Gac Sanit. 2019;33(3):229–234 Original Trends in cancer mortality in Spain: the influence of the financial crisis 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 a r t i c l e i n f o a b s t r a c t Article history: Objective: To determine if the onset of the economic crisis in Spain affected cancer mortality and mortality Received 22 August 2017 trends. Accepted 8 November 2017 Method: We conducted a longitudinal ecological study based on all cancer-related deaths and on specific Available online 13 February 2018 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 Keywords: the crisis on cancer mortality and trends therein. Economic crisis Results: After the onset of the economic crisis, cancer mortality continued to decline, but with a significant Austerity Health care cuts slowing of the yearly rate of decline (men: RR = 0.987, 95%CI = 0.985-0.990, before the crisis, and RR = 0.993, Cancer 95%CI = 0.991-0.996, afterwards; women: RR = 0.990, 95%CI = 0.988-0.993, before, and RR = 1.002, 95%CI Financial crisis = 0.998-1.006, afterwards). In men, lung cancer mortality was reduced, continuing the trend observed in Mortality 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. © 2018 SESPAS. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Evolución de la mortalidad por cáncer en España: influencia de la crisis económica r e s u m e n Palabras clave: Objetivo: Determinar si el inicio de la crisis económica en España afectó a la mortalidad por cáncer y sus Crisis económica tendencias. Austeridad Método: Estudio ecológico longitudinal que analiza todas las muertes por cáncer y por tipos específicos Recortes en salud de cáncer (pulmón, colon, mama y próstata) en España entre 2000 y 2013. Se estimaron las tasas de Cáncer mortalidad estandarizadas por edad en hombres y mujeres, y se ajustaron modelos mixtos de Poisson Crisis financiera Mortalidad 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 tenden- cia 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. © 2018 SESPAS. Publicado por Elsevier España, S.L.U. Este es un artı́culo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/). ∗ Corresponding author. E-mail address: mgotsens@aspb.cat (M. Gotsens). https://doi.org/10.1016/j.gaceta.2017.11.008 0213-9111/© 2018 SESPAS. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc- nd/4.0/). 230 J. Ferrando et al. / Gac Sanit. 2019;33(3):229–234 Introduction estimated annual mortality rates for all cancers, individually for lung and colon cancer in both sexes, for prostate in men, and for The impact of an economic crisis on health depends on vari- breast cancer in women. Rates were standardised by age using the ous factors.1,2 While economic crises have adverse effects on both direct method in which the reference population was the Span- the determinants and inequalities of health,3,4 they can in fact ish population of 2001. Data were also represented graphically to provide an opportunity to promote primary prevention healthcare visibly highlight the trends. measures.5 Finally, we constructed mixed Poisson models to analyse the History has already shown that economic crises can be accom- effect of the crisis on mortality, including its general trends both panied by an increase in mortality, particularly among certain before and during the crisis (see Model 1; where I = autonomous population subgroups, such as children.6,7 Within the European community, and t = year). We accounted for the variability between Union for instance, a reduction in public spending on health- autonomous communities by including random effects in the con- care during times of crisis has been found to be associated with stant and coefficients of the variables for crisis (dichotomous increased mortality.8 Interestingly, some studies have not observed variable taking value 0 for 2000-2007, and 1 for 2008-2013) (b1i ), an increase in overall mortality, but rather an increase in the num- year (b2i ), and the interaction between crisis and year (b3i ). Using ber of suicides,9–11 offset by a decrease in other causes of death, our model, we determined the relative risk (RR) for each type of such as those due to traffic injuries.12,13 cancer by estimating the differences in mortality between the first Increased