Radiol Oncol 2020; 54(1): 1-13. doi: 10.2478/raon-2020-0008
1
 review
Socioeconomic inequalities in cancer incidence 
in Europe: a comprehensive review of 
population-based epidemiological studies
Ana Mihor, Sonja Tomsic, Tina Zagar, Katarina Lokar, Vesna Zadnik
Epidemiology and Cancer Registry, Institute of Oncology, Ljubljana, Slovenia
Radiol Oncol 2020; 54(1): 1-13.
Received 21 January 2020
Accepted 5 February 2020
Correspondence to: Assoc. Prof. Vesna Zadnik, M.D., Ph.D., Epidemiology and Cancer Registry, Institute of Oncology Ljubljana, 
Zaloška cesta 5, SI-1000 Ljubljana, Slovenia. E-mail: vzadnik@onko-i.si
Disclosure: No potential conflicts of interest were disclosed. 
Background. Since the end of the previous century, there has not been a comprehensive review of European studies 
on socioeconomic inequality in cancer incidence. In view of recent advances in data source linkage and analytical 
methods, we aimed to update the knowledge base on associations between location-specific cancer incidence 
and individual or area-level measures of socio-economic status (SES) among European adults.
Materials and methods. We systematically searched three databases (PubMed, Scopus and Web of Science) 
for articles on cancer incidence and SES. Qualitative synthesis was performed on the 91 included English language 
studies, published between 2000 and 2019 in Europe, which focused on adults, relied on cancer registry data and 
reported on relative risk (RR) estimates.
Results. Adults with low SES have increased risk of head and neck, oesophagogastric, liver and gallbladder, pancre-
atic, lung, kidney, bladder, penile and cervical cancers (highest RRs for lung, head and neck, stomach and cervix). 
Conversely, high SES is linked with increased risk of thyroid, breast, prostate and skin cancers. Central nervous system 
and haematological cancers are not associated with SES. The positive gap in testicular cancer has narrowed, while 
colorectal cancer shows a varying pattern in different countries. Negative associations are generally stronger for men 
compared to women.
Conclusions. In Europe, cancers in almost all common locations are associated with SES and the inequalities can be 
explained to a varying degree by known life-style related factors, most notably smoking. Independent effects of many 
individual and area SES measures which capture different aspects of SES can also be observed.
Key words: socioeconomic status; socioeconomic inequality; cancer incidence; adults; Europe; cancer registry; 
relative risk
Introduction
Health and disease are not distributed equally and 
often also not equitably. This has been observed 
since ancient times by prominent historical fig-
ures, such as Hippocrates (or else his contemporar-
ies), who pointed out that higher social standing 
(power, wealth, freedom, etc.) was reflected in bet-
ter health1, German physician Johann Peter Frank, 
a pioneer in public health who held the view that 
misery of the common people was the mother of 
disease2, and Louis René Villermé, who in 19th cen-
tury France combined census and mortality data 
and used this innovative way to show that disease 
distribution and life expectancy were associated 
with the distribution of poverty in terms of occu-
pational class3,4, to name but a few.
When it comes to cancer, some of the earliest 
studies investigating social inequalities in Europe 
date back over a century. It was firmly established 
by then that certain occupations were undoubtedly 
associated with the development of malignancies 
– lung cancer in miners and scrotal cancer in chim-
ney sweeps being the most notorious – but links 
Radiol Oncol 2020; 54(1): 1-13.
Mihor A et al. / Socioeconomic inequalities in cancer incidence in Europe: a review2
between social class and cancer were only starting 
to be explored. There were already observations 
that social classes differ with respect to cancer rates 
and mortality. According to some early research-
es, cancer on the whole was considered a disease 
of affluence5, while others found the opposite6,7, 
with differences probably being the result of unre-
fined, developing methodology. Later, when spe-
cific cancer types, most commonly gynaecological 
cancers in women, were investigated, clear differ-
ences were seen between classes, such that cervical 
and uterine cancers were found more frequently 
among poor while breast cancer was more com-
mon among wealthy women.8
A century or so after the first studies, in 1997 
the International Agency for Research on Cancer 
(IARC) gathered available evidence from numer-
ous epidemiological studies on the association 
between socioeconomic status (SES) and cancer 
morbidity and mortality which were considered 
to stem from associations between SES and cancer 
risk factors.2 A 2019 IARC report responded to the 
knowledge gap for medium and low-income coun-
tries and addressed the importance of political 
will and know-how to reduce inequalities that are 
consistently found throughout the world.9 Since 
the original IARC report, to our knowledge no 
detailed review of cancer incidence in adults and 
SES in Europe has been published. In the interven-
ing time, many new approaches for investigating 
inequalities have been developed, notably linkage 
methods that are increasingly used to combine 
data from many different databases with complete 
and accurate information on important socioeco-
nomic variables, such as education, occupation and 
income. At the same time, methods have evolved 
which use area-based deprivation indices in deter-
mining how neighbourhoods influence the risk of 
cancer among their residents.9 Finally, cancer in-
equalities should be viewed as dynamic instead of 
static, because the magnitude and direction of dis-
parities can change in tandem with socially driven 
changes in determinants of health and disease.4
The aim of our work was thus to comprehen-
sively review studies that have assessed the direc-
tion and magnitude of socioeconomic inequali-
ties in location-specific cancer incidence among 
European adults in the 21st century. We specifically 
focused on studies that utilised population-based 
cancer registry data linked to individual or area-
level measures of SES. As a result, a large burden of 
disease that could potentially be attributed to dif-
ferences in SES in Europe is highlighted.
