Original Articles
Vol. 21 No. 1 (2026)
Spatial inequalities in cancer with special reference to lung cancer across Europe and their implications for environmental health policy
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All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Published: 14 April 2026
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This study investigates spatial disparities in cancer and lung-cancer mortality across Europe through an integrative geospatial epidemiological framework. Using age-standardised Eurostat mortality data for 2022 at the NUTS-2 level, we combine Getis-Ord Gi* and Anselin Local Moran’s I to detect statistically significant hot/cold spots, while multivariate regressions incorporate environmental and topographic predictors. Results reveal pronounced east-west and urban–rural gradients: persistent high-mortality clusters span Central and Eastern Europe, where historical industrialisation, elevated smoking prevalence, and structural healthcare gaps converge. By contrast, Southern European regions – Portugal, western Spain, and southern Greece – are associated with lower observed mortality levels, plausibly reflecting favourable behavioural profiles, environmental conditions, and healthcare accessibility. Spatial outliers identify territories where localised factors, such as air-pollution peaks or differential diagnostic capacity, modify broader regional patterns. Overall, the findings highlight geography as a structuring context for exposure, vulnerability, and access to care, rather than as a direct causal driver of cancer risk, and demonstrate the value of spatial epidemiology for territorial health governance, environmental monitoring, and urban planning. Policy relevance is twofold. First, the evidence supports region-specific interventions aligned with the Sustainable Development Goals (SDG) – especially SDG 3 (health), SDG 10 (reduced inequalities), and SDG 11 (sustainable cities). Second, the spatial outputs provide a robust empirical basis for informing the health-equity ambitions of Europe’s Beating Cancer Plan and the environmental-justice agenda of the European Green Deal. By bridging granular geospatial evidence with EU-wide priorities, the study underscores the need for place-based, equity-oriented frameworks in cancer prevention and control across heterogeneous European landscapes.
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Alahmad B, Khraishah H, Althalji K, Borchert W, Al-Mulla F, Koutrakis P, 2023. Connections between air pollution, climate change, and cardiovascular health. Canadian J Cardiol 39:1182–90. DOI: https://doi.org/10.1016/j.cjca.2023.03.025
Anselin L, 1995. Local indicators of spatial association—LISA. Geographical Analysis 27:93–115. DOI: https://doi.org/10.1111/j.1538-4632.1995.tb00338.x
Bambra C, Smith KE, Pearce J, 2019. Scaling up: The politics of health and place. Soc Sci Med 232:36–42. DOI: https://doi.org/10.1016/j.socscimed.2019.04.036
Ben-Shlomo Y, Kuh D, 2002. A life course approach to chronic disease epidemiology: Conceptual models, empirical challenges and interdisciplinary perspectives. Int J Epidemiol 31:285–93. DOI: https://doi.org/10.1093/ije/31.2.285
Borrell C, Marí-Dell’olmo M, Palència L, Gotsens M, Burström BO, Domínguez-Berjón F, Rodríguez-Sanz M, Dzúrová D, Gandarillas A, Hoffmann R, Kovacs K, Marinacci C, Martikainen P, Pikhart H, Corman D, Rosicova K, Saez M, Santana P, Tarkiainen L, Puigpinós R, Morrison J, Pasarín MI, Díez È, 2014. Socioeconomic inequalities in mortality in 16 European cities. Scandinavian J Public Health 42:245–54. DOI: https://doi.org/10.1177/1403494814522556
Börsch-Supan A, Brandt M, Hunkler C, Kneip T, Korbmacher J, Malter F, Schaan B, Stuck S, Zuber S; SHARE Central Coordination Team, 2013. Data resource profile: The Survey of Health, Ageing and Retirement in Europe (SHARE). Int J Epidemiol 42:992–1001. DOI: https://doi.org/10.1093/ije/dyt088
