|A 50% higher prevalence of life-shortening chronic conditions among cancer patients with low socioeconomic status.|
|Jump to Full Text|
|PMID: 20978508 Owner: NLM Status: MEDLINE|
|BACKGROUND: Comorbidity and socioeconomic status (SES) may be related among cancer patients.
METHOD: Population-based cancer registry study among 72,153 patients diagnosed during 1997-2006.
RESULTS: Low SES patients had 50% higher risk of serious comorbidity than those with high SES. Prevalence was increased for each cancer site. Low SES cancer patients had significantly higher risk of also having cardiovascular disease, chronic obstructive pulmonary diseases, diabetes mellitus, cerebrovascular disease, tuberculosis, dementia, and gastrointestinal disease. One-year survival was significantly worse in lowest vs highest SES, partly explained by comorbidity.
CONCLUSION: This illustrates the enormous heterogeneity of cancer patients and stresses the need for optimal treatment of cancer patients with a variety of concomitant chronic conditions.
|W J Louwman; M J Aarts; S Houterman; F J van Lenthe; J W W Coebergh; M L G Janssen-Heijnen|
Related Documents :
|3594388 - End results for urologic cancers. trends and interhospital differences.
22904388 - Ps1-10: spiritual well-being and the challenges of living with an ostomy: resilience, a...
3933808 - Cost-effectiveness in the diagnosis and treatment of carcinoma of unknown primary origin.
2064928 - Assessment of physician perceptions on the fatality of cancer.
22129918 - Targeting the oncogene eif4e in cancer: from the bench to clinical trials.
8416768 - Detection and localization of early lung cancer by imaging techniques.
|Type: Journal Article; Research Support, Non-U.S. Gov't Date: 2010-10-26|
|Title: British journal of cancer Volume: 103 ISSN: 1532-1827 ISO Abbreviation: Br. J. Cancer Publication Date: 2010 Nov|
|Created Date: 2010-11-24 Completed Date: 2010-12-15 Revised Date: 2013-07-03|
Medline Journal Info:
|Nlm Unique ID: 0370635 Medline TA: Br J Cancer Country: England|
|Languages: eng Pagination: 1742-8 Citation Subset: IM|
|Comprehensive Cancer Centre South (IKZ), Eindhoven Cancer Registry, PO Box 231, Eindhoven 5600 AE, The Netherlands. email@example.com|
|APA/MLA Format Download EndNote Download BibTex|
Cardiovascular Diseases / etiology
Diabetes Mellitus / etiology
Neoplasms / complications*, mortality
Journal ID (nlm-ta): Br J Cancer
Publisher: Nature Publishing Group
Copyright © 2010 Cancer Research UK
Revision Received Day: 17 Month: 08 Year: 2010
Accepted Day: 15 Month: 09 Year: 2010
Print publication date: Month: 11 Year: 2010
Electronic publication date: Day: 26 Month: 10 Year: 2010
Volume: 103 Issue: 11
First Page: 1742 Last Page: 1748
Publisher Item Identifier: 6605949
PubMed Id: 20978508
|A 50% higher prevalence of life-shortening chronic conditions among cancer patients with low socioeconomic status Alternate Title:Socioeconomic status and comorbidity|
|W J Louwman12*|
|M J Aarts1|
|F J van Lenthe2|
|J W W Coebergh12|
|M L G Janssen-Heijnen12|
1Comprehensive Cancer Centre South (IKZ), Eindhoven Cancer Registry, PO Box 231, Eindhoven 5600 AE, The Netherlands
2Department of Public Health, Erasmus University Medical Center Rotterdam, PO Box 2040, Rotterdam 3000 CA, The Netherlands
3MMC Academy, Máxima Medical Center, PO Box 7777, Veldhoven 5500 MB, The Netherlands
People of a lower socioeconomic status (SES) generally have poorer health status and higher mortality than people of higher SES (Jemal et al, 2008; Mackenbach et al, 2008), also with respect to cancer, with in general higher incidence rate of all cancers combined among people from lower socioeconomic groups (Dalton et al, 2008). A differential distribution of known risk factors for specific neoplasms between SES groups seems a likely explanation for the above inequalities. For example, the prevalence of smokers has become higher among lower classes (Lahelma et al, 1997; Stronks et al, 1997), probably resulting in higher rates of cancer of the lung, larynx, mouth, pharynx, oesophagus, and bladder (Siemiatycki et al, 1995; Stellman and Resnicow, 1997; Tyczynski et al, 2003). However, smoking is not only related to cancer but also to chronic obstructive pulmonary diseases (COPD) and cardiovascular diseases (Doll et al, 1994). Hence, the high prevalence of comorbidity among lung cancer patients (Janssen-Heijnen et al, 1998). Socioeconomic status may thus be associated with comorbidity among cancer patients. Thus, medical doctors are presented with a heterogeneous group of cancer patients, for whom appropriate individual treatment must be chosen, taking concomitant conditions into account (Ayanian et al, 2003; Lash et al, 2003; Janssen-Heijnen et al, 2004; Lemmens et al, 2005; Louwman et al, 2005; van Spronsen et al, 2005).