Methodology
Se arch strategy and inclusion/exclusion 
criteria
Pursuant to the main aim of our work and fol-
lowing the PRISMA guidelines10, in July 2019 we 
systematically searched three databases (PubMed, 
Scopus and Web of Science) for articles investigating 
the relationship between cancer incidence in adults 
in Europe and SES, operationalised either on an in-
dividual or area level, that relied (at least in part) 
on cancer registry/database data. The search strat-
egy was thus constructed by combining six dif-
ferent main search terms with the Boolean opera-
tor ‘AND’ while using ‘OR’ for individual terms’ 
synonyms. The computer-assisted searches were 
designed and performed by a research librarian. 
The main terms were: cancer, incidence, socioeco-
nomic status, cancer registry, adults and Europe 
(for the full search strategy, refer to Supplementary 
table 1). European countries were defined accord-
ing to the United Nations’ definition of world re-
gions, while any country that was a member of the 
European Network of Cancer Registries (ENCR) 
was additionally included. We searched in titles 
and abstracts of English-language articles pub-
FIGURE 1. The PRISMA diagram detailing the study selection process and results. 
Reasons for exclusion of full-text articles are indicated by numbers as they feature 
and are explained in the text under the subheading Search strategy and inclusion/
exclusion criteria.
Radiol Oncol 2020; 54(1): 1-13.
Mihor A et al. / Socioeconomic inequalities in cancer incidence in Europe: a review 3
lished between 2000 and 2019. The search was up-
dated in December 2019.
The PRISMA diagram detailing the study selec-
tion process and results is presented in Figure 1. 
First, duplicates were removed. After that two 
authors (AM and ST) independently selected ar-
ticles for further reading based on their title and 
abstracts. Exclusion criteria at this stage (Screening 
in Figure 1) were: (1) the article was a review or 
a meta-analysis that included already identified 
studies; (2) the abstract did not include a descrip-
tion of methods used to assess the relationship be-
tween any SES measure (e.g. education, income, 
occupational social class, housing or other mate-
rial determinant of SES, area deprivation) and in-
cidence of any cancer, or did not at least mention 
that one of the goals/results was assessment of this 
relationship; (3) the study investigated exclusively 
all cancers combined; (4) the study population did 
not include adults; (5) the focus was comparison 
of two or more larger regions/countries; (6) the fo-
cus was on comparing rural and urban regions or 
else analysis by population density; (7) the study 
assessed primarily occupational risk or exposure 
through stratifying participants by type of occupa-
tion only (and not by occupational class); (8) the fo-
cus was on comparing immigrants and native-born 
or by ethnicity; (9) the study exclusively analysed 
incidence by marital status or cohabitation; (10) 
the study focused on SES-specific risk of advanced 
disease or primarily on the influence of screening 
(i.e. analysis of inequalities in detection rather than 
incidence of cancer was the main research goal); 
(11) the data on cancer was evidently not from a 
European country; (12) secondary (and not pri-
mary) cancers were analysed; (13) exploration of 
methodological issues was the main goal; (14) the 
study did not at all rely on data from cancer regis-
tries/databases.
If at least one author considered an article 
should be read in full, it was included in the list 
for full-text reading. In the next stage, two authors 
independently read each article in full to assess 
whether it should be included in the final selection. 
If there was uncertainty, a third author’s opinion 
(VZ) was sought. Read articles were screened again 
using the above criteria, while a further exclu-
sion requirement was also assessed (Eligibility in 
Figure 1). Namely, (15) if studies did not report re-
sults in terms of relative risk (RR) estimate between 
groups of SES, either as risk ratio, incidence rate 
ratio, odds ratio, age-standardised incidence rate 
ratio, standardised incidence ratio, relative index 
of inequality, standardised rate ratio, hazard ratio 
or similar. In addition, a snowball approach was 
used whereby reference lists of articles that were 
read in full were searched manually for eligible re-
cords and conversely, articles that referenced the 
studies included in the final selection were manu-
ally examined. Several English-language cancer 
registry/database websites were also searched for 
relevant literature (reported under Identification in 
Figure 1).
