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Gaceta Sanitaria

Print version ISSN 0213-9111

Gac Sanit vol.33 n.3 Barcelona May./Jun. 2019  Epub Nov 25, 2019

http://dx.doi.org/10.1016/j.gaceta.2017.11.008 

ORIGINAL ARTICLES

Trends in cancer mortality in Spain: the influence of the financial crisis

Evolución de la mortalidad por cáncer en España: influencia de la crisis económica

Josep Ferrandoa  , Laia Palènciaa  b  c  , Mercè Gotsensa  b  c  *  , Vanessa Puig-Barrachinaa  , Marc Marí-Dell’Olmoa  b  c  , Maica Rodríguez-Sanza  b  c  d  , Xavier Bartolla  c  , Carme Borrella  b  c  d 

a Agència de Salut Pública de Barcelona, Barcelona, Spain.

b CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.

c Institut d’Investigació Biomèdica IIB Sant Pau, Barcelona, Spain.

d Departamento de Ciencias Experimentales y de la Salud, Facultad de Ciencias de la Salud y de la Vida, Universitat Pompeu Fabra, Barcelona, Spain.

ABSTRACT

Objective

To determine if the onset of the economic crisis in Spain affected cancer mortality and mortality trends.

Method

We conducted a longitudinal ecological study based on all cancer-related deaths and on specific types of cancer (lung, colon, breast and prostate) in Spain between 2000 and 2013. We computed age-standardised mortality rates in men and women, and fit mixed Poisson models to analyse the effect of the crisis on cancer mortality and trends therein.

Results

After the onset of the economic crisis, cancer mortality continued to decline, but with a significant slowing of the yearly rate of decline (men: RR = 0.987, 95%CI = 0.985-0.990, before the crisis, and RR = 0.993, 95%CI = 0.991-0.996, afterwards; women: RR = 0.990, 95%CI = 0.988-0.993, before, and RR = 1.002, 95%CI = 0.998-1.006, afterwards). In men, lung cancer mortality was reduced, continuing the trend observed in the pre-crisis period; the trend in colon cancer mortality did not change significantly and continued to increase; and the yearly decline in prostate cancer mortality slowed significantly. In women, lung cancer mortality continued to increase each year, as before the crisis; colon cancer continued to decease; and the previous yearly downward trend in breast cancer mortality slowed down following the onset of the crisis.

Conclusions

Since the onset of the economic crisis in Spain the rate of decline in cancer mortality has slowed significantly, and this situation could be exacerbated by the current austerity measures in healthcare.

Keywords: Economic crisis; Austerity; Health care cuts; Cancer; Financial crisis; Mortality

RESUMEN

Objetivo

Determinar si el inicio de la crisis económica en España afectó a la mortalidad por cáncer y sus tendencias.

Método

Estudio ecológico longitudinal que analiza todas las muertes por cáncer y por tipos específicos de cáncer (pulmón, colon, mama y próstata) en España entre 2000 y 2013. Se estimaron las tasas de mortalidad estandarizadas por edad en hombres y mujeres, y se ajustaron modelos mixtos de Poisson para analizar el efecto de la crisis sobre la mortalidad por cáncer y sus tendencias.

Resultados

Después del inicio de la crisis económica, la mortalidad por cáncer continuó su tendencia a la baja, pero con una disminución significativa del decrecimiento anual (hombres: riesgo relativo [RR] = 0,987, intervalo de confianza del 95% [IC95%] = 0,985-0,990, antes de la crisis, y RR = 0,993, IC95% = 0,991-0,996 después; mujeres: RR = 0,990, IC95% = 0,988-0,993, antes, y RR = 1,002, IC95% = 0,998-1,006 después). En los hombres, la mortalidad por cáncer de pulmón se redujo, continuando la tendencia observada en el periodo anterior a la crisis; la tendencia en la mortalidad por cáncer de colon no cambió significativamente y siguió aumentando; y la disminución anual de la mortalidad por cáncer de próstata se desaceleró significativamente. En las mujeres, la mortalidad por cáncer de pulmón continuó aumentando cada año, como antes de la crisis; el cáncer de colon continuó disminuyendo; y la tendencia a la disminución de la mortalidad por cáncer de mama se desaceleró después del inicio de la crisis.

Conclusiones

Desde el inicio de la crisis económica en España, la disminución de la tasa de mortalidad por cáncer se ha desacelerado significativamente y esta situación podría verse exacerbada por las actuales medidas de austeridad en el sistema sanitario.