We studied in a large population-based group of cancer patients the prevalence of comorbidity according to SES, not only by number of concomitant diseases, but also for specific diseases that affect patients with the various tumour sites.
The Eindhoven Cancer Registry records data on all patients newly diagnosed with cancer in the south of the Netherlands (2.4 million inhabitants, 15% of the Dutch population); it also records serious comorbidity according to an adaptated list (Charlson et al, 1987). Chronic obstructive pulmonary diseases, cardio- and cerebrovascular diseases, peripheral arterial disease, other malignancies, and diabetes mellitus, connective tissue diseases, rheumatoid arthritis, kidney, bowel, and liver diseases, dementia, tuberculosis and other chronic infections were also recorded. For most analyses peripheral arterial disease was included in the cardiovascular diseases, although gastrointestinal diseases were grouped (gastric diseases, Crohn's disease, ulcerative colitis, liver cirrhosis, and hepatitis). Comorbidity was defined as life-shortening disease that was present at the time of cancer diagnosis and/or received treatment or surveillance. Trained registry personnel actively collect data on diagnosis, staging, and treatment from the medical records after notification by pathologists and medical registration offices. Previous admissions, letters from and to general practitioners and other specialists, the medical history and preoperative screening were used as sources.
Patients with cancer of the oesophagus, stomach, colon or rectum, pancreas, lung, melanoma, breast, cervix uteri, corpus uteri, ovary, prostate, bladder, kidney, and non-Hodgkin's lymphoma (NHL), newly diagnosed between 1997 and 2006 (n=72 153), were included in this study; cancers diagnosed at autopsy (n=369) were excluded.
Statistics Netherlands developed an indicator of SES, using individual fiscal data on the economic value of the home and household income, and is provided at aggregated level for each postal code (covering an average of 17 households). Socioeconomic status was categorised as low (deciles 1–3), medium (deciles 4–7), or high social class (deciles 8–10), and a separate class for postal codes for a long-term care providing institution (such as a nursing home; van Duijn and Keij, 2002). We calculated the distribution of cancer patients across socioeconomic strata according to tumour localisation, also by gender and age. Patients for whom the SES was unknown (n=766, 1%) or for whom the postal code included a care providing institution (n=3569, 5%), as well as those with unknown comorbidity (n=8399, 12%) were excluded from the analyses of SES and comorbidity. Differences in distribution were tested with the χ2 test. Logistic regression analyses of the odds of having a specific concomitant disease were performed age- and gender-adjusted for all tumour sites combined, and according to tumour site for four concomitant diseases separately; cardiovascular disease, COPD, diabetes mellitus, and gastrointestinal disease. Statistical significance of an overall effect of SES on the prevalence of a specific condition was tested using the χ2-likelihood ratio test. Crude 1-year survival rates were calculated for all studied tumours combined and for the most important tumour sites separately. Cox's regression models were used to compute multivariate rates (hazard ratio=HR) and 95% confidence intervals (95% CI). The relative contribution (%) of adding comorbidity to the model was calculated as follows: ((HR model A−HR model B)/(HR model A−1)) × 100, where A is the basic model (age- and gender-adjusted) and in model B comorbidity is added to model A. All statistical analyses were performed using SAS V9.12 (SAS Institute Inc., Cary, NC, USA).