Study data extraction and results 
synthesis
After the articles for final inclusion were selected, 
we extracted from studies the following data: first 
author’s full last name and first name initials; arti-
cle title; studied country/-ies; journal (if available); 
publication year; study type, period and popula-
tion; investigated cancer(s) with ICD or ICD-O 
codes (if available); SES indicator (and its level – 
individual/area); analysis methods and inequality 
measures; adjustment/stratification factors; possi-
ble study limitations; and main research findings. 
Descriptive methods were used to report on the 
synthesis of research results regarding associa-
tions between different measures of SES and many 
different cancers in Europe. To examine more 
closely the gap between highest and lowest SES, 
we compiled cancer location-specific tables with 
RR estimates for the lowest compared to highest 
SES category. RR estimates were, when necessary, 
transformed so that highest SES was always the 
reference group, except in instances where SIR was 
calculated with reference to the whole population. 
The extracted information is provided comprehen-
sively in the Supplementary tables 2–29, stratified 
by cancer site and by the type of the SES measure 
applied (individual or area-level).
Results and discussion
Lung cancer
Globally, lung cancer remains the most common 
cancer in absolute number of new cases11 and 3rd in 
Europe where estimated age-standardised rates in 
men are roughly twice as high compared to wom-
en.12 Smoking is the most important contributing 
cause of lung cancer and smoking rates vary sig-
nificantly by SES. A vast amount of information on 
lung cancer and SES is available from across Europe 
that overwhelmingly points to increased risk with 
lower affluence, especially in men.13-35 With re-
spect to individual level SES (Supplementary table 
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Mihor A et al. / Socioeconomic inequalities in cancer incidence in Europe: a review4
2), lowest education was associated with a more 
than threefold risk in certain studies (RR for men 
and women generally around 1.8 and 1.5, respec-
tively).13,14,23-25,31-33,36 Very few studies have failed to 
confirm an increased risk, and only for women.29,30 
Occupational social class, the second most studied 
indicator of SES, is also a more prominent factor 
for men.13,29,35 Comparatively few studies have at-
tempted to evaluate the effect of material compo-
nents of SES through income, housing tenure or 
characteristics and car ownership with similar or 
only slightly greater RR estimates in men compared 
to women.13,15,29 Studies relying on area-level SES as 
a proxy for individual SES (Supplementary table 
3) provided RR estimates in the same range.16-22 
Different individual and area factors when mu-
tually adjusted or unadjusted exhibit comparable 
strength of association. Aside from unemploy-
ment, for which observed RRs were occasionally 
found to exceed 413 (a finding which could result 
also from reverse causality or significant comor-
bidity that was not adjusted for), generally, point 
estimates do not exceed RR of 2. Smoking inequal-
ity contributes most to lung cancer inequality, as 
confirmed by studies adjusting for smoking where 
it accounted for roughly 40–70% of the increased 
risk in low SES , whereas other lifestyle factors con-
tribute much less.23,26,33
Cancers of the upper aerodigestive tract 
and stomach cancer
Many European studies have shown cancers of the 
upper aerodigestive tract (UADT) to be strongly 
associated with lower SES (Supplementary tables 
4 and 5).15-19,27,29,30,32,36-44 As with lung cancer, the 
association is much stronger for men than wom-
en. In Italian29,30, Lithuanian32 and multi-country 
European42 studies for example, excess incidence 
of UADT and head and neck cancers among the 
lowest educated could only be confirmed for men. 
Similarly, in Germany, area deprivation was asso-
ciated with elevated risk for oral cavity and upper 
respiratory tract cancers in men only.19 The most 
studied individual-level SES indicator is educa-
tion, for which overall RR estimates in men range 
from 1.5 to 3 and are generally even higher than 
those found for lung cancer. Effect of area depri-
vation in men in France16,17,37, Germany18,19, Spain38 
and Italy29 was found to be between 1.5 and 2.0, 
whereas in a Scottish study cancers of the mouth, 
oropharynx and larynx were each shown to be 
twice to over 3-times as likely in people from the 
most deprived compared to the least deprived ar-
eas, though they did not stratify by sex.39 There is 
convincing evidence that area deprivation has an 
independent effect on UADT cancer risk, not ex-
plained by individual factors.
