Edinburgh Napier University

  Background
People living in more deprived areas of high-income countries have lower cancer survival than those in less deprived areas. However, associations between individual-level socio-economic circumstances and cancer survival are relatively poorly understood. Moreover, few studies have addressed contextual effects, where associations between individual-level socio-economic status and cancer survival vary depending on area-based deprivation.

Methods
Using 9,276 individual-level observations from a longitudinal study in England and Wales, we examined the association with cancer survival of area-level deprivation and individual-level occupation, education, and income, for colorectal, prostate and breast cancer patients aged 20-99 at diagnosis. With flexible parametric excess hazard models, we estimated excess mortality across individual-level and area-level socio-economic variables and investigated contextual effects.

Results
For colorectal cancers, we found evidence of an association between education and cancer survival in men with Excess Hazard Ratio EHR=0.80, 95% CI [0.60;1.08] comparing “degree-level qualification and higher” to “no qualification” and EHR=0.74 [0.56;0.97] comparing “apprenticeships and vocational qualification” to “no qualification”, adjusted on occupation and income; and between occupation and cancer survival for women with EHR=0.77 [0.54;1.10] comparing “managerial/professional occupations” to “manual/technical,” and EHR=0.81 [0.63;1.06] comparing “intermediate” to “manual/technical”, adjusted on education and income. For breast cancer in women, we found evidence of an association with income (EHR=0.52 [0.29;0.95] for the highest income quintile compared to the lowest, adjusted on education and occupation), while for prostate cancer, all three individual-level socio-economic variables were associated to some extent with cancer survival. We found contextual effects of area-level deprivation on survival inequalities between occupation types for breast and prostate cancers, suggesting wider individual-level inequalities in more deprived areas compared to least deprived areas. Individual-level income inequalities for breast cancer were more evident than an area-level differential, suggesting that area-level deprivation might not be the most effective measure of inequality for this cancer. For colorectal cancer in both sexes, we found evidence suggesting area- and individual-level inequalities, but no evidence of contextual effects.

Conclusions
Findings highlight that both individual and contextual effects contribute to inequalities in cancer outcomes. These insights provide potential avenues for more effective policy and practice.