Palabras clave: Crisis económica; Austeridad; Recortes en salud; Cáncer; Crisis financiera; Mortalidad

Introduction

The impact of an economic crisis on health depends on various factors.1 2 While economic crises have adverse effects on both the determinants and inequalities of health,3 4 they can in fact provide an opportunity to promote primary prevention healthcare measures.5

History has already shown that economic crises can be accompanied by an increase in mortality, particularly among certain population subgroups, such as children.6 7 Within the European Union for instance, a reduction in public spending on healthcare during times of crisis has been found to be associated with increased mortality.8 Interestingly, some studies have not observed an increase in overall mortality, but rather an increase in the number of suicides,9-11 offset by a decrease in other causes of death, such as those due to traffic injuries.12 13

Increased unemployment along with lower investment in the public health sector are known to be associated with an increase in total cancer mortality, particularly of breast, colon, prostate and lung cancer.14-18 Furthermore, it has been shown in some countries that complete public health coverage or greater public health expenditure counteract the negative effect of unemployment, and thus these countries do not show an increase in cancer mortality.15 19 20

The most recent economic crisis began to affect Spain in 2008, and a recent study analysed the effect that this crisis had on both general mortality and some specific causes.21 This study found that overall mortality was declining before the onset of the crisis (2004-2007), and that the same trend continued during the subsequent years (2008-2011), particularly among disadvantaged socioeconomic groups. These two periods also saw a lower number of cancer-related deaths, especially in men, although this study only analysed data until 2011, and did not distinguish between the different types of cancer.

In response to the 2008 crisis in Spain, the Spanish government activated various economic adjustment procedures, including healthcare reform encompassing a set of legislative measures aimed at cutting health expenditure. This reform, brought into action by the approval of Royal Decree Law 16/2012, was a key health austerity measure.7 22 23 However, the effect of the economic crisis in Spain has been heterogeneous with respect to the different autonomous communities, which may be because each region has some control over how social cuts are implemented.24

Given the limited research on economic crises and cancer mortality, the objective of our study was to determine if cancer mortality, and its overall trends, have changed since the onset of the latest economic crisis in Spain.

Methods

We conducted a longitudinal study of the period 2000 to 2013, with 2008 considered as the year the economic crisis started, and the study population consisted of all residents in Spain during 2000 to 2013. We collected information from the Spanish Mortality Registry, a resource based on the Statistical Bulletin of Deaths, and from the ongoing population census. We analysed all deaths caused by cancer in general (CIE-10: C00-C96), as well as those caused by four specific types of malignant neoplasm: colon (CIE-10: C18), bronchus and lung (CIE-10: C34), breast (CIE-10: C50), and prostate (CIE-10: C61). For our analysis, we considered the following variables: year of death, age at death, gender, autonomous community, and cause of death.

We performed a descriptive analysis of the population according to the number of deaths caused by each of the types of cancer in men and women for each year of the study period. We then estimated annual mortality rates for all cancers, individually for lung and colon cancer in both sexes, for prostate in men, and for breast cancer in women. Rates were standardised by age using the direct method in which the reference population was the Spanish population of 2001. Data were also represented graphically to visibly highlight the trends.

Finally, we constructed mixed Poisson models to analyse the effect of the crisis on mortality, including its general trends both before and during the crisis (see Model 1; where I = autonomous community, and t = year). We accounted for the variability between autonomous communities by including random effects in the constant and coefficients of the variables for crisis (dichotomous variable taking value 0 for 2000-2007, and 1 for 2008-2013) (b1i), year (b2i), and the interaction between crisis and year (b3i). Using our model, we determined the relative risk (RR) for each type of cancer by estimating the differences in mortality between the first year of the crisis (2008) and the last year before the onset of the crisis (2007; RR crisis; 95%CI). Finally, to evaluate annual trends in mortality, we determined the relative risks for the pre-crisis (RR pre-crisis years; 95%CI) and crisis (RR crisis years; 95%CI) periods.

Model 1:

deathit ~ Poissonλit, i=1, ..., 17, t=1, ..., 14

logλit=logpopit+β0+b0i+β1+b1i*crisist+β2+b2i*yeart-2008+β3+b3i*crisist*yeart-2008+εit

where:

crisist=1 if yeart 20080 if yeart <2008

b0iN0, σ02, b1i ~ N0, σ12, b2i ~ N0, σ22, b3i ~ N0, σ32

Results

Table 1 shows the number of cancer-related deaths in Spain in the years 2000 to 2013, overall, and for lung, colon, prostate and breast cancer. Overall, the data show higher cancer mortality in men than women, with lung and breast cancer being the principal causes of cancer mortality in men and women, respectively.

