Cancer inequity: what causes inequalities of cancer care and access to treatment?

Written by: Rosie Lobley and Ben Caldwell

Following on from our overview of how the cancer care gap manifests, this article explores the wide range of factors that lead to unequal access to cancer care and how they interact.

 

Economic inequality

Economic inequality is a key determinant of access to cancer care. From the often prohibitive cost of treatment to the health risks of living in poverty, a patient’s socioeconomic status has both direct and indirect effects on the quality and availability of cancer care.

The cost of cancer medicines, which is increasing year-on-year, is a key factor affecting access to care across all countries, including both low- and middle-income countries (LMICs) and high-income countries (HICs). High prices for novel treatments have the highest impact in LMICs and countries with strict public cancer care budgets, meaning that many patients in these countries who could benefit significantly from novel medicines must instead resort to chemotherapy, which, while accessible and affordable, is frequently associated with reduced effectiveness and higher toxicity.1

Several cancer types, including cancers of the lung, mouth, stomach and bowel, are associated with lifestyle factors that are in turn disproportionately associated with poverty, such as smoking, alcohol use, diet, and obesity.2 Inadequate or poor-quality housing conditions are also associated with a higher risk of cancer.3

Cancer incidence can itself have an impact on the patient’s socioeconomic position. Adults who are diagnosed with cancer may face out-of-pocket expenses even in countries with publicly funded or universal healthcare models – as well as additional costs for home care and household support, bills, transport to and from medical appointments, hospital parking, caregiver accommodation, and potential home modifications for ease of living.4 The financial impact of cancer can then, in turn, have a tangible negative effect on patients’ quality of life and wellbeing outcomes.5 Meanwhile, in the case of childhood cancer, parents may need to take time off or even leave work to manage their child’s treatment.6

Regional inequality

Geography is a key determinant of access to and quality of cancer care, with wide disparities between countries and regions. Patients’ experience of care can be affected by the distance to their nearest cancer clinic, as well as the socioeconomic and geopolitical status of the country where they live.

Because many cancer therapies require treatment to be administered regularly over a period of time, cancer treatment in LMICs often entails escalating costs of medicine and travel; this can result in patients abandoning a course of treatment before it is completed.7

International conflict and forced displacement affect both access to care and exposure to cancer risk factors.8 In eastern Ukraine, access to care has been radically affected by Russian bombing of hospitals; while cancer care in Russia has been impacted by inflation and international sanctions.9 Patients who have been displaced from their homes by conflicts in Iraq, Lebanon, Libya, Palestine, Somalia, Sudan and Yemen are faced with healthcare facilities that have been destroyed and non-functional infrastructure, as well as the longer-term issue of ‘brain drain’, whereby specialists and experts leave conflict-affected zones to find work in more stable, higher-income regions.10

The majority of refugee displacements are from one LMIC to another: 83% of refugees in 2021 settled in LMICs, where resources are already stretched and the majority of aid allocation is directed towards immediate and emergent medical issues, primarily infectious diseases such as malaria and measles.11 In addition, some host countries’ health systems may deny care to refugees due to their immigration status.12

However, disparities in care are not limited to lower-income nations. The US is essentially unique among high-income countries in its absence of a universal coverage system for healthcare or medical insurance.13 Despite healthcare spending well above that of other HICs,14 and the highest drug cancer prices in the world – up to six times higher than other HICs15 – its performance is comparatively very poor.14 Cancer referral centres are often excluded from private health insurance plans,16 and in 2019 one in four Americans reported deferring treatment for a serious medical issue due to the cost.17

Social inequality

Many of the differences in access to cancer care which occur within countries and regions are related to social inequalities. Vulnerable and marginalised communities are often more likely to have difficulty accessing prompt, comprehensive cancer care, and many therapeutic programmes are not optimised for the distinct needs of members of these communities. Alongside sex and race inequality, education is a significant determinant of access to cancer care – primarily because patients with higher levels of education are better equipped to identify potentially troubling symptoms and more likely to be proactive in seeking treatment.

Racial inequality affects all stages of cancer care, from prevention to screening to treatment.18 Minority ethnic groups and women are vastly underrepresented in clinical trials, meaning both that they are denied access to potential treatments at the development stage, and that sex- or race-specific side effects may be overlooked.19

The impact of education on early detection of cancer symptoms is a particular issue in LMICs, where screening programmes are rare, meaning the onus is on patients to identify symptoms and seek treatment.20 The racial background and socioeconomic status of patients are closely linked to disparities in education and awareness of key symptoms.21 Among black American communities in particular, mistrust of the medical system can contribute to reluctance to seek out cancer screening and treatment.22 While education is a key influence on this phenomenon, much of this mistrust is rooted in a long-standing history in the US of medical mistreatment and exploitation of black people.23

Cancer inequality

Conclusion

The multitude of factors affecting inequality of cancer care interlock and feed into one another: lifestyle factors are linked to poverty, lack of education is closely related to socioeconomic background, while regional disparities in access to care are exacerbated by differences in household income. Economic factors in particular play a key role in other seemingly disparate issues, from education to housing to the fundamental availability of care. In our next piece in this series, we’ll examine the ways in which inequality of access to cancer care can be alleviated and what is already being done to close the cancer care gap.

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