Research on oesophageal and stomach cancers 
and SES also points to higher risks with lower 
individual (Supplementary table 6) and area 
(Supplementary table 7) SES.16,17,19,27,32,36,45-47 Yet 
again, incidence in women seems to be less influ-
enced by SES than in men. In several European 
countries, men of the lowest social standing or 
from the most deprived regions had between 1.3 
to 3.0-times the risk of developing cancer of the 
oesophagus, whereas many studies found either 
less increased45,46 or could not confirm an increased 
risk17,19,32,47 for women, though even in the latter 
case the effect estimates were always positive, of-
ten with a discernible trend across SES categories. 
Given that different risk factors have been identi-
fied for the two major histological types, adeno-
carcinoma and squamous cell carcinoma (SCC), 
invaluable information comes from studies that in-
vestigated these subtypes and attempted to control 
for known risk factors in order to clarify to what 
extent they contribute to inequality. A nationwide 
case-control study in Sweden48 found that fruit and 
vegetable intake as well as Helicobacter pylori in-
fection (a potentially protective factor for oesopha-
geal adenocarcinoma) could not explain any of 
the SES inequality for either histological subtype. 
Adjusting for reflux symptoms, body mass index 
(BMI) and tobacco in adenocarcinoma could ex-
plain only part of the SES inequality, whereas to-
bacco and alcohol in SCC did not contribute to SES 
inequality. Similarly, in a European multi-centre 
study49 smoking, alcohol, BMI, physical activity 
and dietary intake of total energy as well as fruit, 
vegetable and meat consumption did not seem to 
contribute significantly to observed SES inequality 
in the incidence of oesophageal adenocarcinoma. 
Therefore, better designed approaches to measure 
these risk factors with minimised residual con-
founding as well as further research into as yet 
unidentified risk/protective factors are needed, es-
pecially given significant observed increases in in-
cidence rates of oesophageal adenocarcinoma.50,51
Stomach cardia adenocarcinoma has been as-
sociated with the same risk factors as oesopha-
geal adenocarcinoma and has also been observed 
to be on the rise.52 On the other hand, occurrence 
of non-cardia adenocarcinoma which is linked to 
infection with Helicobacter pylori, has been de-
clining.53 Recent European registry-based studies 
that looked at the incidence of stomach cancer as 
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Mihor A et al. / Socioeconomic inequalities in cancer incidence in Europe: a review 5
a whole found about 1.5-times (range from 1.1 to 
about 2) increased risk in lower SES individuals, 
predominantly men.16,19,29-32,45,54,55 Rarely, no associ-
ation could be confirmed for either sex.17,25,29 There 
seem to be no major differences in terms of which 
SES indicator is used, though an Italian study, after 
adjusting for individuals’ education, occupational 
class and housing characteristics, found no addi-
tional effect of area deprivation.29 A meta-analysis 
of 11 European case-control and cohort studies es-
timated that the relative index of educational in-
equality (which takes into account the trend over 
categories and category sizes) for stomach cancer 
was as high as 2.92 (95% CI: 1.37-6.19).56 When 
stomach cardia and non-cardia are analysed sepa-
rately, conflicting conclusions are seen: sometimes 
associations of similar magnitudes are found for 
both subsites46; are somewhat stronger for non-car-
dia47; or somewhat stronger for cardia.49,57 The two 
latter studies were large multi-centric case-control 
studies that also stratified by histological subtype 
and found more pronounced educational effects 
for intestinal compared to diffuse type of gastric 
adenocarcinoma. Furthermore, they investigated 
to what extent major risk factors explain SES in-
equality and both found that surprisingly little of 
the inequality could be attributed to lifestyle fac-
tors such as smoking, alcohol, diet, BMI and physi-
cal inactivity, or Helicobacter pylori infection.
Liver, gallbladder and pancreatic 
cancers
Liver and gallbladder cancers are relatively rare in 
Europe, while the opposite is the case for pancreat-
ic cancer. All come with a high mortality burden.58 
Relative risks for these three cancers of digestive 
organs comparing lowest to highest individual and 
area-level SES are listed in Supplementary tables 8 
and 9.
High area-deprivation and low education 
are linked with up to twofold (usually around 
1.5) increased risk of liver and gallbladder can-
cer.16,17,19,29,30,36,46,59-61 Considering that many of the 
causes for these cancers are modifiable (chronic 
hepatitis B and C infection, alcohol, smoking, 
non-alcoholic fatty liver disease, obesity and gall-
stones62-64), they are very likely responsible for part 
of the observed SES inequality, though we can only 
speculate to what extent since we could not find 
studies adjusting for these factors.
