Socio-economic inequalities in suffering at the end of life among advanced cancer patients: results from the APPROACH study in five Asian countries.

Journal Article (Journal Article)


A systematic understanding of socio-economic inequalities in end-of-life (EOL) suffering among advanced cancer patients is required to inform efforts to reduce these inequalities as part of Universal Health Coverage goals.


To assess inequalities in multiple domains of EOL suffering among advanced cancer patients - physical, functional, psychological, social, and spiritual -, using two socio-economic status (SES) indicators, education and perceived economic status of the household.


We used cross-sectional data from surveys of stage IV cancer patients (n = 1378) from seven hospitals across five countries (China, Sri Lanka, India, Vietnam and Myanmar). We conducted separate multivariable linear regression models for each EOL suffering domain. We also tested interactions between the two SES indicators and between each SES indicator and patient age.


Patients living in low economic status households /with fewer years of education reported greater suffering in several domains. We also found significant interaction effects between economic status of the household and years of education for all EOL suffering outcomes. Age significantly moderated the association between economic status of the household and social suffering and between years of education and psychological, social, and spiritual suffering (p < 0.05 for all).


Results highlight that SES inequalities in EOL suffering vary depending on the suffering domain, the SES indicator assessed, and by patient age. Greater palliative care resources for patients with low SES may help reduce these inequalities.

Full Text

Duke Authors

Cited Authors

  • Malhotra, C; Krishnan, A; Yong, JR; Teo, I; Ozdemir, S; Ning, XH; Hapuarachchi, T; Palat, G; Bhatnagar, S; Joad, AK; Tuong, PN; Ssu, WM; Finkelstein, E

Published Date

  • September 10, 2020

Published In

Volume / Issue

  • 19 / 1

Start / End Page

  • 158 -

PubMed ID

  • 32912232

Pubmed Central ID

  • PMC7488341

Electronic International Standard Serial Number (EISSN)

  • 1475-9276

International Standard Serial Number (ISSN)

  • 1475-9276

Digital Object Identifier (DOI)

  • 10.1186/s12939-020-01274-5


  • eng