Table 1 Number of deaths due to cancer, total population in Spain and standardised mortality rate (SMR) per 100,000 inhabitants. Men and women, 2000-2013 (Source: Spanish Mortality Registry, Spanish Institute of Statistics). 

All cancer Lung cancer Colon cancer Prostate cancer/Breast cancer
Deaths Population SMR Deaths Population SMR Deaths Population SMR Deaths Population SMR
Men
2000 58,926 19,748,953 352.6 15,389 19,748,953 88.31 4,720 19,748,953 29.08 5,437 19,748,953 37.05
2001 60,939 20,091,592 354.3 16,177 20,091,592 90.60 5,028 20,091,592 30.10 5,644 20,091,592 36.97
2002 60,817 20,489,697 346.6 15,918 20,489,697 87.51 5,029 20,489,697 29.27 5,652 20,489,697 36.16
2003 62,037 20,961,194 345.4 16,459 20,961,194 88.59 5,261 20,961,194 29.98 5,588 20,961,194 34.84
2004 62,661 21,212,679 342.2 16,580 21,212,679 87.34 5,515 21,212,679 30.82 5,664 21,212,679 34.42
2005 62,388 21,709,232 333.0 16,573 21,709,232 85.91 5,548 21,709,232 30.27 5,497 21,709,232 32.43
2006 62,856 22,027,923 327.0 16,812 22,027,923 84.88 5,627 22,027,923 29.78 5,400 22,027,923 30.89
2007 64,059 22,265,841 326.8 17,114 22,265,841 84.81 5,897 22,265,841 30.69 5,561 22,265,841 30.96
2008 64,075 22,772,016 318.6 17,088 22,772,016 82.91 5,955 22,772,016 30.18 5,451 22,772,016 29.45
2009 64,677 23,039,626 314.9 17,231 23,039,626 82.12 6,244 23,039,626 30.89 5,504 23,039,626 28.88
2010 65,844 23,146,097 314.3 17,221 23,146,097 80.62 6,503 23,146,097 31.55 5,859 23,146,097 29.83
2011 66,745 23,200,766 311.2 17,447 23,200,766 79.98 6,658 23,200,766 31.44 6,019 23,200,766 29.57
2012 68,071 23,213,839 310.6 17,604 23,213,839 79.34 6,914 23,213,839 31.94 6,026 23,213,839 28.77
2013 67,422 23,110,309 303.0 17,497 23,110,309 78.02 6,918 23,110,309 31.31 5,769 23,110,309 26.80
Women
2000 35,687 20,609,303 154.6 1,873 20,609,303 8.33 4,021 20,609,303 17.03 5,652 20,609,303 25.20
2001 36,353 20,880,752 153.2 1,941 20,880,752 8.44 4,060 20,880,752 16.66 5,880 20,880,752 25.60
2002 36,489 21,202,842 150.9 2,100 21,202,842 8.98 4,062 21,202,842 16.42 5,732 21,202,842 24.50
2003 37,327 21,612,476 150.7 2,241 21,612,476 9.35 4,177 21,612,476 16.41 5,879 21,612,476 24.47
2004 37,371 21,842,335 148.1 2,423 21,842,335 9.99 4,245 21,842,335 16.42 5,804 21,842,335 23.73
2005 37,357 22,258,534 144.8 2,455 22,258,534 9.88 4,277 22,258,534 16.10 5,691 22,258,534 22.70
2006 38,347 22,538,309 145.0 2,616 22,538,309 10.37 4,275 22,538,309 15.64 5,927 22,538,309 23.07
2007 38,818 22,788,853 144.0 2,781 22,788,853 10.77 4,487 22,788,853 16.13 5,959 22,788,853 22.80
2008 39,501 23,236,969 142.9 3,032 23,236,969 11.52 4,607 23,236,969 16.14 6,016 23,236,969 22.35
2009 40,034 23,554,047 141.4 3,108 23,554,047 11.64 4,566 23,554,047 15.54 6,089 23,554,047 21.95
2010 40,956 23,718,321 141.8 3,442 23,718,321 12.73 4,702 23,718,321 15.63 6,264 23,718,321 22.14
2011 42,175 23,828,875 142.4 3,568 23,828,875 12.83 4,987 23,828,875 16.15 6,279 23,828,875 21.78
2012 42,508 23,886,662 140.8 3,812 23,886,662 13.61 4,813 23,886,662 15.23 6,245 23,886,662 21.18
2013 43,136 23,851,615 140.9 4,088 23,851,615 14.37 4,893 23,851,615 15.19 6,443 23,851,615 21.56

Between 2000 and 2013, cancer mortality as a whole decreased, especially in men (Figure 1). However, we observe an upward trend in the most common cancer types, especially colon cancer in men, and lung cancer in women.

