Early Cancer Diagnoses Decline During Trying Economic Times

Pam Harrison

February 15, 2017

The incidence of certain cancers declined fairly dramatically in recent years, and at least part of this decline appears to be attributable to higher unemployment rates during the recession, the first study of its kind suggests.

The study was published online February 3 in Cancer Causes & Control.

Specifically, cancer diagnoses overall declined 3.3% for males and 1.4% for females between 2008 and 2012.

"The coincidence of these incidence changes with the U.S. Great Recession (December 2007–June 2009), the most significant economic challenge since the Great Depression of the 1930s, suggests that the economic hardships of the Recession may have influenced cancer incidence rates," say the authors.

"[W]e have found that yearly total cancer incidence rates declines were greater during the recession/recovery period...and dropped most precipitously for prostate, lung, and colorectal cancers, and for early-stage prostate and colorectal cancers," lead author Scarlett Lin Gomez, MD, Cancer Prevention Institute of California, Fremont, and colleagues write.

"The association of lower incidence rates with higher unemployment rates for screenable cancers suggests that individuals' decreased engagement in preventive health behaviors during trying economic times may delay diagnoses particularly of clinically less urgent cancers," they add.

Study Details

The team used data from the California Cancer Registry, which tracks incident cancer rates, between 2008 and 2012 and compared rates to those from prerecession years between 1996 and 2007.

"We focused on the 30 most populous of California's 58 counties, capturing both urban and rural areas," the investigators observe. As they note, 35.7 million people lived in these 30 counties in 2010, or 91.9% of the state's total population.

"Incidence rates of all cancers declined starting after 2007 among males and after 2008 among females," Dr Gomez and colleagues write.

For both males and females, diagnoses of all cancers combined declined in the years before the recession but the incidence declined more rapidly during the recession/recovery period, they add.

However, trends in the incidence of different cancers were quite variable. For example, rates of melanoma and kidney and liver cancer actually increased in the pre-recession years, then stabilized in the later years among men.

Among women, large decreases in the incidence of lung cancer were documented during the later years, as were declines in colorectal cancer and non-Hodgkin's lymphoma (NHL).

Perhaps in keeping with their hypothesis, breast cancer was less likely to be diagnosed among women in both time periods but in situ breast cancer was diagnosed less frequently in the recession/recovery period, the investigators point out.

The team quantified changes in incidence rates of these cancers as an annual percentage change (APC) before the recession and after, "confirming that, indeed, cancer incidence in general did decline much faster during the recession/post-recession period than prior to the recession period," Dr Gomez explained to Medscape Medical News in an email.

Age-Adjusted Average Cancer Incidence APC for Certain Screenable Cancers: 1996–2012

Cancer APC: Males, 1996–2007 APC: Males, 2008–2012 APC: Females, 1996–2007 APC: Females, 2008–2012
All sites combined –0.7 –3.3 –0.5 –1.4
Prostate cancer –1.0 –6.3    
Prostate cancer (localized) –1.3 –6.3    
Breast cancer: in situ     1.7 –1.9
Lung cancer –2.3 –4.8 –1.3 –3.0
Colon and rectal cancer –1.8 –5.0 –1.5 –4.6
NHL –0.2 –1.4 0.3 –2.0
Melanoma 2.0 –0.0 1.4 –1.0


Cancer Case Counts

Investigators then analyzed cancer case counts and their potential association with unemployment rates across the years under study.

"Among males…total cancer case counts did not change with unemployment in either the pre-recession or recession/recovery periods," the study authors write.

However, "[d]ecreases in case counts were associated with increases in unemployment for both periods for prostate cancer (all stages combined and localized), NHL, and melanoma (all stages combined and localized)," they add.

Furthermore, across both time periods, lung cancer incidence rates in males increased as unemployment rates rose across both time periods, while cancers of the bladder, kidney, and renal pelvis increased in the recession/recovery period as well.

Again, investigators qualified their observations, noting that only a drop in prostate cancer case counts in the recession/recovery period was really strongly associated with unemployment rates.

Among females, a drop in the combined cancer case diagnoses was actually slightly more pronounced in the pre-recession period.

However, investigators did document a decrease in diagnoses with increasing unemployment for breast cancer, melanoma, and ovarian cancer irrespective of the time period analyzed.

For both men and women, "the largest associations occurred for melanoma, with as large a decrease as 3.6% in incident cases with every 1% increase in unemployment," Dr Gomez and colleagues observe.

"I think one take-home message is that the number of cancers diagnosed seems to be sensitive to the larger economic environment," Dr Gomez told Medscape Medical News. "One potential reason that fewer cancers would be diagnosed during times of economic hardship may be due to decreased utilization of healthcare because people's economic resources have decreased, their health insurance may have changed or they are undergoing great stress [or all of the above]," she added.

"[Since] we noted that declines were greatest for early-stage disease, which are more likely to be detected with routine screening, this study suggests that ensuring healthcare coverage for preventive care, including cancer screening, is important," Dr Gomez said.

This work was funded in part by the Stanford Cancer Institute and the National Cancer Institute's Surveillance, Epidemiology, and End Results Program (under contract HHSN261201000140C awarded to the Cancer Prevention Institute of California). Dr Gomez and all coauthors have disclosed no relevant financial relationships.

Cancer Causes Control. Published online February 3, 2017. Abstract

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