Supportive Care in Cancer

, Volume 25, Issue 5, pp 1391–1399 | Cite as

Socio-economic disparities in long-term cancer survival—10 year follow-up with individual patient data

  • Susanne Singer
  • Michael Bartels
  • Susanne Briest
  • Jens Einenkel
  • Dietger Niederwieser
  • Kirsten Papsdorf
  • Jens-Uwe Stolzenburg
  • Sophie Künstler
  • Sabine Taubenheim
  • Oliver Krauß
Original Article



Reasons for the social gradient in cancer survival are not fully understood yet. Previous studies were often only able to determine the socio-economic status of the patients from the area they live in, not from their individual socio-economic characteristics.


In a multi-centre cohort study with 1633 cancer patients and 10-year follow-up, individual socio-economic position was measured using the indicators: education, job grade, job type, and equivalence income. The effect on survival was measured for each indicator individually, adjusting for age, gender, and medical characteristics. The mediating effect of health behaviour (alcohol and tobacco consumption) was analysed in separate models.


Patients without vocational training were at increased risk of dying (rate ratio (RR) 1.5, 95% confidence interval (CI) 1.1–2.2) compared to patients with the highest vocational training; patients with blue collar jobs were at increased risk (RR 1.2; 95% CI 1.0–1.5) compared to patients with white collar jobs; income had a gradual effect (RR for the lowest income compared to highest was 2.7, 95% CI 1.9–3.8). Adding health behaviour to the models did not change the effect estimates considerably. There was no evidence for an effect of school education and job grade on cancer survival.


Patients with higher income, better vocational training, and white collar jobs survived longer, regardless of disease stage at baseline and of tobacco and alcohol consumption.


Socio-economic position Socio-economic status Cancer Health inequality Health inequity Disparities Income Education Job grade Survival 


Compliance with ethical standards


This work was supported by a grant from the German Federal Ministry of Education and Research (grant number 01ZZ0106) to Prof. Reinhold Schwarz for baseline data collection. The mortality follow-up received no funding.

Conflicts of interest

The authors declare that they have no conflict of interest.

Supplementary material

520_2016_3528_MOESM1_ESM.docx (17 kb)
ESM 1 (DOCX 17 kb)


