The Danish lung cancer registry: A nationwide validation study

BACKGROUND

This study evaluates the validity of the information in the Danish Lung Cancer Registry (DLCR). Since 2000, the DLCR has been a tool for monitoring interventions and outcome of all Danish lung cancer patients with the intent to streamline and improve treatment and survival. The DLCR receives information from the Danish Patient Registries in addition to clinical information from the treating physicians. In the year 2022, more than 50 papers have been published using DLCR as a data source. However, the DLCR has not previously been validated.

METHODS

A random sample of 1000 patients diagnosed with non-small cell lung cancer from 2014 to 2016 and recorded in the DLCR were included for validation. Medical records were reviewed and were considered as the "gold standard" to which data listed in the DLCR were compared.

RESULTS

Information was retrieved from medical charts for all patients. Agreement on stage at diagnosis was 90.1 % (95 % CI 88.0-91.9) and on date of diagnoses was 93.8 (95 % CI 92.1-93.2). Agreement on smoking status in pack years (+/- 10 pack years) was 91.2 % (95 % CI 88.6-93.2). The positive predictive value of treatment intent was 87.4 (95 % CI 85.1-89.6).

CONCLUSION

The data in the DLCR are complete, detailed and accurate. The comparison of data from the DLCR with the medical records revealed overall high validity of the data in the registry.

Nurse-Led Individualized Follow-Up Versus Regular Physician-Led Visits After Early Breast Cancer (MyHealth): A Phase III Randomized, Controlled Trial

PURPOSE

Follow-up after breast cancer with regular visits has failed to detect recurrences, be cost-effective, and address patient needs.

METHODS

MyHealth is a phase III randomized controlled trial (ClinicalTrials.gov identifier: NCT02949167). Patients, who recently completed primary treatment for stage I-II breast cancer, were randomly assigned in variable block sizes and stratified by age and human epidermal growth factor receptor 2 status to intervention or control follow-up. The nurse-led intervention comprised three to five individual self-management sessions, regular reporting of symptoms, and navigation to health care services. The control follow-up comprised regular outpatient visits with the physician. The primary outcome was breast cancer-specific quality of life (QoL) measured by the Trial Outcome Index-Physical/Functional/Breast summary score of the Functional Assessment of Cancer Therapy-Breast 2 years after random assignment. Secondary outcomes were fear of recurrence, anxiety, depression, and health care utilization. Analyses were intention-to-treat and P values were two-sided with 95% confidence level set at 0.005 because of multiple comparisons.

RESULTS

Among 1,101 eligible patients, 875 were invited and 503 were randomly assigned to control (n = 252) or intervention (n = 251) follow-up. At 2 years, patients in the intervention group reported a significantly and clinically relevant higher QoL (mean, 75.69 [standard deviation [SD], 12.27]) than patients in the control group (71.26 [SD, 14.08]), with a mean difference of 5.05 (95% CI, 3.30 to 6.79; P < .001). The intervention group reported significantly less fear of recurrence, anxiety, and depression; they had fewer physician consultations but more nurse contacts and an unchanged diagnostic imaging pattern. The effect on all outcomes was stable through a 3-year follow-up.

CONCLUSION

The MyHealth study suggested a new strategy for follow-up after early breast cancer as it provided significant improvements in QoL.

Machine learning applied in patient-reported outcome research-exploring symptoms in adjuvant treatment of breast cancer

BACKGROUND

Patient-reported outcome (PRO) data may help us better understand the life of breast cancer patients. We have previously collected PRO data in a national Danish breast cancer study in patients undergoing adjuvant chemotherapy. The aim of the present post-hoc explorative study is to apply Machine Learning (ML) algorithms using permutation importance to explore how specific PRO symptoms influence nonadherence to six cycles of planned adjuvant chemotherapy in breast cancer patients.

METHODS

We here investigate ePRO-data from the 347 patients. The ePRO presented 42 PROCTCAE questions on 25 symptoms. Patients completed the ePRO before each cycle of chemotherapy. Number of patients with completion of the scheduled six cycles of chemotherapy were registered. Two ML models were applied. One aimed at discovering the individual relative importance of the different questions in the dataset while the second aimed at discovering the relationships between the questions. Permutation importance was used.

RESULTS

Out of 347 patients 238 patients remained in the final dataset, 15 patients dropped out. Two symptoms: aching joints and numbness/tingling, were the most important for dropout in the final dataset, each with an importance value of about 0.04. Model's average ROC-AUC-score being 0.706. In the second model a low performance score made the results very unreliable.

CONCLUSION

In conclusion, this explorative data analysis using ML methodologies in an ePRO dataset from a population of women with breast cancer treated with adjuvant chemotherapy unravels that the symptoms aching joints and numbness/tingling could be important for drop out of planned adjuvant chemotherapy.

The gold standard program (GSP) for smoking cessation: a cohort study of its effectiveness among smokers with and without cancer

BACKGROUND

Smoking cessation treatment is an important prognostic factor for survival after a cancer diagnosis, especially for tobacco-related cancers. After being diagnosed with lung cancer, approximately 50% of patients continue smoking or frequently relapse after a quit attempt. Given the importance of smoking cessation treatment for cancer survivors, the objective was to compare the effectiveness of a 6-week intensive smoking cessation intervention, the Gold Standard Program (GSP), among cancer survivors compared with smokers without cancer. Second, we compared successful quitting among socioeconomically disadvantaged cancer survivors with that among nondisadvantaged cancer survivors.

MATERIALS AND METHODS

This was a cohort study based on 38,345 smokers from the Danish Smoking Cessation Database (2006-2016). Linkage to the National Patient Register was used to identify cancer survivors undergoing the GSP after being diagnosed with cancer (except nonmelanoma skin cancer). Linkage to the Danish Civil Registration System was used to identify participants who died, went missing, or emigrated before the follow-up. Logistic regression models were applied to evaluate effectiveness.

RESULTS AND CONCLUSION

Six percent (2438) of the included smokers were cancer survivors at the time they undertook the GSP. Their 6-month successful quitting showed no difference compared to that of smokers without cancer, neither before nor after adjustment; 35% versus 37% in crude rates and an aOR of 1.13 (95% CI: 0.97-1.32). Likewise, the results for disadvantaged compared to nondisadvantaged cancer survivors were not significantly different (32% versus 33% and an adjusted aOR of 0.87 (95% CI 0.69-1.11)). Overall, an intensive smoking cessation program seems effective in helping both people without cancer and cancer survivors become successful quitters.

The association between education and fear of recurrence among breast cancer patients in follow-up - and the mediating effect of self-efficacy

BACKGROUND

Major restructuring of surveillance after breast cancer treatment with less follow-up consultations may result in insecurity and fear of recurrence (FCR) among the less resourceful breast cancer patients. We investigate the association between breast cancer patients' education and FCR and if self-efficacy mediates the associations between education and FCR.

