Unemployment increases are associated with rises in cancer mortality; universal health coverage seems to protect against this effect.— Mahiben Maruthappu, MA, and colleagues
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The global economic crisis has been associated with increased unemployment and reduced public-sector expenditure on health care. In a study reported in The Lancet, Mahiben Maruthappu, MA, of Imperial College London, and colleagues found that the global economic crisis beginning in 2008 was associated with a large excess in cancer mortality during 2008 to 2010.1
The study included data from the World Bank and the World Health Organization (WHO). Analysis of mortality data included breast cancer in women, prostate cancer in men, and colorectal cancer in men and women as ‘treatable cancer’ and lung and pancreatic cancers as ‘untreatable cancer.’ Multivariable regression analyses controlling for country-specific demographics and infrastructure with time-lag analyses were used to assess the relationship between unemployment, public-sector expenditure on health care, and cancer mortality with and without universal health coverage. Trend analysis was used to project mortality rates on the basis of trends before the unemployment increase that occurred in many countries from 2008 to 2010, with these rates being compared with observed rates.
Data were available for 75 countries (representing 2.106 billion people) for the analysis of effects of unemployment and for 79 countries (representing 2.156 billion people) for the public-sector expenditure on health-care analysis.
Association With Increase in Unemployment
A 1% increase in unemployment was associated with an increase in mortality for five of the six cancer subtypes evaluated: prostate cancer (regression coefficient [R] = .0981, P = .0022), breast cancer in women (R = .1583, P < .0001), lung cancer in men (R = .2260, P < .0001), colorectal cancer in men (R = .0596, P = .0042), and colorectal cancer in women (R = .0676, P < .0001); a significant negative association was found for unemployment and lung cancer in women (R = –.0593, P = .0058).
Overall, all-cancer mortality (R = .3745, P = .0001) and treatable cancer mortality were significantly associated with unemployment (R = .1256, P = .0265), whereas untreatable cancer mortality was not (R = .0820, P = .1919). Lag analysis indicated that the associations of mortality with unemployment were maintained for 5 years after unemployment increases for breast cancer in women, colorectal cancer in women, lung cancer in men, and overall cancer mortality.
Effect of Universal Health Coverage
Countries with universal health coverage were defined as those with legislation mandating universal health coverage, > 90% health-care coverage, and > 90% skilled birth attendance. In analysis adjusting for universal health coverage status, no significant associations were found between cancer mortality and unemployment within the first year of an increase in unemployment for any of the six subtypes, all cancers, or treatable or untreatable cancers.
Association With Public-Sector Expenditure on Health Care
Increased public-sector expenditure on health care as a proportion of gross domestic product was significantly associated with mortality reductions in prostate cancer (R = –.0013, P < .0001), breast cancer in women (R = –.0023, P < .0001), lung cancer in men (R = –.0037, P < .0001), colorectal cancer in men (R = –.0011, P < .0001), colorectal cancer in women (R = –.0011, P < .0001), treatable cancers (R = –.0023, P < .0001), and all cancers (R = –.0053, P < .0001) but not lung cancer in women (R = .0007, P = .0001) or untreatable cancers (R = .0006, P = .1492).
Trend analyses indicated excess deaths due to treatable cancers from 2008 to 2010 on the basis of mortality expected from 2000 to 2007 trends. Predicted age-standardized death rates for treatable cancers were significantly lower than observed rates in non–universal health coverage countries but not in universal health coverage countries, for 2008 to 2010. Overall, it was estimated that there were 312,847 additional deaths in the 75-country data set, with an estimated 263,221 additional deaths in the 34 countries in the Organisation for Economic Co-operation and Development.
The investigators concluded:
Unemployment increases are associated with rises in cancer mortality; universal health coverage seems to protect against this effect. Public-sector expenditure on health-care increases is associated with reduced cancer mortality. Access to health care could underlie these associations. We estimate that the 2008–2010 economic crisis was associated with about 260,000 excess cancer-related deaths in the Organisation for Economic Co-operation and Development alone. ■
Disclosure: For full disclosures of the study authors, visit www.thelancet.com.
1. Maruthappu M, Watkins J, Noor AM, et al: Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990–2010: A longitudinal analysis. Lancet. May 25, 2016 (early release online).
The results of this study, plus the coverage gaps still in existence among those states that have declined to expand Medicaid under the ACA, raise the question of whether mortality due to treatable cancer in the United States is higher than it could otherwise be.— Kenneth L. ...