title: The Impact of Economic Recession on the Incidence and Treatment of Cancer.
abstract: OBJECTIVE
  The impact of economic recessions on the incidence and treatment of cancer is unknown. We test the hypothesis that cancer incidence and treatment rates decrease during a recession, and that this relationship is more pronounced in cancers that present with mild, more easily ignored symptoms.
  
  
  METHODS
  Data on incidence and treatment for all cancers, and breast and pancreatic cancers specifically, from 1973-2008, were collected using Surveillance Epidemiology and End RESULTS (SEER). The data was adjusted for race, income, and education. Unemployment rate was used as the measure of economic recession. Data was log-transformed, and multivariate linear mixed regression was used.
  
  
  RESULTS
  Adjusting for socioeconomic factors, the data revealed a significant inverse correlation between unemployment and rates of cancer incidence and treatment. Every 1% increase in unemployment was associated with a 2.2% (95% CI: 1.6-2.8%, p<0.001) reduction in cancer incidence, a 2.0% (1.2-2.8%, p=0.0157) decrease in surgery, and a 9.1% (8.2-10.0% p<0.001) decrease in radiation therapy (RT). Breast cancer incidence and treatment had a dramatic inverse relationship - 7.2% (6.3-8.1%), 6.7% (5.7-7.6%), and 19.0% (18.1-19.8%), respectively (p<0.001 for all). The decrease in incidence was only significant for in situ and localized tumors, but not in regional or distant breast cancer. Compared to breast cancer, pancreatic cancer had a weaker relationship between unemployment and incidence: 2.6% (1.8-3.3%, p=0.0005), surgery: 2.4% (2.0-2.7%, p<0.001), and RT: 1.9% (1.5-2.2% p<0.001).
  
  
  CONCLUSIONS
  Increasing unemployment rates are associated with a decrease in the incidence and treatment of all cancers. This effect is exaggerated in breast cancer, where symptoms can more easily be ignored and where there are widely used screening tests relative to pancreatic cancer.
authors.affiliation: 1. Mount Sinai Roosevelt Hospital.
authors.forename: Kevin Y
authors.initials: KY
authors.lastname: Ennis
authors.affiliation: 2. Department of Statistics, University of Connecticut.
authors.forename: Ming-Hui
authors.initials: MH
authors.lastname: Chen
authors.affiliation: 1. Mount Sinai Roosevelt Hospital.
authors.forename: Glenna C
authors.initials: GC
authors.lastname: Smith
authors.affiliation: 3. Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School.
authors.forename: Anthony V
authors.initials: AV
authors.lastname: D'Amico
authors.affiliation: 4. Novartis Institutes for BioMedical Research.
authors.forename: Yuanye
authors.initials: Y
authors.lastname: Zhang
authors.affiliation: 5. Department of Pathology and Cell Biology, Columbia University.
authors.forename: S Aidan
authors.initials: SA
authors.lastname: Quinn
authors.affiliation: 1. Mount Sinai Roosevelt Hospital.
authors.forename: Shannon N
authors.initials: SN
authors.lastname: Ryemon
authors.affiliation: 1. Mount Sinai Roosevelt Hospital.
authors.forename: Daniel
authors.initials: D
authors.lastname: Goltz
authors.affiliation: 6. Moffitt Cancer Center and Research Institute, Tampa, Florida.
authors.forename: Louis B
authors.initials: LB
authors.lastname: Harrison
authors.affiliation: 1. Mount Sinai Roosevelt Hospital.
authors.forename: Ronald D
authors.initials: RD
authors.lastname: Ennis
keywords: cancer; economic recessions; treatment