MATERIAL AND METHODS

A questionnaire survey was conducted from 2017 to 2019, among 1773 breast cancer patients shortly after having their follow-up switched from regular outpatient visits with an oncologist to either nurse-led or patient-initiated follow-up, with a subsequent questionnaire after 12 months. Data on disease and treatment characteristics were extracted from medical records and the Danish Breast Cancer Group Database. Logistic regression analyses were used to examine the association between education and FCR. Separate analyses were conducted for patients ≤ and >5 years since diagnosis and all models were adjusted for age and cohabitation status. To explore potential mediation by self-efficacy, we conducted regression analyses on education and FCR further adjusting for self-efficacy.

RESULTS

The participation rate was 57%, and after the exclusion of patients due to missing data, 917 were included in analyses. Patients with long education had significantly less FCR compared to patients with short education (OR (95% CI) 0.71 (0.51;0,99)). When separated by time since diagnosis, there was no association among patients >5 years since diagnosis while the OR was 0.51 (95% CI, 0.30;0.85) for patients ≤5 years since diagnosis. Further adjusting for self-efficacy among patients <5 years since diagnosis resulted in an OR of 0.56 (95% CI, 0.33;0.95) among patients with long compared to short education.

CONCLUSION

Up to 5 years after diagnosis, breast cancer patients with long education are less likely to experience FCR than patients with short education. Self-efficacy mediated only a very small part of this association, indicating that other factors play a role in socioeconomic differences in FCR among breast cancer patients.

Obesity and breast cancer prognosis: pre-diagnostic anthropometric measures in relation to patient, tumor, and treatment characteristics

PURPOSE

Examine the association between obesity and clinical outcomes in early breast cancer and assess if patient, tumor, and treatment characteristics modify such associations in Malmö Diet and Cancer Study patients (MDCS).

METHODS

The MDCS enrolled 17,035 Swedish women from 1991 to 1996. At enrollment, participants' body mass index (BMI), waist circumference and body fat percentage measures were collected. We identified all female MDCS participants with invasive breast cancer from 1991 to 2014. Follow-up began at breast cancer diagnosis and ended at breast cancer recurrence (BCR), death, emigration, or June 8, 2020. The World Health Organization guidelines were used to classify BMI, waist circumference, and body fat percentage into three categories of healthy weight, overweight, and obesity. We fit Cox regression models to compute adjusted hazard ratios (HRs) with 95% confidence intervals (CI) of BCR according to body composition. To evaluate effect measure modification, we stratified Cox models by patient, tumor, and treatment characteristics.

RESULTS

In total, 263 BCRs were diagnosed over 12,816 person-years among 1099 breast cancer patients with a median follow-up of 11.1 years. Obesity according to BMI (HR = 1.44 [95%CI 1.00-2.07]), waist circumference (HR = 1.31 [95%CI 0.98-1.77]), and body fat percentage (HR = 1.41 [95%CI 1.02-1.98]) was associated with increased risk of BCR compared with healthy weight. Obesity was stronger associated with BCR in patients with low socioeconomic position (HR = 2.55 [95%CI 1.08-6.02]), larger tumors > 20 mm (HR = 2.68 [95%CI 1.42-5.06]), estrogen-receptor-negative breast cancer (HR = 3.13 [95%CI 1.09-8.97]), and with adjuvant chemotherapy treatment (HR = 2.06 [95%CI 1.08-4.31]).

CONCLUSION

Higher pre-diagnostic BMI, waist circumference, and body fat percentage was associated with increased risk of BCR. The association between obesity and BCR appears dependent on patient, tumor, and treatment characteristics.

Effects on Pediatric Cancer Survivors: The FAMily-Oriented Support (FAMOS) Randomized Controlled Trial

OBJECTIVE

To examine as secondary analyses the effect the FAMily-Oriented Support (FAMOS) family therapy program on reducing parent-reported medical traumatic stress in the sub-sample of pediatric cancer survivors, age 2-5 years.

METHODS

The FAMOS study was a national multicenter randomized controlled trial with all four pediatric oncology departments in Denmark (Clinicaltrials.gov [NCT02200731]). Families were randomized in parallel design (1:1) to intervention or usual care. The FAMOS program includes seven home-based psychotherapeutic sessions and is based on family systems therapy to address the individuals in the family system using cognitive behavioral, problem-solving and goal-setting techniques. Questionnaires were completed by parents at baseline, 6, and 12 months. In linear mixed-effects models, the effect of FAMOS on reducing children's trauma-related behavior after 6 and 12 months was examined in 62 children (31 in the intervention and 29 in the control group, respectively). It was also examined if a trauma-related behavior effect was mediated through reduced symptoms of depression in mothers and fathers, respectively.

RESULTS

On average, children in the intervention group experienced significantly larger decreases in trauma-related behaviors at 6 and 12 months than the control group (predicted mean difference -3.89, p = .02 and -6.24, p = .003, respectively). The effect on trauma-related behavior was partly mediated through reduced symptoms of depression in mothers, but not fathers.

CONCLUSIONS

Adding to previously reported positive effects of the FAMOS intervention on parents' symptoms of post-traumatic stress and depression, significant improvements were found in young children's trauma related-behavior. Further research is needed to develop therapy for children with cancer.

Lung cancer registries in Denmark, Finland, Norway and Sweden: a comparison and proposal for harmonization

BACKGROUND

Lung cancer is the leading cause of cancer-related death in all Nordic countries which, though similar in demographics and healthcare systems, have noticeable differences in lung cancer survival. Historically, Denmark and Finland have had higher lung cancer incidences and lower survival than Norway and Sweden. All four countries have national cancer registries. Data in these registries are often compared, but their full potential as a source of learning across the Nordic countries is impeded by differences between the registries. In this paper, we describe and compare the Nordic registries on lung cancer-specific data and discuss how a more harmonized registration practice could increase their usefulness as a source for mutual learning and quality improvements.

METHODS

We describe and compare the characteristics of data on lung cancer cases from registries in Denmark, Finland, Norway and Sweden. Moreover, we compare the results from the latest annual reports and specify how data may be acquired from the registries for research.

RESULTS

Denmark has a separate clinical lung cancer registry with more detailed data than the other Nordic countries. Finland and Norway report lung cancer survival as relative survival, whereas Denmark and Sweden report overall survival. The Danish Lung Cancer Registry and the Swedish Cancer Registry do not receive data from the Cause of Death registries in contrast to the Finnish Cancer Registry and the Cancer Registry of Norway.

CONCLUSION

The lung cancer registries in Denmark, Finland, Norway and Sweden have high level of completeness. However, several important differences between the registries may bias comparative analyses.

Cohort profile: life with neurofibromatosis 1 - the Danish NF1 cohort

PURPOSE

The Danish neurofibromatosis 1 (NF1) cohort was initiated to study health-related, socioeconomic and psychological consequences of living with the monogenetic disorder NF1 using a nationwide and population-based approach.

