Socioeconomic Differences and Lung Cancer Survival-Systematic Review and Meta-Analysis

Abstract

Background: The impact of socioeconomic differences on cancer survival has been investigated for several cancer types showing lower cancer survival in patients from lower socioeconomic groups. However, little is known about the relation between the strength of association and the level of adjustment and level of aggregation of the socioeconomic status measure. Here, we conduct the first systematic review and meta-analysis on the association of individual and area-based measures of socioeconomic status with lung cancer survival. Methods: In accordance with PRISMA guidelines, we searched for studies on socioeconomic differences in lung cancer survival in four electronic databases. A study was included if it reported a measure of survival in relation to education, income, occupation, or composite measures (indices). If possible, meta-analyses were conducted for studies reporting on individual and area-based socioeconomic measures. Results: We included 94 studies in the review, of which 23 measured socioeconomic status on an individual level and 71 on an area-based level. Seventeen studies were eligible to be included in the meta-analyses. The meta-analyses revealed a poorer prognosis for patients with low individual income (pooled hazard ratio: 1.13, 95 % confidence interval: 1.08-1.19, reference: high income), but not for individual education. Group comparisons for hazard ratios of area-based studies indicated a poorer prognosis for lower socioeconomic groups, irrespective of the socioeconomic measure. In most studies, reported 1-, 3-, and 5-year survival rates across socioeconomic status groups showed decreasing rates with decreasing socioeconomic status for both individual and area-based measures. We cannot confirm a consistent relationship between level of aggregation and effect size, however, comparability across studies was hampered by heterogeneous reporting of socioeconomic status and survival measures. Only eight studies considered smoking status in the analysis. Conclusions: Our findings suggest a weak positive association between individual income and lung cancer survival. Studies reporting on socioeconomic differences in lung cancer survival should consider including smoking status of the patients in their analysis and to stratify by relevant prognostic factors to further explore the reasons for socioeconomic differences. A common definition for socioeconomic status measures is desirable to further enhance comparisons between nations and across different levels of aggregation.

Keywords: area-based; cancer survival; education; income; index; lung cancer; occupation; socioeconomic status.

Figure 1

PRISMA flow diagram of study selection process for a systematic review and meta-analysis on socioeconomic differences and lung cancer survival.

Figure 2

Meta-analyses of studies on the association of individual education / income (reference: high income/education) and survival after lung cancer. NSCLC, non-small cell lung cancer. Kravdal (55): highest educational group, men = 17+ years, women = 13–17+ years. Chang et al. (46): high income category = high individual AND high neighborhood income (reference), low income category = low individual AND low neighborhood income.

Figure 3

Association of area-based education (reference: high education) and survival after lung cancer. Order: small to large area level. NSCLC, non-small cell lung cancer.

Figure 4

Association of area-based income (reference: high income) and survival after lung cancer. Order: small to large area level. NSCLC, non-small cell lung cancer; SCLC, small cell lung cancer.

Figure 5

Association of area-based index measures (reference: high socioeconomic group) and survival after lung cancer. Order: region and small to large area level. NSCLC, non-small cell lung cancer; SCLC, small cell lung cancer; UK, United Kingdom.

Figure 6

Meta-analysis of studies from the United States on the association of area-based income (reference: high income) and survival after lung cancer. Order: small to large area level. NSCLC, non-small cell lung cancer; SCLC, small cell lung cancer.