Male cancer patients were older than female patients (Table 1), the median age being 69 and 64 years, respectively (P<0.0001). At the time of the diagnosis of the cancer 71% of male and 58% of female cancer patients had at least one concomitant disease. The most frequent concomitant condition for males with cancer was cardiovascular disease (23%), for women hypertension (20%), among cancer patients older than 70 the prevalence of these diseases was 34% and 31%, respectively. In the subgroup of cancer patients with two or more concomitant diseases, the most frequent combination of diseases among males was cardiovascular disease with hypertension (14%) and in females diabetes with hypertension (21%).
The proportion of patients by SES varied for the different tumour sites (Table 2). Patients under age 70 with stomach, lung, bladder, or cervical cancer more often had low SES. High SES was more frequent among patients with melanoma or breast, colorectal, or prostate cancer in this age group.
Among patients aged 70+ with cancer of the oesophagus, stomach, or lung, low SES was clearly over-represented. High SES was more frequent among patients with prostate cancer or NHL.
For all tumour localisations the proportion of patients without comorbidity was highest in the high SES group (Figure 1). A gradient towards more concomitant conditions appeared in lower SES groups (P<0.001), which had a significantly higher risk of cardiovascular disease (ORlow vs high SES=1.4, 95% CI: 1.3–1.5), COPD (OR=1.8 (1.7–1.9)), diabetes mellitus (OR=1.5 (1.4–1.6)), cerebrovascular disease (OR=1.5 (1.4–1.7)), tuberculosis (OR=1.3 (1.1–1.6)), dementia (OR=1.3 (1.0–1.8)), gastrointestinal disease (OR=1.5 (1.4–1.6)), and two or more concomitant conditions (OR=1.8 (1.7–1.9)) in addition to their cancer (Table 3). The risk of having cancer and also at least one other serious concomitant disease was 50% higher in the low SES than in the high SES group (OR=1.5 (1.4–1.6)).
For four concomitant conditions we stratified by tumour localisation (Figure 2). The risk of cardiovascular disease among low compared with high SES patients was significantly higher (1.4–1.6 times) for patients with stomach, colorectal, lung, breast, prostate, and bladder cancer. The risk of COPD was elevated among low SES patients with cancer of the stomach, colorectum, pancreas, lung, breast, corpus uteri, prostate, and kidney (OR's ranging from 1.4 to 2.2). The risk of diabetes mellitus was highest among people from low SES with breast cancer (OR=2.0 (1.2–2.4)) and the risk of gastrointestinal diseases was highest among patients with oesophageal cancer (OR=2.0 (1.2–3.4)).
Crude 1-year survival of cancer patients from lower SES was worse compared with the highest SES for all tumour sites combined and for the major sites separately (Table 4). The age-adjusted risk of death was significantly elevated for both men (HRlow vs high SES=1.40, 95% CI: 1.3–1.4) and women (HR 1.40 (1.3–1.5)). Adding comorbidity to the model reduced HR to 1.35 for men and 1.34 for women. The relative contribution of comorbidity in explaining the inequality in 1-year survival varied from 0% for lung cancer to 33% among female colorectal cancer patients.