PARTICIPANTS

The cohort includes all 2467 individuals in Denmark who were hospitalised with or due to NF1 from 1977 to 2013 or registered in the RAREDIS Database (1995-2013), a national clinical database for rare diseases, or both. A comparison cohort matched to individuals with NF1 on sex and date of birth was identified in the Civil Registration System (n=20 132).

FINDINGS TO DATE

All cohort members were linked to the unique Danish registries to obtain information on hospital contacts, birth outcomes, education and partnership. A questionnaire was completed by 244 of the 629 adult cohort members with NF1 registered in the RAREDIS Database to evaluate the psychosocial and emotional burden. Further, neuropsychological tests were performed on 103 adult cohort members with NF1 and 38 adult population comparisons. To date, six studies have been published. Individuals with NF1 had an increased risk for (1) hospitalisation for disorders affecting all organ systems of the body throughout all decades of life, (2) psychiatric disorders, (3) attaining a short or medium long education and (4) not forming a life partner. Women with NF1 had an increased risk for spontaneous abortions and stillbirths. Finally, adults with NF1 had an impaired quality of life and a high need for professional support for physical, psychological and work-related problems, which was partly associated with disease severity and visibility.

FUTURE PLANS

The cohort will regularly be updated with newly diagnosed patients in the RAREDIS Database as well as with outcome information in the Danish registries. New studies are in progress to assess other medical and socioeconomic dimensions of living with NF1.

Patients in phase 1 cancer trials: psychological distress and understanding of trial information

BACKGROUND

Psychological distress may be present among patients who are considering enrollment in phase 1 cancer trials, as they have advanced cancer and no documented treatment options remain. However, the prevalence of psychological distress has not been previously investigated in larger cohorts. In complex phase 1 cancer trials, it is important to ensure adequate understanding of the study premises, such as the undocumented effects and the risk of adverse events.

MATERIALS AND METHODS

In a prospective study, patients completed questionnaires at two time points. We investigated psychological distress, measured as stress, anxiety, and depression, among patients at their first visit to the phase 1 unit (N = 229). Further, we investigated the understanding of trial information among patients who were enrolled in a phase 1 cancer trial (N = 57).

RESULTS

We enrolled 75% of 307 eligible patients. We found a lower mean score of stress in our population compared to population norms, while the mean scores of anxiety and depression were higher. A total of 9% showed moderate to severe symptoms of anxiety and 11% showed moderate to severe symptoms of depression, which indicates higher levels than cancer patients in general. A total of 46 (81% of enrolled patients) completed questionnaires on trial information and consent. The understanding of the information on phase 1 cancer trials in these patients was slightly lower than the level reported for cancer trials in general. Some aspects relating to purpose, benefit, and additional risks were understood by fewer than half of the patients.

CONCLUSION

Our results suggest that distress is not as prevalent in the population of patients referred to phase 1 cancer trials as in the general cancer population. Although patients' understanding of trial information was reasonable, some aspects of complex phase 1 cancer trials were not easily understood by enrolled patients.

Trends in survival of epithelial ovarian/tubal cancer by histology and socioeconomic status in Denmark 1996-2017

OBJECTIVES

To examine time trends in ovarian/tubal cancer relative survival, excess mortality, and all-cause mortality for different histological types and levels of socioeconomic position.

METHODS

Women with ovarian/tubal cancer diagnosed 1996-2017 were identified in the Danish Cancer Registry (n = 11,755). Age-standardized 5-year relative survival over time was estimated by histology, socioeconomic status, and stage. Furthermore, 5-year excess mortality rate ratios (EMRR) according to calendar time for all categories of histology and socioeconomic status were calculated using a Poisson regression model. Finally, all-cause mortality by histology and socioeconomic status was estimated in multivariate Cox proportional hazards regression models.

RESULTS

Statistically significant improvements in 5-year relative survival occurred for all histological types over time except mucinous tumors (5-year EMRR, localized: 0.92 (95% CI: 0.71-1.16); advanced: 0.96 (95% CI: 0.85-1.08). Increase in relative survival over time and corresponding decrease in excess mortality was observed for all categories of socioeconomic status except for women with localized disease in the lowest income group (5-year EMRR = 0.91 (95% CI:0.76-1.10)). The impact of histology and socioeconomic status on all-cause mortality depended on time since diagnosis. Among the socioeconomic factors, especially low educational level and living alone were associated with increased all-cause mortality, particularly in the first year after diagnosis.

CONCLUSIONS

Ovarian/tubal cancer survival generally increased over time across histological types and socioeconomic factors. However, the lack of improvement for mucinous tumors needs further research. Additionally, the results for women with low income and education shows that continued focus on social equality in survival is necessary.

Health-Related Quality of Life, Dysphagia, Voice Problems, Depression, and Anxiety After Total Laryngectomy

OBJECTIVES/HYPOTHESIS

The aims were to determine health-related quality of life (HRQoL), including voice problems, dysphagia, depression, and anxiety after total laryngectomy (TL), and investigate the associations between HRQoL and the late effects.

STUDY DESIGN

Cross-sectional study.

METHODS

172 participants having received a TL 1.6 to 18.1 years ago for laryngeal/hypopharyngeal cancer filled in the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire, Core and Head and Neck module (EORTC QLQ-C30, EORTC QLQ-H&N35), Voice-Related Quality of Life questionnaire (V-RQOL), M.D. Anderson Dysphagia Inventory (MDADI), and Hospital Anxiety and Depression Scale (HADS) questionnaires.

RESULTS

Participants scored worse than normative reference populations on all scales/items of the EORTC questionnaires, except one, and almost half of the scales/items showed a clinically relevant difference. Moderate/severe dysphagia was present in 46%, moderate/severe voice problems in 57%, depression in 16%, and anxiety in 20%. Decreasing age, increasing numbers of comorbidities, increasing voice problems, increasing dysphagia, and increasing depression symptoms, were associated with a lowered EORTC QLQ-C30 summary score.

CONCLUSION

A substantial proportion of participants experienced clinically significant late effects and increasing levels of these were associated with a lowered HRQoL.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Cannabis use among Danish patients with cancer: a cross-sectional survey of sociodemographic traits, quality of life, and patient experiences

PURPOSE

Patients with cancer are using cannabis for self-treatment. The reasons, experienced effects, and prevalence of use are unknown in the European general oncological population.

METHODS

Adult patients with cancer attending outpatient oncology clinics were invited to participate in a cross-sectional survey. The questionnaire consisted of sociodemographic questions, validated scales on quality of life, neuropathy, anxiety and depression as well as questions regarding use of cannabis.

