Prostate cancer and deprivationBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2043 (Published 22 April 2010) Cite this as: BMJ 2010;340:c2043
- 1Department of Urology and Clinical Research Institute HUCH Ltd, Helsinki University Central Hospital, Haartmaninkatu 4/Tutkijatilat H3011, PO Box 105, 00029 Helsinki, Finland
- 2Tampere School of Public Health, University of Tampere, 33014 Tampere, Finland
The Alma-Ata Declaration of 1978 states: “The existing gross inequality in the health status of the people particularly between developed and developing countries, as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.”1 Many studies have shown large disparities in the burden of cancer according to race or ethnicity and socioeconomic status. Indeed, socioeconomic factors such as poverty, inadequate education, and lack of health insurance are more important determinants than biological differences.2 3 In the linked study (doi:10.1136/bmj.c1928), Lyratzopoulos and colleagues use a population based cancer registry to assess variations in the management of prostate cancer in patients of different socioeconomic status.4
Prostate cancer is the most common non-cutaneous cancer in men in most industrialised countries. Stage at diagnosis and mode of treatment are the main determinants of the outcome for most cancers.5 Differences in survival from prostate cancer according to socioeconomic status, after adjustment for stage at diagnosis, are well documented.5 However, the effect of socioeconomic status on therapeutic decisions is less clear. A study of patients with prostate cancer in the United States found that those with the lowest socioeconomic status were less likely to receive surgery and radiotherapy (independent of age, ethnicity, disease stage, and geographical region).6 Similarly, a recent study in the United Kingdom found that men from more affluent areas were more likely to receive radical treatments.7
Lyratzopoulos and colleagues assessed the relation between initial radical treatment (radiotherapy and radical surgery) and socioeconomic status, measured using a small area deprivation index. Incident cases of prostate cancer (35 171 men aged over 50 diagnosed 1995-2006) were identified from the population based cancer registry in Cambridge, which covers 5.5 million people. Information on cancer stage was available for 16 020 patients (45.5%).
Radical treatment was less common in patients from the most deprived areas even after adjustment for stage at diagnosis. Among the most affluent, about 8% were treated with radical surgery and 29% with radiotherapy, whereas the corresponding figures were about 4% and 21% for the most deprived. These socioeconomic differences in odds of treatment use were also found in the multivariate analyses after adjustment for age, diagnosis period, and morphology. The authors concluded that the differences are unlikely to be artefactual and probably reflect true differences in clinical management.4
Their study confirms earlier findings that lower socioeconomic status is associated with less frequent use of radical treatment for prostate cancer.6 7 Possible explanations are behavioural (values, attitudes, health behaviour), social (communication skills, social support, economic resources, insurance), and clinical (comorbidity, choice of treatment, access to health care).5 Interpretation of the results should consider the potential limitations—individual socioeconomic status was not assessed, which could reduce differences, and no information was available on comorbidity or ethnicity.
The study provides no explanation for the variation in treatment seen. Factors involved in treatment decisions include contraindications for treatment (comorbidity and functional status), complications, and patients’ preferences. Furthermore, we do not know how eliminating these differences in treatment would reduce inequalities in survival. Strategies to reduce disparities in survival related to socioeconomic status must be based on an understanding of their cause.
One possible reason for variations in management by socioeconomic status is the lack of evidence about the relative merits of treatments. Several treatments are available (including surgery, radiation, cryotherapy, hormonal treatment, combination of these treatments, and expectant management) and few trials have compared them.8 9 10 Hence, treatment decisions cannot be made on evidence alone but require a doctor’s judgment and negotiation with the patient. Better educated patients may process information more easily, and doctor-patient communication may be more effective or fluent when doctor and patient have similar social backgrounds.5 11
Prostate specific antigen (PSA) testing has increased the detection of prostate cancer and resulted in overdiagnosis and overtreatment.12 Yet Lyratzopoulos and colleagues think of undertreatment as a potential problem in patients with a low socioeconomic status.4 The most deprived men could be having too few radical prostatectomies and radiation treatments or the most affluent could be having too many. Because the reasons for these socioeconomic disparities are unclear and the best way to reduce them is unknown, future studies should investigate the contribution of various prognostic factors to differences in survival. It would also be useful to evaluate such differences within the treatment arms of randomised trials.
Cite this as: BMJ 2010;340:c2043
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: (1) No financial support for the submitted work from anyone other than their employer; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; (4) No non-financial interests that may be relevant to the submitted work.”
Provenance and peer review: Commissioned; not externally peer reviewed.