Tackling Inequalities Across the Cancer Care Spectrum
Nicolò Matteo Luca Battisti and Hendrik Van Poppel, European Cancer Organisation Inequalities Network Co-Chairs
The Community 365 Roundtable on Inequalities focused on Treating Ageing Patients with Cancer and the East–West Divide, which are important aspects of how inequalities in cancer care play out across Europe. However, there are a number of other inequalities in cancer care that, taken together, constitute a form of discrimination of patients of all kinds.
These relate to ethnicity, gender, including sexual and gender minorities, disability and socioeconomic factors such as literacy and language, income and social and family support. There are also geographic inequalities in cancer care that extend beyond the east-west divide.
The impact of these inequalities is felt across the whole of the cancer care continuum, from screening and early detection, over diagnostic procedures and treatment, to survivorship and quality of life and access to supportive care. There are also inequalities in possible inclusion in clinical trials, as well as in access to cancer prevention.
Geography
While the geographical inequalities between eastern and western European countries were explored in-depth at the Roundtable (see Page 2), there exists also a north-south divide, as well as one between European Union (EU) and non-EU countries.1
Looked at as a whole, there is a series of inequalities between high-, medium- and low-income countries, with a broad gradient running from north and west to south and east. This is revealed in the stark disparity between cancer incidence and mortality rates. Overall, rates of cancer incidence are highest in northern and western European countries and lowest in eastern and southern European, with the opposite pattern seen for mortality rates.
Moreover, there is often a ‘postcode lottery’ within countries. That means that individuals living in different regions, or those living in rural versus urban areas, face inequalities in access to cancer care.
Ethnicity
An individual’s ethnicity affects their risk for several types of cancer. Moreover, it plays a role all along the care pathway, with ethnicity-related differences in screening uptake and routes to diagnosis, as well as access to treatment and survivorship.
Together, these lead to ethnicity-related disparities in mortality rates for a whole range of cancers, including lung, breast, prostate, colorectal and liver cancer; an effect that is likely to be exacerbated by the increase in migration across the European region.2,3
Gender
There are also actionable disparities in cancer care between men and women that are expressed in, for example, mortality rates in breast versus prostate cancer, differences of early detection, for example between screening for breast and cervix versus prostate cancer, and in take-up of the human papillomavirus vaccination programmes.4
These gender inequalities affect screening and early detection, risk factors and prevention, presentation, stage at diagnosis and even access to treatment and clinical trials.
Sexual and Gender Minorities
While studies have shown that lesbian, gay, transgender, queer or questioning (LGBTQ+) individuals have higher rates of several viral-related cancers, there is a general lack of data on the prevalence of other cancers among sexual and gender minorities.5,6 The impact of health behaviours such as smoking and obesity, as well as exogenous hormone exposure, is also unclear.
What is known is that LGBTQ+ individuals access healthcare services less than other people due to a fear of discrimination, and have less uptake of cervical screening programmes due misconceptions about risk factors.6 Individuals have also experienced a lack of understanding of their needs from healthcare staff.5,7
Disability
Individuals with disabilities face a number of barriers to accessing cancer services that result from a range of inequalities. These include a lack of preparation among healthcare professionals and institutions and, in some cases, physical accessibility, as well as a lack of acknowledgement of disability-related needs. In addition, cancer decision-making often does not take into account an individual’s disabilities.8
In one example, this has left women with disabilities significantly less likely to participate in breast cancer or colorectal cancer screening than their able-bodied counterparts.9
Socioeconomic Factors
Literary and language isolation
Poor health literacy affects screening uptake, shared decision-making and risk perception, including fears for cancer progression, as well as medication adherence, perioperative care and follow-up compliance. Yet this is a valuable and highly actionable target to help address inequalities.10
Income
Income disparities in access to cancer management play out across the care spectrum and have an ongoing impact on patient survival. This is demonstrated by the persistently delayed uptake of novel cancer treatments among, for example, poorer women with breast cancer or men with rectal cancer. While the resulting deprivation gap in survival for individuals with breast cancer appears to have narrowed in recent decades, it has continued to increase for recall cancer patients, with no sign of reducing.11
Social and family support
Social support is a crucial aspect of cancer care, from screening to survivorship or end-of-life care. It includes patient mobility, helps with practical tasks and attending medical appointments, as well as personal care, looking after children and other dependents and patients’ emotional needs.12
All of this can have a substantial impact on cancer outcomes, particularly among certain age groups and ethnicities. The social support needs of patients may also correlate with income levels and deprivation, as well as geographic factors such as rural versus urban areas. With many of these patients already experiencing inequalities, addressing their social support needs becomes all the more important.
