title: National economic and development indicators and international variation in prostate cancer incidence and mortality: an ecological analysis.
abstract: BACKGROUND
  Macroeconomic indicators are likely associated with prostate cancer (PCa) incidence and mortality globally, but have rarely been assessed.
  
  
  METHODS
  Data on PCa incidence in 2003-2007 for 49 countries with either nationwide cancer registry or at least two regional registries were obtained from Cancer Incidence in Five Continents Vol X and national PCa mortality for 2012 from GLOBOCAN 2012. We compared PCa incidence and mortality rates with various population-level indicators of health, economy and development in 2000. Poisson and linear regression methods were used to quantify the associations.
  
  
  RESULTS
  PCa incidence varied more than 15-fold, being highest in high-income countries. PCa mortality exhibited less variation, with higher rates in many low- and middle-income countries. Healthcare expenditure (rate ratio, RR 1.46, 95 % CI 1.45-1.47) and population growth (RR 1.15, 95 % CI 1.14-1.16), as well as computer and mobile phone density, were associated with a higher PCa incidence, while gross domestic product, GDP (RR 0.94, 95 % CI 0.93-0.95) and overall mortality (RR 0.72, 95 % CI 0.71-0.73) were associated with a low incidence. GDP (RR 0.55, 95 % CI 0.46-0.66) was also associated with a low PCa mortality, while life expectancy (RR 3.93, 95 % CI 3.22-4.79) and healthcare expenditure (RR 1.20, 95 % CI 1.09-1.32) were associated with an elevated mortality.
  
  
  CONCLUSIONS
  Our results show that healthcare expenditure and, thus, the availability of medical resources are an important contributor to the patterns of international variation in PCa incidence. This suggests that there is an iatrogenic component in the current global epidemic of PCa. On the other hand, higher healthcare expenditure is associated with lower PCa death rates.
authors.affiliation: School of Health Sciences, University of Tampere, 33014, Tampere, Finland.
authors.forename: Subas
authors.initials: S
authors.lastname: Neupane
authors.affiliation: Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France.
authors.forename: Freddie
authors.initials: F
authors.lastname: Bray
authors.affiliation: School of Health Sciences, University of Tampere, 33014, Tampere, Finland. anssi.auvinen@uta.fi.
authors.forename: Anssi
authors.identifier: http://orcid.org/0000-0003-1125-4818
authors.initials: A
authors.lastname: Auvinen
mesh_terms: D000368:Aged; D016001:Confidence Intervals; D019049:Developed Countries; D003906:Developing Countries; D018572:Disease-Free Survival; D014943:Global Health / Q000191:economics*; D005102:Health Expenditures; D006295:Health Resources / Q000191:economics*; D006801:Humans; D038622:Internationality; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000191:economics; D011471:Prostatic Neoplasms / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy*; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012959:Socioeconomic Factors; D016019:Survival Analysis
keywords: Health care; Incidence; Medical resources; Mortality; Prostate cancer