  1. 1.
    Dixit N, Crawford GB, Lemonde M, Rittenberg CN, Fernandez-Ortega P (2016) Left behind: cancer disparities in the developed world. Support Care Cancer 24:3261–3264CrossRefPubMedGoogle Scholar
  2. 2.
    Quaglia A, Lillini R, Mamo C, Ivaldi E, Vercelli M, SEIH (Socio-Economic Indicators HWG (2013) Socio-economic inequalities: a review of methodological issues and the relationships with cancer survival. Critical Reviews in Oncology and Hematology 85:266–277CrossRefGoogle Scholar
  3. 3.
    Diez Roux AV, Nieto FJ, Muntaner C, Tyroler HA, Comstock GW, Shahar E, Cooper LS, Watson RL, Szklo M (1997) Neighborhood environments and coronary heart disease: a multilevel analysis. Am J Epidemiol 146:48–63CrossRefPubMedGoogle Scholar
  4. 4.
    Robert SA, Strombom I, Trentham-Dietz A, Hampton JM, McElroy JA, Newcomb PA, Remington PL (2004) Socioeconomic risk factors for breast cancer—distinguishing individual-and community-level effects. Epidemiology 15:442–450CrossRefPubMedGoogle Scholar
  5. 5.
    Diez Roux A, Merkin SS, Arnett D, Chambless L, Massing M, Nieto FJ, Sorlie P, Szklo M, Tyroler HA, Watson RL (2001) Neighborhood of residence and incidence of coronary heart disease. N Engl J Med 345:99–106CrossRefPubMedGoogle Scholar
  6. 6.
    Geyer S, Hemström O, Peter R, Vågerö D (2006) Education, income, and occupational class cannot be used interchangeably in social epidemiology. Empirical evidence against a common practice. J Epidemiol Community Health 60:804–810CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Akinyemiju TF, Soliman AS, Johnson NJ, Altekruse SF, Welch K, Banerjee M, Schwartz K, Merajver S (2013) Individual and neighborhood socioeconomic status and healthcare resources in relation to black-white breast cancer survival disparities. Journal of cancer epidemiology 2013: Article ID 490472Google Scholar
  8. 8.
    Shariff-Marco S, Yang J, John EM, Sangaramoorthy M, Hertz A, Koo J, Nelson DO, Schupp CW, Shema SJ, Cockburn M, Satariano WA, Yen IH, Ponce NA, Winkleby M, THM K, Gomez SL (2014) Impact of neighborhood and individual socioeconomic status on survival after breast cancer varies by race/ethnicity: the neighborhood and breast cancer study. Cancer Epidemiol Biomark Prev 23:793–811CrossRefGoogle Scholar
  9. 9.
    Jansen L, Eberle A, Emrich K, Gondos A, Holleczek B, Kajuter H, Maier W, Nennecke A, Pritzkuleit R, Brenner H (2014) Socioeconomic deprivation and cancer survival in Germany: an ecological analysis in 200 districts in Germany. Int J Cancer 134:2951–2960CrossRefPubMedGoogle Scholar
  10. 10.
    Rachet B, Woods LM, Mitry E, Riga M, Cooper N, Quinn MJ, Steward J, Brenner H, Esteve J, Sullivan R, Coleman MP (2008) Cancer survival in England and Wales at the end of the twentieth century. Br J Cancer 99:S2–S10CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Brusselaers N, Ljung R, Mattsson F, Johar A, Wikman A, Lagergren P, Lagergren J (2013) Education level and survival after oesophageal cancer surgery: a prospective population-based cohort study. British Medical Journal Open 3:e003754. doi: 10.1136/bmjopen-2013-003754 Google Scholar
  12. 12.
    Hastert TA, Beresford SAA, Sheppard L, White E (2015) Disparities in cancer incidence and mortality by area-level socioeconomic status: a multilevel analysis. J Epidemiol Community Health 69:168–176CrossRefPubMedGoogle Scholar
  13. 13.
    Hystad P, Carpiano RM, Demers PA, Johnson KC, Brauer M (2013) Neighbourhood socioeconomic status and individual lung cancer risk: evaluating long-term exposure measures and mediating mechanisms. Soc Sci Med 97:95–103CrossRefPubMedGoogle Scholar
  14. 14.
    CC W, Hsu TW, Chang CM, CH Y, Wang YF, Lee CC (2014) The effect of individual and neighborhood socioeconomic status on gastric cancer survival. PLoS One 9(2):e89655CrossRefGoogle Scholar
  15. 15.