Bray F, Laversanne M, Weiderpass E, Soerjomataram I, 2021. The ever-increasing importance of cancer as a leading cause of premature death worldwide. Cancer 127:3029–30. DOI: https://doi.org/10.1002/cncr.33587
Brennan P, Bray I, 2002. Recent trends and future directions for lung cancer mortality in Europe. Br J Cancer 87:43–8. DOI: https://doi.org/10.1038/sj.bjc.6600352
Brugge D, Durant JL, Rioux C, 2007. Near-highway pollutants in motor vehicle exhaust: A review of epidemiologic evidence of cardiac and pulmonary health risks. Environ Health 6:23. DOI: https://doi.org/10.1186/1476-069X-6-23
Brulle RJ, Pellow DN, 2006. Environmental justice: Human health and environmental inequalities. Ann Rev Public Health 27:103–24. DOI: https://doi.org/10.1146/annurev.publhealth.27.021405.102124
Carvalho RN, Randi G, Giusti F, Martos C, Dyba T, Dimitrova N, Neamtiu L, Rooney R, Nicholson N, Bettio M, 2018. Cancer burden indicators in Europe: Insights from national and regional information (Socio-economic regional microscope series. Publications Office of the European Union. https://doi.org/10.2760/845184
Ciabattini M, Rizzello E, Lucaroni F, Palombi L, Boffetta P, 2021. Systematic review and meta-analysis of recent high-quality studies on exposure to particulate matter and risk of lung cancer. Environ Res 196:110440. DOI: https://doi.org/10.1016/j.envres.2020.110440
Clougherty JE, 2010. A growing role for gender analysis in air pollution epidemiology. Environ Health Perspect118:167–76. DOI: https://doi.org/10.1289/ehp.0900994
Cromley EK, McLafferty SL, 2012. GIS and public health (2nd ed.). Guilford Press.
Curtis S, Pain R, Fuller S, Kearns RA, Moon G, 2021. The geography of health inequalities in the developed world. Routledge.
de Hoogh K, Gulliver J, van Donkelaar A, Martin RV, Marshall JD, Bechle MJ, Cesaroni G, Pradas MC, Dedele A, Eeftens M, Forsberg B, Galassi C, Heinrich J, Hoffmann B, Jacquemin B, Katsouyanni K, Korek M, Künzli N, Lindley S, Lepeule J, Meleux F, Nazelle AD, Nieuwenhuijsen M, Nystad W, Raaschou-Nielsen O, Peters A, Peuch V-H, Roui L, Udvardy O, Slama R, Stempfelet M, Stephanou EG, Tsai MY, Yli-Tuomi T, Weinmayr G, Brunekreef B, Vienneau D, Hoek G 2016. Development of West-European PM2.5 and NO2 land use regression models incorporating satellite-derived and chemical transport modelling data. Environ Res 151:1–10. DOI: https://doi.org/10.1016/j.envres.2016.07.005
Elliott P, Wartenberg D, 2004. Spatial epidemiology: Current approaches and future challenges. Environ Health Perspect 112:998–1006. DOI: https://doi.org/10.1289/ehp.6735
EuroGeographics, 2020. ETRS89 / LAEA Europe - EPSG:3035. Available from: https://epsg.io/3035
European Commission, 2018. NUTS - Nomenclature of territorial units for statistics – Overview. Publications Office of the European Union. Available from: https://ec.europa.eu/eurostat/web/nuts
European Commission., 2021. Europe’s beating cancer plan. Available from: https://health.ec.europa.eu/system/files/2022-02/eu_cancer-plan_en_0.pdf
Eurostat, 2022. Causes of death—standardised death rate by residence (per 100 000 inhabitants). Available from: https://ec.europa.eu/eurostat
Getis A, Ord JK, 1992. The analysis of spatial association by use of distance statistics. Geographical Analysis 24:189–206. DOI: https://doi.org/10.1111/j.1538-4632.1992.tb00261.x
Hu Y, Wang R, Pan Y, 2013. Spatiotemporal variation of ecosystem services value and its response to land use change in the Pearl River Delta, China. Environmental Monitoring and Assessment, 185;2063–79.
Institute of Medicine, 2002. Cancer and the environment: Gene–environment interaction (S. Wilson, L. Jones, C. Coussens, and K. Hanna, Eds.). National Academies Press.
Lawlor DA, Sterne JAC, Tynelius P, Davey Smith G, Rasmussen F, 2006. Association of childhood socioeconomic position with cause-specific mortality in a prospective record linkage study of 1,839,384 individuals. Am J Epidemiol 164:907–15. DOI: https://doi.org/10.1093/aje/kwj319
Lee D, Lawson A, 2014. Cluster detection and risk estimation for spatio-temporal health data. arXiv preprint, arXiv:1408.1191.
