Faculty of Medicine, Imperial College London, London, UK.
Institute for Mathematical & Molecular Biomedicine, King's College London, London, UK; Department of Research Oncology, King's College London, London, UK; PILAR Research and Education, Cambridge, UK.
Lancet. 2016 Aug 13;388(10045):684-95. doi: 10.1016/S0140-6736(16)00577-8. Epub 2016 May 25.
The global economic crisis has been associated with increased unemployment and reduced public-sector expenditure on health care (PEH). We estimated the effects of changes in unemployment and PEH on cancer mortality, and identified how universal health coverage (UHC) affected these relationships.
For this longitudinal analysis, we obtained data from the World Bank and WHO (1990-2010). We aggregated mortality data for breast cancer in women, prostate cancer in men, and colorectal cancers in men and women, which are associated with survival rates that exceed 50%, into a treatable cancer class. We likewise aggregated data for lung and pancreatic cancers, which have 5 year survival rates of less than 10%, into an untreatable cancer class. We used multivariable regression analysis, controlling for country-specific demographics and infrastructure, with time-lag analyses and robustness checks to investigate the relationship between unemployment, PEH, and cancer mortality, with and without UHC. We used trend analysis to project mortality rates, on the basis of trends before the sharp unemployment rise that occurred in many countries from 2008 to 2010, and compared them with observed rates.
Data were available for 75 countries, representing 2.106 billion people, for the unemployment analysis and for 79 countries, representing 2.156 billion people, for the PEH analysis. Unemployment rises were significantly associated with an increase in all-cancer mortality and all specific cancers except lung cancer in women. By contrast, untreatable cancer mortality was not significantly linked with changes in unemployment. Lag analyses showed significant associations remained 5 years after unemployment increases for the treatable cancer class. Rerunning analyses, while accounting for UHC status, removed the significant associations. All-cancer, treatable cancer, and specific cancer mortalities significantly decreased as PEH increased. Time-series analysis provided an estimate of more than 40,000 excess deaths due to a subset of treatable cancers from 2008 to 2010, on the basis of 2000-07 trends. Most of these deaths were in non-UHC countries.
Unemployment increases are associated with rises in cancer mortality; UHC seems to protect against this effect. PEH increases are associated with reduced cancer mortality. Access to health care could underlie these associations. We estimate that the 2008-10 economic crisis was associated with about 260,000 excess cancer-related deaths in the Organisation for Economic Co-operation and Development alone.
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全球经济危机与失业率上升和公共部门医疗保健支出减少有关。我们评估了失业率和公共部门医疗保健支出变化对癌症死亡率的影响，并确定了全民健康覆盖如何影响这些关系。
在这项纵向分析中，我们使用了世界银行和世界卫生组织（1990-2010 年）的数据。我们将女性乳腺癌、男性前列腺癌和男性和女性结直肠癌的死亡率数据汇总到一个可治疗的癌症类别中，这些癌症的生存率超过 50%。我们还将肺癌和胰腺癌的数据汇总到一个不可治疗的癌症类别中，这些癌症的 5 年生存率低于 10%。我们使用多变量回归分析，控制国家特定的人口统计学和基础设施，进行时间滞后分析和稳健性检查，以调查失业率、公共部门医疗保健支出和癌症死亡率之间的关系，包括有无全民健康覆盖。我们使用趋势分析，根据许多国家 2008 年至 2010 年失业率急剧上升之前的趋势，预测死亡率，并将其与观察到的死亡率进行比较。
在失业分析中，有 75 个国家的数据可供使用，代表 21.066 亿人，在公共部门医疗保健支出分析中，有 79 个国家的数据可供使用，代表 21.566 亿人。失业率上升与所有癌症死亡率以及除女性肺癌外的所有特定癌症的死亡率上升显著相关。相比之下，不可治疗的癌症死亡率与失业率变化没有显著关联。滞后分析显示，在失业率上升 5 年后，可治疗癌症类别的显著关联仍然存在。在考虑全民健康覆盖状况的同时，重新进行分析消除了显著关联。随着公共部门医疗保健支出的增加，所有癌症、可治疗癌症和特定癌症的死亡率都显著下降。时间序列分析根据 2000-07 年的趋势，估计 2008 年至 2010 年期间，由于一组可治疗癌症，有超过 4 万人死于可治疗癌症。这些死亡大多发生在非全民健康覆盖国家。
失业率上升与癌症死亡率上升有关；全民健康覆盖似乎可以防止这种影响。公共部门医疗保健支出的增加与癌症死亡率的降低有关。获得医疗保健可能是这些关联的基础。我们估计，仅在经济合作与发展组织内，2008-10 年的经济危机就导致了约 26 万与癌症相关的额外死亡。
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