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Impact of symptom burden on health related quality of life of cancer survivors in a Danish cancer rehabilitation program: A longitudinal study

Abstract Introduction. Little research has been conducted on the effect of self-reported rating of symptom severity on quality of life (QoL) among cancer survivors. The aim of the study was to examine the prevalence of symptoms and whether information about self-reported symptom severity adds value to QoL measurements. Material and methods. A questionnaire including the EORTC QLQ-C30 and an empirically derived symptom check-list was completed by 2 486 cancer survivors participating in a rehabilitation program at baseline and at 1, 6 and 12 months’ follow-up. We used multivariate linear regression models to evaluate the association between QoL and the dichotomous variables for perceived symptom severity (high vs. low) and cancer stage (high vs. low), with adjustment for age, gender, education and time since diagnosis. Results. Of the 2 379 participants who reported having one or more symptoms, 1 479 (62%) considered the reported symptom to be severe. This subgroup had significantly poorer QoL at baseline for all sites, ranging from −15.9 to −10.2, compared to those who did not regard their symptom as severe. Significantly lower baseline levels on all functional subscales were seen for all sites in association with high perceived symptom severity (range from −9.9 to −3.0 (physical functioning), from −21.1 to −13.0 (social functioning), from −18.8 to −8.5 (emotional functioning), and from −18.4 to −9.6 (cognitive functioning). The impairment of physical, social, emotional, and cognitive functioning persisted through 12 months for participants with cancer of the breast, lung and those with lymphomas, although not all reached significance. Discussion. Cancer survivors, irrespective of cancer site, experience a high burden of symptoms. Thorough monitoring and assessment of symptoms and careful scrutiny of cancer survivors’ perceptions of how symptoms affect their lives is critical for clinical identification of patients who might benefit from enhanced medical attention and may be an important supplement to QoL measures.

Exposure to metal welding fume particles and risk for cardiovascular disease in Denmark: a prospective cohort study.

Objectives To study welding fume particles in relation to cardiovascular diseases. Methods In 1986, 10 059 male metal workers in 75 welding companies were sent a questionnaire about their welding experience and lifestyle (83.3% response rate). Of these, 5866 were available for analysis and had ever welded at baseline. Information on exposure to welding fumes after 1986 was obtained by individual linkage to the National Pension Fund. Lifelong exposure to welding fume particles was estimated from a job–exposure matrix based on more than 1000 welding-specific measures of fume particles. Hospital contacts for cardiovascular disease were obtained from the Danish National Patient Registry by individual linkage. The nine disease outcomes considered were acute myocardial infarct (AMI), angina pectoris, other acute ischaemic heart diseases, chronic ischaemic heart disease (CHD), cardiac arrythmias, cardiac arrest, heart failure, cerebral infarct, arterial embolism and thrombosis. The cohort was followed up from baseline until the end of 2006. Results When the incidence of each of the nine cardiovascular outcomes among welders was compared with 5-year age- and calendar year-specific male national rates, the number of observed cases significantly exceeded that expected for AMI (standardised incidence ratio, 95% CI) (1.12, 1.01 to 1.24), angina pectoris (1.11, 1.01 to 1.22), CHD (1.17, 1.05 to 1.31) and cerebral infarct (1.24, 1.06 to 1.44). Internal comparisons of the cohort with adjustment for tobacco smoking, alcohol and hypertension medicines showed a significantly increasing hazard rate ratio for CHD and non-significant increases for AMI, angina pectoris and cerebral infarct with increasing exposure to particles. Conclusions This study supports the hypothesis that exposure to welding processed particles increases the risk for cardiovascular disease.