Lindley S, O’Neill J, Kandeh J, Lawson N, Christian R, O’Neill M, 2011. Climate change, justice and vulnerability. Joseph Rowntree Foundation. Available from: https://www.jrf.org.uk/report/climate-change-justice-and-vulnerability
Malek Ž, Verburg PH, 2020. Mapping global patterns of land use decision-making. Global Environ Change 65:102170. DOI: https://doi.org/10.1016/j.gloenvcha.2020.102170
McKenzie K, Murray A, Booth T, 2013. Do urban environments increase the risk of anxiety, depression and psychosis? An epidemiological study. J Affect Dis 150:1019–24. DOI: https://doi.org/10.1016/j.jad.2013.05.032
National Environmental Justice Advisory Council., 2016. National Environmental Justice Advisory Council 20-Year Retrospective Report. U.S. Environmental Protection Agency. Available from: https://www.epa.gov/sites/default/files/2016-10/documents/njeac_20_year_retrospective_report.pdf
National Research Council (US) Committee on Environmental Epidemiology, and National Research Council (US) Commission on Life Sciences., 1997. Environmental epidemiology: Volume 2: Use of the gray literature and other data in environmental epidemiology. National Academies Press. Available from: https://doi.org/10.17226/5804 DOI: https://doi.org/10.17226/5804
Ni L, Zhang D, Yang Y, Huang J, 2024. Exploring the influence of relative attractiveness in green spaces on urban movements: A potential to kinetic energy framework. J Cleaner Production 434:139850. DOI: https://doi.org/10.1016/j.jclepro.2023.139850
Nieuwenhuijsen MJ, Gascon M, Martinez D, Ponjoan A, Blanch J, Garcia-Gil MDM, Ramos R, Foraster M, Mueller N, Espinosa A, Cirach M, Khreis H, Dadvand P, Basagaña X, 2018. Air pollution, noise, blue space, and green space and premature mortality in Barcelona: A mega cohort. Int J Environ Res Public Health 15:2405. DOI: https://doi.org/10.3390/ijerph15112405
Nykiforuk CI, Flaman LM, 2011. Geographic information systems (GIS) for health promotion and public health: A review. Health Promotion Practice 12:63–73. DOI: https://doi.org/10.1177/1524839909334624
O’Campo P, Wheaton B, Nisenbaum R, Glazier RH, Dunn JR, Chambers C, 2015. The Neighbourhood Effects on Health and Well-being (NEHW) study. Health Place 31:65–74. DOI: https://doi.org/10.1016/j.healthplace.2014.11.001
Office for National Statistics., 2022. Health state life expectancies by national deprivation deciles, England: 2018 to 2020. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthinequalities/bulletins/healthstatelifeexpectanciesbyindexofmultipledeprivationimd/2018to2020
Pike RJ, Evans IS, Hengl T, 2009. Geomorphometry: A brief guide. Develop Soil Sci 33:3–30. DOI: https://doi.org/10.1016/S0166-2481(08)00001-9
Pukkala E, Martinsen JI, Lynge E, Gunnarsdottir HK, Sparén P, Tryggvadottir L, Weiderpass E, Kjaerheim K, 2009. Occupation and cancer – Follow-up of 15 million people in five Nordic countries. Acta Oncologica 48:646–790. DOI: https://doi.org/10.1080/02841860902913546
Raaschou-Nielsen O, Andersen ZJ, Beelen R, Samoli E, Stafoggia M, Weinmayr G, Hoffmann B, Fischer P, Nieuwenhuijsen MJ, Brunekreef B, Xun WW, Katsouyanni K, Dimakopoulou K, Sommar J, Forsberg B, Modig L, Oudin A, Oftedal B, Schwarze PE, Nafstad P, De Faire U, Pedersen NL, Ostenson CG, Fratiglioni L, Penell J, Korek M, Pershagen G, Eriksen KT, Sørensen M, Tjønneland A, Ellermann T, Eeftens M, Peeters PH, Meliefste K, Wang M, Bueno-de-Mesquita B, Key TJ, de Hoogh K, Concin H, Nagel G, Vilier A, Grioni S, Krogh V, Tsai MY, Ricceri F, Sacerdote C, Galassi C, Migliore E, Ranzi A, Cesaroni G, Badaloni C, Forastiere F, Tamayo I, Amiano P, Dorronsoro M, Trichopoulou A, Bamia C, Vineis P, Hoek G, 2013. Air pollution and lung cancer incidence in 17 European cohorts: Prospective analyses from the European Study of Cohorts for Air Pollution Effects (ESCAPE). Lancet Oncol 14:813–22. DOI: https://doi.org/10.1016/S1470-2045(13)70279-1
