Kathrine Carlsen

Social inequality and incidence of and survival from breast cancer in a population-based study in Denmark, 1994-2003

We investigated the effects of socioeconomic, demographic and health-related indicators on the incidence of and survival from lung cancer diagnosed in Denmark in 1994-2003 with follow-up through 2006 using information from nationwide registers. The analyses were based on data on 21,492 patients with lung cancer in a cohort of 3.22 million persons born between 1925 and 1973 and aged >or=30 years. There was a general pattern of decreasing lung cancer incidence with increasing social advantage, being married and decreasing urbanicity. The presence of somatic or psychiatric disorders increased the incidence. The most advantaged groups of men had better short-term survival, and a similar tendency was seen for women. The relative 5-year survival after lung cancer was similarly low in most groups, 8% for men and 9% for women, except for groups of patients living in small apartments, with unknown tenure or schizophrenia and for divorced or single men.

The relation between socioeconomic and demographic factors and tumour stage in women diagnosed with breast cancer in Denmark, 1983–1999

The authors investigated the association between socioeconomic position and stage of breast cancer at the time of diagnosis in a nationwide Danish study. All 28 765 women with a primary invasive breast cancer diagnosed between 1983 and 1999 were identified in a nationwide clinical database and information on socioeconomic variables was obtained from Statistics Denmark. The risk of being diagnosed with a high-risk breast cancer, that is size >20 mm, lymph-node positive, ductal histology/high histologic grade and hormone receptor negative, was analysed by multivariate logistic regression. The adjusted odds ratio (OR) for high-risk breast cancer was reduced with longer education with a 12% reduced risk (95% confidence interval (CI), 0.80,0.96) in women with higher education and increased with reduced disposable income (low income group: OR, 1.22; 95% CI, 1.10,1.34). There was an urban–rural gradient, with higher risk among rural women (OR 1.10; 95 % CI, 1.02, 1.18) and lower risk among women in the capital suburbs (OR, 0.85; 95% CI, 0.78, 0.93) and capital area (OR, 0.93; 95% CI, 0.84–1.02). These factors were significant only for postmenopausal women, although similar patterns were observed among the premenopausal women, suggesting a subgroup of aggressive premenopausal breast cancers less influenced by socioeconomic factors.

Cancer and the risk for taking early retirement pension: A Danish cohort study

Aims: The purpose of this study was to determine the risk for taking early retirement pension (ERP) in cancer survivors who were working at the time of diagnosis. Methods: We conducted a nationwide and population based cohort study including 44,905 persons aged 30—60 years diagnosed with selected cancers in the period 1981—2000 and 211,562 randomly sampled cancer-free controls. Information on socioeconomic status, demography and physical and psychiatric comorbidity was obtained from Danish administrative registries. Results: We analyzed the risk for ERP adjusted for known risk factors and found that cancer patients has an excess risk of ERP compared to cancer-free controls (RR, 1.60; 95% CI, 1.55—1.65 and RR, 1.55; 95% CI, 1.46—1.65 for women and men, respectively). The observed risk factors for taking ERP were late age, dissimilated disease, manual job, sickness leave the year before taking ERP, physical and psychological comorbidity, low education and low income. Three risk categories were identified (high, medium and low) by cancer site and we found that in the high risk category, people diagnosed with leukemia, prostate cancer or ovary cancer had a more than two-fold increased risk for ERP and the risk remained increased with up to 8 years of follow-up. Conclusions: We observed a significantly increased risk for taking early retirement up to 8 years after the cancer diagnosis and that the magnitude of the risk was dependent of cancer sites.

Risk for unemployment of cancer survivors: A Danish cohort study

AIM To investigate whether cancer survivors are at an increased risk for unemployment after cancer. MATERIALS AND METHODS A cohort of 65,510 patients who were part of the workforce in the year before diagnosis and a random sample of 316,925 age and gender-matched controls were followed for up to 20 years in a longitudinal register-based cohort study. Demographic, socioeconomic and health-related information were obtained through Danish administrative registers. RESULTS Cancer survivors had a small but significantly increased risk for unemployment following cancer. Stratified analyses showed that the risk for unemployment was highest amongst persons aged 50-60 years at time of diagnosis. Risk factors for unemployment were found to be manual work, medium income and vocational education. CONCLUSION Generally, cancer patients were at a small increased risk for unemployment and low socioeconomic position was a significant risk factor.