unemployment along with lower investment in the year of the crisis (2008) and the last year before the onset of the public health sector are known to be associated with an increase crisis (2007; RR crisis; 95%CI). Finally, to evaluate annual trends in total cancer mortality, particularly of breast, colon, prostate in mortality, we determined the relative risks for the pre-crisis and lung cancer.14–18 Furthermore, it has been shown in some (RR pre-crisis years; 95%CI) and crisis (RR crisis years; 95%CI) peri- countries that complete public health coverage or greater public ods. health expenditure counteract the negative effect of unemploy- Model 1: ment, and thus these countries do not show an increase in cancer mortality.15,19,20 deathit ∼ Poisson(␭it ), i = 1,. . .,17, t = 1,. . .,14 The most recent economic crisis began to affect Spain in 2008, log(␭it ) = log(popit ) + (␤0 + b0i ) + (␤1 + b1i )*crisist + (␤2 + and a recent study analysed the effect that this crisis had on both b2i )*(yeart -2008) + (␤3 + b3i )*crisist *(yeart -2008) + ␧it where: general mortality and some specific causes.21 This study found   that overall mortality was declining before the onset of the cri- 1 if yeart ≥ 2008 sis (2004-2007), and that the same trend continued during the crisist = 0 if yeart < 2008 subsequent years (2008-2011), particularly among disadvantaged socioeconomic groups. These two periods also saw a lower num- b0i ∼ N(0,␴0 2 ), b1i ∼ N(0,␴1 2 ), b2i ∼ N(0,␴2 2 ), b3i ∼ N(0,␴3 2 ) ber of cancer-related deaths, especially in men, although this study only analysed data until 2011, and did not distinguish between the Results different types of cancer. In response to the 2008 crisis in Spain, the Spanish govern- Table 1 shows the number of cancer-related deaths in Spain ment activated various economic adjustment procedures, including in the years 2000 to 2013, overall, and for lung, colon, prostate healthcare reform encompassing a set of legislative measures and breast cancer. Overall, the data show higher cancer mor- aimed at cutting health expenditure. This reform, brought into tality in men than women, with lung and breast cancer being action by the approval of Royal Decree Law 16/2012, was a key the principal causes of cancer mortality in men and women, health austerity measure.7,22,23 However, the effect of the economic respectively. crisis in Spain has been heterogeneous with respect to the different Between 2000 and 2013, cancer mortality as a whole decreased, autonomous communities, which may be because each region has especially in men (Fig. 1). However, we observe an upward trend some control over how social cuts are implemented.24 in the most common cancer types, especially colon cancer in men, Given the limited research on economic crises and cancer and lung cancer in women. mortality, the objective of our study was to determine if cancer According to our model (Table 2), mortality decreased in men mortality, and its overall trends, have changed since the onset of following the onset of the crisis (RR = 0.986; 95%CI = 0.976-0.996), the latest economic crisis in Spain. although the rate of decline was slower (pre-crisis period, RR = Methods 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 We conducted a longitudinal study of the period 2000 to 2013, = 0.988-0.993) was disrupted by the onset of the crisis (RR = 1.002; with 2008 considered as the year the economic crisis started, and 95%CI = 0.998-1.006; p <0.001), such that there is now no statisti- the study population consisted of all residents in Spain during cally significant difference between mortality before and since the 2000 to 2013. We collected information from the Spanish Mortality onset of the crisis. Registry, a resource based on the Statistical Bulletin of Deaths, and Regarding mortality due to specific types of cancer in men, from the ongoing population census. We analysed all deaths caused lung cancer mortality decreased with the onset of the crisis (RR by cancer in general (CIE-10: C00-C96), as well as those caused = 0.979; 95%CI = 0.964-0.995), but without a significant change by four specific types of malignant neoplasm: colon (CIE-10: C18), in the general trend. In contrast, colon cancer mortality did not