To our knowledge, this is the first large population-based study to demonstrates the impact of SES on the prevalence of concomitant diseases among cancer patients, with increased prevalence of comorbidity in lower socioeconomic strata for each type of cancer. Cancer patients with low SES had a 50% higher risk of suffering from at least one other serious disease compared with those with high SES. The prevalence of comorbidity was significantly higher with newly diagnosed cancer of lower compared with higher SES for all 14 cancer sites studied. The diseases significantly related to SES among cancer patients were cardiovascular disease, COPD, diabetes mellitus, cerebrovascular disease, tuberculosis, diseases of the central nervous system, and gastrointestinal disease. Although both the prevalence of comorbidity and the proportional distribution of SES vary significantly among tumour types, the gradient of more comorbidity from high to low SES was apparent among all tumour types.
Smoking is probably responsible for the higher risk of cardiovascular disease, COPD, and cerebrovascular disease among low SES groups (Doll et al, 1994; Stellman and Resnicow, 1997). This is confirmed by the higher prevalence of those diseases among patients with smoking-related tumours: cancers of the stomach, lung, bladder, and kidney (Janssen-Heijnen et al, 1998; Koppert et al, 2004). Diabetes was more frequent among low SES for patients with cancers of the colorectum, pancreas, lung, breast, corpus uteri or prostate, or melanoma or NHL. Diabetes has been linked to pancreas cancer (Jain et al, 1991; Kalapothaki et al, 1993) either as a risk factor or as the clinical manifestation of the cancer itself (Warshaw and Fernandez-del Castillo, 1992). Diabetes has also been associated with an increased risk for breast (Xue and Michels, 2007), endometrial (Parazzini et al, 1991), and colorectal cancer (Polednak, 2006) probably because of a relation with obesity (Reeves et al, 2007). Substantial evidence exists for the association of obesity with low SES (Sobal and Stunkard, 1989; Wardle et al, 2002; McLaren, 2007).
The prevalence of gastrointestinal diseases was highest for low SES patients with oesophageal, colorectal, lung, breast, prostate or kidney cancer, or NHL. Oesophageal cancer has also been associated with gastrointestinal diseases (Koppert et al, 2004). A lower consumption of vegetables, fruit, and fibres, which may protect from oesophageal (Tzonou et al, 1996; Terry et al, 2001b) and colorectal cancer (Pietinen et al, 1999; Michels et al, 2000; Voorrips et al, 2000; Terry et al, 2001a; Bueno-de-Mesquita et al, 2002; Flood et al, 2002), has been reported among lower SES (Wallstrom et al, 2000; Hulshof et al, 2003; Wardle and Steptoe, 2003).
We used an indicator of SES based on the postal code of a residential area. This aggregate covers a very small geographical area, and thus represents a reliable approximation of individual SES. Furthermore, routinely collected income tax data (no questionnaires or interviews) have been found to provide reliable estimates of household income. Previous studies have proven that socioeconomic differences based on neighbourhood data tend to reflect such differences well at the individual level (Bos et al, 2000, 2001; Smits et al, 2001). Furthermore, this objective measure of SES is also applicable to older women (born before 1955), whose occupation or education does not always properly reflect their social class (Berkman and Macintyre, 1997).
Previously, we found that patients with comorbidity were often treated less aggressively, if alternative treatment strategies were available. Except for patients with a tumour with poor survival, comorbidity has an independent prognostic effect (Janssen-Heijnen et al, 2005). This negative impact of comorbidity on survival of cancer might have several mechanisms: the increased risk of death due to the comorbid condition itself, more contra-indications for the cancer treatment, more indications for dose reduction and a higher rate of treatment-related complications such as infections and cardiovascular events. In several of our recent studies, the adverse effects of comorbidity on survival appeared to be independent of treatment, so less aggressive treatment could not (fully) account for the observed differences in survival between patients with and without comorbidity (Post et al, 2001; Lemmens et al, 2005; Louwman et al, 2005; van Spronsen et al, 2005; Houterman et al, 2006). As SES represents a combination of lifestyle, health, and risk of suboptimal treatment, cancer patients with comorbidity could also (partly) explain the poorer prognosis. Although an in-depth study remains necessary to reveal whether stage at diagnosis and treatment contributed to the SES gradient in survival, also for longer survival periods, our preliminary analyses demonstrated a clear gradient in 1-year survival rates, which could partly be attributed to comorbidity.