Influence of socioeconomic factors on survival after breast cancer—A nationwide cohort study of women diagnosed with breast cancer in Denmark 1983-1999

The reasons for social inequality in breast cancer survival are far from established. Our study aims to study the importance of a range of socioeconomic factors and comorbid disorders on survival after breast cancer surgery in Denmark where the health care system is tax‐funded and uniform. All 25,897 Danish women who underwent protocol‐based treatment for breast cancer in 1983–1999 were identified in a clinical database and information on socioeconomic variables and both somatic and psychiatric comorbid disorders was obtained from population‐based registries. We used Cox proportional hazards models to estimate the association between socioeconomic position and overall survival and further to analyse breast cancer specific deaths in a competing risk set‐up regarding all other causes of death as competing risks. The adjusted hazard ratio (HR) for death was reduced in women with higher education (HR, 0.91; 95% confidence interval (CI), 0.85–0.98), with higher income (HR, 0.93; 95% CI, 0.87–0.98) and with larger dwellings (HR, 0.90; 95% CI, 0.85–0.96 for women living in houses larger than 150 m2). Presence of comorbid disorders increased the HR. An interaction between income and comorbid disorders resulting in a 15% lower survival 10 year after primary surgery in poor women with low‐risk breast cancer having comorbid conditions (∼65%) compared to rich women with similar breast cancer prognosis and comorbid conditions (∼80%) suggests that part of the explanation for the social inequality in survival after breast cancer surgery in Denmark lies in the access to and/or compliance with management of comorbid conditions in poorer women.

Research in Danish cancer rehabilitation: Social characteristics and late effects of cancer among participants in the FOCARE research project

Worldwide, the number of cancer survivors is increasing, owing to improvements in cancer therapy, resulting in an increased need to address the physical and mental sequelae of cancer. This paper introduces a Danish psychosocial cancer intervention and presents the baseline characteristics of the cancer survivors with respect to cancer site, sociodemographic variables, social network, lifestyle, self-rated health and the prevalence of cancer-related late effects. The study is part of the FOCARE research project, in which the long-term effects of the rehabilitation programme are evaluated systematically. The study is based on data from a self-administered baseline questionnaire filled in by 2 174 cancer survivors who registered for a 1-week, publicly paid rehabilitation retreat and were invited to participate in the FOCARE study in the period 25 November 2002 to 31 December 2005. The response rate at baseline was 86% (n = 1876). Most participants were younger women with breast cancer. They were generally well educated and working. The cancer survivors reported having comprehensive social networks and being physically active. Several cancer-related symptoms were reported by women with cancers at selected sites, of which fatigue was the most prevalent. More than half reported good-to-excellent self-rated health, while fair-to-poor health was reported by 40%, most of whom were survivors of lung (56%) and haematological (48%) cancers. The results indicate that Danish cancer survivors experience considerably reduced physical health, possibly as late physical effects of treatment. The problems reported by the cancer survivors suggest that cancer rehabilitation should include these aspects of living after cancer and take account of differences among cancer survivors with regard to cancer site, sex, age, family, working status and social position. These challenges might be addressed optimally in multi-dimensional rehabilitation programmes.

Self-reported work ability in long-term breast cancer survivors. A population-based questionnaire study in Denmark

Abstract Background. Although up to 80% of women can return to work after treatment for breast cancer, maintaining an affiliation to the labour market may be a challenge, as shown by the fact that the risks for unemployment and early retirement are increased in the years after treatment of cancer. It is important to understand the work problems experienced by cancer survivors, including their ability to work. The aim of this study was to determine whether the ability of long-term breast cancer survivors to work was different from that of a cancer-free control group. Material and methods. In this population-based cross-sectional questionnaire study, 776 breast cancer survivors were matched with 1552 cancer-free women. Women with breast cancer diagnosed in 1997–2000 were identified in the Danish Cancer Registry, and the cancer-free controls were sampled from the Central Population Registry. Work ability was measured from a single question on the ‘work ability index’. Furthermore, the questionnaire contained questions on socioeconomic factors, health-related factors and factors related to the workplace. Results. The overall response rate was 57% (493 survivors and 830 controls). After exclusions, the study population consisted of 170 survivors and 391 controls. Women with a diagnosis of breast cancer who had survived at least five years and had returned to work reported significantly poorer work ability than cancer-free controls. In models with adjustment for socioeconomic factors, health-related factors and support at work, the factors most strongly associated with impaired work ability were low income, fatigue and little help and support from a supervisor. Conclusion. Our findings indicate that the work ability of long-term breast cancer survivors who are disease-free and back in work is impaired in comparison with that of cancer-free women.

The transition between work, sickness absence and pension in a cohort of Danish colorectal cancer survivors

Objectives The aim of this study was to evaluate the impact of socioeconomic and clinical factors on the transitions between work, sickness absence and retirement in a cohort of Danish colorectal cancer survivors. Design Register-based cohort study with up to 10 years of follow-up. Setting Population-based study with use of administrative health-related and socioeconomic registers. Participants All persons (N=4343) diagnosed with colorectal cancer in Denmark during the years 2001–2009 while they were in their working age (18–63 years) and who were part of the labour force 1 year postdiagnosis. Primary and secondary outcome measures By the use of multistate models in Cox proportional hazards models, we analysed the HR for re-employment, sickness absence and retirement in models including clinical as well as health-related variables. Results 1 year after diagnosis, 62% were working and 58% continued until the end of follow-up. Socioeconomic factors were found to be associated with retirement but not with sickness absence and return to work. The risk for transition from work to sickness absence increased if the disease was diagnosed at a later stage (stage III) 1.52 (95% CI 1.21 to 1.91), not operated curatively 1.35 (95% CI 1.11 to 1.63) and with occurrence of postoperative complications 1.25 (95% CI 1.11 to 1.41). The opposite was found for the transition from sickness absence back to work. Conclusions This nationwide study of colorectal cancer patients who have survived 1 year shows that the stage of disease, general health condition of the individual, postoperative complications and the history of sickness absence and unemployment have an impact on the transition between work, sickness absence and disability pension. This leads to an increased focus on the rehabilitation process for the more vulnerable persons who have a combination of severe disease and a history of work-related problems with episodes outside the working market.

Impact of Gender, Co-Morbidity and Social Factors on Labour Market Affiliation after First Admission for Acute Coronary Syndrome. A Cohort Study of Danish Patients 2001–2009

Background Over the last decades survival after acute coronary syndrome (ACS) has improved, leading to an increasing number of patients returning to work, but little is known about factors that may influence their labour market affiliation. This study examines the impact of gender, co-morbidity and socio-economic position on subsequent labour market affiliation and transition between various social services in patients admitted for the first time with ACS. Methods From 2001 to 2009 all first-time hospitalisations for ACS were identified in the Danish National Patient Registry (n = 79,714). For this population, data on sick leave, unemployment and retirement were obtained from an administrative register covering all citizens. The 21,926 patients, aged 18–63 years, who had survived 30 days and were part of the workforce at the time of diagnosis were included in the analyses where subsequent transition between the above labour market states was examined using Kaplan-Meier estimates and Cox proportional hazards models. Findings A total of 37% of patients were in work 30 days after first ACS diagnosis, while 55% were on sick leave and 8% were unemployed. Seventy-nine per cent returned to work once during follow-up. This probability was highest among males, those below 50 years, living with a partner, the highest educated, with higher occupations, having specific events (NSTEMI, and percutaneous coronary intervention) and with no co-morbidity. During five years follow-up, 43% retired due to disability or voluntary early pension. Female gender, low education, basic occupation, co-morbidity and having a severer event (invasive procedures) and receiving sickness benefits or being unemployed 30 days after admission were associated with increased probability of early retirement. Conclusion About half of patients with first-time ACS stay in or return to work shortly after the event. Women, the socially disadvantaged, those with presumed severer events and co-morbidity have lower rates of return.

Unemployment among breast cancer survivors

Aim: Though about 20% of working age breast cancer survivors do not return to work after treatment, few studies have addressed risk factors for unemployment. The majority of studies on occupational consequences of breast cancer focus on non-employment, which is a mixture of sickness absence, unemployment, retirement pensions and other reasons for not working. Unemployment in combination with breast cancer may represent a particular challenge for these women. The aim of the present study is therefore to analyze the risk for unemployment in the years following diagnosis and treatment for breast cancer. Method: This study included 14,750 women diagnosed with breast cancer in Denmark 2001–2009 identified through a population-based clinical database and linked with information from Danish administrative population based registers for information on labour market affiliation, socio-demography and co-morbid conditions. Multivariable analyses were performed by Cox’s proportional hazard models. Results: Two years after treatment, 81% of patients were still part of the work force, 10% of which were unemployed. Increasing duration of unemployment before breast cancer was associated with an adjusted HR = 4.37 (95% CI: 3.90–4.90) for unemployment after breast cancer. Other risk factors for unemployment included low socioeconomic status and demography, while adjuvant therapy did not increase the risk of unemployment. Conclusions: Duration of unemployment before breast cancer was the most important determinant of unemployment after breast cancer treatment. This allows identification of a particularly vulnerable group of patients in need of rehabilitation.