bronchus and lung (CIE-10: C34), breast (CIE-10: C50), and prostate undergo any significant change after the start of the crisis, and (CIE-10: C61). For our analysis, we considered the following vari- continued to follow the same gradual increasing trend that had ables: year of death, age at death, gender, autonomous community, been observed during the pre-crisis period. Prostate cancer mor- and cause of death. tality did not vary markedly with the onset of the crisis, as the We performed a descriptive analysis of the population accord- downward trend observed before the crisis underwent a signifi- ing to the number of deaths caused by each of the types of cancer cant regression (pre-crisis trend, RR = 0.969; crisis trend, RR = 0.992; in men and women for each year of the study period. We then p < 0.001). J. Ferrando et al. / Gac Sanit. 2019;33(3):229–234 231 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 In women, mortality due to lung cancer increased annually was a change in this trend −the rate of decline in cancer mortality before the crisis (RR = 1.037; 95%CI = 1.030-1.044), and this trend decreased with the onset of the crisis. continued after the start of the crisis. Similarly, the decreasing death The health reform introduced by Royal Decree Law 16/2012 trend in mortality due to colon cancer observed before the crisis could lead to the dismantling of the current public health sys- also continued into the crisis period. In contrast, the decline in tem. This reform had many consequences, including a decrease in breast cancer mortality observed before the crisis has stagnated the number of available hospital beds, a reduction in emergency since 2008, (pre-crisis trend, RR = 0.984; crisis trend, RR = 0.995; services hours, closure of certain medical services, cancellation of p = 0.007). surgical operations, longer waiting lists, privatization of health ser- vices, and poorer access to the health system and pharmaceutical assistance.22,23,26–30 Between 2009 and 2013 public health expen- Discussion diture in Spain decreased by 18.2%, which had a strong impact on the health system’s equity and universality.31,32 Cancer mortality as a whole has continued to decrease since the A recent study has highlighted how austerity measures nega- onset of the crisis, especially in men, although this decrease has tively affect the quality of healthcare and population health,33 and slowed since 2008. However, this has not been the case for all types cancer patients in particular are routinely confronted with vari- of cancer, such as colon cancer, for which the number of deaths has ous economic burdens, such as co-payment for pharmacological increased, particularly since the onset of the crisis. In women, the treatments and non-urgent medical transport, and payment for decline in cancer-related deaths overall has slowed down since the orthopaedic prostheses and dietary products. These pressures may start of the crisis, while those due to lung cancer continue to rise. drive patients in a precarious economic situation to interrupt their Our results are consistent with a previous report on over- medical treatment.34,35 all cancer mortality in Spain during the 2004-2011 period,21 but According to medical oncologists,36 lung cancer is one of the encompass a larger time frame (2000-2013) and include an evalu- tumours most affected by cutbacks in healthcare, which results in ation of specific cancers with higher mortality rates. lower patient survival rate.37 In countries whose healthcare system The trends observed in Spain are similar to those reported in has been severely affected by the crisis, the situation for lung cancer Greece, where cancer mortality has continued to decline since the patients has worsened,38 which should be cause for serious reflec- onset of the crisis.19 One of the reasons for this continued decline tion given the increasing prevalence of lung cancer among women is that the Greek public health system continued to function effec- in Spain. tively despite cuts imposed by the government in response to the According to a survey among cancer patients,39 the care they crisis. Although there are some differences between the Greek and receive has been markedly affected by the crisis, including restric- Spanish health systems, they are both public systems25 that provide tions on innovative cancer therapies, increases waiting times, and full access to healthcare services and thereby buffer the influence of failures to implement and continue early cancer screening pro- unemployment and reduced healthcare expenditure on increased grams. Such programs are one of the best strategies for reducing cancer mortality during times of crisis.15 In Spain, however, there cancer mortality.40 A national screening portfolio had not been 232 J. Ferrando et al. / Gac Sanit. 