Our study shows considerable variation in comorbidity by tumour type and a higher risk of concomitant disease among patients from lower SES. Given the aetiology of the type of tumours as well as the aetiology of the concomitant diseases that occur more frequently among patients from low SES background, a lot can probably be gained from preventive measures related to lifestyle (such as smoking and obesity). Considering survival is worse for patients of low SES, our results stress the need for reduction of socioeconomic differences in health.
Supported by a grant from the Dutch Cancer Society (IKZ 2000-2260).
|Ayanian JZ,Zaslavsky AM,Fuchs CS,Guadagnoli E,Creech CM,Cress RD,O'Connor LC,West DW,Allen ME,Wolf RE,Wright WE. Year: 2003Use of adjuvant chemotherapy and radiation therapy for colorectal cancer in a population-based cohortJ Clin Oncol211293130012663717|
|Berkman LF,Macintyre S. Year: 1997The measurement of social class in health studies: old measures and new formulationsIARC Sci Publ13851649353663|
|Bos V,Kunst AE,Mackenbach JP. Year: 2000Nationale gegevens over sociaal-economische sterfteverschillen op basis van informatie over kleine geografische eenhedenVerslag aan de programmacommissie Sociaal-economische gezondheidsverschillen IIInstituut Maatschappelijke Gezondheidszorg, Erasmus Universiteit: Rotterdam|
|Bos V,Kunst AE,Mackenbach JP. Year: 2001De omvang van sociaal-economische sterfteverschillen gemeten op buurtniveau: vergelijking met schattingen op basis van informatie op individueel niveauSociaal-economische gezonheidsverschillen: Van verklaren naar verkleinenStronks K (ed) Vol. 5, pp820Zon/MW: Den Haag|
|Bueno-de-Mesquita HB,Ferrari P,Riboli E. Year: 2002Plant foods and the risk of colorectal cancer in Europe: preliminary findingsIARC Sci Publ156899512484134|
|Charlson ME,Pompei P,Ales KL,MacKenzie CR. Year: 1987A new method of classifying prognostic comorbidity in longitudinal studies: development and validationJ Chronic Dis403733833558716|
|Dalton SO,Schuz J,Engholm G,Johansen C,Kjaer SK,Steding-Jessen M,Storm HH,Olsen JH. Year: 2008Social inequality in incidence of and survival from cancer in a population-based study in Denmark, 1994–2003: summary of findingsEur J Cancer44(142074208518674895|
|Doll R,Peto R,Wheatley K,Gray R,Sutherland I. Year: 1994Mortality in relation to smoking: 40 years' observations on male British doctorsBr Med J309901911|
|Flood A,Velie EM,Chaterjee N,Subar AF,Thompson FE,Lacey JV Jr,Schairer C,Troisi R,Schatzkin A. Year: 2002Fruit and vegetable intakes and the risk of colorectal cancer in the Breast Cancer Detection Demonstration Project follow-up cohortAm J Clin Nutr7593694311976170|
|Houterman S,Janssen-Heijnen ML,Hendrikx AJ,Berg HA,Coebergh JW. Year: 2006Impact of comorbidity on treatment and prognosis of prostate cancer patients: A population-based studyCrit Rev Oncol Hematol58606716213153|
|Hulshof KF,Brussaard JH,Kruizinga AG,Telman J,Lowik MR. Year: 2003Socio-economic status, dietary intake and 10 y trends: the Dutch National Food Consumption SurveyEur J Clin Nutr5712813712548307|
|Jain M,Howe GR,St Louis P,Miller AB. Year: 1991Coffee and alcohol as determinants of risk of pancreas cancer: a case-control study from TorontoInt J Cancer473843891993545|