Smoking, Helicobacter pylori infection and obe-
sity could potentially explain up to half of all inci-
dent cases of pancreatic adenocarcinoma, the most 
prevalent form of this cancer65, though our review 
did not reveal a uniform link with SES. On the one 
hand, low individual SES in Slovenia27, Denmark45 
and Sweden36 and area deprivation in the United 
Kingdom (UK)59 were linked to increased risk (RRs 
between 1.1-1.6). In Lithuania32, Germany19 and 
Finland46, only men with lowest SES had a slightly 
increased risk. On the other hand, no effects could 
be seen in France16,17 or Italy 30 and women in 
Lithuania with the lowest education actually had 
a reduced risk (RR 0.92).32 Within the EPIC cohort, 
at first no significant effect was seen, although af-
ter the results were updated, RR estimates were 
further from unity and a higher risk in men with 
primary education or less was found. Confounding 
by known risk factors was also examined—risk 
was partly (in men) to almost fully (in women) 
accounted for by smoking, obesity, diabetes and 
physical inactivity.66,67
Gynaecological and breast cancers
We found that low SES strongly increases the risk 
of invasive cervical cancer (Supplementary tables 
10 and 11). RR estimates found in Europe vary 
between about 1.2 to 2.5 for the lowest compared 
to highest educated women.25,29-33,44,68-70 When ar-
ea deprivation is used, effect sizes are generally 
similar and also independent of individual SES.16-
19,21,29,70-72 Particularly prominent seem to be the ef-
fects of neighbourhood deprivation29,70 and individ-
ual level material dimension of SES (e.g. income) 
which seemingly influence risk even more than 
education.29,44,68 No contemporary studies investi-
gating in situ carcinoma were found, though previ-
ously risk for in situ carcinoma was also higher with 
lower SES.73 Very few authors adjusted for known 
risk factors, namely those relating to Human papil-
loma virus (HPV) infection, which is necessary for 
occurrence of cervical cancer, and smoking, which 
could hasten transformation of precancerous le-
sions into carcinoma.74,75 In England, area effect was 
diminished when teenage conception rates, smok-
ing rates and screening coverage were taken into 
account.76 Similarly, in Norway, higher risk among 
the lower educated was not significant anymore, 
after controlling for smoking, age at first birth and 
participation in screening, though the hazard ratio 
was still close to 2.33 Importantly, smoking account-
ed for more than 30% of the inequality, whereas 
screening and age at first birth contributed only 
approximately 3 and 6%, respectively. HPV sero-
positivity might explain the rest of the inequality, 
but as far as we know, neither this nor any other 
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Mihor A et al. / Socioeconomic inequalities in cancer incidence in Europe: a review6
study in Europe to date was able to make use of 
such data. Different histological subtypes have also 
rarely been studied separately—even though both 
squamous cell carcinoma and adenocarcinoma re-
quire HPV infection to develop, in Finland adeno-
carcinoma did not show an association with SES 
which could imply aetiology of the two subtypes 
varies to a larger degree than previously thought.69 
Cancers of the vulva and vagina are also associated 
with HPV infection, thus unsurprisingly, a negative 
association with SES has been observed with RR es-
timates as high as 2.44,59
Some of the highest rates of breast cancer in-
cidence and mortality in the world are found in 
Europe where in places cumulative life-time risk for 
women is as high as 30%.58 Unhealthy lifestyle, hor-
monal and reproductive factors (menarche, meno-
pause, parity, age at first birth and breastfeeding) 
increase its risk.77-80 As shown in Supplementary 
table 12, most studies found women with higher 
SES are at an increased risk of developing breast 
cancer.14,16,18,19,21,22,26-33,36,81-89 Age-only adjusted RR 
estimates comparing lowest to highest education 
are between 0.6 and 0.9, mostly around 0.8. Similar 
estimates are reported when measuring area-SES 
(Supplementary table 13). Other measures of SES 
are used rarely and there seem to be less consisten-
cy between them, particularly in those that reflect 
material SES. Therefore, education through delay 
in childbearing seemingly explains most of the SES 
effect.90,91 Studies that attempted to adjust also for 
reproductive and life-style factors found RRs either 
significantly closer to unity, when adjustment was 
incomplete82,85,87, or equal risk across SES categories 
both in pre- and postmenopausal women when 
adjustment was very careful.33,83,84,92 Furthermore, 
no significant educational differences were found 
among nulliparous women.92 Inequalities are also 
stronger for in situ compared to invasive breast 
cancer and remain partially unexplained by known 
risk factors30,87,92 strongly suggesting the effect of 
screening. Overall, inequalities in breast cancer 
can thus, to a substantial degree, be explained by 
known risk factors.