2019;33(3):229–234 Men and women, 2000-2013. Table 2 Relative risks (RR) and 95% confidence intervals (95%CI) for cancer mortality. Men 400 and women, Spain, 2000-2013. Source: Spanish Mortality Registry, Spanish Institute 350 of Statistics. Mortality rates 300 Men Women 250 RR (95%CI) RR (95%CI) 200 All cancer, men 150 All cancer All cancer, women Crisis (after 2008 compared 0.986 (0.976-0.996) 1.003 (0.991-1.016) 100 before 2008) 50 Trend in pre-crisis years 0.987 (0.985-0.990) 0.990 (0.988-0.993) 0 Trend in crisis years 0.993 (0.991-0.996) 1.002 (0.998-1.006) p-value (crisis*year) <0.001 <0.001 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Lung cancer Men, 2000-2013. Crisis (after 2008 compared 0.979 (0.964-0.995) 1.007 (0.968-1.048) 100 before 2008) 90 Trend in pre-crisis years 0.992 (0.988-0.995) 1.037 (1.030-1.044) 80 Trend in crisis years 0.989 (0.983-0.995) 1.045 (1.037-1.053) Mortality rates 70 p-value (crisis*year) 0.405 0.147 60 Prostate cancer Colon cancer 50 Colon cancer Crisis (after 2008 compared 0.990 (0.961-1.019) 1.019 (0.984-1.056) 40 before 2008) 30 Lung cancer Trend in pre-crisis years 1.005 (1.000-1.011) 0.992 (0.987-0.997) 20 Trend in crisis years 1.011 (1.004-1.018) 0.997 (0.989-1.005) 10 p-value (crisis*year) 0.128 0.322 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Breast cancer Crisis (after 2008 compared 1.010 (0.984-1.038) before 2008) Women, 2000-2013 Trend in pre-crisis years 0.984 (0.978-0.989) 30 Trend in crisis years 0.995 (0.988-1.002) 25 p-value (crisis*year) 0.007 Mortality rates Prostate cancer 20 Crisis (after 2008 compared 0.998 (0.966-1.031) 15 Colon cancer before 2008) Lung cancer Trend in pre-crisis years 0.969 (0.964-0.974) 10 Breast cancer Trend in crisis years 0.992 (0.985-0.999) p-value (crisis*year) <0.001 5 RR for cancer mortality with respect to the effect of the crisis (mortality after the 0 year 2008 compared to mortality before 2008), and RRs associated with the trends 2012 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2013 before and during the crisis (increase in annual mortality during the pre-crisis [2000-2008] and crisis [2008-2013] periods). Significant differences between the Figure 1. Standardised mortality rates per 100,000 inhabitants for all cancers and two trends are represented using p-values (interaction between year and crisis). for specific cancers. Men and women, Spain 2000-2013. Source: Spanish Mortality Registry, Spanish Institute of Statistics. defined until 2013, although screening was already being car- of cancer. Because this information is not available in the Span- ried out in all autonomous communities for some types of cancer, ish Mortality Registry, it would be useful to investigate these such as breast cancer.41 As of 2013, breast and colorectal cancers variables in future studies to determine if they are linked to the have both been the target of population screening programs, and gender differences observed in our study. cervical cancer of an opportunistic program. Those autonomous While cancer mortality has continued to decline since the onset communities that had not yet implemented screening programs of the crisis, its effects on cancer could be slow to appear. Con- were given a period of five years to initiate the programs, and 10 sequently, another limitation of our study is that we analysed a years to achieve full coverage (basically for colon cancer), although post-crisis period of five years, which may be insufficient to detect the current economic situation will not make it easy to achieve major changes in mortality. In addition, given the latency periods these goals.42 While population-based programs