Lynne Forrest

Socioeconomic inequalities in lung cancer treatment : systematic review and meta-analysis.

In a systematic review and meta-analysis, Lynne Forrest and colleagues find that patients with lung cancer who are more socioeconomically deprived are less likely to receive surgical treatment, chemotherapy, or any type of treatment combined, compared with patients who are more socioeconomically well off, regardless of cancer stage or type of health care system.

The influence of childhood IQ and education on social mobility in the Newcastle Thousand Families birth cohort

BackgroundIt has been suggested that social, educational, cultural and physical factors in childhood and early adulthood may influence the chances and direction of social mobility, the movement of an individual between social classes over his/her life-course. This study examined the association of such factors with intra-generational and inter-generational social mobility within the Newcastle Thousand Families 1947 birth cohort.MethodsMultivariable logistic regression was used to examine the potential association of sex, housing conditions at age 5 years, childhood IQ, achieved education level, adult height and adverse events in early childhood with upward and downward social mobility.ResultsChildhood IQ and achieved education level were significantly and independently associated with upward mobility between the ages of 5 and 49-51 years. Only education was significantly associated (positively) with upward social mobility between 5 and 25 years, and only childhood IQ (again positively) with upward social mobility between 25 and 49-51 years. Childhood IQ was significantly negatively associated with downward social mobility. Adult height, childhood housing conditions, adverse events in childhood and sex were not significant determinants of upward or downward social mobility in this cohort.ConclusionsAs upward social mobility has been associated with better health as well as more general benefits to society, supportive measures to improve childhood circumstances that could result in increased IQ and educational attainment may have long-term population health and wellbeing benefits.

The role of receipt and timeliness of treatment in socioeconomic inequalities in lung cancer survival: population-based, data-linkage study

Background Lung cancer survival is socioeconomically patterned, and socioeconomic inequalities in receipt of treatment have been demonstrated. In England, there are target waiting times for the referral (14 days) and treatment intervals (31 days from diagnosis, 62 days from GP referral). Socioeconomic inequalities in the time intervals from GP referral have been found. Cancer registry, Hospital Episode Statistics and lung cancer audit data were linked in order to investigate the contribution of these inequalities to socioeconomic inequalities in lung cancer survival. Methods Logistic regression was used to examine the likelihood of being alive 2 years after diagnosis, by socioeconomic position, for 22 967 lung cancer patients diagnosed in 2006–2009, and in a subset with stage recorded (n=5233). Results Socioeconomic inequalities in survival were found in a multivariable analysis adjusted for age, sex, histology, year, timely GP referral, performance status and comorbidity, with those in the most deprived socioeconomic group significantly less likely to be alive after 2 years (OR=0.77, 95% CI 0.66 to 0.88, p<0.001). When receipt of treatment was included in the analysis, the association no longer remained significant (OR=0.87, 95% CI 0.75 to 1.00, p=0.06). Addition of timeliness of treatment did not alter the conclusion. Patients treated within guideline targets had lower likelihood of two-year survival. Conclusions Socioeconomic inequalities in survival from lung cancer were statistically explained by socioeconomic inequalities in receipt of treatment, but not by timeliness of referral and treatment. Further research is required to determine the currently unexplained socioeconomic variance in treatment rates.

Factors associated with timeliness of post-primary care referral, diagnosis and treatment for lung cancer: population-based, data-linkage study

Background:The NHS Cancer Plan for England set waiting time targets for cancer referral (14 days from GP referral to first hospital appointment) and treatment (31 days from diagnosis, 62 days from urgent GP referral). Interim diagnostic intervals can also be calculated. The factors that influence timely post-primary care referral, diagnosis and treatment for lung cancer are not known.Methods:Northern and Yorkshire Cancer Registry, Hospital Episode Statistics and lung cancer audit data sets were linked. Logistic regression was used to investigate the factors (socioeconomic position, age, sex, histology, co-morbidity, year of diagnosis, stage and performance status (PS)) that may influence the likelihood of referral, diagnosis and treatment within target, for 28 733 lung cancer patients diagnosed in 2006–2010.Results:Late-stage, poor PS and small-cell histology were associated with a higher likelihood of post-primary care referral, diagnosis and treatment within target. Older patients were significantly less likely to receive treatment within the 31-day (odds ratio (OR)=0.79, 95% confidence interval (CI) 0.69–0.91) and 62-day target (OR=0.80, 95% CI 0.67–0.95) compared with younger patients.Conclusions:Older patients waited longer for treatment and this may be unjustified. Patients who appeared ill were referred, diagnosed and treated more quickly and this ‘sicker quicker’ effect may cancel out system socioeconomic inequalities that might result in longer time intervals for more deprived patients.