Ovarian, fallopian tube and endometrial cancers 
have rarely been found to be positively associated 
with SES, most often no association was clearly 
determinable (Supplementary tables 10 and 11).16-
19,30,32,36,68,93,94 This is unexpected since reproductive/
hormonal factors also play a role in tumorigen-
esis.95,96 Equally rarely, increased risk of uterine97,98 
and ovarian36 cancer among low SES groups has 
also been reported. No strong conclusion could be 
drawn for these cancers.
Male genital and prostate cancers
Testicular cancer afflicts mostly adolescents and 
young men.99 While it was previously thought that 
most of the risk for its development is determined 
already in utero, it is now evident that postnatal 
factors also play an important role, perhaps by in-
fluencing progression of existing in situ testicular 
carcinomas.100 Across the world, increased risk of 
testicular cancer, which is predominantly of germ 
cell type classified into seminoma and non-semi-
noma, had often been reported with high SES but 
the gap has started to narrow in recent decades.101 
Since 2000 in Europe, many countries do not re-
port an association (Supplementary tables 14 and 
15); no difference in incidence was thus found in 
Denmark102, Slovenia27, Germany19,103, France16,17 or 
Italy.30 On the other hand, high area deprivation 
and household overcrowding in England59,104,105, 
low education in Sweden36 and low occupational 
social class in Finland106 were associated with low-
er risk of seminoma and non-seminoma cancer (RR 
estimates about 0.7-0.9), though in Finland, the RRs 
have decreased substantially. In line with findings 
that HPV infection, poor hygiene, smoking and 
obesity increase risk for penile cancer107, we found 
that most44,59,108, though not all106, identified stud-
ies also reveal an association between penile cancer 
and low SES, sometimes stronger for invasive than 
in situ carcinoma. 
Representing over 20% of all incident cancer 
cases (excluding non-melanoma skin cancer), 
prostate cancer is the most common cancer among 
European men today.12 The latest data shows that 
in most of Europe, incidence rates have stabilised 
or started decreasing.109 Some of the potential 
lifestyle-related factors are smoking, alcohol, obe-
sity, physical inactivity and diet, though no as-
sociations have been unequivocally proven.110,111 
However, today it is clear that the burden and its 
trend is highly influenced by availability of oppor-
tunistic screening for prostate cancer by Prostate 
Specific Antigen (PSA) testing. As shown in many 
studies (Supplementary tables 16 and 17), lower 
SES is associated with lower prostate cancer risk, 
though not everywhere.19,26,28,112 RRs are between 
approx. 0.5–0.9, most often around 0.8, again 
with independent effects of different SES indica-
tors.14,16-18,22,25,27,29-32,36,71,102,106,113-116 Higher RRs are 
reported for less compared to more advanced dis-
ease106,113,115; this points to screening as one of the 
reasons for the positive gap (affluent men have 
better access to or are more motivated to undergo 
opportunistic screening). The gap was increasing 
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Mihor A et al. / Socioeconomic inequalities in cancer incidence in Europe: a review 7
during the first decade of the 21st century59,115, but 
has since decreased in certain places22, perhaps 
due to changes in clinical use of PSA testing after 
negative outcomes related to opportunistic screen-
ing were becoming increasingly recognised. In a 
randomised intervention study113, screening some-
what narrowed the gap for advanced disease when 
education and income were used as measures of 
SES, while the gap for renters compared to home-
owners widened. Finally, a cohort study in the UK 
found that adjustment for PSA testing narrowed 
the gap in risk between least and most deprived 
only slightly and therefore PSA testing is probably 
not the only factor behind higher incidence of pros-
tate cancer with increasing SES.116 Lifestyle factors, 
which could also explain part of the effect, have not 
been sufficiently studied yet in this regard.
Urinary tract cancers
Kidney cancer is roughly twice as common in men 
than in women.12 Incidence is higher in more devel-
oped countries where it is on the rise.117 Identified 
risk factors are for the most part life-style related, 
and are thus influenced by SES118,119, though with-
in this review studies looking at the association 
between SES and kidney cancer have provided 
varied results (Supplementary tables 18 and 19). 
Nevertheless, it seems that more often than not, 
lower SES, measured most often as education or 
area deprivation, is associated with higher inci-
dence in both sexes but slightly more strongly in 
women.19,33,36,59,120,121 RRs are most often around 1.2–
1.3 and rarely above 1.5. Controlling for risk factors 
was seldom performed. One study investigated the 
explanatory power of smoking and alcohol and 
found that smoking accounted for approximately 
30% of the higher risk in low educated women, 
whereas higher alcohol consumption was appar-
ently protective.33 In Italy30 and Lithuania32, the as-
sociation was reversed, i.e. risk was increased with 
higher SES, while in France no association could be 
found.16,17 The reason behind the reversed findings 
is not known, though may be due to advances in 
diagnostic activities.