RESULTS

The overall response rate was 83% (2839 patients) and 13% of patients were using or had used cannabis during their treatment. Rate of use was higher in smokers (19% vs 11%, p adjusted 0.002), in patients in active cancer treatment (14% vs 10%, p adjusted = 0.02), and in patients with depression (19% vs 11%, adjusted p = 0.002). Cannabis use was also correlated with lower quality of life (EORTC C30 SumScore mean diff. =  - 7.61, 95% CI = [- 9.69; - 5.53]). In total, 77% of users experienced at least one positive effect of cannabis, 18% experienced no effect, and 5% experienced other effects. At least one side effect was experienced by 33% of users. Management of pain and nausea were the primary reasons for initiating cannabis use (39% for both). Less nausea and better sleep were the most common effects experienced (26% for both). Oils for oral use were the most common route of administration (88%).

CONCLUSION

Cannabis use among patients with cancer is prevalent and correlated with worse quality of life. Patients report using cannabis for symptom management and many experience relief of their symptoms. However, one third of patients experienced side effects.

Psychiatric disorders in individuals with neurofibromatosis 1 in Denmark: A nationwide register-based cohort study

The aim of this study was to assess the risks of psychiatric disorders in a large cohort of 905 individuals with NF1 and 7614 population comparisons matched on sex and year of birth. The cohort was linked to the Danish Psychiatric Central Research Register to ascertain information on hospital contacts for psychiatric disorders based on the International Classification of Diseases version 8 and 10. The hazard ratio (HR) for a first psychiatric hospital contact was higher in girls (4.19, 95% confidence interval [CI] 1.81-9.69) and boys with NF1 (5.02, 95% CI 3.27-7.69) <7 years of age than in the population comparisons. Both sexes had increased HRs for developmental disorders, including attention deficit/hyperactivity disorders, autism spectrum disorders, and intellectual disabilities in childhood. Females with NF1 had also increased HRs for unipolar depression, other emotional and behavioral disorders, and severe stress reaction and adjustment disorders in early adulthood. The HRs for psychoses, schizophrenia, bipolar disorders, and substance abuse were similar in individuals with NF1 and the population comparisons. Finally, the cumulative incidence of a first hospital contact due to any psychiatric disorder by age 30 years was 35% (95% CI 29-41) in females and 28% (95% CI 19-37) in males with NF1. Thus, screening for psychiatric disorders may be important for early diagnosis and facilitation of appropriate and effective treatment in individuals with NF1.

Interrater Reliability of Dynamic Muscle Testing After Breast Cancer Surgery in Women at High Risk of Lymphedema: To Improve Quality in Clinical Practice

Background: The purpose of this study is to determine the interrater reliability of dynamic muscle tests in the early rehabilitation phase in women after breast cancer surgery with axillary lymph node dissection (ALND) based on the "preventive intervention against lymphedema after breast cancer" (LYCA) randomised controlled trial. Methods: Fifteen women treated with breast cancer surgery including ALND were recruited from participants in the LYCA trial. In this interrater reliability study, women were tested in 4 dynamic muscle tests by 2 physiotherapists at a Capital Hospital in Denmark. Intraclass correlation coefficients (ICCs) with 95% confidence intervals (CIs) was used to assess the relative reliability between raters. A Bland-Altman plot and limits of agreement were calculated to describe the absolute reliability. Results: All 6 subtests displayed high interrater reliability. ICC values were: leg press 0.96 (95% CI = 0.87-0.99), elbow flexion (contralateral) 0.94 (0.83-0.98), elbow flexion (affected arm) 0.93 (0.80-0.98), elbow extension 0.80 (0.41-0.93), shoulder abduction (contralateral) 0.89 (0.68-0.96), and shoulder abduction (affected arm) 0.91 (0.74-0.97). Cumulated interrater reliability for the test battery was very high (ICC = 0.99, 95% CI = 0.990-1.0). The absolute reliability of this study was considered high, and the absence of large shifts between mean and the line of 0 difference suggest no systematic bias that could influence clinical interpretation. Conclusions: The dynamic muscle tests evaluated in this study had high interrater reliability and can be used reliably in women in the postoperative phase after breast cancer surgery with ALND.

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.

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.

Multiphasic Prehabilitation Across the Cancer Continuum: A Narrative Review and Conceptual Framework

The field of cancer survivorship has significantly advanced person-centered care throughout the cancer continuum. Within cancer survivorship, the last decade has seen remarkable growth in the investigation of prehabilitation comprising pre-treatment interventions to prevent or attenuate the burden of oncologic therapies. While the majority of evidence remains in the surgical setting, prehabilitation is being adapted to target modifiable risk factors that predict poor treatment outcomes in patients receiving other systemic and localized anti-tumor treatments. Here, we propose a multiphasic approach for prehabilitation across the cancer continuum, as a conceptual framework, to encompass the variability in cancer treatment experiences while adopting the most inclusive definition of the cancer survivor.

Early indicators of primary brain tumours: a population-based study with 10 years' follow-up

BACKGROUND AND PURPOSE

To improve diagnoses of primary brain tumours, knowledge about early indicators is needed. Nationwide Danish health registries were used to conduct a population-based case-control study including all persons diagnosed with a primary brain tumour between 2005 and 2014 in Denmark.

METHODS

All 5135 adults diagnosed with a primary brain tumour in the Danish Cancer Registry were matched to 19 572 general population comparisons from the Danish Civil Registration System. Conditional logistic regression analyses were applied to estimate age- and multivariable-adjusted odds ratios (ORs) for the occurrence of a primary brain tumour up to 10 years after hospital diagnoses or prescription of medications related to nervous system diseases and mental and behavioural disorders.

RESULTS

Increased odds for primary brain tumour after nervous system diseases and mental and behavioural disorders manifested up to 10 years before tumour diagnosis were found. Increased odds were seen especially for hospital contacts for inflammatory nervous system diseases [OR 11.3; 95% confidence interval (CI) 6.5-19.7], epilepsy (OR 9.0; 95% CI 7.6-10.7) and antiepileptic medications (OR 3.6; 95% CI 3.2-4.0), whilst antidementia medications provided a strong, protective association for primary brain tumours (OR 0.5; 95% CI 0.3-0.8).

CONCLUSIONS

Sub-groups of patients diagnosed with or being prescribed certain medications targeting nervous system diseases and mental and behavioural disorders may be at increased risk of being diagnosed with a primary brain tumour. Further studies should disentangle the potential underlying common pathogenetic pathways. The results are important for the development of systematic clinical approaches to ensure early diagnosis of primary brain tumours.

Incidence and Mortality of Second Primary Cancers in Danish Patients With Retinoblastoma, 1943-2013

IMPORTANCE

In heritable retinoblastoma, there is a significantly increased risk of second primary cancers (SPCs). Improved knowledge about the incidence and influence of heritability and treatment is important during therapy for patients with retinoblastoma.

OBJECTIVE

To assess the incidence of SPC in patients diagnosed with retinoblastoma in Denmark from 1943 to 2013 with a focus on heritability and the association of external radiotherapy with mortality.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, data were extracted from the Danish Ocular Oncology Group Database containing complete data on all patients diagnosed with retinoblastoma , and obtained from the Danish Cancer Registry, which includes information on all patients with cancer from 1943 to December 31, 2013. Data analysis was conducted from December 1, 2017, to October 1, 2019. Data on 323 patients were included.

