Elsevier

European Journal of Cancer

Volume 46, Issue 15, October 2010, Pages 2681-2695
European Journal of Cancer

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

https://doi.org/10.1016/j.ejca.2010.04.026Get rights and content

Abstract

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.

Section snippets

Background

Socioeconomic inequalities in incidence and outcome have been reported for a variety of cancer types.1, 2, 3, 4, 5, 6 In general, cancer mortality is about 20–80% higher among individuals with a lower socioeconomic status (SES).7 This disadvantage may be the result of a higher cancer incidence in some countries and/or lower cancer survival rates in most of them. A comprehensive review of studies published up to 1995 revealed an opposite trend for colorectal cancer (CRC)7 – worldwide the third

Materials and methods

The electronic database of Pubmed was searched using the following strategy: (‘Neoplasms’[Majr:NoExp] or ‘Colorectal Neoplasms’[Mesh]) and (‘Socioeconomic Factors’[Mesh]). Only articles in English added to Pubmed between 1st January 1995 and 1st October 2009 were included. All types of studies focusing on incidence, (determinants of) treatment and outcome (i.e. survival and mortality) were included, except reviews. All patients with colon or rectal cancer were included, independent of their

Results

The Pubmed search yielded 1808 articles, which were scanned by title (resulting in 232 abstracts) and then by abstract (resulting in 120 full-text articles). Of these, 55 were included in this review. After scanning the reference lists, seven additional articles were included. Nineteen articles on incidence, 14 on survival, 20 on mortality and 14 on treatment were included; five studies concentrated on combinations of two of these, i.e. one on incidence and survival; one on incidence and

Discussion

A higher incidence of colorectal cancer was observed among low SES groups compared to high SES groups in the US and Canada, but not in Europe, where higher SES classes were at increased risk. Treatment, survival and mortality all showed less favourable results for people with a lower socioeconomic status: patients with a low SES had less chance of receiving (neo)adjuvant chemotherapy, had worse survival and mortality rates thus were highest in the lowest SES groups.

A high colon cancer incidence

Conflict of interest statement

None declared.

Acknowledgement

This work was supported by a grant from the Dutch Cancer Society 2006 (IKZ 2006-3588).

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