Unemployment and reduced public-sector health spending following the 2008 global economic crisis were associated with increased cancer mortality, according to a new study published in The Lancet. The study estimates that the recent economic crisis was associated with over 260000 additional cancer deaths in countries within the Organisation for Economic Development (OECD) by 2010, of which 160000 were in the European Union.
The study is the first global analysis to look at the effect of unemployment and changes in public-sector healthcare spending on cancer deaths, and suggests universal health care coverage may protect patients from the health consequences of rising unemployment and reduced public-sector healthcare spending.
"Cancer is a leading cause of death worldwide so understanding how economic changes affect cancer survival is crucial" says lead author Dr Mahiben Maruthappu from Imperial College London, UK. "We found that increased unemployment was associated with increased cancer mortality, but that universal health coverage protected against these effects. This was especially the case for treatable cancers including breast, prostate and colorectal cancer." 
He adds: "We also found that public healthcare spending was tightly associated with cancer mortality -- suggesting healthcare cuts could cost lives. If health systems experience funding constraints, this must be matched by efficiency improvements to ensure patients are offered the same level of care, regardless of economic environment or employment status." 
Researchers at Harvard University (US), Oxford University (UK), Imperial College London (UK) and King's College London (UK) used data from the World Bank and World Health Organisation to look at the link between unemployment, public health care spending and cancer mortality in over 70 countries, representing over 2 billion people. They looked at trends over 20 years, from 1990 to 2010.
Several cancers were included in the analysis - prostate cancer in men, breast cancer in women, colorectal cancer in men and women, and lung cancer in men and women. Cancers were classified as treatable (survival rates over 50%) or untreatable (survival rates less than 10%).
The study found that rises in unemployment were associated with an increase in deaths across all cancers but the association disappeared when universal health care was taken into account. The association between unemployment and cancer mortality was strongest for treatable cancers, and the authors say that this reinforces the importance of having access to care. A 1% increase in unemployment was associated with 0.37 additional deaths from all cancers per 100000 people (Appendix, table S3).
The study also found that cancer mortality increased as public health expenditure decreased. A 1% decrease in public healthcare spending as a percentage of GDP (gross domestic product) was associated with 0.0053 additional deaths from all cancers per 100000 people (Appendix, table S3). The researchers then extrapolated the findings for countries in the OECD (some of which were not included in the original data set), and estimate that the economic crisis was associated with an additional 263221 deaths in the OECD, of which 169129 were in the European Union .
"In countries without universal health coverage, access to health care can often be provided via an employment package," explains co-author Professor Rifat Atun, Harvard University. "Without employment, patients may be diagnosed late, and face poor or delayed treatment." 
Cancer accounted for 8.2 million deaths in 2012, and the number of cases is expected to increase from 14 million in 2012 to 22 million in 2030. The economic crisis beginning in 2008 saw a substantial rise in unemployment, and caused many countries to cut public-sector health care spending. Several studies have shown the impact of these changes on mental and physical health - for instance increases in suicide or cardiovascular disease.
The authors say that the study published today can only show an association between mortality, unemployment and public-sector spending, and cannot prove cause and effect. However, they say that the study found a chronological correlation - changes in unemployment were followed by changes in cancer mortality which they say lends support to a causal link. They also add that since high quality data was only available up until 2010, they were unable to analyse the longer-term effect of economic fluctuations on cancer mortality.
Writing in a linked Comment, Dr Graham A Colditz, Washington University School of Medicine, St Louis, MO, USA and Dr Karen M Emmons, Kaiser Foundation Research Institute, Oakland, CA, USA, say the new data "add to the evidence that the implementation of universal health coverage would further reduce the toll of cancer by making it possible to implement evidence based treatments and prevention strategies that are already in hand. Universal health coverage is a key UN Development Programme Sustainable Development Goal (SDG 3) and is described as the single most powerful concept that public health has to offer."
"Although in many countries universal health-care coverage is seen as an important societal investment, so far this has not been the case in the USA. The country might find the promise of improving treatments difficult to achieve without first providing coverage to those affected by cancer. Universal health coverage, specifically for all patients with cancer, would meet the Institute of Medicine recommendation to reduce disparities in access to cancer care for vulnerable and underserved populations. Furthermore, universal cancer coverage would generate a great return on investment."
NOTES TO EDITORS:
The study received no funding.
 Quote direct from author and cannot be found in the text of the Article.
 Excluding Croatia, which joined the European Union in 2013. List of OECD countries available at: http://www.oecd.org/about/membersandpartners/list-oecd-member-countries.htm
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