Figure 1 Standardised mortality rates per 100,000 inhabitants for all cancers and for specific cancers. Men and women, Spain 2000-2013. Source: Spanish Mortality Registry, Spanish Institute of Statistics. 

According to our model (Table 2), mortality decreased in men following the onset of the crisis (RR = 0.986; 95%CI = 0.976-0.996), although the rate of decline was slower (pre-crisis period, RR = 0.987; crisis period, RR = 0.993; p <0.001). Among women, the positive decline in mortality before the crisis (RR = 0.990; 95%CI = 0.988-0.993) was disrupted by the onset of the crisis (RR = 1.002; 95%CI = 0.998-1.006; p <0.001), such that there is now no statistically significant difference between mortality before and since the onset of the crisis.

Table 2 Relative risks (RR) and 95% confidence intervals (95%CI) for cancer mortality. Men and women, Spain, 2000-2013. Source: Spanish Mortality Registry, Spanish Institute of Statistics. 

Men Women
RR (95%CI) RR (95%CI)
All cancer
Crisis (after 2008 compared before 2008) 0.986 (0.976-0.996) 1.003 (0.991-1.016)
Trend in pre-crisis years 0.987 (0.985-0.990) 0.990 (0.988-0.993)
Trend in crisis years 0.993 (0.991-0.996) 1.002 (0.998-1.006)
p-value (crisis*year) <0.001 <0.001
Lung cancer
Crisis (after 2008 compared before 2008) 0.979 (0.964-0.995) 1.007 (0.968-1.048)
Trend in pre-crisis years 0.992 (0.988-0.995) 1.037 (1.030-1.044)
Trend in crisis years 0.989 (0.983-0.995) 1.045 (1.037-1.053)
p-value (crisis*year) 0.405 0.147
Colon cancer
Crisis (after 2008 compared before 2008) 0.990 (0.961-1.019) 1.019 (0.984-1.056)
Trend in pre-crisis years 1.005 (1.000-1.011) 0.992 (0.987-0.997)
Trend in crisis years 1.011 (1.004-1.018) 0.997 (0.989-1.005)
p-value (crisis*year) 0.128 0.322
Breast cancer
Crisis (after 2008 compared before 2008)   1.010 (0.984-1.038)
Trend in pre-crisis years   0.984 (0.978-0.989)
Trend in crisis years   0.995 (0.988-1.002)
p-value (crisis*year)   0.007
Prostate cancer
Crisis (after 2008 compared before 2008) 0.998 (0.966-1.031)  
Trend in pre-crisis years 0.969 (0.964-0.974)  
Trend in crisis years 0.992 (0.985-0.999)  
p-value (crisis*year) <0.001  

RR for cancer mortality with respect to the effect of the crisis (mortality after the year 2008 compared to mortality before 2008), and RRs associated with the trends before and during the crisis (increase in annual mortality during the pre-crisis [2000-2008] and crisis [2008-2013] periods). Significant differences between the two trends are represented using p-values (interaction between year and crisis).

Regarding mortality due to specific types of cancer in men, lung cancer mortality decreased with the onset of the crisis (RR = 0.979; 95%CI = 0.964-0.995), but without a significant change in the general trend. In contrast, colon cancer mortality did not undergo any significant change after the start of the crisis, and continued to follow the same gradual increasing trend that had been observed during the pre-crisis period. Prostate cancer mortality did not vary markedly with the onset of the crisis, as the downward trend observed before the crisis underwent a significant regression (pre-crisis trend, RR = 0.969; crisis trend, RR = 0.992; p < 0.001).

In women, mortality due to lung cancer increased annually before the crisis (RR = 1.037; 95%CI = 1.030-1.044), and this trend continued after the start of the crisis. Similarly, the decreasing death trend in mortality due to colon cancer observed before the crisis also continued into the crisis period. In contrast, the decline in breast cancer mortality observed before the crisis has stagnated since 2008, (pre-crisis trend, RR = 0.984; crisis trend, RR = 0.995; p = 0.007).