Compared to women, bladder cancer rates are 
as much as five times higher among European men 
in whom it represents the fourth most commonly 
diagnosed cancer.12 Like for kidney cancer, RRs 
comparing lowest and highest education are mod-
erately elevated in lower educated men and wom-
en (Supplementary tables 20 and 21) and range up 
to 1.5 but are mostly between 1.2–1.3.16-19,27,30,32,120,121 
We could not identify any European study that 
looked into how known and potential risk factors, 
primarily smoking and exposure to occupational 
carcinogens122, contribute to SES inequality in blad-
der cancer incidence. Considering smoking is such 
an important factor, most of the inequality is likely 
present on its account.
Colorectal cancers
Colorectal cancer is strongly related to lifestyle and 
is the second most common malignant tumour (ex-
cluding non-melanoma) in Europe with respect to 
the absolute number of cases.12,123 Incidence used 
to be higher among affluent Europeans2,124,125 but a 
review of studies shown in Supplementary tables 
20 and 2116-20,22,25-28,30-33,46,126-130 has reinforced that in 
several countries, a reversal towards higher inci-
dence among lower SES groups has occurred. For 
example, before the 1990s affluent Finnish men and 
women had an increased risk of colon and rectal 
cancers46 but Finland has since seen a gradual nar-
rowing of the educational gap, almost to the point 
of reversal, especially among men, which is due 
to relatively larger increases in incidence in lower 
SES individuals.127 A similar pattern emerged in 
Norway.131 In Denmark at the turn of the century, 
both colon and rectal cancers were already more 
common with greater individual disadvantage, 
particularly material and in men.126 In Sweden128 
and Italy30, the lowest educated men and women 
now have up to about 30% and 15% increased risk 
for rectal cancer, respectively, with no differences 
for colon cancer. In the UK 22,129 and Germany 18-
20, area deprivation is associated with higher inci-
dence of colorectal cancer as a whole, primarily in 
men. On the other hand, risk was lower in lower 
educated men and women in Lithuania for both co-
lon and rectum31,32, while no clear association could 
be shown in Ireland28, the Netherlands 26, France 
16,17 and Iceland.25
Melanoma and non-melanoma skin 
cancer
In Europe, skin cancer, including melanoma and 
non-melanoma (basal cell carcinoma – BCC and 
squamous cell carcinoma – SCC), has seen some of 
the fastest growing incidence rates among all can-
cers. For melanoma, body locations associated with 
the highest increases are limbs and trunk, which 
are intermittently exposed to sun radiation.132
Many studies in Europe (Supplementary tables 
22 and 23) have found a positive association for 
melanoma and SES.16-19,21,25,27,29,30,32,33,36,59,133-138 RRs 
Radiol Oncol 2020; 54(1): 1-13.
Mihor A et al. / Socioeconomic inequalities in cancer incidence in Europe: a review8
comparing the lowest to highest educated vary 
between 0.5–0.9 and are most often between 0.6–
0.7. In a stratified analysis by body location, only 
melanoma of the limbs and trunk could be linked 
with SES.134 When area-SES was investigated, RRs 
were slightly higher (around 0.8). This, along with 
the fact that in a study after mutual adjustment for 
individual-SES effect of area-SES could no longer 
be found29, points to individual SES as the primary 
factor for observed differences. Though controlling 
for risk factors has been scarcely attempted, high 
intermittent sun exposure among persons with 
higher SES could explain most of the gap. No study 
controlled for skin type in Europe, though popu-
lations in most countries are homogenous in this 
respect. Therefore, it is not surprising, for example, 
that in Norwegian women the number of sunburns 
accrued and latitude of residence explained most 
of the excess risk.33
Fewer studies were found for non-melanoma 
skin cancer (Supplementary tables 22 and 23). 
In Lithuania31, melanoma and non-melanoma 
showed equal RRs with respect to education and 
in Germany18 non-melanoma cancer showed even 
stronger positive associations with area depriva-
tion than melanoma though neither distinguished 
between SCC and BCC. In Denmark, BCC excess 
risk according to different indicators of high SES 
was virtually identical to RRs found for melanoma. 
SCC on the other hand was marginally associ-
ated only with higher income.133,139 Conversely, in 
Nordic countries SCC was clearly more common 
in people with the highest education and occupa-
tional class36,140, while in Ireland141 and Scotland137, 
along with BCC, SCC was also positively associ-
ated with area deprivation. This could mean that 
chronic exposure, which is generally considered 
higher in manual outdoor workers, is actually 
higher among the affluent, at least in the studied 
countries, or else they undertake more diligent 
screening.