    Chang TS, Chang CM, Hsu TW, Lin YS, Lai NS, YC S, Huang KY, Lin HL, Lee CC (2013) The combined effect of individual and neighborhood socioeconomic status on nasopharyngeal cancer survival. PLoS One 8(9):e73889CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Kaffashian F, Godward S, Davies T, Solomon L, McCann J, Duffy SW (2003) Socioeconomic effects on breast cancer survival: proportion attributable to stage and morphology. Br J Cancer 89:1693–1696CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Schrijvers CTM, Mackenbach JP, Lutz JM, Quinn MJ, Coleman MP (1995) Deprivation and survival from breast-cancer. Br J Cancer 72:738–743CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Lyratzopoulos G, Barbiere JM, Rachet B, Baum M, Thompson MR, Coleman MP (2011) Changes over time in socioeconomic inequalities in breast and rectal cancer survival in England and Wales during a 32-year period (1973-2004): the potential role of health care. Ann Oncol 22:1661–1666CrossRefPubMedGoogle Scholar
  19. 19.
    Thomson CS, Hole DJ, Twelves CJ, Brewster DH, Black RJ (2001) Prognostic factors in women with breast cancer: distribution by socioeconomic status and effect on differences in survival. J Epidemiol Community Health 55:308–315CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Ahnquist J, Wamala SP, Lindstrom M (2012) Social determinants of health—a question of social or economic capital? Interaction effects of socioeconomic factors on health outcomes. Soc Sci Med 74:930–939CrossRefPubMedGoogle Scholar
  21. 21.
    Schrijvers CTM, Mackenbach JP, Lutz JM, Quinn MJ, Coleman MP (1995) Deprivation, stage at diagnosis and cancer survival. Int J Cancer 63:324–329CrossRefPubMedGoogle Scholar
  22. 22.
    Rutherford MJ, Hinchliffe SR, Abel GA, Lyratzopoulos G, Lambert PC, Greenberg DC (2013) How much of the deprivation gap in cancer survival can be explained by variation in stage at diagnosis: an example from breast cancer in the east of England. Int J Cancer 133:2192–2200CrossRefPubMedGoogle Scholar
  23. 23.
    Berglund A, Lambe M, Luchtenborg M, Linklater K, Peake MD, Holmberg L, Moller H (2012) Social differences in lung cancer management and survival in south East England: a cohort study. British Medical Journal Open 2:e001048. doi: 10.1136/bmjopen-2012-001048 Google Scholar
  24. 24.
    Groome P, Schulze KM, Keller S, Mackillop WJ, O’Sullivan B, Irish JC, Bissett RJ, Dixon PF, Eapen LJ, Gulavita SP, Hammond JA, Hodson DI, Mackenzie RG, Schneider KM, Warde PR (2006) Explaining socioeconomic status effects in laryngeal cancer. Clinical Oncology (R Coll Radiol) 18:283–292CrossRefGoogle Scholar
  25. 25.
    O'Malley CD, Le GM, Glaser SL, Shema SJ, West DW (2003) Socioeconomic status and breast carcinoma survival in four racial/ethnic groups—a population-based study. Cancer 97:1303–1311CrossRefPubMedGoogle Scholar
  26. 26.
    Polednak AP (2002) Survival of breast cancer patients in Connecticut in relation to socioeconomic and health care access indicators. Journal of Urban Health-Bulletin of the New York Academy of Medicine 79: 211–218Google Scholar
  27. 27.
    Woods LM, Rachet B, Coleman MP (2006) Origins of socio-economic inequalities in cancer survival: a review. Ann Oncol 17:5–19CrossRefPubMedGoogle Scholar
  28. 28.
    Macleod U, Ross S, Gillis C, McConnachie A, Twelves C, Watt GCM (2000) Socio-economic deprivation and stage of disease at presentation in women with breast cancer. Ann Oncol 11:105–107CrossRefPubMedGoogle Scholar
  29. 29.
    Brewster DH, Thomson CS, Hole DJ, Black RJ, Stroner PL, Gillis CR (2001) Relation between socioeconomic status and tumour stage in patients with breast, colorectal, ovarian, and lung cancer: results from four national, population based studies. Br Med J 322:830–831CrossRefGoogle Scholar
  30. 30.
    Hagenaars A, de Vos K, Zaidi MA (1994) Poverty statistics in the late 1980s: research based on micro-data. Office for Official Publications of the European Communities, LuxembourgGoogle Scholar
  31. 31.
    Verband deutscher Rentenversicherungsträger (1999) Förderschwerpunkt “Rehabilitationswissenschaften”. Empfehlungen der Arbeitsgruppen “Generische Methoden”, “Routinedaten” und “Reha-Ökonomie”. DRV-Schriften ed. VDR, Frankfurt am MainGoogle Scholar
  32. 32.
    First M, Spitzer R, Gibbon M, Williams J (1997) Structured clinical interview for DSM-IV Axis I disorders (SCID-I), clinician version. American Psychiatric Press, Washington, DCGoogle Scholar
  33. 33.