Reich BJ, Yang S, Guan Y, Giffin AB, Miller MJ, Rappold A, 2021. A review of spatial causal inference methods for environmental and epidemiological applications. Int Statistical Rev 89:605–34. DOI: https://doi.org/10.1111/insr.12452
Ribeiro AI, Launay L, Guillaume E, Launoy G, Barros H, 2018. The Portuguese version of the European Deprivation Index: Development and association with all-cause mortality. PLOS ONE, 13:e0208320. DOI: https://doi.org/10.1371/journal.pone.0208320
Saurel-Cubizolles, M-J, Chastang J-F, Menvielle G, Leclerc A, Luce D, 2009. Social inequalities in mortality by cause among men and women in France. J Epidemiol Comm Health 63:197–202. DOI: https://doi.org/10.1136/jech.2008.078923
Schlosberg D, 2007. Defining environmental justice: Theories, movements, and nature. Oxford University Press. DOI: https://doi.org/10.1093/acprof:oso/9780199286294.001.0001
Su JG, Jerrett M, de Nazelle A, Wolch J, 2011. Does exposure to air pollution in urban parks have socioeconomic, racial or ethnic gradients? Environ Res 111:319–28. DOI: https://doi.org/10.1016/j.envres.2011.01.002
Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F, 2021. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 71:209–49. DOI: https://doi.org/10.3322/caac.21660
Svensson A, 2019. Urban green spaces and mental health: A cross-sectional study in Stockholm (Master’s thesis, Stockholm University). DiVA portal. Available from: https://www.diva-portal.org/smash/get/diva2:1307934/FULLTEXT01.pdf
Van Hemelrijck WMJ, Rosskamp M, De Schutter H, Verdoodt F, Vanthomme K, 2021. Cancer risk among individuals of migrant origin in Belgium during the 2000s – Evidence of migration as a “cancer risk transition”? Soc Sci Med 269:113591. DOI: https://doi.org/10.1016/j.socscimed.2020.113591
Vienneau D, de Hoogh K, Faeh D, Kaufmann M, Wunderli JM, Röösli M, SNC Study Group, 2017. More than clean air and tranquillity: Residential green is independently associated with decreasing mortality. Environ Int 108:176–84. DOI: https://doi.org/10.1016/j.envint.2017.08.012
Woodruff TJ, Parker JD, Darrow LA, Slama R, Bell ML, Choi H, Glinianaia S, Hoggatt KJ, Karr CJ, Lobdell DT, Wilhelm M, 2009. Methodological issues in studies of air pollution and reproductive health. Environ Res109:311–20. DOI: https://doi.org/10.1016/j.envres.2008.12.012
World Health Organization (WHO), 2020. Cancer: Fact sheets. Available from: https://www.who.int/news-room/fact-sheets/detail/cancer
World Health Organization. Regional Office for Europe (WHO), 2021. Review of evidence on health aspects of air pollution: REVIHAAP project: Technical report. World Health Organization. Available from: https://iris.who.int/handle/10665/341712
Yang X, Geng L, 2022. An integrated analysis of social, economic, and environmental indicators’ effects on public health and health inequality globally: from the perspective of vulnerability. Soc Indic Res 162:1261–79. DOI: https://doi.org/10.1007/s11205-022-02877-x
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Spatial inequalities in cancer with special reference to lung cancer across Europe and their implications for environmental health policy. (2026). Geospatial Health, 21(1). https://doi.org/10.4081/gh.2026.1453
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