EXPOSURES

Heritability and retinoblastoma treatment.

MAIN OUTCOMES AND MEASURES

Standardized incidence rate, excess absolute risk, cumulative incidence of SPC, and mortality from SPC. Association of heritability and treatment with outcomes was estimated.

RESULTS

Of the 323 patients included in the analysis, 181 were men (56%), 133 had heritable retinoblastoma (41%), and 190 had nonheritable retinoblastoma (59%). The median age at diagnosis of SPC was 32.4 (interquartile range, 15.4-43.9) years in patients with heritable retinoblastoma and 38.6 (interquartile range, 20.5-49.4) years in those with nonheritable retinoblastoma. Twenty-five SPCs were identified in patients with heritable retinoblastoma vs 14 in patients with nonheritable retinoblastoma. Standardized incidence rate (SIR) of SPC in patients with heritable retinoblastoma was 11.39 (95% CI, 7.37-16.81) with an excess absolute risk of 70 cases per 10 000 person-years; the highest SIRs were for sarcoma (181.13; 95% CI, 98.94-303.92) and malignant melanoma (26.78; 95% CI, 9.78-58.30). The SIR for SPC in patients with nonheritable retinoblastoma was 1.52 (95% CI, 0.81-2.60). The cumulative incidence of SPCs at age 60 years was significantly higher in patients with heritable retinoblastoma (51%) compared with those with nonheritable retinoblastoma (13%) (P < .001) (hazard ratio, 5.0; 95% CI, 2.5-10.3). No significant differences were identified in overall risk of SPC in patients with heritable retinoblastoma treated with 3 different modalities: external radiotherapy, plaque (but no external) radiotherapy, and enucleation only, but an increased proportion of sarcomas was noted in the irradiated field. Mortality due to SPC was also higher in survivors of heritable retinoblastoma compared with those with nonheritable retinoblastoma (cumulative mortality, 34% vs 12% at age 60 years; P = .03).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that the incidence and mortality associated with SPC were significantly higher in patients with heritable retinoblastoma vs patients with nonheritable retinoblastoma. The largest increases in risk were noted for sarcoma and malignant melanoma. External radiotherapy did not appear to increase the risk. These findings are relevant when treating patients with retinoblastoma to manage the risk for SPC.

Health-Related Quality of Life Following Total Laryngectomy: A Systematic Review

OBJECTIVE

Treatment of advanced laryngeal and hypopharyngeal cancer has shifted from total laryngectomy (TL) toward laryngeal-preserving therapies due to a general perception that TL has a significantly negative impact on the individual's life. However, whether the physical impairments related to TL translate to a reduced health-related quality of life (HRQoL) has not yet been determined. Therefore, the objective of this systematic review was to determine how HRQoL is affected following TL.

METHODS

Systematic searches were conducted in PubMed, Embase, and Cochrane. Inclusion criteria were original studies describing quality of life following TL after larynx/hypopharynx cancer using a formally developed patient-reported questionnaire. Study quality assessment was carried out with the tool developed by the National Heart, Lung, and Blood Institute.

RESULTS

Forty-six studies using 12 different questionnaires were included. The majority were cross-sectional (85%), and study quality was rated poor in 30%, fair in 30%, and good in 39% of studies. When comparing results from the four most frequently used questionnaires with normative data, we found that in more than 60% of studies, differences to the reference population were of clinical importance, with only few exceptions.

CONCLUSIONS

In general, we found that people who received TL have a worse HRQoL than the male normative reference population. However, even though TL patients experience a clinically important difference in many domains when compared with normative data, their burden of symptoms is generally mild. The current review also makes it evident that despite the relatively large number of studies conducted, the strength of evidence remains weak. Laryngoscope, 131:820-831, 2021.

Cancer patients, physicians, and nurses differ in their attitudes toward the decisional role in do-not-resuscitate decision-making

PURPOSE

Do-not-resuscitate (DNR) decision-making in severely ill patients presents many difficult medical, ethical, and legal challenges. The primary aim of this study was to explore cancer patients' and health care professionals' attitudes regarding DNR decision-making authority and timing of the decision.

METHODS

This study was a questionnaire survey among Danish cancer patients and their attending physicians and nurses in an oncology outpatient setting. Potential differences between patients', physicians', and nurses' answers to the questionnaire were analyzed using Fisher's exact test.

RESULTS

Responses from 904 patients, 59 physicians, and 160 nurses were analyzed. The majority in all three groups agreed that DNR decisions should be made in collaboration between physician and patient. However, one-third of the patients answered that the patient alone should make the decision regarding DNR, which contrasts with the physicians' and nurses' attitudes, 0% and 6% pointing to the patient as sole decision-maker, respectively. In case of disagreement between patient and physician, a majority of both patients (66%) and physicians (86%) suggested themselves as the ultimate decision-maker. Additionally, 43% of patients but only 19% of physicians preferred the DNR discussion being brought up early in the course of the disease.

CONCLUSIONS

With regard to the decisional role of patient vs. physician and the timing of the DNR discussion, we found a substantial discrepancy between the attitudes of cancer patients and physicians. This discrepancy calls for a greater awareness and discussion of this sensitive topic among both health care professionals and the public.

Follow-up strategies following completion of primary cancer treatment in adult cancer survivors

BACKGROUND

Most cancer survivors receive follow-up care after completion of treatment with the primary aim of detecting recurrence. Traditional follow-up consisting of fixed visits to a cancer specialist for examinations and tests are expensive and may be burdensome for the patient. Follow-up strategies involving non-specialist care providers, different intensity of procedures, or addition of survivorship care packages have been developed and tested, however their effectiveness remains unclear.

OBJECTIVES

The objective of this review is to compare the effect of different follow-up strategies in adult cancer survivors, following completion of primary cancer treatment, on the primary outcomes of overall survival and time to detection of recurrence. Secondary outcomes are health-related quality of life, anxiety (including fear of recurrence), depression and cost.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, four other databases and two trials registries on 11 December 2018 together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included all randomised trials comparing different follow-up strategies for adult cancer survivors following completion of curatively-intended primary cancer treatment, which included at least one of the outcomes listed above. We compared the effectiveness of: 1) non-specialist-led follow-up (i.e. general practitioner (GP)-led, nurse-led, patient-initiated or shared care) versus specialist-led follow-up; 2) less intensive versus more intensive follow-up (based on clinical visits, examinations and diagnostic procedures) and 3) follow-up integrating additional care components relevant for detection of recurrence (e.g. patient symptom education or monitoring, or survivorship care plans) versus usual care.

