%0 Generic
%A Finke, Isabelle
%C Heidelberg
%D 2022
%F heidok:31444
%K Relatives Überleben, Krebsprognose, sozioökonomischer Status
%R 10.11588/heidok.00031444
%T Regional variations in cancer outcome in Germany – assessing the impact of socioeconomic deprivation and cancer care
%U https://archiv.ub.uni-heidelberg.de/volltextserver/31444/
%X Area-based socioeconomic inequalities in cancer survival have been reported in several countries and for several cancer sites showing that cancer patients living in affluent regions have better survival than those living in deprived regions. It has been shown that deprivation-associated survival disparities might be more apparent when using smaller area-level deprivation measures. Possible reasons for these survival disparities could originate in differences in clinical prognostic factors or cancer care. The aims of this dissertation were to first give a comprehensive summary of the current literature on socioeconomic differences in lung cancer survival and then mainly to investigate deprivation-associated differences in cancer survival in Germany and if these differences depend on patient characteristics, clinical prognostic factors or cancer care. Furthermore, a comparison of survival disparities was made between individual and area-based education by using data for patients with colorectal cancer from the Finnish Cancer Registry.  First, a systematic review and meta-analysis was conducted including studies reporting a measure of lung cancer survival in relation to education, income, occupation, or composite measures on individual or area-based level. In total, 23 studies measured the socioeconomic status on individual level and 71 on area-based level. The meta-analyses revealed a poorer prognosis for lung cancer patients with low individual income. Group comparisons of area-based studies indicated a poorer prognosis for lower socioeconomic groups. A consistent relationship between level of aggregation and effect size could not be confirmed due to heterogeneous reporting of measurements.  To investigate the association between municipality-level socioeconomic deprivation and cancer survival in Germany, data for the 25 most common cancer sites from seven population-based cancer registries (covering 32 million inhabitants) were used. Patients were diagnosed in 1998-2014 and socioeconomic deprivation was assessed using the categorized German Index of Multiple Deprivation on municipality level. Relative survival was estimated using the period approach for 2012-2014 and model-based period analysis to calculate relative excess risk adjusted for age and stage. In total, 2,333,547 cases were included. For most cancer sites, the most deprived quintile had lower 5-year relative survival compared to the least deprived quintile even after adjusting for stage (all cancer sites combined, relative excess risk 1.16, 95 % confidence interval 1.14-1.19).   To further investigate the underlying reasons for deprivation-associated survival disparities in Germany, data from three clinical cancer registries (Regensburg, Dresden, and Erfurt, covering 4 million inhabitants) were used. Patients diagnosed with lung cancer in 2000-2015 and female patients diagnosed with breast cancer in 2006-2016 were included. For lung cancer, the association of deprivation with overall survival was investigated using Cox regression models. For breast cancer, 5-year relative survival using the period approach for 2011-2016 and model-based period analysis to calculate relative excess risk was used. Both models were adjusted for age, stage, and grading, the breast cancer models additionally for estrogen receptor status. Region-specific analyses and subgroup analyses for patients receiving specific types of treatment were conducted. Overall, 22,905 lung cancer and 31,357 breast cancer cases were included. For lung cancer, the most deprived group had a lower overall survival compared to the least deprived group in the fully adjusted model. Patients diagnosed with stage I-III showed a lower survival in the most deprived quintile which persisted when further restricting to surgery but was attenuated for chemo- or radiotherapy subgroups. For breast cancer, the fully adjusted model showed no association between deprivation and 5-year relative survival. By contrast, there was an association between region and breast cancer survival, even after adjustment for socioeconomic deprivation.  Regarding the comparison of cancer survival disparities between individual and municipality-level education, data of colorectal cancer patients diagnosed in 2007-2016 in Finland were used. Relative survival and relative excess risk were estimated by sex using period approach adjusted for age, stage at diagnosis, cancer site, urbanity, hospital district and municipality. In total, 24,462 cases were included. Area-based education revealed smaller effect estimates than individual education in colorectal cancer survival. Associations for individual education persisted even after adjustment for municipality-level education.  The results of this dissertation show that a further approach for Germany should be to include individual socioeconomic status as well as area-based indices in analyses of cancer survival disparities. These future studies should include region, prognostic factors, complete data on cancer treatment but also other possibly relevant factors such as comorbidities. Furthermore, these analyses should be conducted stratified by cancer site as the present analyses showed different patterns for different cancer types.