen, dass sie in niedrigen sozioökonomischen Statusgruppen häufiger vorkommen als in statushöheren Gruppen, z. B. für die koronare Herzkrankheit [35], den Diabetes mellitus [36], die chronische Bronchitis [37] und bei Männern auch für den Lungenkrebs [38]. Als weitere Risikofaktoren für schwere Verläufe von COVID-19 wurden bisher das Zigarettenrauchen [39] und das starke Übergewicht [40] diskutiert.…”