1. DiGiulio, Sarah

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With global economic crisis comes increased unemployment, as well as reduced public sector spending on health care, and-according to new research-a rise in cancer mortality.

Mahiben Maruthappu, ... - Click to enlarge in new windowMahiben Maruthappu, MD. Mahiben Maruthappu, MD

"Rise of unemployment was associated with increased cancer deaths-and particularly in treatable cancers, which suggests that access to health care is ultimately important (because rates of non-treatable cancer deaths remained indifferent)," the study's lead author Mahiben Maruthappu, MD, Senior Fellow to the CEO of England's National Health Service and a practicing physician, explained about the research, which was published online ahead of print in The Lancet ( "We were surprised by how neatly it fit together."


Other studies have compared socioeconomic change and socioeconomic status with cancer outcomes, but this is the first study Maruthappu said he is aware of that demonstrated these findings on this scale across so many countries.


Maruthappu and his colleagues gathered data from the World Bank on unemployment rates for 75 countries (representative of 2.106 billion people) and public-sector expenditure on health care for 79 countries (representative of 2.156 billion people). They compared those numbers to cancer mortality data from the World Health Organization between 1990 and 2010.


In an interview with Oncology Times, Maruthappu discussed what the data showed and their implications for practicing oncologists.


1 What were the key findings from this study?

"We found that public spending in health care systems was associated with reduced cancer mortality, and a rise in unemployment was associated with increased cancer mortality. Interestingly, in this analysis controlling for universal health coverage removed the association between unemployment and cancer mortality.


"And we also found that treatable cancers are far more sensitive in these analyses to macroeconomic changes than non-treatable cancers.


"We then conducted a time trend analysis that aimed to estimate the number of excess cancer deaths that occurred in countries with universal coverage and without universal health coverage. We found that in the full group of countries [the data covered] there was a significantly increased number of cancer deaths from 2008 to 2010. But those deaths were largely in countries without universal health coverage. We estimate that there were 260,000 additional cancer deaths between 2008 and 2010 alone.


"Universal health coverage protected, and people who were unemployed [in those countries with universal health care coverage], therefore, had potentially greater access to the health care services they need. And, when we did an actual experiment looking at the recent economic crisis, these trends all stood true.


"That is quite a powerful indicator that universal health coverage has quite a significant role to play in the mechanism that links these economic changes to cancer outcomes."


2 Could you explain why and how you separated out treatable versus non-treatable cancers? What did you learn from those analyses?

"We labeled cancers as treatable or untreatable based upon whether they had survival rates that were comparatively low compared to those that were quite high. And the cancers that were categorized as treatable were breast, prostate, and colorectal cancers, which are also the most common. And the ones that were categorized as untreatable in this context were lung cancers and pancreatic cancers.


"We found that the sensitivity of treatable cancers to economic changes was far greater and had a much stronger association in unemployment and spending cuts than non-treatable cancers. And in turn, the protective role universal health coverage played was much stronger for cancers that were treatable, which logically and intuitively made sense given our rationale for what's going on.


"We believed that if people become unemployed or are in economic hardship they may have reduced access to health care services, which means that their cancer may not be picked up as early on or may not be treated as well-which in turn means that they may be more likely to die.


"And if a cancer is treatable, that means like for breast cancer or colorectal cancer, having access to health care resources you need generally plays a big role, whether it be chemotherapy, radiotherapy, or surgery that you need. In contrast, if your cancer is largely untreatable, having access to the health care resources you need probably won't make that big a difference or as big a difference. And that's exactly what we found."


3 What should practicing oncologists and oncology care providers know about these findings?

"Oncologists need to be quite proactive if they are providing care to people who are potentially unemployed. In the same way that we consider other risk factors for certain types of cancers, we need to be looking at socioeconomic status and employment status and factor that into our equation. And that's because if they are unemployed they will be less likely to continue a treatment or have compliance with treatment. We, as healthcare professionals, need to be aware of that and have a proactive response."