Socioeconomic Position and Stage of Cervical Cancer in Danish Women Diagnosed 2005 to 2009

Background: To reduce social disparities in cervical cancer survival, it is important to understand the mechanisms by which social position influence cancer prognosis. We investigated the relations between socioeconomic factors, comorbidity, time since last Papanicolau smear, and stage at diagnosis in Danish women with cervical cancer. Methods: We identified 1,651 cervical cancer cases diagnosed 2005 to 2009 from the Danish Gynaecological Cancer Database. Date of diagnosis, clinical cancer stage, tumor histology, and treating hospital were retrieved; Pap smear registrations were obtained from the Danish Pathology Register; data on comorbid conditions from the Danish National Patients Register; and data on education, income, and cohabitation from Statistics Denmark. Logistic regression models were used to analyze the relations between socioeconomic factors and cancer stage in a four-step model, with stepwise inclusion of mediators. Results: The risk for advanced (stage II–IV) compared with early-stage cancer (stage I) was increased for women with short and medium education (OR = 2.40; 1.67–3.45 and 1.76; 1.44–2.16), women living without a partner (OR = 1.31; 1.10–1.55), and older women (OR = 1.07; 1.06–1.08 increase per year). The relations between socioeconomic factors and cancer stage were partly mediated by time since last Pap smear test and to a lesser extent by comorbidity. Conclusions: Shorter education, living alone, and older age were related to advanced stage cervical cancer, due partly to Pap smear testing and less to comorbidity. Impact: It is relevant to further investigate how to decrease delay in cervical cancer diagnosis among disadvantaged groups. Cancer Epidemiol Biomarkers Prev; 21(5); 835–42. ©2012 AACR.

The Danish nationwide clinical register for patients with rheumatoid arthritis: DANBIO

Introduction DANBIO is a research register and a data source for rheumatologic diseases (rheumatoid arthritis [RA], axial spondyloarthritis, and psoriatic arthritis) for monitoring clinical quality at the national, regional, and hospital levels. Study population The register includes patients with rheumatologic diseases who are treated at a hospital or a private rheumatologic clinic. Registration is mandatory for all patients with RA regardless of treatment and also for patients with other diagnoses if treated with biological disease-modifying antirheumatic drugs. Since 2006, the registration has been done electronically, including patient-reported outcome measures registered electronically by the patients with the use of touch screens. Main variables Core variables such as diagnosis, year of diagnosis, age, and sex are registered at the beginning. Data entered at later visits included the following: patient-reported outcomes for disease activity, pain, fatigue, functional status, and physician-reported objective measures of disease activity, treatment, C-reactive protein, and, when indicated, imaging. For subgroups of patients, the variables such as quality of life, sociodemographic factors, lifestyle, and comorbidity are also registered. Descriptive data The DANBIO cohort comprised ∼26,000 patients with RA, 3,200 patients with axial spondyloarthritis, and 6,200 patients with psoriatic arthritis in 2015. DANBIO has high nationwide coverage and completeness on key data variables. More than 60 original papers as well as annual reports of clinical quality (since 2005) have been published. Conclusion DANBIO is a powerful register for research in rheumatologic diseases and furthermore serves as a Clinical Quality Register with the aim of monitoring treatment quality in patients with RA in Denmark.

'Socioeconomic position and survival after cervical cancer: influence of cancer stage, comorbidity and smoking among Danish women diagnosed between 2005 and 2010

Background:In an attempt to decrease social disparities in cancer survival, it is important to consider the mechanisms by which socioeconomic position influences cancer prognosis. We aimed to investigate whether any associations between socioeconomic factors and survival after cervical cancer could be explained by socioeconomic differences in cancer stage, comorbidity, lifestyle factors or treatment.Methods:We identified 1961 cases of cervical cancer diagnosed between 2005 and 2010 in the Danish Gynaecological Cancer database, with information on prognostic factors, treatment and lifestyle. Age, vital status, comorbidity and socioeconomic data were obtained from nationwide administrative registers. Associations between socioeconomic indicators (education, income and cohabitation status) and mortality by all causes were analysed in Cox regression models with inclusion of possible mediators. Median follow-up time was 3.0 years (0.01–7.0).Results:All cause mortality was higher in women with shorter rather than longer education (hazard ratio (HR), 1.46; 1.20–1.77), among those with lower rather than higher income (HR, 1.32; 1.07–1.63) and among women aged<60 years without a partner rather than those who cohabited (HR, 1.60; 1.29–1.98). Socioeconomic differences in survival were partly explained by cancer stage and less by comorbidity or smoking (stage- and comorbidty- adjusted HRs being 1.07; 0.96–1.19 for education and 1.15; 0.86–1.52 for income).Conclusion:Socioeconomic disparities in survival after cervical cancer were partly explained by socioeconomic differences in cancer stage. The results point to the importance of further investigations into reducing diagnosis delay among disadvantaged groups.

