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

Abstract

Background: Intervention-generated inequalities are unintended variations in outcome that result from the organisation and delivery of health interventions. Socioeconomic inequalities in treatment may occur for some common cancers. Although the incidence and outcome of lung cancer varies with socioeconomic position (SEP), it is not known whether socioeconomic inequalities in treatment occur and how these might affect mortality. We conducted a systematic review and meta-analysis of existing research on socioeconomic inequalities in receipt of treatment for lung cancer.

Methods and findings: MEDLINE, EMBASE, and Scopus were searched up to September 2012 for cohort studies of participants with a primary diagnosis of lung cancer (ICD10 C33 or C34), where the outcome was receipt of treatment (rates or odds of receiving treatment) and where the outcome was reported by a measure of SEP. Forty-six papers met the inclusion criteria, and 23 of these papers were included in meta-analysis. Socioeconomic inequalities in receipt of lung cancer treatment were observed. Lower SEP was associated with a reduced likelihood of receiving any treatment (odds ratio [OR] = 0.79 [95% CI 0.73 to 0.86], p<0.001), surgery (OR = 0.68 [CI 0.63 to 0.75], p<0.001) and chemotherapy (OR = 0.82 [95% CI 0.72 to 0.93], p = 0.003), but not radiotherapy (OR = 0.99 [95% CI 0.86 to 1.14], p = 0.89), for lung cancer. The association remained when stage was taken into account for receipt of surgery, and was found in both universal and non-universal health care systems.

Conclusions: Patients with lung cancer living in more socioeconomically deprived circumstances are less likely to receive any type of treatment, surgery, and chemotherapy. These inequalities cannot be accounted for by socioeconomic differences in stage at presentation or by differences in health care system. Further investigation is required to determine the patient, tumour, clinician, and system factors that may contribute to socioeconomic inequalities in receipt of lung cancer treatment.

Figure 1. Flow diagram of study selection and exclusion.

CI, confidence interval; SEP, socioeconomic position.

Figure 2. Meta-analysis of odds of receipt of surgery in low versus high SEP.

CI, confidence interval; non-UHCS, non-universal health care system; NSCLC, non-small cell lung cancer; OR, odds ratio; SE, standard error; SEP, socioeconomic position; UHCS, universal health care system.

Figure 3. Meta-analysis of odds of receipt of chemotherapy in low versus high SEP.

CI, confidence interval; non-UHCS, non-universal health care system; OR, odds ratio; SE, standard error; SEP, socioeconomic position; UHCS, universal health care system.

Figure 4. Meta-analysis of odds of receipt of radiotherapy in low versus high SEP.

CI, confidence interval; non-UHCS, non-universal health care system; OR, odds ratio; SE, standard error; SEP, socioeconomic position; UHCS, universal health care system.

Figure 5. Meta-analysis of odds of receipt of unspecified treatment in low versus high SEP.

CI, confidence interval; OR, odds ratio; SE, standard error; SEP, socioeconomic position.