Lymphoid and haematopoietic cancers
Haematological cancers, the aetiology of which is 
unclear, are more frequent in males compared to 
females.142 Overall, we could not confirm that these 
cancers are associated with SES (Supplementary 
tables 24 and 25).16,17,27,30,32,36,59,143,144 In Italy30, risk 
of Hodgkin lymphoma was non-significantly re-
duced with RR around 0.8; elsewhere, no asso-
ciations were found16,17,32,143 or risk was higher in 
lower SES groups, such as among men with lowest 
education and male renters compared to owners in 
Denmark144 and in most deprived areas in England 
with RR of 1.6 for males and 1.4 for females.59 
Overall, non-Hodgkin lymphoma, multiple my-
eloma and leukaemia also do not seem to be asso-
ciated with SES, excluding some reports of varied 
associations. In Germany, for example, risk for all 
lymphoid and haematopoietic cancers combined 
was higher in deprived men and women but this 
categorisation was too crude.19 Authors of a report 
from the Haematological Malignancy Research 
Network in the UK concluded (aside from report-
ing on lower risk of myeloma in very deprived ar-
eas) that there are no SES inequalities for a myriad 
of disease entities categorised according to the de-
tailed WHO classification.143
Central nervous system cancers
Though rare, in adults gliomas and meningiomas 
are the most common tumours of the central nerv-
ous system (CNS).145 The only well-established 
modifiable risk factor for CNS tumours is ionising 
radiation whereas at present there are no conclu-
sive findings regarding exposure to non-ionising 
radiation (e.g. mobile phone use).146 Within this re-
view we could not confirm a clear association with 
SES (Supplementary tables 26 and 27). Given that 
CNS tumours encompass a variety of types, unsur-
prisingly, no clear direction of association could be 
ascertained when all types are analysed together. 
Thus, with increasing affluence, risk was increased 
in men in Denmark147 and Sweden 36 and women in 
England 59, decreased in men in Italy 30 and in parts 
of France 17 or else equal in France 16, Germany 
19, Lithuania 32 and Norway.33 Regarding specific 
types, there are some indications that glioma and 
acoustic neurinoma are less common with lower 
affluence while meningioma showed no unequal 
distribution according to SES.148-150
Thyroid cancer
Influenced in part by improved detection of 
asymptomatic cancers, incidence of thyroid cancer 
is on the rise.151 Our review (Supplementary tables 
28 and 29) showed that thyroid cancer risk was 
greater among Lithuanian men and women with 
higher education (SIR between 0.8-0.9)32 and in ar-
eas with lower deprivation in Germany (SRR be-
tween 0.6-0.7).19 Risk was also increased, although 
not significantly, in highly educated Norwegian 
women (HR 0.7).33 In other countries, researchers 
could not confirm this link16,17,59, whereas a study 
in Sweden found higher risks for lower educated 
Radiol Oncol 2020; 54(1): 1-13.
Mihor A et al. / Socioeconomic inequalities in cancer incidence in Europe: a review 9
people.36 Elevated risk in groups with higher SES 
could be explained by differential access to diag-
nostic procedures in favour of high-SES groups. 
Since there are no studies adjusting for multiple 
SES measures and risk factors, independent effects 
of different SES indicators as they relate to differ-
ing dimensions of SES (such as material, cognitive 
etc.) are as yet indeterminable.
Conclusions
In our review we aimed to take stock of national 
or international studies that have investigated the 
link between the socioeconomic factors and can-
cer incidence, focusing specifically on Europe and 
studies based on cancer registry data published in 
the 21st century. It was necessary to consider two 
parts, one dealing with the social status (individu-
al level) and the other with the social environment 
(neighbourhood level studies). It is evident that 
very few cancers are not associated with SES: head 
and neck, oesophagogastric, liver and gallbladder, 
pancreas, lung, kidney, bladder, penis and cervix 
are associated with low SES; conversely, high SES 
is associated with breast, prostate, thyroid and skin 
cancers. For other investigated locations, no asso-
ciations were observed or else results are too few 
or varied to make firm conclusions.
Generally, negative associations are stronger for 
men than women and can be explained to a very 
large degree by known life-style related factors, 
most notably smoking as the single most impor-
tant modifiable cause of a multitude of different 
cancers. Interestingly, the studies that mutually 
adjusted for either several different individual or 
individual as well as area SES measures have rein-
forced what has already been known, namely that: 
i) individual-level SES measures are not simply in-
terchangeable but reflect different aspects of socio-
economic position, from material and cognitive to 
cultural; and ii) both area and individual SES have 
independent effects on cancer risk, again highlight-
ing the complexity of the concept of socioeconomic 
status.
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