Affiliation to the work market after curative treatment of head-and-neck cancer: A population-based study from the DAHANCA database

Abstract Objectives. Survivors of squamous cell carcinoma of the head and neck (HNSCC) are more severely affected in regard to affiliation to the work market than other cancer survivors. Few studies have investigated associations between socioeconomic and disease-related factors and work market affiliation after curative treatment of HNSCC. We investigated the factors for early retirement pension due to disability and unemployment in patients who had been available for work one year before diagnosis. Methods. In a nationwide, population-based cohort study, data on 2436 HNSCC patients treated curatively in 1992–2008 were obtained from the Danish Head and Neck Cancer Group database and linked to Danish administrative population-based registries to obtain demographic and socioeconomic variables. We used multivariate logistic regression models to assess associations between socioeconomic factors (education, income and cohabitating status), cancer-specific variables such as tumour site and stage, comorbidity, early retirement pension and unemployment, with adjustment for age, gender and year of diagnosis. Results. Short education [odds ratio (OR) 4.8; 95% confidence interval (CI) 2.2–10.4], low income (OR 3.2; 95% CI 1.8–5.8), living alone (OR 3.0; 95% CI 2.1–4.4) and having a Charlson comorbidity index score of 3 or more (OR 5.9; 95% CI 3.1–11) were significantly associated with early retirement overall and in all site groups. For the subgroup of patients who were employed before diagnosis, the risk pattern was similar. Tumour stage was not associated with early retirement or unemployment. Conclusions. Cancer-related factors were less strongly associated with early retirement and unemployment than socioeconomic factors and comorbidity. Clinicians treating HNSCC patients should be aware of the socioeconomic factors related to work market affiliation in order to provide more intensive social support or targeted rehabilitation for this patient group.

No change in health behavior, BMI or self-rated health after a psychosocial cancer rehabilitation: Results of a randomized trial

Abstract Introduction. The aim of cancer rehabilitation is to enable patients to attain and maintain optimal physical, psychological and social functioning. We evaluated the effect on health behavior, BMI and self-rated health of a residential psychosocial rehabilitation course for cancer patients. Material and methods. Patients with a primary cancer of the breast, prostate, colon or rectum were randomized to either a six-day multi-focus psychosocial residential rehabilitation intervention that included lectures, discussions and peer group discussions on issues related to treatment and life with cancer or to usual care. The end points were changes in smoking, alcohol consumption, physical activity, body mass index and self-rated health between baseline and follow-up after one and six months. The primary analyses included all participants who received their allocated condition. The two follow-up times were analyzed separately in general linear and logistic regression models for continuous and dichotomous outcomes, respectively. The analyses were adjusted for baseline outcome score, cancer site, time since diagnosis, age and education. Results. Of the 507 participants who were randomly assigned, 452 were included in the analysis, of whom 404 completed the one month and 394 completed the six month assessment. The intervention group showed slightly more positive changes in health behavior, BMI and self-rated health than the usual care group, but the differences between the groups were small and not significant. Discussion. Participation in a six-day cancer rehabilitation course did not significantly influence health behavior, BMI or self-rated health among cancer patients.