ensure more equi- of these cancers studied, their effects may appear in the next years. table access to the health system compared to opportunistic-based Thus, it would be useful to continue monitoring trends in cancer programs,41 some inequalities may persist, such as lower partic- mortality in the coming years in conjunction with the evolution of ipation by ethnic minorities and underprivileged socioeconomic the economic crisis. groups.40,41,43–51 In conclusion, our study demonstrates an overall downward In countries where healthcare cuts affect screening programs, trend in cancer mortality both before and after the onset of the cancer mortality is expected to increase in the coming years.52 economic crisis, but with a notable slowing down in the rate of Thus, it is essential that that the implementation and continuity of decline since the crisis began. For lung cancer, there was a down- cancer screening programs in Spain are not affected by healthcare ward trend in men but an upward trend in women, while for colon cuts. cancer the trends are reversed and less pronounced. With respect Despite the negative consequences, periods of economic crisis to prostate and breast cancer, the onset of the crisis caused a slight can actually help promote primary cancer prevention by reduc- slowing of their previous decline in men and women, respectively. ing unhealthy habits such as alcohol and tobacco consumption.5,21 These trends could change if the current austerity measures are One of the limitations of our study is that we did not evaluate maintained during the coming years, which would cause significant health-related behaviours, socioeconomic variables or cancer stage deterioration of the Spanish public healthcare system. Abolishing at diagnosis time which are also often modified during times of current austerity measures will be crucial in preventing a rise in economic crisis and can influence the appearance and severity cancer mortality in the future. J. Ferrando et al. / Gac Sanit. 2019;33(3):229–234 233 5. Martin-Moreno JM, Alfonso-Sanchez JL, Harris M, et al. The effects of the financial What is known about the topic? crisis on primary prevention of cancer. Eur J Cancer. 2010;46:2525–33. 6. Falagas ME, Vouloumanou EK, Mavros MN, et al. Economic crises and mortality: Increased unemployment along with lower investment in a review of the literature. Int J Clin Pract. 2009;63:1128–35. the public health sector are known to be associated with an 7. Segura Benedicto A. Cuts, austerity and health. SESPAS report 2014. Gac Sanit. 2014;28 Suppl 1:7–11. increase in total cancer mortality, particularly of breast, colon, 8. Budhdeo S, Watkins J, Atun R, et al. Changes in government spending on prostate and lung cancer. However, there are a limited research healthcare and population mortality in the European Union, 1995-2010: a cross- on economic crises and cancer mortality. sectional ecological study. J R Soc Med. 2015;108:490–8. 9. Coope C, Gunnell D, Hollingworth W, et al. Suicide and the 2008 economic What does this study add to the literature? recession: who is most at risk?Trends in suicide rates in England and Wales 2001-2011. Soc Sci Med. 2014;117:76–85. 10. Haw C, Hawton K, Gunnell D, et al. Economic recession and suicidal Since the onset of the economic crisis in Spain the rate of behaviour: possible mechanisms and ameliorating factors. Int J Soc Psychiatry. decline in cancer mortality has slowed significantly. This situ- 2015;61:73–81. ation could be exacerbated by the current austerity measures 11. Parmar D, Stavropoulou C, Ioannidis JPA. Health outcomes during the 2008 in healthcare. Abolishing current austerity measures will be financial crisis in Europe: systematic literature review. BMJ. 2016;354, i4588. 12. Baumbach A, Gulis G. Impact of financial crisis on selected health outcomes in crucial in preventing a rise in cancer mortality in the future in Europe. Eur J Public Health. 2014;24:399–403. Spain. 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. 14. Maruthappu M, Watkins JA, Waqar M, et al. Unemployment, public-sector Editor in charge health-care spending and breast cancer mortality in the European Union: 1990- 2009. Eur J Public Health. 2015;25:330–5. 