|Janssen-Heijnen ML,Houterman S,Lemmens VE,Louwman MW,Maas HA,Coebergh JW. Year: 2005Prognostic impact of increasing age and co-morbidity in cancer patients: a population-based approachCrit Rev Oncol Hematol5523124015979890|
|Janssen-Heijnen ML,Schipper RM,Razenberg PP,Crommelin MA,Coebergh JW. Year: 1998Prevalence of co-morbidity in lung cancer patients and its relationship with treatment: a population-based studyLung Cancer211051139829544|
|Janssen-Heijnen ML,Smulders S,Lemmens VE,Smeenk FW,van Geffen HJ,Coebergh JW. Year: 2004Effect of comorbidity on the treatment and prognosis of elderly patients with non-small cell lung cancerThorax5960260715223870|
|Jemal A,Thun MJ,Ward EE,Henley SJ,Cokkinides VE,Murray TE. Year: 2008Mortality from leading causes by education and race in the United States, 2001Am J Prev Med341818083444|
|Kalapothaki V,Tzonou A,Hsieh CC,Toupadaki N,Karakatsani A,Trichopoulos D. Year: 1993Tobacco, ethanol, coffee, pancreatitis, diabetes mellitus, and cholelithiasis as risk factors for pancreatic carcinomaCancer Causes Control43753828347787|
|Koppert LB,Janssen-Heijnen ML,Louwman MW,Lemmens VE,Wijnhoven BP,Tilanus HW,Coebergh JW. Year: 2004Comparison of comorbidity prevalence in oesophageal and gastric carcinoma patients: a population-based studyEur J Gastroenterol Hepatol1668168815201582|
|Lahelma E,Rahkonen O,Berg MA,Helakorp S,Prattala R,Puska P,Uutela A. Year: 1997Changes in health status and health behavior among Finnish adults 1978–1993Scand J Work Environ Health23(Suppl 385909456073|
|Lash TL,Thwin SS,Horton NJ,Guadagnoli E,Silliman RA. Year: 2003Multiple informants: a new method to assess breast cancer patients' comorbidityAm J Epidemiol15724925712543625|
|Lemmens VE,Janssen-Heijnen ML,Verheij CD,Houterman S,Repelaer van Driel OJ,Coebergh JW. Year: 2005Co-morbidity leads to altered treatment and worse survival of elderly patients with colorectal cancerBr J Surg9261562315779071|
|Louwman WJ,Janssen-Heijnen ML,Houterman S,Voogd AC,van der Sangen MJ,Nieuwenhuijzen GA,Coebergh JW. Year: 2005Less extensive treatment and inferior prognosis for breast cancer patient with comorbidity: a population-based studyEur J Cancer4177978515763655|
|Mackenbach JP,Stirbu I,Roskam AJ,Schaap MM,Menvielle G,Leinsalu M,Kunst AE. Year: 2008Socioeconomic inequalities in health in 22 European countriesN Engl J Med3582468248118525043|
|McLaren L. Year: 2007Socioeconomic status and obesityEpidemiol Rev29294817478442|
|Michels KB,Edward G,Joshipura KJ,Rosner BA,Stampfer MJ,Fuchs CS,Colditz GA,Speizer FE,Willett WC. Year: 2000Prospective study of fruit and vegetable consumption and incidence of colon and rectal cancersJ Natl Cancer Inst921740175211058617|
|Parazzini F,La Vecchia C,Bocciolone L,Franceschi S. Year: 1991The epidemiology of endometrial cancerGynecol Oncol411162026352|
|Pietinen P,Malila N,Virtanen M,Hartman TJ,Tangrea JA,Albanes D,Virtamo J. Year: 1999Diet and risk of colorectal cancer in a cohort of Finnish menCancer Causes Control1038739610530608|
|Polednak AP. Year: 2006Comorbid diabetes mellitus and risk of death after diagnosis of colorectal cancer: a population-based studyCancer Detect Prev3046647217069990|
|Post PN,Hansen BE,Kil PJ,Janssen-Heijnen ML,Coebergh JW. Year: 2001The independent prognostic value of comorbidity among men aged <75 years with localized prostate cancer: a population-based studyBJU Int8782182611412219|