Influence of metabolic indicators, smoking, alcohol and socioeconomic position on mortality after breast cancer

Abstract Background. Factors differently distributed among social groups like obesity, metabolic syndrome, diabetes, smoking, and alcohol intake predict survival after breast cancer diagnosis and therefore might mediate part of the observed social inequality in survival. Material and methods. We conducted a cohort study among 1250 postmenopausal breast cancer patients identified among 29 875 women in the Danish Diet, Cancer and Health Study. Participants completed questionnaires and anthropometric measurements were made at enrollment. Information on survival, socioeconomic position, and comorbidity was obtained by linkage to national Danish registries. Clinical information was obtained from the nationwide Danish Breast Cancer Database. Selected information was obtained from hospital records at time of diagnosis. All analyses were based on Cox proportional hazard models, using death from all causes as outcome. Results. Median follow-up was 9.6 years [interquartile range (IQR), 2.2–17.0 years]. The hazard ratio (HR) for death from all causes increased with lower education (p for trend, 0.01). Adjustment for disease-related prognostic factors, comorbidity and metabolic indicators measured as BMI, waist circumference and diabetes, and smoking and alcohol affected but did not explain the social gradient. Conclusion. The findings indicate that these factors explain some but not all the social inequality in survival after breast cancer and that improvement of lifestyle to some extent would improve survival among women with low socioeconomic position.

Do stage of disease, comorbidity or access to treatment explain socioeconomic differences in survival after ovarian cancer? - A cohort study among Danish women diagnosed 2005-2010

AIMS In order to reduce social inequality in cancer survival, knowledge is needed about where in the cancer trajectory disparities occur, and how social and health-related aspects may interact. We aimed to determine whether socioeconomic factors are related to cancer diagnosis stage, and whether socioeconomic disparities in survival after ovarian cancer can be explained by socioeconomic differences in cancer stage, comorbidity, treatment or lifestyle factors. METHODS In the Danish Gynaecological Cancer Database we identified 2873 cases of ovarian cancer diagnosed between 2005 and 2010. From this data we retrieved information on prognostic factors, treatment information and lifestyle factors. Age, vital status, comorbidity, education, income and cohabitation status were ascertained from nationwide administrative registers. Associations were analyzed with logistic regression and Cox regression models. RESULTS Educational level was weakly associated with cancer stage. Short education, lower income and living without a partner were related to poorer survival after ovarian cancer. Among women with early cancer stage, HR (95% CI) for death was 1.75 (1.20-2.54) in shorter compared to longer educated women. After adjustment for comorbid conditions, cancer stage, tumour histology, operation status and lifestyle factors, socioeconomic differences in survival persisted. CONCLUSIONS Socioeconomic disparities in survival after ovarian cancer were to some extent, but not fully explained by differences in important prognostic factors, suggesting further investigations into this problem, however implying that socially less advantaged ovarian cancer patients should receive attention during cancer treatment and rehabilitation.

Validity and completeness of rheumatoid arthritis diagnoses in the nationwide DANBIO clinical register and the Danish National Patient Registry

Objectives In Denmark, patients with rheumatoid arthritis (RA) are registered in the nationwide clinical DANBIO quality register and the Danish National Patient Registry (DNPR). The aim was to study the validity of the RA diagnosis and to estimate the completeness of relevant RA cases in each registry. Study design and setting Patients registered for the first time in 2011 with a diagnosis of RA were identified in DANBIO and DNPR in January 2013. For DNPR, filters were applied to reduce false-positive cases. The diagnosis was verified by a review of patient records. We calculated the positive predictive values (PPVs) of the RA diagnosis registrations in DANBIO and DNPR, and estimated the registry completeness of relevant RA cases for both DANBIO and DNPR. Updated data from 2011 to 2015 from DANBIO were retrieved to identify patients with delayed registration, and the registry completeness and PPV was recalculated. Results We identified 1,678 unique patients in DANBIO or in DNPR. The PPV (2013 dataset) was 92% in DANBIO and 79% in DNPR. PPV for DANBIO on the 2015 update was 96%. The registry completeness of relevant RA cases was 43% in DANBIO, increasing to 91% in the 2015 update and 90% in DNPR. Conclusion DANBIO held a high proportion of true RA cases (96%) and was found to be superior to the DNPR (79%) with regard to the validity of the diagnosis. Both registries were estimated to have a high completeness of RA cases treated in hospital care (~90%).