Discussion

Cancer mortality as a whole has continued to decrease since the onset of the crisis, especially in men, although this decrease has slowed since 2008. However, this has not been the case for all types of cancer, such as colon cancer, for which the number of deaths has increased, particularly since the onset of the crisis. In women, the decline in cancer-related deaths overall has slowed down since the start of the crisis, while those due to lung cancer continue to rise.

Our results are consistent with a previous report on overall cancer mortality in Spain during the 2004-2011 period,21 but encompass a larger time frame (2000-2013) and include an evaluation of specific cancers with higher mortality rates.

The trends observed in Spain are similar to those reported in Greece, where cancer mortality has continued to decline since the onset of the crisis.19 One of the reasons for this continued decline is that the Greek public health system continued to function effectively despite cuts imposed by the government in response to the crisis. Although there are some differences between the Greek and Spanish health systems, they are both public systems25 that provide full access to healthcare services and thereby buffer the influence of unemployment and reduced healthcare expenditure on increased cancer mortality during times of crisis.15 In Spain, however, there was a change in this trend −the rate of decline in cancer mortality decreased with the onset of the crisis.

The health reform introduced by Royal Decree Law 16/2012 could lead to the dismantling of the current public health system. This reform had many consequences, including a decrease in the number of available hospital beds, a reduction in emergency services hours, closure of certain medical services, cancellation of surgical operations, longer waiting lists, privatization of health services, and poorer access to the health system and pharmaceutical assistance.22 23 26-30 Between 2009 and 2013 public health expenditure in Spain decreased by 18.2%, which had a strong impact on the health system's equity and universality.31 32

A recent study has highlighted how austerity measures negatively affect the quality of healthcare and population health,33 and cancer patients in particular are routinely confronted with various economic burdens, such as co-payment for pharmacological treatments and non-urgent medical transport, and payment for orthopaedic prostheses and dietary products. These pressures may drive patients in a precarious economic situation to interrupt their medical treatment.34 35

According to medical oncologists,36 lung cancer is one of the tumours most affected by cutbacks in healthcare, which results in lower patient survival rate.37 In countries whose healthcare system has been severely affected by the crisis, the situation for lung cancer patients has worsened,38 which should be cause for serious reflection given the increasing prevalence of lung cancer among women in Spain.

According to a survey among cancer patients,39 the care they receive has been markedly affected by the crisis, including restrictions on innovative cancer therapies, increases waiting times, and failures to implement and continue early cancer screening programs. Such programs are one of the best strategies for reducing cancer mortality.40 A national screening portfolio had not been defined until 2013, although screening was already being carried out in all autonomous communities for some types of cancer, such as breast cancer.41 As of 2013, breast and colorectal cancers have both been the target of population screening programs, and cervical cancer of an opportunistic program. Those autonomous communities that had not yet implemented screening programs were given a period of five years to initiate the programs, and 10 years to achieve full coverage (basically for colon cancer), although the current economic situation will not make it easy to achieve these goals.42 While population-based programs ensure more equitable access to the health system compared to opportunistic-based programs,41 some inequalities may persist, such as lower participation by ethnic minorities and underprivileged socioeconomic groups.40 41 43-51

In countries where healthcare cuts affect screening programs, cancer mortality is expected to increase in the coming years.52 Thus, it is essential that that the implementation and continuity of cancer screening programs in Spain are not affected by healthcare cuts.

Despite the negative consequences, periods of economic crisis can actually help promote primary cancer prevention by reducing unhealthy habits such as alcohol and tobacco consumption.5 21 One of the limitations of our study is that we did not evaluate health-related behaviours, socioeconomic variables or cancer stage at diagnosis time which are also often modified during times of economic crisis and can influence the appearance and severity of cancer. Because this information is not available in the Spanish Mortality Registry, it would be useful to investigate these variables in future studies to determine if they are linked to the gender differences observed in our study.

While cancer mortality has continued to decline since the onset of the crisis, its effects on cancer could be slow to appear. Consequently, another limitation of our study is that we analysed a post-crisis period of five years, which may be insufficient to detect major changes in mortality. In addition, given the latency periods of these cancers studied, their effects may appear in the next years. Thus, it would be useful to continue monitoring trends in cancer mortality in the coming years in conjunction with the evolution of the economic crisis.

