Is Cancer Care Worse in Poorer Neighborhoods?

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According to one recent study: no.

To be more precise, according to one recent study, areas of social deprivation have an equal supply of cancer care services as more well-to-do areas.

Elizabeth Lamont and colleagues, of Harvard Medical School, set out to determine “whether area social factors are associated with the area health care supply,” according to the abstract of their report, published in the Journal of Clinical Oncology. Using Census Bureau records, the authors noted the social factors at play in 3,096 urban zip codes, and checked the health care supply in the 465 hospital service areas that corresponded to those zip codes. Focusing specifically on breast cancer and colorectal cancer, the authors cross-checked the data to see if social factors were associated with the supply of health care services, namely screening, treatment, and post-treatment surveillance.

The authors found no such association. The supply of physicians conducting these three areas of care was no different for disadvantaged neighborhoods than it was for more advantaged neighborhoods.

In the quest to understand why health outcomes are worse among people living in poor areas, this study is a small step that rules out one potential variable. Okay, so, the number of people providing important services isn’t the problem. So if there is an adequate supply, then what’s the problem?

As Sandra Swain notes in a Reuters article on the study, insurance, money, medical literacy and transportation may all be contributing to the difference in outcomes.

Though the causes remain unclear, the link between social deprivation (is that a euphemism or a more nuanced and accurate way to speak about poverty?) and worse outcomes among people with cancer is undeniable. A few startling findings:

Among 7290 colorectal cancer patients in the UK who underwent surgery, social deprivation was associated with higher postoperative mortality (death after surgery) and a longer hospital stay — and that difference was on a sliding scale; as deprivation worsened, so did outcomes.

This report from Cancer Research UK notes that unskilled workers are more likely to die from cancer than are professionals, and cancer mortality rates, though varying widely across geographic areas in the country, are highest in areas with dramatic levels of social deprivation. Interestingly, the report authors assert that much of this difference can be chalked up to smoking prevalence.

But smoking can’t be the only factor. Another study of 762 women with breast cancer (also in England) found that wealthier women were less likely to be diagnosed with invasive ductal tumors, high-grade tumors, and estrogen receptor-negative tumors. That study also found that poorer women may have been having more potentially unnecessary mastectomies.

This report presents a more global view of the socioeconomic determinants of cancer, with an emphasis of the problem in developing countries.

The connection with social deprivation and race has also come under some scrutiny. As this report (albeit from several years ago) highlights, breast cancer incidence may not be that different among white women and black women, but breast cancer mortality is higher among the latter.

It’s true that most of the reports noted above are not from the United States, and perhaps the supply of services is an issue in other countries. My guess would be not, that the issues linking social deprivation to cancer in developed countries are, by and large, the same. But what are they?

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