Tackling cancer inequalities
There are a number of ways that the myriad inequalities faced by cancer patients can be addressed. These include earlier cancer detection and better access to treatment through the improved affordability of medicines and devices, and through linking to treatment optimisation networks. There also needs to be improved access to innovation and to digitalisation of healthcare.
While there have been several initiatives to tackle inequalities at a European level in recent years, the upcoming EU Cancer Plan offers a unique opportunity to place these at the heart of the agenda.
Change needs to happen not just on a regional level, however, but also within countries and between centres, and this is where every healthcare professional involved in cancer care can make a difference.
References
1. Cancer Today. International Agency for Cancer Research. https://gco.iarc.fr/today/home (accessed Sept 30, 2020).
2. Islami F, Siegel RL, Jemal A. The changing landscape of cancer in the USA - opportunities for advancing prevention and treatment. Nat Rev Clin Oncol 2020; 17: 631–649. doi: 10.1038/s41571-020-0378-y
3. Johnson HC, Lafferty EI, Eggo RM et al. Effect of HPV vaccination and cervical cancer screening in England by ethnicity: a modelling study. Lancet Public Health 2018; 3: e44–e51. doi: 10.1016/S2468-2667(17)30238-4
4. White A, Ironmonger L, Steele RJC et al. A review of sex-related differences in colorectal cancer incidence, screening uptake, routes to diagnosis, cancer stage and survival in the UK. BMC Cancer 2018; 18: 906. doi: 10.1186/s12885-018-4786-7
5. Cathcart-Rake EJ. Cancer in Sexual and Gender Minority Patients: Are We Addressing Their Needs. Curr Oncol Rep 2018; 20: 85. doi: 10.1007/ s11912-018-0737-3
6. National LGBT Survey: Research report. Government Equalities Office. https://www.gov.uk/ government/publications/national-lgbt-survey- summary-report (accessed Sept 30, 2020).
7. Berner AM, Hughes DJ, Tharmalingam H et al. 1614P. LGBTQ+ cancer patients: Are UK oncologists being supported to develop essential knowledge, attitudes and behaviours to provide quality care? ESMO Virtual Congress 2020: Presented September 19, 2020.
8. Sakellariou D, Anstey S, Gaze S et al. Barriers to accessing cancer services for adults with physical disabilities in England and Wales: an interview-based study. BMJ Open 2019; 9: e027555. doi: 10.1136/ bmjopen-2018-027555
9. Floud S, Barnes I, Verfürden M et al. Disability and participation in breast and bowel cancer screening in England: a large prospective study. Br J Cancer 2017; 117: 1711–1714. doi: 10.1038/bjc.2017.331
10. Lastrucci V, Lorini C, Caini S et al. Health literacy as a mediator of the relationship between socioeconomic status and health: A cross-sectional study in a population-based sample in Florence. PLoS ONE 2019; 14: e0227007. doi: 10.1371/journal. pone.0227007
11. Lyratzopoulos G, Barbiere JM, Rachet B et al. Changes over time in socioeconomic inequalities in breast and rectal cancer survival in England and Wales during a 32-year period (1973-2004): the potential role of health care. Ann Oncol 2011; 22: 1661–1666. doi: 10.1093/annonc/mdq647
12. Hidden at Home. Macmillan Cancer Support. https://www.macmillan.org.uk/documents/getinvolved/campaigns/carers/hidden-at-home.pdf (accessed Sept 30, 2020).