DATA COLLECTION AND ANALYSIS

We used the standard methodological guidelines by Cochrane and Cochrane Effective Practice and Organisation of Care (EPOC). We assessed the certainty of the evidence using the GRADE approach. For each comparison, we present synthesised findings for overall survival and time to detection of recurrence as hazard ratios (HR) and for health-related quality of life, anxiety and depression as mean differences (MD), with 95% confidence intervals (CI). When meta-analysis was not possible, we reported the results from individual studies. For survival and recurrence, we used meta-regression analysis where possible to investigate whether the effects varied with regards to cancer site, publication year and study quality.

MAIN RESULTS

We included 53 trials involving 20,832 participants across 12 cancer sites and 15 countries, mainly in Europe, North America and Australia. All the studies were carried out in either a hospital or general practice setting. Seventeen studies compared non-specialist-led follow-up with specialist-led follow-up, 24 studies compared intensity of follow-up and 12 studies compared patient symptom education or monitoring, or survivorship care plans with usual care. Risk of bias was generally low or unclear in most of the studies, with a higher risk of bias in the smaller trials. Non-specialist-led follow-up compared with specialist-led follow-up It is uncertain how this strategy affects overall survival (HR 1.21, 95% CI 0.68 to 2.15; 2 studies; 603 participants), time to detection of recurrence (4 studies, 1691 participants) or cost (8 studies, 1756 participants) because the certainty of the evidence is very low. Non-specialist- versus specialist-led follow up may make little or no difference to health-related quality of life at 12 months (MD 1.06, 95% CI -1.83 to 3.95; 4 studies; 605 participants; low-certainty evidence); and probably makes little or no difference to anxiety at 12 months (MD -0.03, 95% CI -0.73 to 0.67; 5 studies; 1266 participants; moderate-certainty evidence). We are more certain that it has little or no effect on depression at 12 months (MD 0.03, 95% CI -0.35 to 0.42; 5 studies; 1266 participants; high-certainty evidence). Less intensive follow-up compared with more intensive follow-up Less intensive versus more intensive follow-up may make little or no difference to overall survival (HR 1.05, 95% CI 0.96 to 1.14; 13 studies; 10,726 participants; low-certainty evidence) and probably increases time to detection of recurrence (HR 0.85, 95% CI 0.79 to 0.92; 12 studies; 11,276 participants; moderate-certainty evidence). Meta-regression analysis showed little or no difference in the intervention effects by cancer site, publication year or study quality. It is uncertain whether this strategy has an effect on health-related quality of life (3 studies, 2742 participants), anxiety (1 study, 180 participants) or cost (6 studies, 1412 participants) because the certainty of evidence is very low. None of the studies reported on depression. Follow-up strategies integrating additional patient symptom education or monitoring, or survivorship care plans compared with usual care: None of the studies reported on overall survival or time to detection of recurrence. It is uncertain whether this strategy makes a difference to health-related quality of life (12 studies, 2846 participants), anxiety (1 study, 470 participants), depression (8 studies, 2351 participants) or cost (1 studies, 408 participants), as the certainty of evidence is very low.

AUTHORS' CONCLUSIONS

Evidence regarding the effectiveness of the different follow-up strategies varies substantially. Less intensive follow-up may make little or no difference to overall survival but probably delays detection of recurrence. However, as we did not analyse the two outcomes together, we cannot make direct conclusions about the effect of interventions on survival after detection of recurrence. The effects of non-specialist-led follow-up on survival and detection of recurrence, and how intensity of follow-up affects health-related quality of life, anxiety and depression, are uncertain. There was little evidence for the effects of follow-up integrating additional patient symptom education/monitoring and survivorship care plans.

Nationwide cohort study of the impact of education, income and social isolation on survival after acute colorectal cancer surgery

Background

Acute colorectal cancer surgery has been associated with a high postoperative mortality. The primary aim of this study was to examine the association between socioeconomic position and the likelihood of undergoing acute versus elective colorectal cancer surgery. A secondary aim was to determine 1‐year survival among patients treated with acute surgery.

Methods

All patients who had undergone a surgical procedure according to the Danish Colorectal Cancer Group (DCCG.dk) database, or who were registered with stent or diverting stoma in the National Patient Register from 2007 to 2015, were reviewed. Socioeconomic position was determined by highest attained educational level, income, urbanicity and cohabitation status, obtained from administrative registries. Co‐variables included age, sex, year of surgery, Charlson Co‐morbidity Index score, smoking status, alcohol consumption, BMI, stage and tumour localization. Logistic regression analysis was performed to determine the likelihood of acute colorectal cancer surgery, and Kaplan–Meier and Cox proportional hazards regression methods were used for analysis of 1‐year overall survival.

Results

In total, 35 661 patients were included; 5310 (14·9 per cent) had acute surgery. Short and medium education in patients younger than 65 years (odds ratio (OR) 1·58, 95 per cent c.i. 1·32 to 1·91, and OR 1·34, 1·15 to 1·55 respectively), low income (OR 1·12, 1·01 to 1·24) and living alone (OR 1·35, 1·26 to 1·46) were associated with acute surgery. Overall, 40·7 per cent of patients died within 1 year of surgery. Short education (hazard ratio (HR) 1·18, 95 per cent c.i. 1·03 to 1·36), low income (HR 1·16, 1·01 to 1·34) and living alone (HR 1·25, 1·13 to 1·38) were associated with reduced 1‐year survival after acute surgery.

Conclusion

Low socioeconomic position was associated with an increased likelihood of undergoing acute colorectal cancer surgery, and with reduced 1‐year overall survival after acute surgery.

Psychotropic Medication Use in Parents of Children Diagnosed With Cancer

BACKGROUND

Objective measures on parental distress after a child's cancer diagnosis are sparse. We examined the risk for first prescription of psychotropic medicine among parents of children with cancer compared with parents of children who were cancer free. In addition, we examined if sociodemographic and clinical characteristics are associated with risk of first prescription of psychotropic medication in parents of children with cancer.

METHODS

We followed all parents of children with cancer (N = 6744) from the Danish Cancer Registry (1998-2014) using parents of matched children who were cancer free (N = 65 747) as a comparison. To identify vulnerable subgroups among parents of children with cancer, we followed all parents of children with cancer from the Childhood Cancer Registry (2003-2015; N = 3290 parents). In Cox proportional hazard models, we estimated hazard ratios (HRs) for a first prescription of psychotropic medication according to cancer status of the child and sociodemographic and clinical risk factors.

RESULTS

Parents of children with cancer were at increased risk for a first prescription of psychotropic medication compared with parents of children who were cancer free up to 2 years after the diagnosis, the risk being highest in the first year (HR, 1.83 [95% confidence interval (CI), 1.66-2.01]). Parents of children with cancer, especially parents who lost their child, had an increased risk for a first prescription of hypnotics (HR, 6.91; 95% CI, 3.50-13.66) and anxiolytics (HR, 4.55, 95% CI, 1.57-13.17) in the first year after diagnosis.

CONCLUSIONS

Efforts should be made to ensure that medical teams are adequately educated to address stress responses in the parents.

