In Italy approximately a quarter of cancer deaths are attributable to low levels of education. Almost 30 thousand (29,727) cancer deaths in 2019 in our country, in the population between 30 and 84 years of age, are in fact correlated to poor education (22,271 deaths in men and 7456 in women), which often also affects subsequent income capacity, as highlighted in a study published in Journal of Public Health which quantified the impact of educational inequalities on cancer mortality in Italy. Health differences were discussed at the national conference “Close the Care Gap” (English for “Closing the care gap”) promoted by the Istituto Superiore di Sanità ISS, the Italian Association of Medical Oncology Aiom and the Aiom Foundation, on the eve of the World Cancer Day, which is celebrated on February 4th and aims to raise citizens’ awareness of the differences in access to care. On the website of World Cancer Daythe new points of call to action to governments.
The social determinants of health
They are called social determinants of health and they are physical-environmental and socio-economic conditions which have a profound influence on the health and well-being of the individual, at least equal to that exerted by biological and genetic characteristics. In this wide range of conditions, there are adequate housing and nutritionaccess toinstructional Work and you have health servicesthe social and environmental healthiness of neighborhood of residence. These factors can no longer be ignored and knowing the patient in his reality is today an essential component of the medical act.
Gaps to fill
The main cause of differences in cancer epidemiology, mortality and survival between European countries and between regions of the same country, think of the lack of homogeneity in the North-Central and South of Italy, it is not so much a lack of knowledge, but is due to determinants that cause inequality (as we told you here). Addressing injustices and inequalities is also an initiative of Cancer beating plan European Union, which addresses cancer-related disparities associated with age, gender, income, education and urbanisation. An analysis, led by the International Agency for Research on Cancer IARC in Lyon, The Lancet Regional Health – Europewhich confirms and quantifies the correlation between socioeconomic differences and cancer mortality, shows that there is a clear “social gradient”: the risk of illness and death increases as socio-economic status decreases.
Financial toxicity
A cancer diagnosis can also cause additional financial hardship for patients. It’s the so-called financial toxicity, which affects 26% of people with cancer and is linked to various factors, including the costs that patients have to bear to travel to places of treatment. Suffice it to say that, in 2022, in Italy almost 28 thousand cancer patients have changed Region for treatmentespecially for surgery. But tools are needed to identify all the causes of financial toxicity and propose solutions to the institutions to remedy them.
Measure to intervene
The first questionnaire in the world capable not only of measuring this condition but also of defining the reasons for it in the context of a public health service is Italian (we told you about it here together with its creator Francesco Perrone, president of Aiom).”Financial toxicity also affects patients in universal healthcare systems like ours,” he explained Francesco Perrone «We have already demonstrated, in a study on 3,760 citizens with cancer in Italy, that at the time of diagnosis 26% have to face economic problems and the 22.5% worsen this uncomfortable condition during treatment. Furthermore, the latter have a 20% higher risk of death in the following months and years. In light of these data, we asked ourselves what the causes were. Hence the Proffit questionnaire (Patient Reported Outcome for Fighting Financial Toxicity), composed of 16 statements to which patients are asked to express their assent or not. Cost was developed in the United States, a questionnaire made up of 11 statements that explore and measure the mainly psychological consequences of financial toxicity, without however investigating its causes, which are taken for granted. In Proffit, however, 9 statements concern the causes of economic difficulties and 7 measure their consequences».
At the time of diagnosis, 26% have to face economic problems and 22.5% worsen this uncomfortable condition during treatment. Furthermore, the latter have a 20% higher risk of death in the following months and years
Francesco Perrone, president of the Italian Medical Oncology Association – Aiom
Proffit’s 16 statements touch on various themes, starting from the quality of the interaction between the patient and the healthcare workers and the ability of the latter to talk to each other and build a welcome network, in which the patient feels taken care of, up to the costs that the system does not cover. «Some issues – continues President Perrone – concern the more or less frequent use of private healthcare. Others touch additional medications or supplementsor useful additional treatments, for example the physiotherapy which is difficult to practice in the public system. Then there are the logistics: the distance between the home and the place where you receive treatment and care transportation fee to support. And this not only in extreme cases health migration from South to North. Problems may arise in reaching specialist centers in large cities from the province. In short, a series of determinants, on which we want raise awareness among political decision-makers and administrators, who can implement policies of change. Proffit is available to the scientific community and has been validated in English for its application also in the United Kingdom, because it is useful in all contexts where there is a public health system. It is important that no citizen, from prevention to access to treatment, is left behind».