The role of patient, tumour and system factors in socioeconomic inequalities in lung cancer treatment: population-based study

Background:Reducing socioeconomic inequalities in lung cancer treatment may reduce survival inequalities. However, the reasons for treatment variation are unclear.Methods:Northern and Yorkshire cancer registry, Hospital Episode Statistics and lung cancer audit data sets were linked. Logistic regression was used to explore the role of stage, histology, performance status and comorbidity in socioeconomic inequalities in lung cancer treatment, for 28 733 lung cancer patients diagnosed in 2006–2010, and in a subgroup with stage recorded (n=7769, 27%).Results:Likelihood of receiving surgery was significantly lower in the most deprived group (odds ratio (OR)=0.75, 95% confidence interval (CI) 0.65–0.86); however, the OR was attenuated when including histological subtype (OR=0.82, 95% CI 0.71–0.96). Patients in the most deprived group were significantly less likely to receive chemotherapy in the fully adjusted full cohort model including performance status (OR=0.64, 95% CI 0.58–0.72) but not in the staged subgroup model when performance status was included (OR=0.88, 95% CI 0.72–1.08). Socioeconomic inequalities in radiotherapy were not found.Interpretation:Socioeconomic inequalities in performance status statistically explained socioeconomic inequalities in receipt of chemotherapy in the selective staged subgroup, but not in the full cohort. Socioeconomic variation in histological subtype may account for some of the socioeconomic inequalities in surgery.

The effect of socioeconomic inequalities in receipt of, and time to, treatment on socioeconomic inequalities in lung cancer survival: an observational, data-linkage study

Abstract Background Socioeconomic inequalities in lung cancer survival have been suggested to be at least partly caused by inequalities in receipt of treatment. In England, there are target waiting times for referral (14 days to first hospital appointment) and treatment (31 days from diagnosis) for suspected cancer. In a systematic review and meta-analysis, we found evidence of socioeconomic inequalities in receipt of lung cancer treatment in the UK, USA, and elsewhere. Northern and Yorkshire Cancer Registry and Information Centre (NYCRIS), Hospital Episode Statistics (HES), and lung cancer audit (LUCADA) data were linked via NHS number to investigate the effect of socioeconomic inequalities in receipt of and time to treatment on lung cancer survival. Methods NYCRIS data for 22 967 patients diagnosed in 2006–09 with a primary diagnosis of lung cancer (ICD 10 C33 and C34) were analysed, including information about referral date and type and date of treatment. Socioeconomic position (SEP) was measured with the income domain of the index of multiple deprivation. Stage and performance status (a measure of patient wellbeing) were recorded in LUCADA for 5233 (23%) of the cohort. Comorbidity score was obtained from HES for 17 621 (77%). Survival time was from date of diagnosis to death or end of follow-up on Dec 31, 2011. Cox regression models were used to calculate hazard of death and logistic regression to examine likelihood of being alive 2 years after diagnosis, by SEP, in the full cohort and the subset with stage recorded. Findings 3513 (15%) of 22 967 patients were alive 2 years after diagnosis. This proportion increased to 1562 (70%) of 2236 who had surgery. Patients referred (odds ratio [OR] 0·76, 95% CI 0·69–0·84; p Interpretation Socioeconomic inequalities in survival from lung cancer were statistically explained by socioeconomic inequalities in receipt of treatment, but not by inequalities in timeliness of referral and treatment. We were unable to examine smoking status and there might be residual confounding from this and other factors. Missing stage and performance status data are an important limitation. However, patterns of survival in the subset of patients with stage data were similar to those in the full cohort. Research into unexplained variance in treatment rates is needed to develop interventions that address socioeconomic inequalities in receipt of treatment and survival. This factor might have a greater effect on improvement of survival than the present clinical focus on time-interval targets. Funding LFF (ESRC studentship ES/I020926/1) is a PhD student funded by ESRC as a member of Fuse, the Centre for Translational Research in Public Health (www.fuse.ac.uk). JA, MW, and GR are funded in part as a staff member (JA), director (MW), and senior investigator (GR) of Fuse. Fuse is a UK Clinical Research Collaboration (UKCRC) Public Health Research Centre of Excellence. Funding for Fuse from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, MRC, NIHR, under the auspices of the UKCRC, is acknowledged. The views expressed do not necessarily represent those of the funders or UKCRC. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Socio-economic inequalities in stage at diagnosis, and in time intervals on the lung cancer pathway from first symptom to treatment: systematic review and meta-analysis.

