For whom the bell tolls
Thank you for this opportunity to speak at the launch of Mouth Cancer Action Month 2010. On my way here I was thinking, as I heard Big Ben’s bell ringing, that my research chimes with the location here in the Houses of Parliament. It also chimes with the current economic and social climate that we live in.
My research on mouth cancer inequalities is a subject that is inherently political. Our research at the University of Glasgow Dental School is focused on understanding and ultimately tackling socioeconomic inequalities in oral health.
Mouth cancer is a horrible, insidious disease. Horrible, as John Diamond – the respected journalist who so vividly documented his suffering and death from oral cancer – described it as “like being on death row”.
Insidious, because it hides under the radar of public and research attention, casting a dark shadow of devastating and often fatal consequences for individuals, families, and communities, while also stretching limited healthcare resources.
The research which I am going to talk about today is a European collaborative with 14 centres across 11 countries – including our own in Glasgow; Manchester and Newcastle were the other UK centres. The research was well funded by the EU framework grant.
We studied mouth cancer alongside pharynx/throat, larynx and oesophagus/gullet – grouped together as upper aerodigestive tract cancers. Collectively, they are among the most common in the world, especially in developing countries, but increasingly in Europe and North America.
Globally there are about 550,000 cases a year, in Europe, about 180,000 cases every year and in the UK, we observe more than 10,000 cases, 1,000 in Scotland.
Socioeconomic inequalities – with the poorest bearing the greatest burden – are increasingly being recognised. In Scotland there is a two-fold greater incidence in the most deprived compared to the least deprived areas.
Traditional risk factors for mouth cancer are well known and described. There is plenty of evidence that smoking and alcohol increase risk. And there is moderate level evidence that diets low in fresh fruit and vegetables, and human papilloma virus (HPV) infection, also increase risk.
Our systematic review of the world literature has also shown definitively that low socioeconomic status by income, education and occupational social class increases risk for mouth cancer significantly. However, the components and nature of this socioeconomic risk are not well understood – with lifestyle risk factors (smoking, and alcohol) being the accepted explanation.
So, in our European study, we aimed to assess socioeconomic factors associated with upper aerodigestive tract cancer risk, both independently and through their influence on known lifestyle behaviours.
We employed a case-control study design with robust methods. This involved hour-long face-to-face interviews by trained research nurses following a detailed standardised script. We investigated full life histories of patients recently diagnosed with cancer and the control group were recruited to the study matched on age and sex only – in that they were broadly identical, but didn’t have cancer.
Data collected included demographics, full-time occupation history, very detailed information on smoking, alcohol and diet behaviours.
Socioeconomic status was measured in several ways: education, occupational social class and unemployment experience.
We managed to recruit large numbers due to the multi-centre collaboration and the good funding arrangements. Some 2,200 people with cancer and a similar number of controls participated – making this the largest study of its kind in the world. More than half the cases were those with mouth cancer.
What were our findings?
- low occupational social class – manual workers – had a 50 per cent increase risk relative to non-manual workers.
- unemployed experience conferred a 60 per cent increase risk
- low educational attainment gave a near two-fold increase risk.
However, when we took into account how much of these differences were explained by alcohol, smoking and diet, significance was diminished in all but education, with education conferring a 30 per cent increase risk independent of lifestyle. This finding was consistent for all cancer subsites – including mouth cancer. It was more prominent in UK and northern and eastern European centres compared to central and southern European centres.
We also found, from the life course of occupational histories, that downward social mobility or being consistently in lower socioeconomic group, relative to a life-time in a higher socioeconomic group gave an increased risk.
So, the explanation for our findings boil down to two pathways: the ’cause of the cause’ explanation – with low socio- economic circumstances influencing behaviour – and we have seen this; and the more ‘direct/ fundamental’ effects of socio-economic status, and we have observed this also.
What was interesting was that low educational attainment was the strongest socioeconomic risk factor. The explanations for this have yet to be fully unbundled, but education potentially:
- reflects childhood socioeconomic circumstances
- influences position in society, social networks and income
- affects access to healthcare services, health information and uptake
- determines values, attitudes, cognitive decision-making, and risky behaviours.
We must also reflect that smoking and alcohol are socially patterned and have been described as social justice issues.
While one could argue that smokers in a sense choose to smoke, we know that this choice is effected by the unequal social circumstances in which they are made. Analysis of the literature reveals important factors such as:
- advertising targeted to more deprived areas and groups
- unequal dissemination of smoking information and availability of smoking cessation services
- social stresses, cultural differences and norms.
In conclusion, our study found:
- socioeconomic inequalities in mouth cancer risk are not totally explained by lifestyle risk
- education is the most powerful of the socioeconomic factors
- further investigation into underlying biological processes is required, including the role of psychosocial stress.
Finally, if I may, and given our location at the heart of political decision making, I would like to extend our research findings into some potential implications for policy and practice:
1 We need upstream action – by that I mean efforts to address the underlying socioeconomic determinants are required if we are to really tackle health inequalities. The ongoing debate about the fairness (or otherwise) of the public sector cuts in the recent comprehensive spending review highlights some acknowledgment of this. The Marmot Review into tackling health inequalities needs to be implemented, but it looks like it may be ignored just as the Black Report was nearly 30 years ago.
2 Maintaining education – as a, if not the, top governmental priority – is essential, particularly in these times.
3 Public health and preventive programmes or behavioural risk factors need to more explicitly acknowledge and be designed to take into account socioeconomic circumstances.
4 Rather than target interventions to deprived communities, activities and services should be developed with communities as full partners.
5 And finally, health services need to further shift from a treatment to a preventive focus.
In these regards, there remains some uncertainty about which direction policy is going with the coalition government. Health inequalities were conspicuous by their absence from the initial coalition agreement.
Health and wellbeing inequalities seem to be lost from the discourse around the government’s spending review – where I would argue that the impact of the cuts should be viewed through this lens and health inequalities’ impact assessed. Moreover, health inequalities seem sidelined in the NHS White Paper.
We need to follow the Dental Health Foundation’s lead with shifting from Mouth Cancer Awareness to Mouth Cancer Action Month – we need more action.
And for all the politicians here, I leave you with a quote from George Orwell’s The Road to Wigan Pier, which I believe encapsulates the will required to tackle inequalities in health, including those we observe for mouth cancer :
“Economic injustice will stop the moment we want it to stop and no sooner, and if we genuinely want it to stop, the method adopted hardly matters.”
David Conway is a Clinical Senior Lecturer in Dental Public Health at the University of Glasgow Dental School