Throughout the world, the poorer people are, the less healthy they are, and France is no exception. Cancer, the leading cause of death in France, is a major contributor to the country’s social inequalities in health, accounting for 40% among men and 30% among women1. How does social status affect cancer? Various studies show that it increases the risk of developing these diseases, makes the treatment process more difficult and contributes to a decline in quality of life after treatment.
Pre-disease: socially marked risk factors
It’s true that breast cancer tends to affect more affluent people. But for the majority of other cancers, the incidence is much higher among people from lower social classes. The deadliest forms of cancers (lung and upper aerodigestive tract) appear to be particularly associated with social deprivation.
How can this be explained? The answer lies essentially in the social determinism of the main risk factors. For example, while tobacco consumption is unanimously recognised as the major risk factor for lung cancer and one of the two main risk factors, alongside alcohol, for cancers of the upper aerodigestive tract, 2.3 times as many people in the low socio-economic classes smoke daily as those in the high socio-economic classes (the trend is reversed for alcohol, however: consumption is 1.3 times higher in the high socio-economic classes2).
But contrary to certain preconceived ideas, this risky consumption is not always the result of a totally free individual choice. In his book La cigarette du pauvre (The Poor Man’s Cigarette), Patrick Peretti-Watel highlights the early socialising role of cigarettes in disadvantaged groups, explaining that “precariousness induces stress, which encourages smoking(…). Precariousness also shortens the time horizon, which impacts the ability to put the harmful effects of smoking in the long-term into perspective”. Quitting smoking, a major act of prevention, is therefore much more difficult for people in precarious situations.
Furthermore, while smoking is rightly singled out as a cause of inequalities, other risk factors with a significant social impact, such as occupational exposure to carcinogens, should not be overlooked. “Studies indicate that the impact of these factors has been much less studied, even though they seem to carry a great deal of weight. Healthcare professionals themselves are less aware of them,” explains Aurore Loretti.
Despite the progress made in recent decades, these exposure remains frequent in France. The latest survey, Surveillance médicale des expositions des salariés aux risques professionnels (Medical Surveillance of Employee Exposure to Occupational Risks), carried out in 2017, showed that 11% of employees had been exposed to at least one carcinogen in the last week worked3. Half of these were blue-collar workers.
During the illness: an accumulation of inequalities
Inequalities are then compounded over the course of treatment. “Whatever the location of the cancer, the lower your socio-economic status, the lower your survival rate” confirms Gwenn Menvielle.
Yet France has a number of advantages. Its healthcare system is more efficient than many of its European neighbours: while the number of cancer cases in the general population is higher (associated with higher average consumption of tobacco and alcohol, and lower vaccination rates against HPV), survival rates are better. Per capita spending on cancer care is among the highest in Europe, and the proportion of healthcare costs that patients pay is the lowest of all European Union countries4.
One might imagine that, with the financial barrier at least partially removed, the influence of patients’ material circumstances would be less marked than in neighbouring countries. But this is not the case. Another obstacle stands in the way of the most disadvantaged people: the need to consult a doctor in the event of symptoms or to undergo screening. Significant delays in diagnosis are observed in the least privileged environments, and participation rates in national screening campaigns (for breast, cervical and colon cancer) are much lower among the most disadvantaged populations. “Living in precarious conditions can lead people to put prevention on the back burner, play down their symptoms and put off seeking medical advice by resorting to self-medication.
But prevention policy also plays an important role. While breast cancer receives a great deal of media coverage, we hear much less about colon cancer, for example, despite the existence of national screening, or VADS cancers. For the latter, campaigns could be run to explain, for example, that you should consult a doctor if you have a lesion in your mouth that hasn’t healed in three weeks”, explains Aurore Loretti. And in fact, according to OECD 2023 figures, the budget spent by France on prevention is well below the European average5.
Post-diagnosis, other difficulties complicate the continuation of care. In 2020, the number of doctors per capita in France was well below the EU average (3.2 per 1,000 inhabitants compared with 4 in Europe). While this shortage affects the population as a whole, it seems to have more adverse effects on disadvantaged people, with longer delays in accessing care in particular, as suggested by the 2014 VICAN2 survey. However, between 2017 and 2022, the number of oncologists increased by 30% and the number of radiotherapists by 8%6.
Material living conditions also have an impact on patients’ decisions and on the treatment options available to them. “Some patients put off treatment because they can’t afford to take time off work; others postpone treatment to allow time to organise care for dependents, made more difficult by precarious financial resources. On the other hand, doctors sometimes refrain from offering major surgery to certain patients who are isolated or in very precarious situations, because they fear that returning home will be too difficult” adds Aurore Loretti.
Studies also show that inequalities are more marked among men than women throughout the health care process, especially when they are isolated. “The fact of being a woman, or having women in one’s immediate circle, compensates in part for social status. Women are more familiar with the idea of care because they are often in charge of the family’s health and have benefited from regular check-ups in the event of pregnancy,” comments Aurore Loretti. Recent data7 shows, however, that while the (significant) inequalities in mortality observed among men are tending to diminish, they are increasing among women. “Here again, the primary cause is tobacco consumption, which has risen sharply among women, particularly from disadvantaged backgrounds, since the 1970s,” adds Gwenn Menvielle.
After the disease, an impact on quality of life
Few studies look at the post-treatment period, but those that do show that social inequalities continue to play an important role once treatment has been completed. Lung cancer, for example, is particularly impacted by social factors, leading to greater social inequalities and greater uncertainty when it comes to returning to work8.
In a recent study9, Gwenn Menvielle and her colleagues looked at the aftermath of breast cancer. The team followed nearly 6,000 patients over a 2‑year period and assessed their quality of life using a score based on several criteria (fatigue, general and psychological state, sexual health, side effects). At diagnosis, the differences in quality of life between the two socio-economic extremes, evaluated at 6.7, were already significant. They increased significantly over the course of the disease (score of 11) and remained at a higher level than at diagnosis once treatment had been completed (score of 10).
For Gwenn Menvielle, “the reasons for these differences are not to be found in the treatment, which was similar for all the women. They probably come from the support elements around the medical treatment: the family environment likely to provide help on a daily basis, and the material and financial capacity to follow care that extends beyond the purely curative, such as psychotherapy or physiotherapy sessions.” The researcher is now working on a more detailed analysis of the impact of these factors.