    Lyratzopoulos G, Abel GA, Brown CH, Rous BA, Vernon SA, Roland M, Greenberg DC (2013) Socio-demographic inequalities in stage of cancer diagnosis: evidence from patients with female breast, lung, colon, rectal, prostate, renal, bladder, melanoma, ovarian and endometrial cancer. Ann Oncol 24:843–850CrossRefPubMedGoogle Scholar
  34. 34.
    Singer S, Roick J, Briest S, Stark S, Gockel I, Boehm A, Papsdorf K, Meixensberger J, Müller T, Prietzel T, Schiefke F, Dietel A, Bräunlich J, Danker H (2016) Impact of socio-economic position on cancer stage at presentation: findings from a large hospital-based study in Germany. Int J Cancer 139:1696–1702CrossRefPubMedGoogle Scholar
  35. 35.
    Doubeni C, Rustgi A (2015) Racial disparities in colorectal cancer survival: is elimination of variation in care the cure? J Natl Cancer Inst 107:djv229. doi: 10.1093/jnci/djv229 CrossRefPubMedGoogle Scholar
  36. 36.
    Bristow RE, Chang J, Ziogas A, Campos B, Chavez LR, Anton-Culver H (2015) Sociodemographic disparities in advanced ovarian cancer survival and adherence to treatment guidelines. Obstet Gynecol 125:833–842CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Boscoe FP, Johnson CJ, Sherman RL, Stinchcomb DG, Lin G, Henry KA (2014) The relationship between area poverty rate and site-specific cancer incidence in the United States. Cancer 120:2191–2198CrossRefPubMedGoogle Scholar
  38. 38.
    Victora CG, Vaughan JP, Barros FC, Silva AC, Tomasi E (2000) Explaining trends in inequities: evidence from Brazilian child health studies. Lancet 356:1093–1098CrossRefPubMedGoogle Scholar
  39. 39.
    Marmot M (2006) Health in an unequal world: social circumstances, biology and disease. Clinical Medicine 6:559–572CrossRefPubMedGoogle Scholar
  40. 40.
    Arndt V, Sturmer T, Stegmaier C, Ziegler H, Becker A, Brenner H (2003) Provider delay among patients with breast cancer in Germany: a population-based study. J Clin Oncol 21:1440–1446CrossRefPubMedGoogle Scholar
  41. 41.
    Backemar L, Lagergren P, Johar A, Lagergren J (2015) Impact of co-morbidity on mortality after oesophageal cancer surgery. Br J Surg 102:1097–1105CrossRefPubMedGoogle Scholar
  42. 42.
    Westmaas JL, Newton CC, Stevens VL, Flanders WD, Gapstur SM, Jacobs EJ (2015) Does a recent cancer diagnosis predict smoking cessation? An analysis from a large prospective US cohort. J Clin Oncol 33:1647CrossRefPubMedGoogle Scholar
  43. 43.
    Sitas F, Weber MF, Egger S, Yap S, Chiew M, O'Connell D (2014) Smoking cessation after cancer. J Clin Oncol 32:3593–3595CrossRefPubMedGoogle Scholar
  44. 44.
    Danker H, Keszte J, Singer S, Thomä J, Täschner R, Brähler E, Dietz A (2011) Alcohol consumption after laryngectomy. Clin Otolaryngol 36:336–344CrossRefPubMedGoogle Scholar
  45. 45.
    Singer S, Keszte J, Thiele A, Klemm E, Täschner R, Oeken J, Meister EF, Danker H, Guntinas-Lichius O, Lautermann J, Meyer A, Dietz A (2010) Rauchverhalten nach Laryngektomie. Laryngo-Rhino-Otologie 89:146–150CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Susanne Singer
    • 1
    • 2
  • Michael Bartels
    • 3
  • Susanne Briest
    • 4
  • Jens Einenkel
    • 4
  • Dietger Niederwieser
    • 5
  • Kirsten Papsdorf
    • 6
  • Jens-Uwe Stolzenburg
    • 7
  • Sophie Künstler
    • 8
  • Sabine Taubenheim
    • 9
  • Oliver Krauß
    • 10
  1. 1.Institute of Medical Biostatistics, Epidemiology and Informatics, Division of Epidemiology and Health Services ResearchUniversity Medical Centre MainzMainzGermany
  2. 2.University Cancer Centre MainzMainzGermany
  3. 3.Department of General and Visceral SurgeryLeipzigGermany
  4. 4.Department of GynaecologyUniversity Medical Centre LeipzigLeipzigGermany
  5. 5.Department of Medical OncologyUniversity Medical Centre LeipzigLeipzigGermany
  6. 6.Department of Radiation OncologyUniversity Medical Centre LeipzigLeipzigGermany
  7. 7.Department of UrologyUniversity Medical Centre LeipzigLeipzigGermany
  8. 8.Department of Social Pedagogy and Adult Education, Faculty of Educational SciencesGoethe UniversityFrankfurtGermany
  9. 9.Regional Clinical Cancer Registry LeipzigUniversity Medical Centre LeipzigLeipzigGermany
  10. 10.Department of PsychotherapyLeipzigGermany

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