Gains in life expectancy from decreasing cardiovascular disease and cancer mortality – an analysis of 28 European countries 1995–2019

In the founding EU countries, continuous economic growth alongside improved health care (e.g. detection and treatment of hypertension, cancer screening and improved treatment) and health promotion and protection policies (e.g. tobacco control and improved road safety) have contributed to steady declines in the mortality of chronic diseases and subsequent increases in life expectancy. In contrast, the less favourable mortality trends in the A10 countries indicate greater economic and health-care challenges and a failure to implement effective health policies [24]. The root causes for such mortality trends include adverse social determinants of health under the backdrop of interrupted economic development, the so-called “state socialist mortality syndrome”, and the transition from socialist to capitalist systems [25‐27]. At the micro level, there have been low levels of health awareness, that have manifested, for example, in high levels of alcohol and tobacco consumption, mostly among lower socioeconomic groups, whereas at the macro level, socialist economies in crisis have been unable to generate the necessary resources for modern and expensive medical technologies [16].

The negative consequences on cancer and CVD mortality are evident in this study of A10 versus founding EU countries. While decreasing inequalities in life expectancy can be observed throughout the EU27 + 1 countries over the quarter century, the absolute level of national LE, and the differences between the two regions are largely maintained, with LE higher and recent gains more evident in the founding EU countries. These countries have observed steep declines in cardiovascular mortality, as part of the so-called “cardiovascular revolution” due to major advances in the control of cardiovascular risk factors (smoking, blood pressure, and cholesterol levels) and improvements in medical care [28] that began in the late-1960s. These occurred decades earlier in founding EU vs A10 countries [10] and advances continues to this day, as can be seen in terms of declining mortality from ischemic heart disease [29] and acute myocardial infarction [30]. However, recent studies have also shown such reductions in CVD mortality to be waning in some high-income settings [31].

Progress against cancer and the extent to which different strategies across the cancer control continuum serve to control the disease has been deliberated for close to 50 years [32]. The assessment of cancer mortality trends and their impact on LE are necessarily complex given malignant neoplasms embrace over 200 types, each with differing (known or unknown) determinants for which selected primary, secondary, and tertiary interventions may be effective in controlling the disease. The continuous decreases in cancer mortality suggest founding EU countries are undergoing cancer transitions not dissimilar to those hypothesized in Japan [33], with a shift away from cancers triggered by unhealthy lifestyles (e.g.: smoking and drinking) and infection (stomach and cervix malignant neoplasms) towards a cancer profile more associated with affluence and non-infectious causes. Yet A10 countries also appear to be in a recovery phase and a transition from the epidemiological crisis to socioeconomic advancement made possible, in some countries, by regime change that has been accelerated with entry to the EU in 2004. Indeed, CVD mortality started to fall steeply from the early-2000s in these countries, though corresponding progress in cancer was confined to lung and stomach cancer through tobacco control [34] and the “unplanned triumphs” of primary prevention, respectively [35]. All of these resulted in disruptions of the life prospects gains in post-socialist societies in recent decades, drawing attention to the essential and persisting social inequalities in cancer mortality [36].

Tobacco consumption is a key risk factor in the development of CVD [37] and numerous cancer types [38]. Recent studies highlight that the excess risk of CVD is rapidly reversible through tobacco cessation [39], while stopping smoking, even after middle age, avoids much of the risk of lung cancer attributable to tobacco [40]. Our study illustrates the association between life expectancy, mortality trends and their respective position in the global smoking epidemic model [41, 42]. For men, increases in life expectancy across many age groups have been seen largely because of declines in lung cancer mortality resulting from effective measures of tobacco control over the last decades. At the same time, our results point to the very limited gains in life expectancy among women in several European countries that often goes against the narrative of the east vs. west divide and the reduction of gender inequalities in cancer mortality. These result from sex-specific historical trends in tobacco consumption [43, 44] and recent trends in female smoking prevalence [45, 46] suggesting that the global smoking epidemic model links to cultural and legislative divergence at the country level, including social acceptance and the targeting of women by the tobacco industry [47]. According to our study, the losses in age-specific life expectancy are minimal in Denmark, Ireland, the Netherlands, and the U.K. relative to the marked impact seen among middle-aged women in France, Spain and several countries in Central and Eastern Europe (Austria, Hungary, Slovenia and Croatia). The smoking-attributable mortality (for which lung cancer predominates) peaked in different periods in different European regions, with forecasts indicating a decline in smoking-attributable mortality occurring before 2030, that will continue until 2040 and will be halved by 2065 [48]. Evidently, the large variations in European regions and countries reflect the relative aggressivity of tobacco control policy, which determines to a considerable extent the potential of primary prevention [49].

After lung, cancers of the breast, colorectum and prostate exhibit the highest mortality rates in Europe [50]. Our analysis provides an illustration of progress in cancer control through rate reductions in breast and prostate cancer mortality that are related to a broad and complex spectrum of cancer control interventions, including early detection through mammography [51], PSA testing and curative treatment [52], as well as improved diagnosis and better access to effective and breakthrough treatments [53]. In contrast, our results show that the respective gains in life expectancy related to these cancers is more limited in Eastern Europe. The gains in LE due to declines in colorectal mortality do not however show clear East-West differences; these may reflect in part changes in the prevalence and distribution of key risk factors that affect incidence as well as the extent to which population-based colorectal screening has been fully implemented [54].

A key strength of our study is the comprehensive assessment of LE changes in relation to CVD and cancer mortality trends that highlights inequalities between and within EU countries by sex and age. A limitation is the use of cause of death statistics, which varies in its robustness from country to country and represents an oversimplification, given for example, smoking is a ubiquitous risk factor that could have a determining role in the development of both CVD and cancer [38] leading to the presence of competing risks in terms of the underlying cause of death. Another caveat is the prospect of multi-morbid chronic conditions which may overlap [55], especially at older ages. Some studies have reported an association with certain cancer therapies and increased risk of CVD [56], including breast, prostate, and bladder cancer patients [57]. A final limitation stems from the methodology used here, which does not provide insights into possible year-to-year fluctuations or trends from 1995–2019 that are masked by this comparison of the first and last five-year periods only.

At present, CVD and cancer rank as either the first or second leading causes of premature death in the majority of countries worldwide, notably in those with higher human development levels and robust health systems and infrastructure [58, 59]. While the increasing global dominance of chronic diseases is evident from the underlying mortality statistics, the extent of local epidemiologic transition depends on national trajectories of social and economic development [60]. This study provides a timely, in-depth analysis of gains in life expectancy over the last quarter-century that are attributable to progress in the control of CVD versus common cancer types; it underscores the continued existence of an East-West divide in life expectancy across the EU27 + 1, evident on benchmarking the founding EU vs. A10 countries.