In conclusion, our study demonstrates an overall downward trend in cancer mortality both before and after the onset of the economic crisis, but with a notable slowing down in the rate of decline since the crisis began. For lung cancer, there was a downward trend in men but an upward trend in women, while for colon cancer the trends are reversed and less pronounced. With respect to prostate and breast cancer, the onset of the crisis caused a slight slowing of their previous decline in men and women, respectively. These trends could change if the current austerity measures are maintained during the coming years, which would cause significant deterioration of the Spanish public healthcare system. Abolishing current austerity measures will be crucial in preventing a rise in cancer mortality in the future.

What is known about the topic?

Increased unemployment along with lower investment in the public health sector are known to be associated with an increase in total cancer mortality, particularly of breast, colon, prostate and lung cancer. However, there are a limited research on economic crises and cancer mortality.

What does this study add to the literature?

Since the onset of the economic crisis in Spain the rate of decline in cancer mortality has slowed significantly. This situation could be exacerbated by the current austerity measures in healthcare. Abolishing current austerity measures will be crucial in preventing a rise in cancer mortality in the future in Spain.

Appendix A.

Supplementary data

Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.gaceta.2017.11.008.

References

1. Cortès-Franch I, González López-Valcárcel B. The economic-financial crisis and health in Spain. Evidence and viewpoints. SESPAS report 2014. Gac Sanit. 2014;28 Suppl 1:1-6. [ Links ]

2. Quaglio G, Karapiperis T, Van Woensel L, et al. Austerity and health in Europe. Health Policy (New York). 2013;113:13-9. [ Links ]

3. Pérez G, Rodríguez-Sanz M, Domínguez-Berjón F, et al. Indicators to monitor the evolution of the economic crisis and its effects on health and health inequalities. SESPAS report 2014. Gac Sanit. 2014;28 Suppl 1:124-31. [ Links ]

4. Bacigalupe A, Escolar-Pujolar A. The impact of economic crises on social inequalities in health: what do we know so far? Int J Equity Health. 2014;13:52. [ Links ]

5. Martin-Moreno JM, Alfonso-Sanchez JL, Harris M, et al. The effects of the financial crisis on primary prevention of cancer. Eur J Cancer. 2010;46:2525-33. [ Links ]

6. Falagas ME, Vouloumanou EK, Mavros MN, et al. Economic crises and mortality: a review of the literature. Int J Clin Pract. 2009;63:1128-35. [ Links ]

7. Segura Benedicto A. Cuts, austerity and health. SESPAS report 2014. Gac Sanit. 2014;28 Suppl 1:7-11. [ Links ]

8. Budhdeo S, Watkins J, Atun R, et al. Changes in government spending on healthcare and population mortality in the European Union, 1995-2010: a crosssectional ecological study. J R Soc Med. 2015;108:490-8. [ Links ]

9. Coope C, Gunnell D, Hollingworth W, et al. Suicide and the 2008 economic recession: who is most at risk? Trends in suicide rates in England and Wales 2001-2011. Soc Sci Med. 2014;117:76-85. [ Links ]

10. Haw C, Hawton K, Gunnell D, et al. Economic recession and suicidal behaviour: possible mechanisms and ameliorating factors. Int J Soc Psychiatry. 2015;61:73-81. [ Links ]

11. Parmar D, Stavropoulou C, Ioannidis JPA. Health outcomes during the 2008 financial crisis in Europe: systematic literature review. BMJ. 2016;354, i4588. [ Links ]

12. Baumbach A, Gulis G. Impact of financial crisis on selected health outcomes in Europe. Eur J Public Health. 2014;24:399-403. [ Links ]

13. Karanikolos M, Heino P, McKee M, et al. Effects of the global financial crisis on health in high-income OECD countries: a narrative review. Int J Health Serv. 2016;46:208-40. [ Links ]

14. Maruthappu M, Watkins JA, Waqar M, et al. Unemployment, public-sector health-care spending and breast cancer mortality in the European Union: 1990-2009. Eur J Public Health. 2015;25:330-5. [ Links ]

15. Maruthappu M, Watkins J, Noor AM, et al. Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990-2010: a longitudinal analysis. Lancet. 2016;6736:1-12. [ Links ]

16. Maruthappu M, Watkins J, Taylor A, et al. Unemployment prostate cancer mortality in the O.E.C.D.1990-2009. Ecancermedicalscience. 2015;9:1-13. [ Links ]

17. Maruthappu M, Watson RA, Watkins J, et al. Unemployment, public-sector healthcare expenditure and colorectal cancer mortality in the European Union: 1990-2009. Int J Public Health. 2016;61:119-30. [ Links ]