15. Maruthappu M, Watkins J, Noor AM, et al. Economic downturns, universal health Carlos Álvarez-Dardet. coverage, and cancer mortality in high-income and middle-income countries, 1990-2010: a longitudinal analysis. Lancet. 2016;6736:1–12. 16. Maruthappu M, Watkins J, Taylor A, et al. Unemployment prostate cancer mor- Transparency declaration tality in the O.E.C.D.1990-2009. Ecancermedicalscience. 2015;9:1–13. 17. Maruthappu M, Watson RA, Watkins J, et al. Unemployment, public-sector The corresponding author on behalf of the other authors guar- healthcare expenditure and colorectal cancer mortality in the European Union: 1990-2009. Int J Public Health. 2016;61:119–30. antee the accuracy, transparency and honesty of the data and 18. Shafique K, Morrison DS. Socio-economic inequalities in survival of patients information contained in the study, that no relevant information with prostate cancer: role of age and Gleason grade at diagnosis. PLoS One. has been omitted and that all discrepancies between authors have 2013:8. been adequately resolved and described. 19. Vrachnis N, Vlachadis N, Salakos N, et al. Cancer mortality in Greece during the financial crisis. Acta Oncol (Madr). 2015;54:287–8. 20. Ades F, Senterre C, de Azambuja E, et al. Discrepancies in cancer incidence and Authorship contributions mortality and its relationship to health expenditure in the 27 European Union member states. Ann Oncol. 2013;24:2897–902. 21. Regidor E, Vallejo F, Granados JAT, et al. Mortality decrease according to socio- All authors made substantial contributions to conception and economic groups during the economic crisis in Spain: a cohort study of 36 design of this study. L. Palència, M. Gotsens, M. Marí-Dell’Olmo million people. Lancet. 2016;6736:1–11. and V. Puig-Barrachina performed data analysis. All authors con- 22. Repullo JR. Changes in the regulation and government of the health system. SESPAS report 2014. Gac Sanit. 2014;28 Suppl 1:62–8. tributed to the interpretation of data. J. Ferrando and L. Palència 23. Cimas M, Gullón P. Dos años de reforma sanitaria: más vidas humanas en riesgo. were involved in drafting the manuscript and the rest of the authors Médicos del Mundo. 2014. revised it critically for important intellectual content. All authors 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 gave final approval of the version to be published Sanit. 2016;30:472–6. 25. Ministerio de Sanidad, Servicios Sociales e Igualdad. Subdirección General de Funding Información Sanitaria e Innovación. Los sistemas sanitarios en los países de la UE: características e indicadores de salud. Madrid; 2013. 26. López-Fernández LA, Martínez Millán JI, Fernández Ajuria A, et al. Is the universal This research has been partially funded by the project entitled coverage of our national health system in danger? Gac Sanit. 2012;26:298–300. Ëfectos de la crisis en la salud de la población y sus determinantes 27. Legido-Quigley H, Otero L, La Parra D, et al. Will austerity cuts dismantle the Spanish healthcare system? BMJ. 2013;346:f2363. ¨ en España(PI13/00897) funded by the Instituto de Salud Carlos III 28. Gallo P, Gené-Badia J. Cuts drive health system reforms in Spain. Health Policy (co-funded by European Regional Development Fund). (New York). 2013;113:1–7. 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. Conflicts of interest 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 None. in Madrid Spain. Int J Health Serv. 2016;46:283–99. 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 Appendix A. Supplementary data Policy (New York). 2016;120:384–95. 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 Supplementary data associated with this article can be found, in context. Eur J Public Health. 2014;24:712–20. the online version, at doi:10.1016/j.gaceta.2017.11.008. 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 References York). 2015;119:100–6. 34. Díaz P. El copago de Mato se ceba con los pacientes con cáncer. 1. Cortès-Franch I, González López-Valcárcel B. The economic-financial crisis and Madrid: Público. 31 enero 2013. Disponible en: http://www.publico. health in Spain. Evidence and viewpoints. SESPAS report 2014. Gac Sanit. es/actualidad/copago-mato-ceba-pacientes-cancer.html 2014;28 Suppl 1:1–6. 