Cancer diagnosis at an early stage increases the chance of curative treatment and of survival. It has been suggested that delays on the pathway from first symptom to diagnosis and treatment may be socio-economically patterned, and contribute to socio-economic differences in receipt of treatment and in cancer survival. This review aimed to assess the published evidence for socio-economic inequalities in stage at diagnosis of lung cancer, and in the length of time spent on the lung cancer pathway. MEDLINE, EMBASE and CINAHL databases were searched to locate cohort studies of adults with a primary diagnosis of lung cancer, where the outcome was stage at diagnosis or the length of time spent within an interval on the care pathway, or a suitable proxy measure, analysed according to a measure of socio-economic position. Meta-analysis was undertaken when there were studies available with suitable data. Of the 461 records screened, 39 papers were included in the review (20 from the UK) and seven in a final meta-analysis for stage at diagnosis. There was no evidence of socio-economic inequalities in late stage at diagnosis in the most, compared with the least, deprived group (OR=1.04, 95% CI=0.92 to 1.19). No socio-economic inequalities in the patient interval or in time from diagnosis to treatment were found. Socio-economic inequalities in stage at diagnosis are thought to be an important explanatory factor for survival inequalities in cancer. However, socio-economic inequalities in stage at diagnosis were not found in a meta-analysis for lung cancer. PROSPERO protocol registration number CRD42014007145.

Socio-economic inequalities in patient, primary care, referral, diagnostic, and treatment intervals on the lung cancer care pathway: protocol for a systematic review and meta-analysis

BackgroundEarly diagnosis and treatment of cancer is thought to be important for improving survival. Longer time between the onset of cancer symptoms and receipt of treatment may help explain the poorer survival of UK cancer patients compared to that in other countries.Socio-economic inequalities in receipt of, and time to, treatment may contribute to socio-economic differences in cancer survival. Socio-economic inequalities in receipt of lung cancer treatment have been shown in a recent systematic review. However, no systematic review of the evidence for socio-economic inequalities in time to presentation (patient interval), time to first investigation (primary care interval), time to secondary care investigation (referral interval), time to diagnosis (diagnostic interval), and time to treatment (treatment interval) has been conducted.This review aims to assess the published and grey literature evidence for socio-economic inequalities in the length of time spent on the lung cancer diagnostic and treatment pathway, examining interim intervals on the pathway where inequalities might occur.MethodsSystematic methods will be used to identify relevant studies, assess study eligibility for inclusion, and evaluate study quality. The online databases of MEDLINE, EMBASE, and CINAHL will be searched to locate cohort studies of adults with a primary diagnosis of lung cancer; where the outcome is mean or median time to the interval endpoint (or a suitable proxy measure of this), or the likelihood of longer or shorter time to the endpoint; analysed by a measure of socio-economic position. Meta-analysis will be conducted if there are sufficient studies available with suitable data.DiscussionThis review will systematically determine if there are socio-economic inequalities in time from symptom onset to treatment for lung cancer. If such inequalities are present, our review evidence will help inform the development of interventions to reduce the time to diagnosis and treatment, ultimately helping to reduce socio-economic inequalities in survival.Trial registrationPROSPERO CRD42014007145

Socio-Economic Differences in the Association between Self-Reported and Clinically Present Diabetes and Hypertension: Secondary Analysis of a Population-Based Cross-Sectional Study.

