Mind the Gap: Cancer and Class
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... or 'The Lumpen Proletariat' ...

Over recent decades, UK cancer death rates have fallen significantly. They began falling in the late 1980s, and by 2006 had fallen by 17%. More people than ever before are surviving cancer, with 78% of women in England and Wales still alive ten years after their breast cancer diagnosis (2010-11).

But there are still big differences between cancer outcomes depending on how wealthy you are. Economic inequality - the polite term for 'class divisions' - is linked to 19,000 cancer deaths per year.

In 2008, the Daily Telegraph sounded the alarm to its affluent readership that the "Middle classes [were] 'more likely to develop breast and skin cancer'". Although the report it cited could only claim to establish statistical correlation between social class and incidence of these cancers rather than the causes of this, the Torygraph was quick to declare the reasons, stating that "Career women delaying having children and exposing themselves more to the sun on foreign holidays are thought to be behind the gap." There is some consolation for the well-to-do, though: their lower-income fellow human beings are more likely to get lung or cervical cancer, "because people from poorer classes are more likely to smoke and skip smear tests."

In fact, a balanced assessment of the study - rather than a glance at a headline - shows the gaps weighing rather more heavily on poorer women. Although the least deprived fifth of women (hardly the 'middle class', then!) were 0.15 times (ie. 15%) more likely to develop breast cancer, the most deprived fifth of women were 2.7 times (ie.170%) more likely to get lung cancer than the top fifth were. Moreover, although poorer women are less likely to get breast cancer, they are more likely to die from it.

Allow me to ponder for a moment on the Telegraph's choice of the work 'skip' to describe poorer women not attending cervical smear tests. Although in this case, the word does not literally mean 'dance gaily through flowery summer meadows', it does project a notion of a carefree, reckless decision not to attend.

Research shows that working-class women are less likely to attend cervical smear tests, and as these results show, breast screening:

  • women who own their own car and women who own their own house are more likely to attend breast screening (2009)
  • 31% of women with manual/routine occupations reported irregular or non attendance at breast screening, compared to 17% of professional or managerial women (2006)
  • in my own, very working-class, home borough of Hackney, east London, only 58.2% of women aged 53-70 attend breast cancer screening, way lower than the English average of 75.4%.

But are they wantonly 'skipping' screening appointments, or is there something else going on? Researchers tend to prefer the term 'lower uptake' to 'skipping', and have variously found that:

Perhaps less measurably, it may be that working-class women's lives are more demanding, more stressful, less supported, and consequently more liable to see 'optional extras' such as cancer screening slip through life's net. With an estimated 1,400 women's lives saved each year by the NHS's breast screening programme (2006), disproportionately few of these saved lives are those of working-class and poor women.

Not only are poorer women less likely to take up screening, they are also less likely to recognise cancer symptoms, a combination which leads to later diagnosis, which in turn reduces the chances of survival. Women who live in deprived areas are more likely to be diagnosed with advanced breast cancer and less likely to survive for five years; women diagnosed at the earliest stage of breast cancer are 26 times more likely to survive than those diagnosed at the latest stage (2006). 

Moreover, the wealthier a person is, the more that person tends to know about cancer risk factors, and the more likely they are to take measures to avoid risk, such as eating five portions of fruit and veg daily, taking physical exercise (2006) and breastfeeding (2013).

So, working-class women live less healthy lives and are more likely to die from breast cancer than rich women. The statistics prove it. But why? The loathsome Margaret Thatcher once described poverty as a "personality defect", and the equally loathsome Boris Johnson argued that some poeple are just too unintellligent to get on in life. Although few right-wing ideologues would state it in such a vulgar way, plenty believe that these inequalities arise from the inherent inferiority of the great unwashed. The poor are poor because they make poor choices. 

Alternatively, perhaps the poor make poor choices because they have little choice because they are poor. Where serious research papers refer to 'lifestyle factors' in cancer outcomes, newspapers will often instead refer to 'lifestyle choices', a sleight of hand which subtly points the finger at the indvidual and strips their choices of their social context. In reality, we do make choices, and we are responsbile for them - but we make those choices in circumstances not always within our control, and the less money we have, the further beyond our control those circumstances are. 

Perhaps poorer people take less physical exercise not because they are lazy but because they can't afford (the time or money) to join the local council's sports centre, let alone the tennis or rugby club. Perhaps the 'choice' to grab some fast food rather than browse the farmers' market for organic veg is a choice shaped by shortage of funds and time. Perhaps you 'skipped' the chance to be screened because you did not receive or understand the letter inviting you or you couldn't get the time off work without losing wages you couldn't afford to lose. Some 'lifestyle factors' - for example, the 5% of breast cancers caused by exposure to carcinogenic factors at work - are not really 'choices' at all. And perhaps at a less practical, more subconscious level, the more pleasant and comfortable your life is, the more effort you will put in to preserve it.

Cancer Research UK does a valuable service in commissioning the research that gives us these facts - a service so valuable that it deserves to be carried out and funded by the government rather than relying on coffee mornings, sponsored sky-dives and funding from the private health industry. CR-UK also has many proposals for reducing the inequalities in cancer outcomes: more research, health promotion targeted at 'hard-to-reach' groups; communication training for health professionals, a drive to increase screening uptake amongst the most deprived groups, and more.

All these would be welcome. But isn't there a more obvious, more fundamental, more straightforward solution? If poverty increases your chances of dying of breast and other cancers, then surely the most effective measure would be to abolish poverty. If class divisions cause inequalities in cancer outcomes, then abolish the division of society into classes: remake society on an equal and co-operative footing. Obviously, advocating such radically common-sense ideas is beyond the remit of a charity. But it is not beyond the remit of this blog.