35. Asociación Española Contra el Cáncer. La AECC pide accelerar los plazos 2. Quaglio G, Karapiperis T, Van Woensel L, et al. Austerity and health in Europe. de implantación de programes de cribado para disminuir muertes evitables Health Policy (New York). 2013;113:13–9. por cáncer de colon. Madrid: Nota de prensa. 30 marzo 2016. Disponible 3. Pérez G, Rodríguez-Sanz M, Domínguez-Berjón F, et al. Indicators to monitor the en: https://www.aecc.es/Comunicacion/NotasdePrensa/Documents/2016/NP evolution of the economic crisis and its effects on health and health inequalities. Colon.pdf SESPAS report 2014. Gac Sanit. 2014;28 Suppl 1:124–31. 36. Instituto de Médicos Científico (INESME). Encuesta INESME - Impacto de la cri- 4. Bacigalupe A, Escolar-Pujolar A. The impact of economic crises on social inequal- sis económica en la aplicación de terapias oncológicas innovadoras. Madrid: ities in health: what do we know so far? Int J Equity Health. 2014;13:52. INESME; 2011. 234 J. Ferrando et al. / Gac Sanit. 2019;33(3):229–234 37. Europa Press. España, entre los diez paises europeos que menos recur- 44. Dorn SD, Wei D, Farley JF, et al. Impact of the 2008-2009 economic recession sos destinan al cáncer de pulmón. Madrid: El Economista. 15 novembre on screening colonoscopy utilization among the insured. Clin Gastroenterol 2013. Disponible en: http://ecodiario.eleconomista.es/salud/noticias/5316182/ Hepatol. 2012;10:278–84. 11/13/Espana-entre-los-paises- 45. Myong JP, Kim HR. Impacts of household income and economic recession on europeos-que-menos-recursos-destinan-al-cancer-de-pulmon.html participation in colorectal cancer screening in Korea. Asian Pacific J Cancer Prev. 38. Saloustros E, Vichas G, Margiolaki A. Lung cancer in the era of Greek economic 2012;13:1857–62. crisis. Lung Cancer. 2014;86:1367–80. 46. Binefa G, García M, Peiró R, et al. How to assess and reduce social inequalities in 39. Encuesta de Qué Sienten Los Pacientes dirigida a pacientes con cáncer cancer screening programmes. Gac Sanit. 2016;30:232–4. de mama. Informe de resultados 2013. Disponible en: http://docplayer. 47. Adams J, White M, Forman D. Are there socioeconomic gradients in stage and es/23600084-Encuesta-de-que-sienten-los-pacientes-dirigida-a-pacientes grade of breast cancer at diagnosis? Cross sectional analysis of UK cancer registry -con-cancer-de-mama-informe-de-resultados-octubre-de-con-la-colaboracion- data. BMJ. 2004;329:142. de.html 48. Forrest LF, Adams J, Wareham H, et al. Socioeconomic inequalities in lung 40. Molina Barceló A, Moreno Salas J, Peiró Pérez R, et al. Análisis del cribado del cancer treatment: systematic review and meta-analysis. PLoS Med. 2013;10: cáncer en España desde una perspectiva de equidad. Valencia: Fundación para el e1001376. Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana 49. Clegg LX, Reichman ME, Miller BA, et al. Impact of socioeconomic status on (FISABIO, Salud Pública); 2016. Informe técnico. Disponible en: http://www. cancer incidence and stage at diagnosis: selected findings from the surveillance, cribadocancer.com/images/archivos/CRIBADO CANCER EQUIDAD.pdf epidemiology, and end results: National Longitudinal Mortality Study. Cancer 41. Palència L, Espelt A, Rodríguez-Sanz M, et al. Socio-economic inequalities in Causes Control. 2009;20:417–35. breast and cervical cancer screening practices in Europe: influence of the type 50. Ennis KY, Chen M-H, Smith GC, et al. The impact of economic recession on the of screening program. Int J Epidemiol. 2010;39:757–65. incidence and treatment of cancer. J Cancer. 2015;6:727–33. 42. Márquez-Calderón S, Villegas-Portero R, Gosalbes Soler V, et al. Health promo- 51. Lawler M, Duffy S, La Vecchia C, et al. America’s cancer care crisis − is Europe tion and prevention in the economic crisis: the role of the health sector. SESPAS any better? Lancet. 2013;382:1628. report 2014. Gac Sanit. 2014;28 Suppl 1:116–23. 52. Tsounis A, Sarafis P, Alexopoulos EC. Austerity and its consequences on cancer 43. Dimitrakaki C, Boulamatsis D, Mariolis A, et al. Use of cancer screening services in screening in Greece. Lancet. 2014;384:2110. Greece and associated social factors: results from the nation-wide Hellas Health I survey. Eur J Cancer Prev. 2009;18:248–57.