MyHealth: specialist nurse-led follow-up in breast cancer. A randomized controlled trial - development and feasibility

Background: Traditionally, women treated for breast cancer (BC) have been followed up through regular oncologist-led visits in outpatient clinics, focusing on detection of recurrences, new primary BC, symptom management, and psychological support. However, this follow-up routine is expensive and its effectiveness has been questioned. Consequently, alternative follow-up programs have been tested. The Guided Self-Determination method (GSD), which facilitates partnership between health-care provider and patient, has been shown to improve self-management in patients with chronic conditions, including cancer. Patient-reported outcomes (PRO) is another increasingly used tool to improve patient-provider communication, symptom monitoring and control. In combination, GSD and PRO may have the potential to meet the objectives of BC follow-up. To test this, we developed the MyHealth study, a randomized controlled trial comparing a nurse-led follow-up program based on GSD, collection of PRO, and patient navigation with routine oncologist-led follow-up. Here we describe how we developed the intervention and are currently testing the feasibility of the MyHealth protocol in terms of recruitment, adherence to the intervention, collection of PRO, and patient navigation. Material and methods: We have invited the first 25 consecutively enrolled patients to test the MyHealth intervention. This consists of (1) 3-5 initial GSD appointments with a nurse, (2) collection of PRO, and (3) symptom management and patient navigation. The randomized trial was launched in January 2017 and is still recruiting. Results of the feasibility study: Of 32 patients invited, 25 accepted participation. At 18-month follow-up, two patients have withdrawn, 143 PRO questionnaires have been completed (mean 5.7/patient) resulting in 59 nurse contacts (mean 2.4 per patient) and 14 project physician contacts (mean 0.6 per patient). Conclusion: A high recruitment rate and response rate to PRO indicate that follow-up led by specialist nurses, based on collection of PRO is feasible and acceptable for patients treated for early stage BC.

Depressive symptoms and mental health-related quality of life in adolescence and young adulthood after early parental death

Aims: Little is known about long-term mental health in young adults who participate in ongoing grief counseling programs after early parental death in childhood, adolescence or young adulthood. The purpose of this study was to examine mental health in young adults according to early parental death and participation in grief counseling. Methods: In a cross-sectional, questionnaire-based study, we included three samples of young adults age 18-41 years. One sample who had lost a parent between age 0 and 30 years and who had participated in grief counseling identified through four Danish grief-counseling organizations, and two registry-based samples of young adults included parentally bereaved and non-bereaved young adults. Multivariate-adjusted regression analyses were performed to characterize risk of depressive symptoms and mental health-related quality of life (HQoL) according to early parental death and participation in grief counseling. Results: A total of 2467 (45%) young adults participated. Bereaved young adults reported significantly more depressive symptoms (p<0.0001) and lower mental HQoL (p<0.0001) than non-bereaved young adults and than general population levels for both depressive symptoms (p<0.0001) and HQoL (p<0.0001). Bereaved young adults who had participated in grief counseling reported significantly more depressive symptoms (p<0.0001) and lower mental HQoL (p<0.0001) than bereaved persons who did not participate in grief counseling. Conclusions: Bereaved young adults report more mental health problems than non-bereaved young adults, and also after participation in grief counseling the death of a parent may be accompanied by subsequent mental health problems.

Incidence of cardiovascular disease up to 13 year after cancer diagnosis: A matched cohort study among 32 757 cancer survivors

We examined the incidence of cardiovascular disease (CVD) among 32 757 cancer survivors and age-, gender-, and geographically matched cancer-free controls during a follow-up period of 1-13 years, and explored whetherCVD incidence differed by received cancer treatment, traditional cardiovascular risk factors, age, or gender. Adult 1-year cancer survivors without a history ofCVD diagnosed with breast (n = 6762), prostate (n = 4504), non-Hodgkin (n = 1553), Hodgkin (n = 173), lung and trachea (n = 2661), basal cell carcinoma (BCC; n = 12 476), and colorectal (n = 4628) cancer during 1999-2011 were selected from the Netherlands Cancer Registry and matched to cancer-free controls without a history ofCVD. Drug dispenses and hospitalizations from thePHARMO Database Network were used as proxy forCVD. Data were analyzed using Cox regression analyses. Prostate (HR: 1.17; 95%CI: 1.01-1.35) and lung and trachea (HR: 1.48; 95%CI: 1.10-1.97) cancer survivors had an increased risk for developingCVD compared to cancer-free controls. This increased risk among lung and trachea cancer survivors remained statistically significant after including traditional cardiovascular risk factors and cancer treatment information (HR: 1.41; 95%CI: 1.06-1.89). Among prostate cancer survivors, the increased risk of incidentCVD was limited to those who received hormones and those without traditional cardiovascular risk factors. Breast, non-Hodgkin,BCC, and colorectal cancer survivors showed no increasedCVD risk compared to cancer-free controls. There was an increased risk of incidentCVD among prostate, and lung and trachea cancer survivors compared to age-, gender- and geographically matched cancer-free controls. Studies including longer follow-up periods are warranted to examine whether cancer survivors are at increased risk of long-term incidentCVD.

Risk for use of antidepressants, anxiolytics, and hypnotics in partners of glioma patients-A nationwide study covering 19 years of prescriptions

OBJECTIVE

Suffering from malignant brain tumor is a stressful condition, for patients and their partners. In a retrospective cohort study using nationwide registries, we examined partners' risk for first use of antidepressants, anxiolytics, or hypnotics.

METHODS

We followed all 4373 partners of adults with glioma, diagnosed in 1998 to 2013 in Denmark and a cohort of 43 808 partners of glioma-free persons matched 1:10. In Cox proportional hazard models, we estimated hazard ratios (HRs) for a first prescription of psychotropic medications (antidepressants, anxiolytics, or hypnotics) according to the partner's glioma status. Among partners of glioma patients, we further estimated HRs for a first prescription of psychotropic medication according to disease characteristics, sociodemographic factors, and bereavement.

RESULTS

Two years after diagnosis, 29% of female and 21% of male partners of glioma patients had had a first prescription of psychotropic medication compared with 10% in female and 8% in male partners of glioma-free persons. Partners of glioma patients had a significantly increased, 4-fold higher risk for a first prescription of psychotropic medications in the first year after diagnosis than partners of glioma-free persons (HR 4.10, 95% CI, 3.80:4.43). Among partners of glioma patients, the risk was significantly reduced in bereaved compared with non-bereaved partners.

CONCLUSIONS

We have documented, for the first time, that the psychological impact of a diagnosis of glioma is such a severe stress exposure that it increases the risk for having medication prescribed to treat symptoms of anxiety, sleep problems, and depression.