Background Diabetes and hypertension are key risk factors for coronary heart disease. Prevalence of both conditions is socio-economically patterned. Awareness of presence of the conditions may influence risk behaviour and use of preventative services. Our aim was to examine whether there were socio-economic differences in awareness of hypertension and diabetes in a UK population. Method Data from the Scottish Health Survey was used to compare self-reported awareness of hypertension and diabetes amongst those found on examination to have these conditions, by socioeconomic position (SEP) (measured by occupation, education and income). Odds ratios of self-reported awareness against presence, and the sensitivity, specificity and predictive value of self-reporting as a measure of the presence of the condition, were calculated. Results Presence and self-reported awareness of both conditions increased as SEP decreased, on most measures. There was only one significant difference in awareness by SEP once other factors had been taken into account. Sensitivity showed that those in the most disadvantaged groups were most likely to self-report awareness of their hypertension, and specificity showed that those in the least disadvantaged groups were most likely to self-report awareness of its absence. There were few differences of note for diabetes. Conclusion We found no consistent pattern in the associations between SEP and the presence and self-reported awareness of hypertension and diabetes amongst those with these conditions. Without evidence of differences, it is important that universal approaches continue to be applied to the identification and management of those at risk of these and other conditions that underpin cardiovascular disease.

PP59 Intervention-generated inequalities in lung cancer care: cohort study using linked cancer registry, Hospital Episode Statistics, and audit data

Background In the UK, lung cancer is the second most incident cancer and the leading cause of cancer mortality. Survival is socio-economically patterned. In England, there are target waiting times for urgent referral (14 days) and treatment intervals (31 days from diagnosis) for cancer. It has been suggested that socio-economic inequalities in receipt of, and time to, treatment may contribute to inequalities in cancer survival. Unintended variations in outcome that result from the way that interventions are organised and delivered have been described as intervention-generated inequalities. Northern and Yorkshire Cancer Registry and Information Centre (NYCRIS), Hospital Episode Statistics (HES) and lung cancer audit (LUCADA) data were linked to investigate socio-economic inequalities in receipt of, and time to, lung cancer treatment and any impact on survival. Methods NYCRIS data for 28,733 lung cancer patients diagnosed in 2006–10 were analysed. Socio-economic position (SEP) was measured using the income domain of the Index of Multiple Deprivation. Stage was recorded in LUCADA for 27% (n = 7769) and co-morbidity score was potentially available for 65% (n = 18,650) in HES. Logistic regression was used to examine the likelihood of receipt of treatment and of receiving timely referral and treatment within target, by SEP. Cox regression models were used to calculate hazard ratios (HRs) for all-cause mortality, in the full cohort and in the subset with stage recorded. Results Socio-economic inequalities in receipt of lung cancer surgery and chemotherapy, and in the referral interval to first hospital appointment, were found. Patients treated within target times had lower likelihood of survival. Socio-economic inequalities in survival were found in a multivariable analysis adjusted for age, sex, histology, year, timely referral, stage, performance status and co-morbidity, with those in the most deprived socio-economic group having significantly higher risk of death (HR=1.11, 95% CI 1.07 to 1.16). When receipt of treatment was included in the analysis the association no longer remained significant (HR=1.02, 95% CI 0.98 to 1.06). Addition of timeliness of treatment did not alter the conclusion. Discussion Socio-economic inequalities in survival from lung cancer were statistically explained by socio-economic inequalities in receipt of treatment, but not by inequalities in timeliness of referral and treatment, in the full cohort. High levels of missing stage and performance status data were a limitation. However, similar patterns of survival were found in the staged subset. Further research is required to determine the unexplained socio-economic variance in treatment rates. Interventions to increase treatment rates in more deprived groups may reduce survival inequalities.