18. Shafique K, Morrison DS. Socio-economic inequalities in survival of patients with prostate cancer: role of age and Gleason grade at diagnosis. PLoS One. 2013:8. [ Links ]

19. Vrachnis N, Vlachadis N, Salakos N, et al. Cancer mortality in Greece during the financial crisis. Acta Oncol (Madr). 2015;54:287-8. [ Links ]

20. Ades F, Senterre C, de Azambuja E, et al. Discrepancies in cancer incidence and mortality and its relationship to health expenditure in the 27 European Union member states. Ann Oncol. 2013;24:2897-902. [ Links ]

21. Regidor E, Vallejo F, Granados JAT, et al. Mortality decrease according to socioeconomic groups during the economic crisis in Spain: a cohort study of 36 million people. Lancet. 2016;6736:1-11. [ Links ]

22. Repullo JR. Changes in the regulation and government of the health system. SESPAS report 2014. Gac Sanit. 2014;28 Suppl 1:62-8. [ Links ]

23. Cimas M, Gullón P. Dos años de reforma sanitaria: más vidas humanas en riesgo. Médicos del Mundo. 2014. [ Links ]

24. Pérez G, Gotsens M, Palència L, et al. Study protocol on the effect of the economic crisis on mortality and reproductive health and health inequalities in Spain. Gac Sanit. 2016;30:472-6. [ Links ]

25. Ministerio de Sanidad, Servicios Sociales e Igualdad. Subdirección General de Información Sanitaria e Innovación. Los sistemas sanitarios en los países de la UE: características e indicadores de salud. Madrid; 2013. [ Links ]

26. López-Fernández LA, Martínez Millán JI, Fernández Ajuria A, et al. Is the universal coverage of our national health system in danger? Gac Sanit. 2012;26:298-300. [ Links ]

27. Legido-Quigley H, Otero L, La Parra D, et al. Will austerity cuts dismantle the Spanish healthcare system? BMJ. 2013;346:f2363. [ Links ]

28. Gallo P, Gené-Badia J. Cuts drive health system reforms in Spain. Health Policy (New York). 2013;113:1-7. [ Links ]

29. Carballo F, Muñoz-Navas M. Prevention or cure in times of crisis: the case of screening for colorectal cancer. Rev Esp Enferm Dig. 2012;104:537-45. [ Links ]

30. Heras-Mosteiro J, Legido-Quigley H, Sanz-Barbero B, et al. Health care austerity measures in times of crisis: the perspectives of primary health care physicians in Madrid Spain. Int J Health Serv. 2016;46:283-99. [ Links ]

31. Cimas M, Gullon P, Aguilera E, et al. Healthcare coverage for undocumented migrants in Spain: regional differences after Royal Decree Law 16/2012. Health Policy (New York). 2016;120:384-95. [ Links ]

32. Suess A, Ruiz Pérez I, Ruiz Azarola A, et al. The right of access to health care for undocumented migrants: a revision of comparative analysis in the European context. Eur J Public Health. 2014;24:712-20. [ Links ]

33. Cervero-Liceras F, McKee M, Legido-Quigley H. The effects of the financial crisis and austerity measures on the Spanish health care system: a qualitative analysis of health professionals' perceptions in the region of Valencia. Health Policy (New York). 2015;119:100-6. [ Links ]

34. Díaz P. El copago de Mato se ceba con los pacientes con cáncer. Madrid: Público. 31 enero 2013. Disponible en: http://www.publico.es/actualidad/copago-mato-ceba-pacientes-cancer.htmlLinks ]

35. Asociación Española Contra el Cáncer. La AECC pide accelerar los plazos de implantación de programes de cribado para disminuir muertes evitables por cáncer de colon. Madrid: Nota de prensa. 30 marzo 2016. Disponible en: https://www.aecc.es/Comunicacion/NotasdePrensa/Documents/2016/NPColon.pdfLinks ]

36. Instituto de Médicos Científico (INESME). Encuesta INESME - Impacto de la crisis económica en la aplicación de terapias oncológicas innovadoras. Madrid: INESME; 2011. [ Links ]

37. Europa Press. España, entre los diez países europeos que menos recursos destinan al cáncer de pulmón. Madrid: El Economista. 15 noviembre 2013. Disponible en: http://ecodiario.eleconomista.es/salud/noticias/5316182/11/13/Espana-entre-los-paiseseuropeos-que-menos-recursos-destinan-al-cancer-de-pulmon.htmlLinks ]