|Reeves GK,Pirie K,Beral V,Green J,Spencer E,Bull D. Year: 2007Cancer incidence and mortality in relation to body mass index in the Million Women Study: cohort studyBr Med J3351134|
|Siemiatycki J,Krewski D,Franco E,Kaiserman M. Year: 1995Associations between cigarette smoking and each of 21 types of cancer: a multi-site case-control studyInt J Epidemiol245045147672889|
|Smits J,Keij I,Westert G. Year: 2001Effecten van sociaal-economische status van kleine, middelgrote en grote geografische eenheden op de sterfteMndstat bevolking11410|
|Sobal J,Stunkard AJ. Year: 1989Socioeconomic status and obesity: a review of the literaturePsychol Bull1052602752648443|
|Stellman SD,Resnicow K. Year: 1997Tobacco smoking, cancer and social classIARC Sci Publ229250|
|Stronks K,van de Mheen HD,Looman CW,Mackenbach JP. Year: 1997Cultural, material, and psychosocial correlates of the socioeconomic gradient in smoking behavior among adultsPrev Med267547669327486|
|Terry P,Giovannucci E,Michels KB,Bergkvist L,Hansen H,Holmberg L,Wolk A. Year: 2001aFruit, vegetables, dietary fiber, and risk of colorectal cancerJ Natl Cancer Inst9352553311287446|
|Terry P,Lagergren J,Hansen H,Wolk A,Nyren O. Year: 2001bFruit and vegetable consumption in the prevention of oesophageal and cardia cancersEur J Cancer Prev1036536911535879|
|Tyczynski JE,Bray F,Parkin DM. Year: 2003Lung cancer in Europe in 2000: epidemiology, prevention, and early detectionLancet Oncol4455512517539|
|Tzonou A,Lipworth L,Garidou A,Signorello LB,Lagiou P,Hsieh C,Trichopoulos D. Year: 1996Diet and risk of esophageal cancer by histologic type in a low-risk populationInt J Cancer683003048903470|
|van Duijn C,Keij I. Year: 2002Sociaal-economische status indicator op postcode niveauMaandstatistiek van de bevolking503235|
|van Spronsen DJ,Janssen-Heijnen ML,Lemmens VE,Peters WG,Coebergh JW. Year: 2005Independent prognostic effect of co-morbidity in lymphoma patients: results of the population-based Eindhoven Cancer RegistryEur J Cancer411051105715862755|
|Voorrips LE,Goldbohm RA,van Poppel G,Sturmans F,Hermus RJ,van den Brandt PA. Year: 2000Vegetable and fruit consumption and risks of colon and rectal cancer in a prospective cohort study: The Netherlands Cohort Study on Diet and CancerAm J Epidemiol1521081109211117618|
|Wallstrom P,Wirfalt E,Janzon L,Mattisson I,Elmstahl S,Johansson U,Berglund G. Year: 2000Fruit and vegetable consumption in relation to risk factors for cancer: a report from the Malmo Diet and Cancer StudyPublic Health Nutr326327110979146|
|Wardle J,Steptoe A. Year: 2003Socioeconomic differences in attitudes and beliefs about healthy lifestylesJ Epidemiol Community Health5744044312775791|
|Wardle J,Waller J,Jarvis MJ. Year: 2002Sex differences in the association of socioeconomic status with obesityAm J Public Health921299130412144988|
|Warshaw AL,Fernandez-del Castillo C. Year: 1992Pancreatic carcinomaN Engl J Med3264554651732772|
|Xue F,Michels KB. Year: 2007Diabetes, metabolic syndrome, and breast cancer: a review of the current evidenceAm J Clin Nutr86s823s83518265476|
Keywords: socioeconomic status, comorbidity, chronic disease, survival.
Previous Document: PHD3 regulates differentiation, tumour growth and angiogenesis in pancreatic cancer.
Next Document: Routine psychosocial distress screening in radiotherapy: implementation and evaluation of a computer...