Economic Crisis of 2008 Followed by Excess Cancer Deaths

Alexander M. Castellino, PhD

May 25, 2016

The global economic crisis of 2008, which saw steep unemployment and reduced public-sector healthcare spending, has now been linked to an increase in cancer mortality — an excess of over 260,000 deaths.

The finding comes from a longitudinal analysis published online on May 25 in The Lancet.

This is the first study to report on the association between an increase in cancer mortality and unemployment at a global level, the authors note.

"The association can be mitigated by universal health coverage," corresponding author Mahiben Maruthappu, MA, BM, BCh, from the Imperial College, London, United Kingdom, told Medscape Medical News. This is because in countries with such coverage, this association was markedly weaker, according to the analysis.

Cancer mortality was higher even in the United States — a country without universal health coverage for its people, according to Dr Maruthappu.

"Changes in economic status, investment in cancer care, and outcomes are complex and difficult to study, but crucial to understand the impact of different policy approaches on cancer morbidity and mortality at a population level," write authors of a linked comment.

The editorialists are Graham A. Colditz, DrPh, MD, MPH, an epidemiologist and public health expert from the Division of Public Health Science at the Washington University School of Medicine, St. Louis, Missouri, and Karen M. Emmons, PhD, vice president for research and director of Kaiser Foundation Research Institute, Oakland, California.

The new data "add to the evidence that the implementation of universal health coverage would further reduce the toll of cancer by making it possible to implement evidence based treatments and prevention strategies that are already in hand," they opine.

Longitudinal Database

The researchers retrieved economic data from the World Bank's Development Indicators & Global Development Finance 2013 edition datasets. High-income and middle-income countries were classified according to the World Bank's Atlas Method based on 2015 data. Mortality data (for 1990 to 2010) for all cancers, prostate cancer (men), breast cancer (women), lung cancer (men and women), and colorectal cancer (men and women) were extracted from the World Health Organization mortality database.

A multivariate regression analysis was used to assess the relation between each cancer, treatable cancers (5-year survival >50%), and untreatable cancers (5-year survival <10%).

The researchers performed a "time-lag analysis" at various years after the crisis and also conducted a "time trend analysis"—first looking at trends in mortality and unemployment from 2000 to 2007 and extrapolating it to 2008 to 2010. "Gathering data across a number of years allowed us to identify key trends in mortality," Dr Maruthappu told Medscape Medical News.

With the estimated mortality rate from the trend analysis and the actual rate from the World Health Organization database, the authors were able to calculate the rate ratio (RR), with an RR greater than 1 corresponding to a higher-than-expected trend estimate.

The Longitudinal Analysis

Unemployment and cancer mortality data were available for 75 countries, representing 2.106 billion people.

The researchers reported that increases in unemployment rate were associated with significant increases in mortality for all cancer and several cancer subtypes, except lung cancer in women. This association was also significant and greatest for all treatable cancers, but not untreatable cancers. A 1% increase in unemployment was associated with 0.37 additional deaths from all cancers per 100,000 people, according to the study.

The absence of a trend for lung cancer in women is complex and may have to do with the fact that survival rates are lower for women than men, Dr Maruthappu speculated.

Increases in public spending on healthcare were associated with reduced cancer mortality in seven categories (prostate cancer, breast cancer, lung cancer in men, colorectal cancer in men and women, treatable cancers, and all cancers).

A 1% decrease in public healthcare spending as a percentage of gross domestic product was associated with 0.0053 additional deaths from all cancers per 100,000 people.

To demonstrate the effect of the global economic crisis of 2008, the researchers performed a trend analysis, using population-based mean values, projected age-specific rates, and age-standardized death rates (ASDRs). ASDRs were significant for both men (RR, 1.0362; P < .001) and women (RR, 1.0428; P < .001).

Using these data, they found, in 2010 alone, an excess of 55,434 more cancer deaths in men and 53,573 more cancer deaths in women than would have been expected from the above estimates (P < .0001).

When the researchers considered the years 2008, 2009, and 2010 together, they found an excess of 252,199 cancer deaths across the 35 countries included in the time-trend analysis.

For countries belonging to the Organisation for Economic Co-operation and Development, the researchers estimated that there were 263,221 additional cancer deaths compared with the trend seen between 2000 and 2007; of these, 169,129 were attributed to countries in the European Union.

"If these data were extrapolated to countries not included, such as India and China, the additional cancer deaths for this time period may well be over 500,000," Dr Maruthappu told Medscape Medical News. "These countries were not included, due to lack of availability in the databases we were using," he added.

For the 26 countries with universal health coverage, no evidence of excess deaths were found (RR, 1.0009; P = .8285).

However, for the nine countries without universal healthcare (Barbados, Latvia, Lithuania, Malta, Mexico, Poland, Russia, United States, and Uruguay), the predicted ASDRs were lower than the actual observed rates (RR, 1.0746; P < .001)—which equated to 21,241 excess cancer deaths in 2010 alone for treatable cancers.

Making a Case for Universal Healthcare

"Our study has at least two major policy implications," the researchers write in their discussion.

First, these findings make a strong case for universal healthcare and its possible moderating effect on those unemployed during an economic downturn, they maintain.

Second, they state: "[A]mid a background of rising healthcare costs, if spending restrictions are not accompanied by proportionate improvements in efficiency, worse quality of care and, in turn, higher mortality levels might follow."

"There is a growing body of evidence that supports universal health coverage and investment into health systems," Dr Maruthappu said.

"These data make a strong case for universal health coverage and its protective effect on cancer mortality. Disparities in cancer outcomes between countries are probably a function of policies on coverage and allocation of health resources," the authors write.

The editorialists are in broad agreement. These new data "add to the evidence that the implementation of universal health coverage would further reduce the toll of cancer by making it possible to implement evidence-based treatments and prevention strategies that are already in hand. Universal health coverage is a key UN Development Programme Sustainable Development Goal (SDG 3) and is described as the single most powerful concept that The adverse effect of recession-induced unemployment public health has to offer."

"[T]he adverse effect of recession-induced unemployment adds further weight to the arguments for standards of care being available to all patients with cancer, irrespective of their personal economic or insurance resources," the editorialists state.

The United States does not have universal health coverage. "[S]tudies within the USA show that patients with cancer, especially those younger than 65 years without access to Medicare (a national social insurance programme) and social security protection, are twice as likely as their same-aged peers to file for bankruptcy," the editorialists write.

Medscape Medical News asked Dr Maruthappu about an analysis for the United States alone. "Although not included in this study, subsequent analyses estimate that the US experienced up to 18,000 additional cancer deaths between 2008 and 2010," he said. "We believe this is possibly due to the economic crisis and lack of universal healthcare during this time period," he added.

Addressing the healthcare coverage issue in the United States, the editorialists write: "Although in many countries universal health coverage is seen as an important societal investment, so far this has not been the case by the USA. The country might find the promise of improving treatments difficult to achieve without first providing coverage to those affected by cancer."

"Universal health coverage, specifically for all patients with cancer, would meet the Institute of Medicine recommendation to reduce disparities in access to cancer care for vulnerable and underserved populations. Furthermore, universal cancer coverage would generate a great return on investment," they conclude.

The study authors have disclosed no relevant financial relationships. Dr Emmons is an employee of Kaiser Permanente, a US managed care consortium.

Lancet. Published online May 25, 2016. Abstract Comment

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