38. Saloustros E, Vichas G, Margiolaki A. Lung cancer in the era of Greek economic crisis. Lung Cancer. 2014;86:1367-80. [ Links ]

39. Encuesta de Qué Sienten Los Pacientes dirigida a pacientes con cáncer de mama. Informe de resultados 2013. Disponible en: http://docplayer.es/23600084-Encuesta-de-que-sienten-los-pacientes-dirigida-a-pacientes-con-cancer-de-mama-informe-de-resultados-octubre-de-con-la-colaboracionde.htmlLinks ]

40. Molina Barceló A, Moreno Salas J, Peiró Pérez R, et al. Análisis del cribado del cáncer en España desde una perspectiva de equidad. Valencia: Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO, Salud Pública); 2016. Informe técnico. Disponible en: http://www.cribadocancer.com/images/archivos/CRIBADOCANCEREQUIDAD.pdfLinks ]

41. Palència L, Espelt A, Rodríguez-Sanz M, et al. Socio-economic inequalities in breast and cervical cancer screening practices in Europe: influence of the type of screening program. Int J Epidemiol. 2010;39:757-65. [ Links ]

42. Márquez-Calderón S, Villegas-Portero R, Gosalbes Soler V, et al. Health promotion and prevention in the economic crisis: the role of the health sector. SESPAS report 2014. Gac Sanit. 2014;28 Suppl 1:116-23. [ Links ]

43. Dimitrakaki C, Boulamatsis D, Mariolis A, et al. Use of cancer screening services in Greece and associated social factors: results from the nation-wide Hellas Health I survey. Eur J Cancer Prev. 2009;18:248-57. [ Links ]

44. Dorn SD, Wei D, Farley JF, et al. Impact of the 2008-2009 economic recession on screening colonoscopy utilization among the insured. Clin Gastroenterol Hepatol. 2012;10:278-84. [ Links ]

45. Myong JP, Kim HR. Impacts of household income and economic recession on participation in colorectal cancer screening in Korea. Asian Pacific J Cancer Prev. 2012;13:1857-62. [ Links ]

46. Binefa G, García M, Peiró R, et al. How to assess and reduce social inequalities in cancer screening programmes. Gac Sanit. 2016;30:232-4. [ Links ]

47. Adams J, White M, Forman D. Are there socioeconomic gradients in stage and grade of breast cancer at diagnosis? Cross sectional analysis of UK cancer registry data. BMJ. 2004;329:142. [ Links ]

48. Forrest LF, Adams J, Wareham H, et al. Socioeconomic inequalities in lung cancer treatment: systematic review and meta-analysis. PLoS Med. 2013;10:e1001376. [ Links ]

49. Clegg LX, Reichman ME, Miller BA, et al. Impact of socioeconomic status on cancer incidence and stage at diagnosis: selected findings from the surveillance, epidemiology, and end results: National Longitudinal Mortality Study. Cancer Causes Control. 2009;20:417-35. [ Links ]

50. Ennis KY, Chen M-H, Smith GC, et al. The impact of economic recession on the incidence and treatment of cancer. J Cancer. 2015;6:727-33. [ Links ]

51. Lawler M, Duffy S, La Vecchia C, et al. America's cancer care crisis - is Europe any better? Lancet. 2013;382:1628. [ Links ]

52. Tsounis A, Sarafis P, Alexopoulos EC. Austerity and its consequences on cancer screening in Greece. Lancet. 2014;384:2110. [ Links ]

Funding: This research has been partially funded by the project entitled “Efectos de la crisis en la salud de la población y sus determinantes en España” (PI13/00897) funded by the Instituto de Salud Carlos III (co-funded by European Regional Development Fund).

Recibido: 22 de Agosto de 2017; Aprobado: 08 de Noviembre de 2017; : 13 de Febrero de 2018

*Corresponding author:mgotsens@aspb.cat (M. Gotsens).

Editor in charge: Carlos Álvarez-Dardet.

Transparency declaration: The corresponding author on behalf of the other authors guarantee the accuracy, transparency and honesty of the data and information contained in the study, that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described.

Authorship contributions: All authors made substantial contributions to conception and design of this study. L. Palència, M. Gotsens, M. Marí-Dell’Olmo and V. Puig-Barrachina performed data analysis. All authors contributed to the interpretation of data. J. Ferrando and L. Palència were involved in drafting the manuscript and the rest of the authors revised it critically for important intellectual content. All authors gave final approval of the version to be published.

Conflicts of interest: None.

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