Watch out for the future
If we fail to reach everyone, “progress loses part of its beauty and becomes a wasted opportunity of rights that are told and not guaranteed” commented Francesco Perrone, going on to list some reasons for concern for the Aiom oncologists: “The increase in patients and the request for assistance but not the dedicated staff; the debacle of independent clinical research, a situation in which we are not generated but search is performed; thethe excessive cost of some drugs not justified by real benefit that entail and this puts the sustainability of the healthcare system at risk; L’differentiated autonomy that will increase the gap instead of reducing it, we want to avoid division and competition between Regions (which already exist); the adoption of unhealthy lifestyles, probably also because prevention costs money.” For this reason, concludes Perrone, «we ask for more investments and more staff, also to free clinicians from too many bureaucratic obligations. Oncology is a cornerstone of the National Health Service, but it must be supported with structural measures.”
Italy: survival is good, prevention is bad
«Italian Oncology, if adequately supported, can establish itself as an engine of development not only in the scientific, but also in the economic and social fields» he explains Mauro Biffoni, director of the Oncology and Molecular Medicine department of the ISS. «The quality of our healthcare system is demonstrated by the 5-year survival from diagnosis, which has higher rates than the European average in the most frequent tumors. ‘World Cancer Day’ aims to highlight the differences in treatments. Even in Italy there are disparities that must be overcome, so that no one is left behind and everyone can access not only the most effective therapies but also screening programs, regardless of where they live.”
«The Italian situation, relating to poor adherence to healthy lifestyles, is serious and shows no signs of improvement» he said Saverio Cinieri, president of the Aiom Foundationpresenting the spread of risky behaviors such as a sedentary lifestyle, a diet rich in meat and alcohol, smoking, overweight (which we told you about here). Yet, Cinieri recalls, there is evidence that vigorous physical activity reduces the risk of falling ill and protects against relapse and these studies have such important implications that they have been presented at the most important oncology conferences in the world.
Air pollution
«Environmental exposures are ubiquitous and widespread, often at low doses and present in the form of a mixture. This has made it rather complicated to study its relationship with health, but today the evidence is there” he explained Paolo Vineis, professor of environmental epidemiology at Imperial College London, citing estimates of deaths attributable to pollution, which have reached 8-9 million per year worldwide, mostly in poor countries. However, the basic necessary measures aimed at separating citizens from the causes, at least those known and quantifiable, of death linked to pollution are missing: «The World Health Organization has released repeated updates to the guidelines for air quality. The recommended limits for PM2.5, the fine particulate matter which is considered carcinogenic to humans, have gone from 10 to 5 micrograms per cubic meter. In October 2022, the European Commission proposed a new Directive to align with the WHO guidelines and to achieve the ambitious ‘zero pollution’ objective set by the Commission for 2050, which would involve, among other things, the reduction of number of premature deaths attributable to fine particulate matter by 55% by 2030, compared to 2005. The Italian standard currently provides for a maximum annual average value for PM2.5 of 25 micrograms per cubic meter. In 2023 four Regions, all in the Po Valley, one of the most polluted areas in Europe, opposed the revision of the European Directive on air quality, asking for less stringent limit values for pollutants than proposed and a temporal exemption. Italy, therefore, risks falling behind in the fight against climate change and environmental pollution, started by the European Commission with the Green Deal”.
Four Regions, all in the Po Valley, one of the most polluted areas in Europe, opposed the revision of the European Air Quality Directive
Paolo Vineis, an epidemiologist at Imperial College London
The dish that helps health and the environment
Recent studies have also tried to estimate, in the context of climate change and environmental crisis, the so-called co-benefits, in other words simultaneously mitigating climate change and reducing mortality. A large study conducted as part of Epic, shows that adopting a healthy diet, with proteins of animal origin and without alcohol, minimizes greenhouse gas emissions linked to nutrition and land use, reduces the environmental footprint, contributes to mitigation of climate change and at the same time improve the health of the population. Other evidence concern the inverse association between biodiversity on the plate and mortality rate.
In the photo, by Matteo Corner/LaPresse, the Charity Village in Milan