Socioeconomic inequalities in lung cancer – a time trend analysis with German health insurance data

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Abstract

Background

Lung Cancer (LC) is one of the most prevalent cancer diseases. Due to the lack of databases which allow the combination of information on individual socioeconomic status (SES) and cancer incidence, research on social inequalities in LC among the German population is rare. The aim of the study is to analyse time trends in social inequalities in LC in Germany.

Methods

The analyses are based on data of a large statutory health insurance provider. The data contain information on diagnoses, occupation and education (working age), and income (full age range) of the insurance population. Trends were analysed for two subpopulations (retirement age and working age) and stratified by sex. The analyses are based on incidence rates and proportional hazard models spanning the periods 2006–2009, 2010–2013 and 2014–2017.

Results

Incidence rates declined in men but increased in women. For men, inequalities were strongest in terms of income and the decline in incidence was most pronounced in middle- and higher-income men. Among women at retirement age, a reversed income gradient was found which disappeared in the second period. The educational gradient among the working-age population decreased over time due to the trend towards increasing incidence among individuals with higher education. Declining gradients were also found for occupational position.

Conclusion

The findings reveal considerable inequalities in LC and that trends vary with respect to SES, sex and age. Widening income inequalities were found in the retired population, while educational and occupational inequalities tend to narrow among the working-age population.

Related collections

Most cited references 41

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The disease risks from cigarette smoking increased in the United States over most of the 20th century, first among male smokers and later among female smokers. Whether these risks have continued to increase during the past 20 years is unclear. We measured temporal trends in mortality across three time periods (1959-1965, 1982-1988, and 2000-2010), comparing absolute and relative risks according to sex and self-reported smoking status in two historical cohort studies and in five pooled contemporary cohort studies, among participants who became 55 years of age or older during follow-up. For women who were current smokers, as compared with women who had never smoked, the relative risks of death from lung cancer were 2.73, 12.65, and 25.66 in the 1960s, 1980s, and contemporary cohorts, respectively; corresponding relative risks for male current smokers, as compared with men who had never smoked, were 12.22, 23.81, and 24.97. In the contemporary cohorts, male and female current smokers also had similar relative risks for death from chronic obstructive pulmonary disease (COPD) (25.61 for men and 22.35 for women), ischemic heart disease (2.50 for men and 2.86 for women), any type of stroke (1.92 for men and 2.10 for women), and all causes combined (2.80 for men and 2.76 for women). Mortality from COPD among male smokers continued to increase in the contemporary cohorts in nearly all the age groups represented in the study and within each stratum of duration and intensity of smoking. Among men 55 to 74 years of age and women 60 to 74 years of age, all-cause mortality was at least three times as high among current smokers as among those who had never smoked. Smoking cessation at any age dramatically reduced death rates. The risk of death from cigarette smoking continues to increase among women and the increased risks are now nearly identical for men and women, as compared with persons who have never smoked. Among men, the risks associated with smoking have plateaued at the high levels seen in the 1980s, except for a continuing, unexplained increase in mortality from COPD.

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Problems with measuring socioeconomic status (SES)-frequently included in clinical and public health studies as a control variable and less frequently as the variable(s) of main interest-could affect research findings and conclusions, with implications for practice and policy. We critically examine standard SES measurement approaches, illustrating problems with examples from new analyses and the literature. For example, marked racial/ethnic differences in income at a given educational level and in wealth at a given income level raise questions about the socioeconomic comparability of individuals who are similar on education or income alone. Evidence also shows that conclusions about nonsocioeconomic causes of racial/ethnic differences in health may depend on the measure-eg, income, wealth, education, occupation, neighborhood socioeconomic characteristics, or past socioeconomic experiences-used to "control for SES," suggesting that findings from studies that have measured limited aspects of SES should be reassessed. We recommend an outcome- and social group-specific approach to SES measurement that involves (1) considering plausible explanatory pathways and mechanisms, (2) measuring as much relevant socioeconomic information as possible, (3) specifying the particular socioeconomic factors measured (rather than SES overall), and (4) systematically considering how potentially important unmeasured socioeconomic factors may affect conclusions. Better SES measures are needed in data sources, but improvements could be made by using existing information more thoughtfully and acknowledging its limitations.

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Author and article information

Contributors

Fabian Tetzlaff:

ORCID: http://orcid.org/0000-0001-6933-4162

tetzlaff.fabian@mh-hannover.de

Journal

Journal ID (nlm-ta): BMC Public Health

Journal ID (iso-abbrev): BMC Public Health

Title: BMC Public Health

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2458

Publication date (Electronic): 19 March 2021

Publication date PMC-release: 19 March 2021

Publication date Collection: 2021

Volume: 21

Electronic Location Identifier: 538

Affiliations

[1 ]GRID grid.10423.34, ISNI 0000 0000 9529 9877, Institute for General Practice, Hannover Medical School, ; Hanover, Germany

[2 ]GRID grid.10423.34, ISNI 0000 0000 9529 9877, Medical Sociology Unit, Hannover Medical School, ; Hanover, Germany

[3 ]GRID grid.10423.34, ISNI 0000 0000 9529 9877, Comprehensive Cancer Center Hannover, Hannover Medical School, ; Hanover, Germany

[4 ]GRID grid.10423.34, ISNI 0000 0000 9529 9877, Department of Pneumology, , Hannover Medical School, ; Hanover, Germany

Author information

Fabian Tetzlaff http://orcid.org/0000-0001-6933-4162

Article

Publisher ID: 10576

DOI: 10.1186/s12889-021-10576-4

PMC ID: 7977592

PubMed ID: 33740928

SO-VID: 1303f830-a1a4-4df5-9478-c5b4e196b661

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 13 November 2020

Date accepted : 7 March 2021

Funding

Funded by: AOK Niedersachsen

Award ID: NA

Award Recipient : Juliane Tetzlaff

Funded by: FundRef http://dx.doi.org/10.13039/501100001659, Deutsche Forschungsgemeinschaft;

Award ID: GE 1167/15-1

Award Recipient : Jelena Epping

Funded by: Medizinische Hochschule Hannover (MHH) (3118)

Custom metadata

ScienceOpen disciplines: Public health

Keywords: lung cancer,time trend,incidence,socioeconomic inequalities,germany

Data availability: