The risk of vaginal, vulvar and anal precancer and cancer according to high-risk HPV status in cervical cytology samples

High-risk human papillomavirus (hrHPV) is the cause of virtually all cervical cancers, most vaginal and anal cancers, and some vulvar cancer cases. With HPV testing becoming the primary screening method for cervical cancer, understanding the link between cervical hrHPV infection and the risk of other anogenital cancers is crucial. We assessed the risk of vulvar, vaginal and anal cancer and precancer (VIN2+, VaIN2+ and AIN2+) in a prospective cohort study including 455,349 women who underwent cervical hrHPV testing in Denmark from 2005 to 2020. We employed Cox proportional hazard models, adjusting for age, calendar year and HPV vaccination status, and estimated hazard ratios (HRs) and 95% confidence intervals (CI). We used the Aalen Johansen estimator to calculate the absolute risks of VIN2+, VaIN2+ and AIN2+. In total, 15% of the women were hrHPV positive at baseline. A positive cervical hrHPV test was associated with increased incidence of vulvar, vaginal and anal squamous cell carcinoma (SCC). Five-year risk estimates of VIN2+, VaIN2+ and AIN2+ among hrHPV-positive women (0.45%, 0.14% and 0.12%) were higher than among hrHPV-negative women (0.14%, 0.01% and 0.05%). Particularly high risk was observed among the hrHPV-positive women of the oldest age, with a history of anogenital precancer and those not HPV vaccinated. In conclusion, our study confirms the association between cervical hrHPV infection and non-cervical anogenital precancers and cancers. Currently, no established risk threshold or guidelines for follow-up. As HPV testing becomes the primary method for cervical cancer screening, future data will help define high-risk groups and acceptable risk thresholds.

APN nurses' core competencies for general clinical health assessment in primary health care. A scoping review

BACKGROUND

The field of Advanced Practice Nursing (APN) has developed over the past six decades. However, the definition of roles and responsibilities of APN nurses seem to be contested due to both a lack of a clear definition of the concept and to institutional and cultural barriers that restrict the nurses' opportunities to practise to the full extent of their competencies.

AIM

The objective of this scoping review was to identify, examine and conceptually map the available literature on APN nurses' core competencies for general health assessment in primary health care.

METHOD

We performed a scoping review, following the methodological guidance for reporting as it is described by the Joanna Briggs Institute (JBI). Furthermore, the PRISMA-ScR statement and checklist for reporting scoping reviews were followed. Guiding the initial process for the search, we used the Population, Concept and Context mnemonic (PCC) to clarify the focus and context of the review.

RESULTS

We found three areas of core competencies on which APN nurse draw in performing general health assessments in primary health care: (1) 'Collaborative, leadership and management skills' (2) 'Person-centred nursing care skills' and (3) 'Academic and educational skills'. Furthermore, we found that the three areas are interrelated, because it is crucial that APN nurses draw on collaborative competencies related to leadership and management to meet the service users' needs and deliver high-quality and person-centred care.

CONCLUSION

There is a need for a more specific investigation into how APN nurses' core competencies play a role during general health assessments of patients in primary care. We suggest an evaluation of what works for whom in what circumstances looking into the interrelation between competencies, skills and knowledge when an APN nurse performs a general health assessment in a primary healthcare setting.

Incidence and clearance of cervical and anal high-risk human papillomavirus in kidney transplant recipients: Results from a Danish prospective clinical study

This study investigates the incidence and clearance of cervical and anal high-risk human papillomavirus (hrHPV) infection in kidney transplant recipients (KTRs) compared to immunocompetent controls. During 2016-2017, we enrolled 125 female KTRs and 125 female controls. Liquid-based cervical and anal cytology samples collected at enrollment and follow-up were tested for human papillomavirus (HPV) DNA using the CLART HPV2 test. All participants answered a questionnaire on lifestyle and sexual behavior at both examinations. KTRs had an increased age-adjusted risk of incident cervical hrHPV infection compared to controls (hazard ratio [HR] = 3.6, 95% CI = 1.2-11.2). Probability of cervical hrHPV clearance at 18 months was lower among KTRs (8.3%) than controls (66.7%). There was no statistically significant difference in anal hrHPV incidence between KTRs and controls (HR = 0.9, 95% CI = 0.4-2.0). Clearance of anal hrHPV was similar between KTRs and controls at 18 months. During the total follow-up, a lower anal hrHPV clearance, although not statistically significant, was observed among KTRs (HR = 0.3, 95% CI = 0.06-1.2). KTRs had higher incidence of cervical hrHPV and lower probability of clearance, especially of cervical hrHPV infections, than controls. Our findings support that KTRs are at increased risk of HPV infection and point to the need for targeted HPV prevention strategies, such as cervical cancer screening.

First pill hardest to swallow: An evaluation study of cardiovascular nurse-led follow-up phone calls

INTRODUCTION

Screening for cardiovascular disease (CVD) followed by preventive medication is expected to reduce CVD (2,3,5). However, insufficient medication adherence may affect screening effectiveness (11-12). It remains uncertain which interventions are suitable to support citizens in their decision-making about taking CVD preventive medication.

OBJECTIVE

We evaluated if and how three nurse-led telephone follow-up (TFU) calls supported citizens in making informed decisions regarding CVD preventive medication and thereby potentially strengthened their medication adherence.

METHODS

Employing a theory-based evaluation design inspired by Dahler-Larsen (39-41), we developed and tested a programme theory describing if and how the TFU calls supported medical decision-making and potentially improved medication adherence. Data were collected via telephone.

FINDINGS

We analysed 61 TFU calls collected between May 2017 and April 2019 and found that TFU calls supported participants' reflections on preventive medication. TFU calls supported informed decision-making regarding initiating medication, allowing participants to consider personal preferences and values, including both opting for and abstaining from medication. The content of the TFU calls revolved around four crucial themes: I) understanding the purpose of taking the medicine; II) meaningfulness and joint reflection support the decision; III) relation to healthcare professionals; and IV) taking medication for the first time.

CONCLUSION

TFU calls effectively supported citizens' understanding and addressed their needs. Trusted healthcare professionals' recommendations were preferred for decisional support. Initiating CVD preventive medication was particularly challenging for citizens who had not previously taken such medication. We recommend scheduling TFU calls early: the first after one week, the second after one month and the third after six months.

Risk of borderline ovarian tumors after fertility treatment - Results from a Danish cohort of infertile women

OBJECTIVE

Results from previous studies examining the association between fertility treatment and borderline ovarian tumors are inconsistent. The aim of this study was to investigate the association between fertility treatment and borderline ovarian tumors in a cohort of infertile women.

METHODS

This cohort study was based on the Danish Infertility Cohort and included all infertile women aged 20-45 years living in Denmark between 1 January 1995 and 31 December 2017 (n = 146,891). Information on use of fertility drugs, borderline ovarian tumors and cancer diagnoses, covariates, emigration, and vital status was obtained by linkage to national registers. Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) with adjustment for potential confounders for overall borderline ovarian tumors and for serous- and mucinous borderline ovarian tumors separately.

RESULTS

During a median 11.3 years of follow-up, 144 women developed a borderline ovarian tumor. No marked associations between ever use of clomiphene citrate, gonadotropins, gonadotropin-releasing hormone receptor modulators, human chorionic gonadotropin or progesterone and borderline ovarian tumors were observed, neither overall nor for serous and mucinous borderline ovarian tumors analysed separately. Further, no clear associations with borderline ovarian tumors were found according to cumulative dose, time since first use or parity status for any fertility drugs.

CONCLUSIONS

No marked associations between use of fertility drugs and borderline ovarian tumors were observed. However, the cohort's relatively young age at end of follow-up emphasizes the importance of extending the follow-up period for women who have used fertility drugs.

Overweight and obesity as risk factors for cervical cancer and detection of precancers among screened women: A nationwide, population-based cohort study

OBJECTIVE

Obesity is a known risk factor for many types of cancer. However, there is no clear evidence whether overweight and obesity increases the risk of cervical cancer. We investigated the association between body mass index (BMI) and detection of squamous and glandular cervical cancer and precancer.

METHODS

Based on the Medical Birth Registry, we conducted a nationwide cohort study in Denmark of 384,559 women with BMI ≥18.5 kg/m2 (pre-pregnancy BMI reported at the start of the pregnancy) having a cervical cytology screening at age 23-49 years within 5 years following the date of childbirth. The cohort was followed for 10 years from the first cervical cytology screening after the childbirth. We assessed absolute risks of cervical lesions according to BMI with the Aalen-Johansen estimator. We conducted Cox proportional hazards regression analyses to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). Analyses were adjusted for age, calendar year, parity, oral contraception use, HPV vaccination, smoking, country of origin, and education.

RESULTS

Overweight and obesity were associated with higher rates of cervical cancer (HR = 1.24, 95% CI 1.04-1.49 and HR = 1.14, 95% CI 0.91-1.43, respectively) and lower rates of cervical precancer detection (HR = 0.88, 95% CI 0.84-0.92 and HR = 0.67, 95% CI 0.63-0.71, respectively).

CONCLUSIONS

Higher than normal BMI was associated with higher incidence rates of cervical cancer and lower rates of precancer detection, emphasizing the importance of further research in possible mechanisms behind this association.

A support nurse may strengthen the participation of patients with low socio-economic status in treatment pathways of head and neck cancer: A theory-based evaluation

AIM

To test and evaluate a support nurse intervention within the head and neck cancer (HNC) pathway.

BACKGROUND

Even though interventions aiming to support patients with a low socio-economic status have been a focus for development and implementation in several countries, research still shows that these patients often have unmet needs and encounter challenges in communicating with health professionals during their treatment pathways. Furthermore, support interventions are few in Denmark and none of the existing interventions target patients with HNC receiving radiation therapy of whom the majority have a low socio-economic status and therefore potentially carry a high risk of being challenged during their treatment pathways.

DESIGN

A theory-based evaluation was used as framework. A support nurse intervention was designed to offer patients with a low socio-economic status help and support in the initial part of the HNC pathway. Eleven patients were included in the trial period.

METHODS

The evaluation of the intervention was based on interviews, a questionnaire survey and field notes.

RESULTS

The expected outputs were achieved, thus: (1) the patients felt supported and assisted, (2) the support nurse was capable of supporting, helping and accompanying the patients, (3) the patients were informed as relevant and understood the information provided. Unexpected outputs were that the support nurse was capable of co-ordinating the pathway in line with the patient's needs and that she facilitated the interaction between patients and health professionals.

CONCLUSIONS

Support for patients with a low socio-economic status improves their ability to engage in their cancer treatment pathway. This, in turn, increases their preparedness for participation and, hence, strengthens their choice of treatment.

REPORTING METHOD

This study is reported using consolidated guideline for reporting interventions Template for intervention description and replication (TIDieR checklist). We used theory-based evaluation as described by Peter Dahler-Larsen.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Organic food consumption and the incidence of type 2 diabetes mellitus in the Danish Diet, Cancer and Health cohort

AIM

To investigate the association between organic food consumption and the incidence of type 2 diabetes mellitus.

METHODS

Among 41,286 cohort participants, aged 50-65 years, organic food consumption of vegetables, fruits, dairy products, eggs, meat, and cereal products, was summarized into an organic food score evaluated as never, low, medium and high consumption and as continuous intake. During follow-up, 4,843 cases were identified in the National Diabetes Register. Organic food consumption was associated to the disease incidence in Cox regression models.

RESULTS

Organic food consumption was linearly associated with a lower incidence of type 2 diabetes mellitus (Women, HR: 0.94, 95% CI: 0.89-1.00, Men, HR: 0.95, 95% CI: 0.90-1.00). Organic food consumption frequency, compared to never consumption, showed HRs below 1.00 for both women (medium intake HR: 0.96, 95% CI: 0.84-1.10, high intake HR: 0.88, 95% CI: 0.74-1.05) and men (low intake, HR: 0.95, 95% CI: 0.85-1.05, medium intake, HR: 0.92, 95% CI: 0.83-1.03, high intake, HR: 0.89, 95% CI: 0.75-1.05) but were not statistically significant. Similar patterns were observed with consumption of the specific organic food groups for women, but not for men.

CONCLUSIONS

Organic food consumption was associated with a suggested lower incidence of type 2 diabetes mellitus.

Exploring intersectoral collaboration in diabetes care: A positioning theoretical perspective

Intersectoral collaboration (IC) plays a significant role in the delivery of diabetes care and treatment of patients with type 2 diabetes (DM2), as the treatment and care of these patients take place in both primary care and specialist settings. The collaboration involves a large number of actors from primary and secondary healthcare sectors, who are expected to fulfil various roles when they engage in IC. We explored the actors' roles by applying the framework of positioning theory with the aim of revealing seemingly embedded understandings of such roles. The empirical data consisted of individual and focus group interviews. Our results indicate that naturalised understandings of the roles of actors interact with the way in which health professionals, patients, managers and relatives strive to develop IC that aims to help and guide patients who live with DM2.

Influence of single-room accommodation on nursing care: A realistic evaluation

Nowadays, it is common that newly built hospitals are designed with single-room accommodation, unlike in the past, where shared accommodation was the favoured standard. Despite this change in hospital design, very little is known about how single-room accommodation affects nurses' work environment and nursing care. This study evaluates how the single-room design affects nurses and nursing care in the single-room hospital design. Nurses working in the single-room design predominantly work alone with little opportunity for peer training, interaction and reflection. In addition, the single-room design affects the nurses' work environment due to changes in sensory stimulation and increased walking distances. Furthermore, a change in the discourse, namely, regarding the single room as the patient's home, makes the nurses react to queries, demands and tasks in a new way. Overall, the new hospital design forces the nurses into a more reactive role and affect their way of providing nursing care. Despite this, the nurses find single-room accommodation beneficial for the patients and their nursing care.

Nurses' work experiences in hospital wards with single rooms: An integrative review

AIM AND OBJECTIVE

To evaluate evidence that examined nurses' work experiences in hospital wards with single rooms. The research question was 'What does the research tell us about nurses' work experiences in hospital wards with single rooms?'

BACKGROUND

In the last decades, new hospital builds have moved towards including a high proportion of single rooms. Yet, single rooms create 'complex environments' that impact the nurses.

DESIGN

A structured integrative review was undertaken of empirical evidence.

METHODS

Original, peer-reviewed articles, written in English, were sourced from four databases: CINAHL, PubMed, Embase and Web of Science. The initial searches were performed in April 2021 and repeated in December 2022. Quality appraisal was undertaken using the Mixed Methods Appraisal Tool. A narrative synthesis approach was used to analyse the data. Reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

Twelve studies, published between 2006 and 2022, with an international origin, and representing n = 826 nurses, were included in this review. The synthesis revealed mixed perspectives about nurses' work experiences in wards with single rooms. Whilst single rooms are 'all good in theory (and) a good idea', the reality was quite different. Synthesised findings are presented in four categories: (i) aesthetics and the physical space, (ii) privacy vs. isolation, (iii) safety, which includes situational awareness and (iv) communication and collaboration.

CONCLUSION

This review describes how single rooms affects nurses' work experience. Whilst nurses shared multiple concerns about single rooms and the challenges they also acknowledged patient preference for the privacy and space afforded by single rooms.

RELEVANCE TO CLINICAL PRACTICE

Findings from this review highlight the need for careful planning to maintain and strengthen teamwork, prevent nurses' sense of working in isolation, as well as creating opportunities for mentorship, and collaboration among nurses when working in single-room settings.

Obstacles for patients with a low socio-economic status treated within the head and neck cancer pathway: A multiple case study

AIMS AND OBJECTIVES

Drawing on ethnographic fieldwork exploring various head and neck cancer treatment pathways of patients with low socio-economic status being treated with radiation therapy in Denmark, our aim was to explore how and why inequality in this treatment pathway might occur in the encounter between these patients and Danish healthcare.

BACKGROUND

In recent years, inequality in cancer treatment of patients with a low socio-economic status has been a growing concern worldwide. The majority of patients with head and neck cancer have a relatively low socio-economic status and are at risk of experiencing inequality in their cancer treatment.

DESIGN/METHODS

Using a method proposed by Robert Yin, we performed a multiple case study of five treatment pathways of patients with a low socio-economic status. The case studies consisted of participant observations and interviews with patients, relatives and health professionals. We applied Herbert Blumer's theory of symbolic interaction as a framework for our analysis.

RESULTS

We identified three concepts that all blocked joint action because patients and health professionals had different perceptions of what interaction required of them in terms of (1) Understanding information; (2) Assuming responsibility for managing practical tasks; and (3) Coordinating one's own treatment pathway.

CONCLUSIONS

We identified how different situations challenged the patients' abilities to assume participation in their own treatment pathway. In their encounter with patients, healthcare professionals did not know which situational impediments to joint action patients were facing.

RELEVANCE TO CLINICAL PRACTICE

We argue that being aware of how challenges unfold in the interaction with patients with low socio-economic status may serve as a starting point for changing practice to reduce inequality in the treatment of these patients.

REPORTING METHOD

This study is reported using consolidated criteria for reporting Qualitative research (SRQR). We used the theory and method of Robert Yin of performing a multi-case study and we applied Herbert Blumer's theory of Symbolic interactionism as a framework for understanding data.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Factors associated with teenage pregnancy in the Scandinavian countries

AIMS

Teenage pregnancy may have negative consequences for the mother and the infant. The aim of the study was to examine whether selected individual factors occurring early in life were associated with teenage pregnancy.

METHODS

In a population-based, cross-sectional questionnaire study among 34,455 women from Denmark, Norway, and Sweden aged 20-45 years, who had first sexual intercourse (FSI) at age 13-19 years, we assessed the association between early smoking and drinking initiation (i.e., before the age of 13), contraceptive use at FSI, and teenage pregnancy. Log-linear binary regression models were fitted to estimate the relative risk (RR) with 95% confidence intervals (CIs) of teenage pregnancy according to the three exposure variables, overall and by age at FSI. Furthermore, the outcomes of the teenage pregnancies were examined according to age at FSI.

RESULTS

Teenage pregnancy occurred in 11% of the population. Both early smoking initiation (RR: 1.6; 95% CI: 1.4-1.8), early drinking initiation (RR: 1.2; 95% CI: 1.0-1.4), and non-use of contraceptives at FSI (RR: 1.9; 95% CI: 1.8-2.0) were associated with teenage pregnancy. The associations for early smoking initiation and non-use of contraceptives remained when analyses were stratified by age at FSI. Almost 60% of all teenage pregnant women had an induced abortion and less than 30% gave birth.

CONCLUSIONS

Individual factors, including early smoking and drinking initiation, and non-use of contraceptives at FSI, were associated with teenage pregnancy regardless of age at FSI. This emphasizes the necessity of focusing on early risk-taking behavior as a potential modifier to prevent teenage pregnancy.

Learning by chance. Student nurses' conditions for learning in single-room hospital design. A realistic evaluation

AIM

The aim of this study was to explore how a single-room hospital design influenced student nurses' learning and competence development in clinical practice compared with shared-room accommodation, refining the programme theory: The student nurses' conditions for learning in single-room hospital design are associated with the values of the patient room as the patient's home during hospitalisation.

BACKGROUND

It is evident that a hospital design with single-room accommodation influences several parameters for both the patients and staff. Furthermore, studies have shown that the physical as well as the psychological learning environment affects the learning outcome for student nurses. A premise for learning and education is that the physical learning space must promote person-centred and collaborative learning in order for the students to achieve their competence development goals.

DESIGN

The study was conducted as a realistic evaluation that compares second and fifth-semester undergraduate nurses' learning and competence development in clinical practice in shared accommodation (a pre-study) to single-room accommodation (a post-study).

METHODS

In the data generation, we drew on an ethnographically inspired participant observation method. We gathered data during the period 2019-2021, covering the time before and approximately one year after relocation to all single-room accommodation. We undertook 120 h of participant observation for the pre-study and 146 h of participant observation for the post-study.

CONCLUSION

We conclude that the learning environment in a single-room accommodation setting promotes task-oriented practices where the patient is often a mediator of activities related to nursing care. The learning environment in single-room accommodation places increased demands on the students' ability to reflect on verbal instructions on nursing activities whenever the chance for reflection presents itself. We also conclude that in a single-room accommodation setting, stakeholders must focus on conscious planning and follow-up on the student nurses' learning and educational activities which must support the students' competence development. Hence, summing up to a refined programme theory developed through the realistic evaluation process: The student nurse's conditions for learning in a single-room hospital design are associated with increased demands on the student's ability to reach out for professional reflection when the chance presents itself. This is because the value of the patient room as the patient's home during hospitalisation promotes a task-solving approach to nursing with the patient and the patient's relatives as instructors.

Risk of nonovarian cancer in a nationwide-based study of nearly 5000 women with borderline ovarian tumors in Denmark

Evidence regarding cancer risk after borderline ovarian tumors (BOTs) is limited. We conducted a nationwide cohort study examining the incidence of nonovarian cancers in women with serous or mucinous BOTs compared with the general female population with up to 41 years of follow-up. Through the nationwide Pathology Registry, we identified nearly 5000 women with BOTs (2506 serous and 2493 mucinous) in Denmark, 1978 to 2018. We computed standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) as relative risk estimates of specific nonovarian cancers. Compared with general female population rates, women with serous BOTs had increased rates of particularly malignant melanoma (SIR = 1.9; 95% CI: 1.3-2.6), thyroid cancer (SIR = 3.0; 95% CI: 1.4-5.4) and myeloid leukemia (SIR = 3.2; 95% CI: 1.5-5.8), and women with mucinous BOTs had elevated rates of lung cancer (SIR = 1.7; 95% CI: 1.3-2.1), pancreatic cancer (SIR = 1.9; 95% CI: 1.2-2.9) and myeloid leukemia (SIR = 2.3; 95% CI: 0.9-4.7). We found no convincing association with neither breast nor colorectal cancer in women with BOTs. This is the first large nationwide study showing that women with specific types of BOTs have increased risks of several nonovarian cancers, likely due to some shared risk factors or genetic characteristics.

Prepregnancy Body Mass Index and Risk of Differentiated Thyroid Cancer: A Prospective Cohort Study of More than 440,000 Danish Women

Background: High body mass index (BMI) has previously been associated with increased risk of differentiated thyroid cancer (DTC); however, only few studies have investigated the association with BMI in a large cohort assessed at a young age and with sufficient data on confounding factors. We assessed the association between excess body weight and the risk of DTC and papillary thyroid cancer (PTC) in a large cohort of young Danish women with substantial confounder control. Methods: We included all parous Danish women registered with a prepregnancy BMI ≥18.5 kg/m² during 2004-2016 in the Danish Medical Birth Registry in the study population. Cox proportional hazards regression models were used to estimate the hazard ratios (HRs) with confidence intervals (CIs) of DTC according to BMI. In subanalyses, we investigated PTC as a separate group. Analyses were adjusted for calendar time, education, smoking status, benign thyroid disease (BTD), type II diabetes, parity, and oral contraceptive use. In addition, we examined the association with increasing BMI stratified for previous BTD. Results: A total of 443,403 women were included in the study population, and the median age at baseline was 30.0 years. Altogether, 463 women were diagnosed with DTC during follow-up. Excess body weight was associated with a higher rate of DTC (overweight, BMI 25-29.9 kg/m²: HR = 1.54; CI 1.25-1.90. Obese, BMI ≥30 kg/m²: HR = 1.32; CI 1.00-1.75) compared with normal weight. Results were similar in PTC. In addition, we found an increased rate of DTC with increasing BMI, when investigating BMI as a continuous variable per 5 kg/m² increase (HR = 1.17; CI 1.07-1.27). The results were similar in women without previous BTD. Conclusions: Our study confirms that excess body weight is associated with an increased incidence of DTC and PTC in women.

A critical discourse analysis of the influence of organisational structures on inequality in head and neck cancer treatment in Denmark

BACKGROUND

Concern is growing about inequality in cancer treatment, and a call has been made for more knowledge of the underlying causes of this inequality. Studies show that patients with low socioeconomic status in general face a greater risk of inequality than patients with a high socioeconomic status.

AIM

The aim of the present study was to uncover how institutional factors may exacerbate inequality in cancer treatment for patients with low socioeconomic status exemplified by patients with head and neck cancer, most of whom have low socioeconomic status.

METHOD

Inspired by Fairclough, we undertook a critical discourse analysis investigating the treatment pathway of patients with head and neck cancer on the basis of policy papers.

RESULTS

These papers, which we conceived as formative instruments, harboured a discourse of efficiency and a discourse of participation, together carving out an effective cancer treatment pathway provided patients act in line with the recommendations.

DISCUSSION

The discourses of efficiency and participation are not unfamiliar in health care, and prior research shows that they may pose difficulties for patients with low socioeconomic status.

CONCLUSION

The discoursal framing of head and neck cancer treatment may exacerbate inequality because most patients with a low socioeconomic status fail to comprehend and act in accordance with these discourses.

Organic food consumption and the incidence of cancer in the Danish diet, cancer and health cohort

PURPOSE

Expected beneficial health effects is a major reason why people purchase organically produced foods, although the existing evidence is limited. We investigated if organic food consumption, overall and by specific food groups, is associated with the incidence of cancer.

METHODS

We used data from the Danish Diet, Cancer and Health cohort. Organic food consumption was reported for vegetables, fruits, dairy products, eggs, meat, and bread and cereal products. Consumption was summarized into an overall organic food score, evaluated as a continuous variable and in categories specified as never, low, medium, and high consumption. We followed 41,928 participants for a median of 15 years, during which 9,675 first cancer cases were identified in the Danish Cancer Registry. We used cox proportional hazard models adjusted for sociodemographic and lifestyle variables to estimate associations between organic food consumption and cancer incidence.

RESULTS

No association was observed between intakes of organic foods and incidence of overall cancer. When compared to never eating organic foods, overall organic food consumption was associated with a lower incidence of stomach cancer (low: HR = 0.50, 95% CI: 0.32-0.78, medium: HR = 0.50, 95% CI: 0.32-0.80, high: HR = 0.54, 95% CI: 0.27-1.07, p-trend = 0.09), and higher incidence of non-Hodgkin lymphoma (low: HR = 1.45, 95% CI: 1.01-2.10, medium: HR = 1.35, 95% CI: 0.93-1.96, high: HR = 1.97, 95% CI: 1.28-3.04, p-trend = 0.05). Similar patterns were observed for the specific food groups.

CONCLUSION

Our study does not support an association between organic food consumption and incidence of overall cancer. The scarce existing literature shows conflicting results with risk of specific cancers.

An inconvenience to the nurse's practice: A Foucault-inspired study of ethnic minority patients

Ethnic minority patients have been discussed and problematised in Western health literature. Drawing on an interpretation of central parts of the French philosopher Michel Foucault's authorship, we analysed a broad selection of materials to identify mechanisms through which the truth about ethnic minority patients is constructed. We identified a single, yet consistent discursive strategy that we termed 'figure of inconvenience' in which ethnic minority patients were classified and assigned a specific subjection illustrating them as 'inconvenient' to the nurse's practice. Concurrently, their relatives were afforded the position of substitutes. The discourse exemplifies how the behaviour or appearances of ethnic minority patients cannot be reconciled with the traits of ethnic Danish patients. Finally, we discussed implications that such a strategy may have for the provision of healthcare services for ethnic minority patients in Denmark.

Psychotropic medication among children who experience parental death to cancer

The psychological consequences of losing a parent to cancer are unclear. We investigated whether experiencing parental death to cancer before 18 years of age increases the risk of psychotropic medication. We used register data of all children born in Denmark between 1 January 1987 and 31 December 2016 (N = 1,488,846). We assessed rate ratios (RRs) with 95% confidence intervals (CIs) for first redeemed prescription of antidepressants, anxiolytics and hypnotics according to parental death status using Poisson multi-state models. We further examined whether the associations differed according to the gender of the deceased parent, child's age at the time of death or the parental length of illness. Cancer-bereaved children had a significantly increased risk of first prescription of psychotropic medication (rate ratio, RR 1.22, 95% confidence interval, CI 1.10-1.34 for males; RR 1.18, 95% CI 1.09-1.28 for females). Associations were strongest if the parent had the same sex as the child and if the parent died within one year of diagnosis. The risk was highest during the first six months after the loss (RR 2.35, 95% confidence interval, CI 1.48-3.73 for males; RR 1.81, 95% CI 1.17-2.80 for females). Children who lose a parent to cancer, particularly in cases when the disease progressed quickly, may need extra psychological support, especially during the first six months after the death.

Association of Smoking, Comorbidity, Clinical Stage, and Treatment Intent With Socioeconomic Differences in Survival After Oropharyngeal Squamous Cell Carcinoma in Denmark

IMPORTANCE

The socioeconomic gap in survival after cancer is pronounced among patients with head and neck cancer. Understanding the mechanisms of this gap is crucial to target intervention strategies.

OBJECTIVE

To investigate socioeconomic differences in survival after oropharyngeal squamous cell carcinoma (OPSCC) according to human papillomavirus (HPV) status and the extent to which smoking, comorbidity, clinical stage, and treatment intent explain the survival gap.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide, population-based cohort study was based on prospectively collected information on all patients with a diagnosis of OPSCC from the Danish Head and Neck Cancer Group database and administrative registries. The study included 4600 patients born in 1921 or later, aged 30 years or older, and residing in Denmark 1 year prior to OPSCC diagnosis. Patients with missing information (547 [12%]) were excluded. Patients were diagnosed between January 1, 2008, and December 31, 2019, and followed up until December 31, 2021. Data were analyzed from June 6 to October 4, 2022.

EXPOSURE

Socioeconomic position (educational level, disposable income, or cohabiting status).

MAIN OUTCOMES AND MEASURES

Socioeconomic differences in 5-year overall survival were estimated in Cox proportional hazards regression models by HPV status. The indirect effect and proportion mediated by smoking, comorbidity, clinical stage, and treatment intent were estimated based on a counterfactual approach.

RESULTS

The analyzed cohort comprised 4053 patients (1045 women [26%] and 3008 men [74%]). The median age was 61 years (IQR, 55-68 years), and 2563 patients (63%) had HPV-positive OPSCC while 1490 patients (37%) had HPV-negative OPSCC. The 5-year standardized overall survival was 10% to 15% lower among patients with a lower educational level, with low disposable income, or who were living alone (patients with HPV-positive OPSCC, 68%-71%; patients with HPV-negative OPSCC, 31%-34%) than patients with a higher educational level, high disposable income, or a cohabiting partner (patients with HPV-positive OPSCC, 81%-86%; patients with HPV-negative OPSCC, 43%-46%). Among patients with HPV-positive OPSCC, a considerable part of this survival gap was estimated to be associated with differences in smoking (27%-48%), comorbidity (10%-19%), clinical stage (8%-19%), and treatment intent (16%-28%). Among those with HPV-negative OPSCC, comorbidity (12%-22%) and treatment intent (16%-42%) were the primary potential mediators.

CONCLUSIONS AND RELEVANCE

This cohort study suggests that, regardless of HPV status, patients with low socioeconomic position had 10% to 15% lower 5-year overall survival than patients with high socioeconomic position. A substantial part of this survival gap was associated with differences in smoking, comorbidity, clinical stage, or treatment intent at diagnosis.

P-783 Fertility treatment and risk of ovarian cancer in a large nationwide cohort of 151,821 infertile Danish women

Study question

Do use of fertility drugs increase the risk of ovarian cancer among infertile women

Summary answer

Use certain types of fertility drugs may modify the risk of ovarian cancer among infertile women, primarily for serous ovarian tumors and among parous women.

What is known already

Even though most previous studies on the association between fertility treatment and ovarian cancer have not been able to show a convincing association, some studies have found an increased risk of this malignancy among women undergoing fertility treatment. However, many of the previous studies have had methodological limitations including selection bias and potential confounding due to missing information of important factors, such as parity status and hormonal contraceptive use, small sample size as well as short- and incomplete follow-up time. Furthermore, only few studies have assessed the association between fertility treatment and ovarian cancer according to histological type.

Study design, size, duration

This retrospective register-based cohort study included virtually all 20-45 year old infertile women in Denmark between 1971 and 2017 as identified in the Danish Infertility Cohort. All women were followed from entry in the cohort (i.e. the date of first infertility diagnosis) to occurrence of ovarian cancer, any other cancer (except non-melanoma skin cancer), death, emigration, bilateral oophorectomy or end of follow-up (December 31, 2017), whichever occurred first. The median follow-up length was 10.3 years

Participants/materials, setting, methods

In total, 332 women were diagnosed with ovarian cancer during the follow-up period. Information on the use of specific fertility drugs (clomiphene citrate, gonadotropins, hCGs, GnRH receptor modulators and progesterone), ovarian cancer, covariates and vital status was obtained from the Danish Infertility Cohort and various Danish national registers. Cox proportional hazard regression models were used to calculate hazard ratios (HRs) and 95% CIs for ovarian cancer overall and for serous ovarian tumors.

Main results and the role of chance

After adjustment for attained age (as the underlying time scale), calendar year of study entry, highest obtained level of education, maternal age at first childbirth, number of childbirths, hormonal contraceptive use as well as mutual adjustment for treatment with any other specific fertility drugs, ever use of hCG (HR 0.62, 95% CI 0.44-0.89) and GnRH receptor modulators (HR 0.63, 95% CI 0.40-1.00) were associated with a decreased risk of overall ovarian cancer. In contrast, ever use of gonadotropins (HR 1.43; 95% CI 0.91-2.24) and especially progesterone (HR 1.81; 95% CI 1.18-2.78) increased the risk of overall ovarian cancer. No marked association was observed for clomiphene citrate (HR 1.07, 95% CI 0.80-1.44)). The rates for serous ovarian cancer generally resembled those observed for overall ovarian cancer; however only the association for progesterone reached statistical significance (HR 2.89; 95% CI 1.67-4.99). The observed associations existed mainly among parous women and did not vary with time since first use of the fertility drug in question and no statistically significant associations were observed with cumulative dose of the specific fertility drugs.

Limitations, reasons for caution

The median age at the end of follow-up was only 42.5 years, which is markedly lower than the usual peak age for ovarian cancer in Denmark (mid 60s). Hence, we were not able to capture the true, potential long-term association between use of fertility drugs and ovarian cancer.

Wider implications of the findings

Use of certain specific types of fertility drugs in fertility treatment may modify the risk of ovarian cancer among subgroups of women. However, although this study is by far the largest to date, additional large epidemiological studies with longer follow-up time are needed to further clarify the observed associations.

Trial registration number

Not applicable.

A nationwide longitudinal study on risk factors for progression of anal intraepithelial neoplasia grade 3 to anal cancer

Little is known about risk factors for progression of high‐grade anal intraepithelial neoplasia (AIN) to anal squamous cell carcinoma (ASCC). In this large, population‐based study, we assess the role of factors related to immune status for the risk of ASCC among individuals from the general population with a diagnosis of AIN3. Individuals diagnosed with AIN3 during 1985‐2016 were identified in the Danish Pathology Registry and followed for subsequent development of ASCC. The study population was linked to the National Patient Registry, the Danish Prescription Registry and the Danish HIV Cohort Study for information on autoimmune disease, genital warts and HIV status. To study the progression rate, Cox regression models with hazard ratios (HR) and 95% confidence intervals (CI) were applied with time since AIN3 as the underlying time scale and with adjustment for age at AIN3 diagnosis, year of AIN3 diagnosis and sex. The study population comprised 1222 individuals with AIN3 contributing 12 824 person‐years of follow‐up. Ninety‐seven individuals (7.9%) developed ASCC. Individuals registered with an autoimmune disease or genital warts before and/or after the AIN3 diagnosis had an increased rate of progression to ASCC compared to individuals without these conditions. People living with HIV had a higher progression rate than HIV‐negative individuals (HR = 4.25; 95% CI: 1.87‐9.65) with the highest progression rate among those with CD4 count ≤200 cells/μL. These associations may be caused by an interplay between HPV infection and immunosuppression.

Fertility drugs and incidence of thyroid cancer in a Danish nationwide cohort of 146 024 infertile women

STUDY QUESTION

Do fertility drugs increase the risk of thyroid cancer among infertile women?

SUMMARY ANSWER

The use of most types of fertility drugs was not associated with an increased risk of thyroid cancer.

WHAT IS KNOWN ALREADY

The incidence of thyroid cancer is higher for women than men, especially during reproductive years, indicating that reproductive hormones may be involved in the development of thyroid cancer. Only a few previous studies have examined the association between the use of fertility drugs and incidence of thyroid cancer and the results are inconclusive.

STUDY DESIGN, SIZE, DURATION

A retrospective, population-based cohort study including all 146 024 infertile women aged 20-45 years and living in Denmark in the period 1995-2017. The women were followed from the date of entry in the cohort (i.e. date of first infertility diagnosis) until the occurrence of thyroid cancer or any other cancer (except non-melanoma skin cancer), death, emigration, total thyroidectomy or the end of follow-up (31 December 2018), whichever occurred first. The median length of follow-up was 11.3 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In total, 167 women were diagnosed with thyroid cancer during the follow-up period. Information on the use of specific fertility drugs (clomiphene citrate, gonadotropins, hCGs, GnRH receptor modulators and progesterone), thyroid cancer, covariates and vital status was obtained from the Danish Infertility Cohort and various Danish national registers. Cox proportional hazard regression models were used to calculate hazard ratios (HRs) and 95% CIs for thyroid cancer overall and for papillary thyroid cancer.

MAIN RESULTS AND THE ROLE OF CHANCE

After adjustment for the calendar year of infertility diagnosis, the highest obtained level of education, parity status, obesity or thyroid disease and mutual adjustment for other registered fertility drugs, no marked associations were observed between the use of clomiphene citrate, hCG, gonadotropins or GnRH receptor modulators and risk of overall or papillary thyroid cancer. However, ever use of progesterone was associated with an increased rate of both overall (HR 1.63; 95% CI 1.07-2.48) and papillary (HR 1.66, 95% CI 1.04-2.65) thyroid cancer after mutual adjustment for other specific fertility drugs. For most specific fertility drugs, we observed a tendency toward higher associations with thyroid cancer within the first 5 years after the start of drug use than after 5 years from the start of use. No marked associations were detected according to the cumulative dose for any of the specific fertility drugs.

LIMITATIONS, REASONS FOR CAUTION

Despite a large study population, the statistical precision in some subgroup analyses may be affected due to the low number of thyroid cancer cases. Although we were able to adjust for a number of potential confounders, residual and unmeasured confounding may potentially have affected the observed associations, as we could not adjust for some factors that may influence the association between fertility drugs and thyroid cancer, including age at menarche and BMI.

WIDER IMPLICATIONS OF THE FINDINGS

Although this study, which is the largest to date, provides reassuring evidence that there is no strong link between the use of fertility drugs and thyroid cancer incidence, we observed a modest increased thyroid cancer incidence after the use of progesterone. However, we cannot rule out that this is a chance finding and the potential association between the use of progesterone and thyroid cancer should therefore be investigated further in large epidemiological studies. The results of the present study provide valuable knowledge for clinicians and other health care personnel involved in the diagnosis and treatment of infertility.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by research grants from the Jascha Foundation and the Aase and Ejner Danielsens Foundation. B.N. received honoraria and/or non-financial support by Gedeon Richter Nordics AB, IBSA Nordic APS and Merck KGAA. The remaining authors have no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Follow-up after abnormal cervical cancer screening in immigrants compared with Danish-born women - A nationwide register study

Cervical cancer screening is offered free-of-charge to women aged 23-64 years in Denmark. Immigrants participate less in screening than Danish-born women, but little is known about their participation in follow-up after abnormal screening results. In this registry-based cohort study, we examined the likelihood of timely follow-up after an abnormal cervical cytology in immigrants from different countries and regions compared with Danish-born women. In nationwide registers, we identified women aged 23-64 years with high-grade (n = 74,335) or low-grade (n = 174,038) abnormal cytology during 1997-2017. Timely follow-up was defined as a new examination within six months for high-grade and 18 months for low-grade abnormalities. We calculated the probability of timely follow-up by country and region of origin and estimated odds ratios (ORs) of timely follow-up between immigrants and Danish-born women. The proportions with timely follow-up after high-grade abnormalities ranged from 90.6%-95.1% in immigrants from different countries or regions, compared with 95.5% in Danish-born women. For low-grade abnormalities, follow-up ranged from 75.2%-92.8% in immigrants, compared with 90.6% in Danish-born women. Women from Sub-Saharan Africa had low probability of timely follow-up after both high-grade (90.9%) and low-grade (75.2%) abnormalities. The differences between immigrants and Danish-born women remained when adjusting for age, year, income, employment and marital status. In conclusion, immigrants from most countries and regions were slightly less likely than Danish-born women to receive timely follow-up after abnormal cervical cytology, also after adjusting for socioeconomic differences. Efforts should be made to improve follow-up of abnormal screening results in immigrant groups with low attendance.

Patients' and Nurses' Experiences of All Single-Room Hospital Accommodation: A Scoping Review

AIM AND OBJECTIVE

To identify, examine, and map literature on the experiences of single-room hospital accommodation, exploring what is known about how single-room accommodation in hospitals is viewed by patients and nurses.

BACKGROUND

Worldwide, hospital design is changing to mainly single-room accommodation. However, there is little literature exploring patients' and nurses' experiences of single-room designs.

DESIGN

Scoping review following the Joanna Briggs Institute guidance on scoping reviews.

METHODS

We conducted the search in medical databases for scientific and gray literature. The four authors independently used a data extraction tool to include sources from the searches. The sources were discussed during the process, and in case of a disagreement between two reviewers, the third and fourth reviewer would be invited to participate in the discussion until consensus was achieved.

RESULTS

We included 22 sources published during the period 2002-2020, with a majority (n = 16) during the period 2013-2020. The sources were distributed on 10 different countries; however, England dominated with 14 publications. We found three main maps for reporting on patients' experiences: (1) personal control, (2) dignity, and (3) by myself. For the nurses' experiences, we found four main maps: (1) the working environment, (2) changes of nursing practice, (3) privacy and dignity, and (4) patient safety.

CONCLUSION

We suggested that patients' and nurses' experiences are predominantly interdependent and that the implications of single-room accommodation is a large and complex issue which goes beyond hospital design.

The role of circumcision, tobacco, and alcohol use in genital human papillomavirus infection among men from Denmark

It is crucial to understand the natural history of genital human papillomavirus (HPV) infection in men to prevent the increasing male HPV-related disease burden. We evaluated the associations between HPV infection and circumcision, smoking, and alcohol use after accounting for sexual behavior. The study included 2331 male personnel from Danish barracks. Penile swabs were tested for HPV DNA with a polymerase chain reaction assay, INNO-LiPA. All men completed a self-administered questionnaire providing data on potential risk factors for HPV such as lifestyle and sexual habits. Using multivariable logistic regression, associations between potential risk factors and HPV infection were estimated and expressed as odds ratios (ORs) with 95% confidence intervals (CI). Current cigarette smoking was associated with increased odds of HPV detection (OR = 1.2; 95% CI: 1.0-1.4), but we found no association with alcohol use in the analysis adjusted for sexual behavior. Circumcision reduced the odds of a prevalent HPV infection (OR = 0.7; 95% CI: 0.5-1.0) although not statistically significantly. Strong associations with lifetime and recent number of female sex partners were observed, but in contrast to uncircumcised men, increasing number of sex partners was not associated with higher HPV prevalence in circumcised men. In conclusion, smoking was associated with increased odds of penile HPV in men from the general population in Denmark, whereas circumcision seemed to reduce the risk. Moreover, our results indicated that there might be differences in the viral susceptibility between circumcised and uncircumcised men.

Contributions to Multidisciplinary Team Meetings in Cancer Care: Predictors of Complete Case Information and Comprehensive Case Discussions

Purpose

Multidisciplinary team (MDT) meetings integrate complex information and base recommendations for clinical management on interdisciplinary and multiprofessional decision-making. To support high-quality decision-making and define key performance indicators, we aimed to determine completeness of case information and contributions to MDT case discussions in cancer care.

Methods

In a prospective observational study design, based on three MDTs, we applied the Metric for Observation of Decision-Making (MODe) tool to assess the quality of case presentation and team members’ contributions to case discussions. The MDTs handled patients with brain tumors, soft tissue sarcomas and hepatobiliary cancers. The results were correlated to patient and team characteristics and to MDT leadership skills.

Results

Data were collected from 349 case discussions during 32 MDT meetings. Information on radiology received the highest scores, followed by case history and information on histopathology. Patient-related information was less frequently mentioned and generally received low scores. Contributions to the case discussions were predominantly by the chair, surgeons, and oncologists with limited contributions from nurses. Leadership skills showed a positive correlation with case presentations scores and failure to reach a treatment recommendation correlated with lower case discussion scores.

Conclusion

Considerable resources are spent on MDT meetings in cancer care, which motivate initiatives to ensure high-quality and efficient decision-making processes. We identify unbalanced contributions from team members during MDT meetings, demonstrate limited provision of patient-related information and show that leadership skills may positively influence the quality of the case presentations. We suggest that MDTs should consider and develop these aspects to ensure high-quality MDT-based case management and decision-making.

Prediction of the postoperative 90-day mortality after acute colorectal cancer surgery: development and temporal validation of the ACORCA model

PURPOSE

The aim of this study was to develop and validate a model to predict 90-day mortality after acute colorectal cancer surgery.

METHODS

The model was developed in all patients undergoing acute colorectal cancer surgery in 2014-2016 and validated in a patient group operated in 2017 in Denmark. The outcome was 90-day mortality. Tested predictor variables were age, sex, performance status, BMI, smoking, alcohol, education level, cohabitation status, tumour localization and primary surgical procedure. Variables were selected according to the smallest Akaike information criterion. The model was shrunken by bootstrapping. Discrimination was evaluated with a receiver operated characteristic curve, calibration with a calibration slope and the accuracy with a Brier score.

RESULTS

A total of 1450 patients were included for development of the model and 451 patients for validation. The 90-day mortality rate was 19% and 20%, respectively. Age, performance status, alcohol, smoking and primary surgical procedure were the final variables included in the model. Discrimination (AUC = 0.79), calibration (slope = 1.04, intercept = 0.04) and accuracy (brier score = 0.13) were good in the developed model. In the temporal validation, discrimination (AUC = 0.80) and accuracy (brier score = 0.13) were good, and calibration was acceptable (slope = 1.19, intercept = 0.52).

CONCLUSION

We developed prediction model for 90-day mortality after acute colorectal cancer surgery that may be a promising tool for surgeons to identify patients at risk of postoperative mortality.

Core competencies of clinical nurse specialists: A comparison across three Nordic countries

AIM

To describe and compare the clinical nurse specialist core competency use in Finland, Denmark and Iceland.

BACKGROUND

Clinical nurse specialist roles were first developed more than 60 years ago in the United States. Within the Nordic countries, the clinical nurse specialist role emerged around 2000. There is scarcity of clinical nurse specialist competency descriptions outside of North America, and research has been limited to examine or validate established competencies across different countries.

DESIGN

A descriptive correlational study.

METHODS

An online survey was conducted from May to September 2019. A population sample of clinical nurse specialists in Finland, Denmark and Iceland was recruited. A validated self-report questionnaire of clinical nurse specialist competencies was used. The data were analysed using descriptive and inferential statistics, and the STROBE checklist was used as the reporting guideline.

RESULTS

A total sample of 184 clinical nurse specialists, 52 from Finland, 95 from Denmark and 37 from Iceland, participated in the study (response rate = 72%, 35% and 48%, respectively). Overall, clinical nurse specialists utilised the organisational competency most frequently followed by the patient, clinical nursing leadership and scholarship competency. Univariate analysis of variance test between-country effects showed statistically significant difference in patient competency (p = .000) and in organisational competency (p < .05). There were no statistically significant differences between counties in the utilisation of clinical nursing leadership and scholarship competency.

CONCLUSION

A small variability was found in the comparison of the clinical nurse specialist use of core competency in the spheres of patient, nursing, organisation and scholarship within three Nordic countries.

RELEVANCE TO CLINICAL PRACTICE

The CNS competency scale may be utilised in benchmarking clinical nurse specialist roles and practice within and across countries. The long-term goal for the competency descriptions is to enhance the clinical nurse specialist role clarity, integration and evaluation as well as inform post-graduate education.

Leadership assumptions on implementation of patient involvement methods

Background

From 2014 to 17, a large-scale project, ‘The User-involving Hospital’, was implemented at a Danish university hospital. Research highlights leadership as crucial for the outcome of change processes in general and for implementation processes in particular. According to the theory on organizational learning by Agyris and Schön, successful change requires organizational learning. Argyris and Schön consider that the assumptions of involved participants play an important role in organizational learning and processes. The purpose was to explore leaders’ assumptions concerning implementation of patient involvement methods in a hospital setting.

Methods

Qualitative explorative interview study with the six top leaders in the implementation project. The semi-structured interviews were conducted and analyzed in accordance with Kvale and Brinkmanns’ seven stages of interview research.

Result

The main leadership assumptions on what is needed in the implementation process are in line with the perceived elements in organizational learning according to the theory of Argyris and Schön. Hence, they argued that implementation of patient involvement requires a culture change among health care professionals. Two aspects on how to obtain success in the implementation process were identified based on leadership assumptions: “The health care professionals’ roles in the implementation process” and “The leaders’ own roles in the implementation process”.

Conclusion

The top leaders considered implementation of patient involvement a change process that necessitates a change in culture with health care professionals as crucial actors. Furthermore, the top leaders considered themselves important facilitators of this implementation process.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06497-y.

Use of Fertility Drugs and Risk of Malignant Melanoma: Results from a Large Danish Population-Based Cohort Study

Fertility drugs have not definitively been linked to malignant melanoma. By the use of data from a large nationwide cohort of women aged 20.0-45.0 years and living in Denmark between January 1, 1995 and December 31, 2011, we assessed the association between the use of fertility drugs and the risk of malignant melanoma. Information on fertility status and the use of fertility drugs was obtained from the population-based Danish Infertility Cohort. Cox proportional hazard regression models were applied to estimate hazard ratios and 95% confidence intervals with adjustment for potential confounders. The study population comprised 1,330,954 women, of whom 86,231 (6.5%) were treated with fertility drugs. During a median follow-up of 21.0 years, 6,139 women were diagnosed with malignant melanoma. Compared with fertile women, women with fertility challenges who had used any fertility drugs had an increased risk of malignant melanoma (hazard ratio = 1.14; 95% confidence interval = 1.02-1.27). Furthermore, the use of specific types of fertility drugs (clomiphene, gonadotropins, human chorionic gonadotropin, gonadotropin-releasing hormone preparations, and progesterone) was also associated with an increased risk of malignant melanoma, with hazard ratios ranging between 1.09 and 1.13; however, the association did not reach statistical significance. Our findings indicate that the use of fertility drugs was associated with a modestly increased risk of malignant melanoma.

Ninth-grade school achievement in Danish children conceived following fertility treatment: a population-based cohort study

OBJECTIVE

To assess whether academic achievement among children conceived following fertility treatment is different from that of children born to fertile women while also considering the underlying infertility.

DESIGN

Population-based cohort study.

SETTING

Denmark.

PATIENT(S)

The study population consisted of all 154,536 firstborn, live-born, singleton children in Denmark between 1995 and 2000 who completed their ninth grade with an examination.

INTERVENTION(S)

The Danish Infertility Cohort was used to identify children conceived after fertility treatment (n = 10,099), and information on mean school marks was obtained from Statistics Denmark.

MAIN OUTCOME MEASURE(S)

Linear regression models were used to estimate mean differences (MDs) and 95% confidence intervals (CIs). Multiple logistic regression models were used to estimate odds ratios (OR) and 95% CI of not passing the ninth-grade examination.

RESULTS

The crude overall mean marks for children conceived after the various fertility treatment procedures were in general higher than in children born to fertile women. However, after adjustment for potential confounders, the overall mean marks were statistically significantly lower for children conceived after the various fertility treatment procedures (e.g., any fertility treatment: MD -0.13; 95% CI -0.18, -0.08) compared with children born to fertile women. Further, children conceived after any fertility treatment had a statistically significant lower crude likelihood of not passing the ninth-grade examination (OR 0.66; 95% CI 0.53, 0.81) compared with children born to fertile women, whereas no difference was observed in the confounder adjusted analyses (OR 1.15; 95% CI 0.89, 1.49). When children born to women requiring fertility assistance but without fertility treatment in the index pregnancy were used as a reference group, no differences in the adjusted overall mean marks and the likelihood of not passing the ninth grade with an examination were observed.

CONCLUSION

Our findings indicate that fertility treatment per se is not associated with lower school marks and the likelihood of not passing the ninth grade with an examination. Hence, we suggest that factors related to both fertility problems and cognitive development may more likely explain the slightly lower academic performance (i.e., modest lower mean marks) among children conceived after fertility treatment.

Toenail selenium, plasma selenoprotein P and risk of advanced prostate cancer: A nested case-control study

Low selenium status may be associated with increased risk of prostate cancer (PC), particularly aggressive PC, and variation in selenoprotein genes may constitute an important modifying factor. We aimed to investigate the association between two selenium status biomarkers [toenail selenium, plasma selenoprotein P (SELENOP)] and risk of advanced, high-grade and advanced-stage PC. We further studied whether variations in selenoprotein genes were associated with PC risk and selenium biomarker concentrations. In the "Diet, Cancer and Health" cohort, 27 178 men aged 50 to 65 years were enrolled from 1993 to 1997. Between baseline and 2012, 1160 cohort participants were diagnosed with advanced PC; among these 462 had high-grade and 281 had advanced-stage disease at diagnosis. Each case was risk set-matched to one control. Toenail selenium and plasma SELENOP concentrations were measured by neutron activation analysis and a SELENOP-ELISA, respectively, and genotyping was performed for 27 selected single nucleotide polymorphisms (SNPs) in 12 selenium pathway genes (including seven selenoproteins) by allele-specific PCR. Toenail selenium and circulating SELENOP concentrations were not associated with advanced, high-grade or advanced-stage PC. After adjustment for multiple testing, none of the genes were associated with PC risk. Neither toenail selenium nor plasma SELENOP was associated with advanced, high-grade or advanced-stage PC.

Pregnancy outcomes in women with neurofibromatosis 1: a Danish population-based cohort study

BACKGROUND

The probability of a pregnancy, live birth, stillbirth and abortion has never been assessed in women with neurofibromatosis 1 (NF1) in a large population-based study.

METHODS

We included 1006 women (15-49 years) registered with NF1 in the Danish National Patient Registry or followed in two national Centers for Rare Diseases and 10 020 women from the Danish population. Information on pregnancy outcomes was ascertained from health registries. Cumulative incidence, mean cumulative count, hazard ratios (HRs) and proportion ratios (PRs) with 95% CIs were calculated.

RESULTS

The cumulative incidence of a first pregnancy at age 50 years was slightly lower in women with NF1 (74%; 95% CI 70 to 77) than in population comparisons (78%; 95% CI 77 to 79). When all pregnancies were included, two pregnancies were expected per woman at age of 50 years, irrespective of a NF1 diagnosis. The hazard of a pregnancy did not differ between women with NF1 (HR 1.03; 95% CI 0.95 to 1.11) and the comparisons after adjustment for somatic and psychiatric disease. The proportion of pregnancies that resulted in a live birth was 63% (783/1252) among women NF1 and 68% (8432/12 465) among the comparisons, yielding a PR of 0.95 (95% CI 0.90 to 1.00). The proportions of stillbirths (PR 2.83; 95% CI 1.63 to 4.93) and spontaneous abortions (PR 1.40; 95% CI 1.09 to 1.79) were increased in women with NF1.

CONCLUSIONS

A similar hazard for pregnancy was observed for women with NF1 and population comparisons after adjustment for potential medical consequences of NF1. However, women with NF1 experienced more spontaneous abortions and stillbirths.

Endometrial cancer risk after fertility treatment: a population-based cohort study

PURPOSE

Using data from a large population-based cohort of women with fertility problems in Denmark, we examined the association between use of fertility drugs and endometrial cancer incidence.

METHODS

Women aged 20-45 years living in Denmark during 1 January 1995-31 December 2017 and diagnosed with fertility problems (i.e., subfertile women) were identified from the Danish Infertility Cohort. Information on use of fertility drugs, endometrial cancer, covariates and vital status was obtained from various Danish national registers. Cox proportional hazard models were used adjusted for calendar year of study entry, highest level of education, parity status, hormonal contraceptive use, obesity and diabetes mellitus.

RESULTS

Of the 146,104 subfertile women, 129,478 (88.6%) were treated with fertility drugs. During a median follow-up of 10.1 years, 119 women were diagnosed with endometrial cancer. Use of any fertility drugs was not associated with an increased rate of overall (HR 0.82; 95% CI 0.50-1.34) or type I endometrial cancer (HR 1.08; 95% CI 0.60-1.95). No associations between use of specific types of fertility drugs and endometrial cancer were observed. No marked associations were observed according to cumulative dose of specific fertility drugs, parity status, or with increasing follow-up time.

CONCLUSIONS

No marked associations between use of fertility drugs and risk of endometrial cancer were observed. The relatively young age of the cohort at end of follow-up, however, highlights the need for longer follow-up of women after fertility drug use.

Association between human papillomavirus status and health-related quality of life in oropharyngeal and oral cavity cancer survivors

OBJECTIVES

The human papillomavirus (HPV) is a risk factor for a subgroup of head and neck cancers (HNC). HPV-positive and HPV-negative HNC patients encompass heterogeneous groups regarding risk factors, sociodemographic and clinical characteristics, which may influence health-related quality of life (HRQL) differently. Since this has been sparsely studied, our study investigated the association between HPV status and HRQL in HNC survivors in Denmark.

MATERIALS AND METHODS

This cross-sectional study included 179 recurrence-free oropharyngeal and oral cavity squamous cell carcinoma (OSCC) survivors. HRQL was assessed on the EORTC QLQ-C30 and QLQ-H&N35 questionnaires. Linear and logistic regression models were adjusted for sociodemographic, clinical and lifestyle factors.

RESULTS

Most unadjusted results showed better HRQL among HPV-positive (n = 119) compared to HPV-negative (n = 60) OSCC survivors (average 18 months since diagnosis). After adjustments, the HPV-positive survivors reported higher role functioning (mean difference [MD] 9.2, 95% confidence interval [CI] 0.1 to -18.4), and fewer problems with speech (MD -9.0, 95% CI -18.0 to -0.1), sexuality (MD -21.9, 95% CI -38.0 to -5.9) and opening mouth (MD -13.7, 95% CI -26.6 to -0.8) compared to HPV-negative survivors.

CONCLUSION

Our findings support that HPV-positive OSCC survivors experience better HRQL than HPV-negative survivors. However, results indicate that sociodemographic, clinical and lifestyle factors explain most of the association between HPV status and HRQL. Findings suggest increased focus on the HPV-negative OSCC survivors with deteriorated HRQL in rehabilitation programs and future research to investigate the long-term effects of treatment among HPV-positive OSCC survivors who may develop symptoms later in survivorship.

Non-participation in cervical cancer screening according to health, lifestyle and sexual behavior: A population-based study of nearly 15,000 Danish women aged 23-45 years

High participation in cervical cancer screening is essential for an effective screening program. In this population-based study, we investigated associations between general health, lifestyle and sexual behavior, and non-participation in cervical cancer screening in Denmark. During 2011-2012, a random sample of women aged 18-45 years from the general female population were invited to participate in a survey regarding health, lifestyle and sexual habits. Altogether 18,631 women responded (response rate: 75.1%), of whom 14,271 women aged 23-45 years were included in this analysis. Information on screening participation within four years after response, and data on sociodemographic characteristics, was obtained from nationwide registers. Logistic regression was used to calculate odds ratios (ORs) for non-participation, crude and adjusted for sociodemographic characteristics. Overall, 13.9% of the women were not screened during follow-up. The odds of non-participation was increased in women who were overweight (OR_adj. = 1.20; 95% CI, 1.06-1.35), obese (OR_adj. = 1.46; 95% CI, 1.27-1.67), perceived themselves as much too fat (OR_adj. = 1.50; 95% CI, 1.29-1.74), had poor self-perceived health (OR_adj. = 1.22; 95% CI, 1.03-1.45) or smoked daily (OR_adj. = 1.81; 95% CI, 1.61-2.03). Conversely, women with previous genital warts or other sexually transmitted infections, and young women with ≥10 lifetime sexual partners or ≥2 new recent partners, had decreased odds of non-participation. In conclusion, obesity, poor self-perceived health and daily smoking were associated with lower participation in cervical cancer screening. Interventions targeting these groups are needed.

The role of body mass index in incidence and persistence of cervical human papillomavirus infection

PURPOSE

This study aimed to assess the association between body mass index and incident or persistent cervical high-risk human papillomavirus (hrHPV) infection.

METHODS

This cohort study included 6809 women from the general Danish population who participated in two clinical visits (in 1991-1993 and in 1993-1995). Height and weight were measured by nurses, lifestyle data were obtained by structured interviews, and cervical cytology samples were obtained for hrHPV DNA testing. We conducted log-binomial regression to estimate risk ratios (RRs) with 95% confidence intervals (CIs) of incident and type-specific persistent hrHPV infection according to body mass index, adjusting for age, education, smoking, and the number of sexual partners in the past year.

RESULTS

We found no increased risk of incident hrHPV infection in women who were underweight (RR_adjusted, 0.97; 95% CI, 0.64-1.48), overweight (RR_adjusted, 0.98, 95% CI, 0.82-1.17), or obese (RR_adjusted, 0.93; 95% CI, 0.63-1.36) compared with women of normal weight. The risk of hrHPV persistence was similar in overweight (RR_adjusted, 0.98; 95% CI, 0.71-1.34) and obese (RR_adjusted, 1.00; 95% CI, 0.56-1.79) women compared with women of normal weight, whereas underweight women had a lower risk (RR_adjusted, 0.32; 95% CI, 0.11-0.95).

CONCLUSIONS

Overweight and obesity were not associated with HPV incidence or persistence when adjusting for sexual behavior.

Does losing a parent early influence the education you obtain? A nationwide cohort study in Denmark

BACKGROUND

Health inequalities are rooted in education and we investigate the association between early parental death and attainment across the educational spectrum.

METHODS

Using total population data on Danes born between 1982 and 2000 (n = 1 043 813), we assess incidence rate ratios (RRs) by gender for attainment of each educational level (basic school, high school or vocational training, bachelor degree or professional programme, and university graduate degree) according to loss of a parent before the age of 18 years. We adjust for family income, education and psychiatric illness and examine parent's gender, cause of death and child's age at time of death as potential moderators.

RESULTS

Bereaved people had significantly lower attainment rates than non-bereaved people: basic school (RR = 0.95; 95% CI: 0.93-0.97 for men and 0.96; 0.94-0.98 for women), high school or vocational training (0.78; 0.76-0.80 for men and 0.82; 0.80-0.84 for women), bachelor degree or professional programme (0.74; 0.70-0.79 for men and 0.83; 0.79-0.86 for women) and university graduate degree (0.77; 0.68-0.86 for men and 0.77; 0.69-0.86 for women). Parent's gender, cause of death and child's age at the death did not modify the associations.

CONCLUSIONS

As education impacts population health, support for bereaved school children may be more important than realized.

A Constructed Reality? A Fairclough-Inspired Critical Discourse Analysis of the Danish HPV Controversy

The World Health Organization (WHO) reports that routine immunization coverage has declined in Europe. In this article, we present the findings of a Norman Fairclough-inspired critical discourse analysis undertaken to explore how the Danish media came to suggest a possible linkage between the human papillomavirus (HPV) vaccine and serious side effects. The findings of the analysis highlight the social consequences of the controversy over the HPV vaccine, identified within the framework of three perspectives: (1) overall criticism of vaccine efficacy and safety, rooted in an ideological opposition; (2) a growing societal tendency to question the authority of the official health bodies; and (3) the specific controversy over the HPV vaccine. We suggest that the controversy over the HPV vaccine is rooted in an ideological conflict, and the declining acceptance implies that the perception that the vaccine causes serious side effects has gained currency among the general public.

Male circumcision and the risk of gonorrhoea, syphilis, HIV and human papillomavirus among men in Tanzania

To examine the association between male circumcision and the risk of gonorrhoea, syphilis, HIV and high-risk (hr) human papillomavirus (HPV). We used data from a cross-sectional study conducted among 1902 men in Tanzania. Circumcision status was assessed at a clinical examination and history of gonorrhoea and syphilis was obtained from questionnaire data. Penile samples were tested for HPV using Hybrid Capture 2 and genotyped by the INNO-LiPA HPV Genotyping Extra test. Blood samples were tested for HIV. Using logistic regression the association between male circumcision and gonorrhoea, syphilis, HIV and hr HPV was assessed estimating odds ratios (ORs) and 95% confidence intervals (CIs). All analyses were adjusted for age and lifetime number of sexual partners. In the multivariable analysis, the odds of gonorrhoea were lower in circumcised men compared with uncircumcised men (OR = 0.52; 95% CI: 0.37–0.74). Likewise, the odds of HIV were considerably lower in circumcised men (OR = 0.42; 95% CI: 0.26–0.67). Furthermore, lower odds of hr HPV were seen in circumcised men compared with uncircumcised men, although not statistically significant (OR = 0.81; 95% CI: 0.56–1.17). Finally, the odds of HPV16 (OR = 0.48; 95% CI: 0.23–0.98) and multiple (≥2) hr HPV types (OR = 0.71; 95% CI: 0.44–1.12) were lower in circumcised men than in uncircumcised men. Circumcised men have a significantly lower risk of gonorrhoea, HIV and HPV16, compared with uncircumcised men.

Risk of endometrial cancer among women with benign ovarian tumors - A Danish nationwide cohort study

OBJECTIVE

The few studies on the association between benign ovarian tumors and endometrial cancer have been inconclusive. Using data from a large Danish register-based cohort study, we assessed the overall and type-specific risk of endometrial cancer among women with a benign ovarian tumor.

METHODS

We identified all Danish women diagnosed with a benign ovarian tumor during 1978-2016 in the Danish National Patient Register (n = 149,807). The study population was followed for subsequent development of endometrial cancer by linkage to the Danish Cancer Register and standardized incidence ratios (SIRs) with corresponding 95% confidence intervals (CIs) were calculated after correction for hysterectomy.

RESULTS

After a one-year delayed study entry, women with benign ovarian tumors had a decreased incidence of endometrial cancer (SIR = 0.74, 95% CI: 0.68-0.81) compared with women in the general Danish population. Both solid benign ovarian tumors (SIR = 0.79, 95% CI 0.70-0.88) and cystic benign ovarian tumors (SIR = 0.68, 95% CI 0.58-0.78) were associated with decreased incidences of endometrial cancer. Likewise, women with benign ovarian tumors had decreased incidences of both type I and type II endometrial cancer. The incidence of endometrial cancer was decreased to virtually the same magnitude irrespective of the age at diagnosis of a benign ovarian tumor and the reduction persisted throughout the follow-up period.

CONCLUSIONS

The risk of endometrial cancer was decreased beyond the first year after a benign ovarian tumor and the decrease persisted for 20 or more years. The possible underlying mechanisms are not known and should be investigated further.

Clinical Performance of Human Papillomavirus (HPV) Testing versus Cytology for Cervical Cancer Screening: Results of a Large Danish Implementation Study

Background

Human papillomavirus (HPV) testing is increasingly used as the primary cervical cancer screening test. In a large pilot implementation, we compared participation, referrals and detection of high-grade cervical intraepithelial neoplasia (CIN) in HPV- versus cytology-based cervical cancer screening.

Methods

The implementation was embedded into the routine screening program at Lillebaelt Hospital, Department of Pathology, Vejle, Denmark. Based on the area of residence, women aged 30–59 years were screened by either HPV testing (with HPV16/18 genotyping and cytology triage) or cytology (with HPV triage for minor abnormalities). Our analysis includes women invited or screened during May 2017–May 2018 (invited: n=35,081; screened: n=28,352) with 6 months of follow-up. Information on screening results and sociodemographic characteristics were obtained from registers. Using logistic regression, we estimated odds ratios (ORs) with 95% confidence intervals (CIs) of participation, referral and CIN3+-detection in HPV- versus cytology-based screening, adjusting for sociodemographic characteristics.

Results

Participation was virtually identical in the HPV- and cytology group (58.4% vs 58.8%; OR_adjusted=0.97, 95% CI, 0.93–1.01). Referral to colposcopy was more common in the HPV- than cytology group (3.8% vs 2.1%; OR_adjusted=1.88, 95% CI, 1.63–2.17). More cases of CIN3+ were detected in the HPV- than cytology group (1.0% vs 0.7%, OR_adjusted=1.47; 95% CI, 1.13–1.91).

Conclusion

Participation did not differ between HPV- and cytology-based screening. HPV-based screening detected more cases of CIN3+, but in this initial screening round also led to more colposcopies than cytology-based screening.

Risk of specific types of ovarian cancer after borderline ovarian tumors in Denmark: A nationwide study

Population-based evidence regarding risk of ovarian cancer after a borderline ovarian tumor (BOT) is sparse. We aimed to examine the incidence of specific types of ovarian cancer in women with serous or mucinous BOTs in a nationwide cohort study with up to 36 years of follow-up. Using the nationwide Danish Pathology Data Bank, we identified 4,281 women with a BOT (2,058 serous BOTs and 2,223 mucinous BOTs) in Denmark during 1978-2012. We computed standardized incidence ratios (SIRs) to compare the incidence of ovarian cancer among women with BOTs compared to general population rates. We found that a serous BOT was especially and strongly associated with subsequent serous ovarian cancer (SIR = 9.2; 95% CI: 6.8-12.2), and that a mucinous BOT was strongly related to mucinous ovarian cancer (SIR = 18.6; 95% CI: 10.8-29.8). The SIRs remained elevated ≥10 years after a serous BOT and up to 5-9 years after a mucinous BOT. The increased incidence of serous ovarian cancer in women with a serous BOT was mostly pronounced in women <50 years at the serous BOT diagnosis. In conclusion, women with a serous BOT experience long-term increased incidence of serous ovarian cancer, and women with a mucinous BOT have long-term elevated incidence of mucinous ovarian cancer compared to the general population. This is the first population-based study to show compelling evidence of the histo-specific increased risk of ovarian cancer following specific types of BOTs. Thus, these results are supportive of the hypothesis that BOTs may be precursor lesions to carcinomas of the corresponding histologic type.