Genetic variants in 5-HTTLPR, BDNF, HTR1A, COMT, and FKBP5 and risk for treated depression after cancer diagnosis

BACKGROUND

The role of gene-environment interactions in the pathogenesis of depression is unclear. Previous studies addressed vulnerability for depression after childhood adversity and stressful life events among carriers of numerous specific genetic variants; however, the importance of individual genetic variants, the environmental exposures with which they interact, and the magnitude of the risk conveyed by these interactions remain elusive.

METHODS

We included 7,320 people with a first primary cancer identified in the prospective Diet, Cancer and Health study in an exposed-only cohort study. The mean age of the individuals was 68 years (5th, 95th percentiles: 58, 78) at cancer diagnosis. Using Cox regression models and cumulative incidence plots, we analyzed the associations between genetic variants in 5-HTTLPR, BDNF, HTR1A, COMT, and FKBP5 and use of antidepressants as well as hospital contact for depression after diagnosis of cancer.

RESULTS

Overall, we observed no statistically significant associations, with nonsignificant hazard ratio estimates for use of antidepressants of 0.95-1.07.

CONCLUSIONS

This study of elderly people indicates that it is unlikely that the investigated genetic variants are clinically relevantly associated with depression after diagnosis of cancer. The mechanisms for gene-environment interactions in younger individuals are probably different, and we advise caution in extrapolating our results to early life stress. However, conclusion from the present study might be generalizable to elderly persons exposed to other stressful life events.

First use of antidepressant medication in male partners of women with breast cancer in Denmark from 1998 to 2011

OBJECTIVE

A diagnosis of breast cancer disrupts the life of the patient, but also the partner may experience adverse psychological effects. We examined partners' risk for first use of antidepressant medication, as a proxy for pharmacologically treated depression.

METHODS

By linkage of national registers, we identified 1 420 592 depression-free men living with a cancer-free female partner in 1998 to 2011. During follow-up, breast cancer was diagnosed in female partners of 26 256 men. In Poisson regression models, we estimated the rate ratios for first use of antidepressant medication compared to partners of breast cancer-free women. Cox regression analyses examined associations between exposed partners' sociodemographic characteristics, somatic comorbidity, death of female partner, and first use of antidepressant medication.

RESULTS

Male partners of women with breast cancer had an increased rate ratio of 1.08 (95% CI, 1.03-1.13) for first use of antidepressant medication compared to the background population, corresponding to excess absolute risk of 12 cases per 10 000 person-years. This increased risk persisted throughout 14 years of follow-up. Higher age, shorter education, somatic comorbidity, and death of female partner were associated with increased risk among men whose partner had breast cancer.

CONCLUSION

The modest, but long term, increased risk for first use of antidepressant medication calls for attention by health care professionals to symptoms of depression among partners of breast cancer patients.

Associations between education and physical functioning and pain in adult Danish cancer survivors

BACKGROUND

Late effects after cancer diagnosis and treatment are common, but only few studies have examined the role of social factors in developing these late effects. The aim of this study was to examine the association between educational level and physical function and pain among cancer survivors two years after diagnosis.

MATERIAL AND METHODS

The study population consisted of adult Danish patients with a first-time cancer diagnosis who were sent a questionnaire in 2010 and followed up in 2012. In total, 4346 returned the first questionnaire shortly after diagnosis and 2568 returned the follow-up questionnaire. After exclusion of 177 due to missing information, we included 2391 cancer survivors in the analyses. Physical function and pain were measured using the EORTC QLQ-C30. Linear regression analyses were conducted separately for men and women, and adjusted for demographic and clinical characteristics. Additionally, analyses were stratified on comorbidity.

RESULTS

Differences in mean scores according to educational level were small. Physical function was better in women with medium (2.8; 95% CI 0.1;5.4) and higher education (3.4; 95% CI 0.9;5.9) compared to women with short education. In contrast, men with medium education reported lower physical function (-2.9; 95% CI -5.7;-0.1) than men with short education. Compared to women with short education, we found lower pain scores among women with medium (-5.0; 95% CI -8.7;-1.4) and higher education (-3.4; 95% CI -6.7;0.0). Similarly, men with higher education experienced lower pain score (-3.4; 95% CI -6.9;0.1) than men with short education. The role of educational level differed between those with and without comorbidity.

CONCLUSION

Educational level is slightly associated with physical function and pain among cancer survivors. However, mean differences in this study were small and below what is considered clinically relevant.

Association between late effects assessed by physicians and quality of life reported by head-and-neck cancer survivors

BACKGROUND

Many survivors of head-and-neck cancer (HNC) suffer from late effects. Their overall quality of life deteriorates during treatment, followed by a slow recovery up to five years after treatment. We examined the association between the severity of physician-assessed late effects and the health-related quality of life (HRQoL) reported by survivors of HNC.

MATERIAL AND METHODS

The analysis was based on data collected during follow-up for 136 survivors of cancer in the oral cavity, pharynx, larynx, or salivary glands. Physicians' assessments of dysphagia, xerostomia, fibrosis, and hoarseness, derived from reports to of the Danish Head and Neck Cancer Group database and patient-reported overall quality of life and social, role, emotional, cognitive, and physical functioning reported on the European Organization for Research and Treatment of Cancer questionnaire. Linear regression models were used to examine the association between the severity of each late effect and HRQoL.

RESULTS

Quality of life was decreased among patients with moderate to severe dysphagia compared to patients without dysphagia (-16 points; 95% CI -21;-3). Also role functioning (-20 points; 95% CI -38;-2), emotional functioning (-19 points; 95% CI -34;-4) and social functioning (-27 points; 95% CI -41;-13) decreased compared with patients without dysphagia. Mild dysphagia was also associated with decreased overall quality of life (-12 points; 95% CI -21;-3). Moderate to severe hoarseness was significantly associated with poorer social functioning (-25 points; 95% CI -41;-10). There was no association between fibrosis or xerostomia and HRQoL.

CONCLUSION

Physician-assessed moderate to severe hoarseness and mild, moderate, or severe dysphagia are associated with clinically relevant decreases in patient-reported quality of life and functioning. Fibrosis and xerostomia of any severity were not associated with changes in any scale of functioning in this study population.

Swallowing therapy and progressive resistance training in head and neck cancer patients undergoing radiotherapy treatment: randomized control trial protocol and preliminary data

BACKGROUND

Head and neck cancer (HNC) patients are often challenged by treatment induced dysphagia and trismus. Traditionally, rehabilitation is initiated when loss of function has already occurred. There is increasing evidence that it is of benefit to patients to initiate an early rehabilitation process before and during treatment. HNC patients have a unique set of functional challenges such as pre- and post-treatment dysphagia, pain and weight loss. The aim of the trial is to investigate the effects of swallowing and mouth-opening exercises combined with progressive resistance training (PRT) during radiotherapy. This report presents the protocol, interim inclusion and feasibility data.

MATERIAL AND METHODS

The trial (clinicaltrials.gov NCT02385929) is a multicenter randomized controlled trial (RCT) with a parallel-group randomization (1:1). The planned sample size of 240 HNC patients is randomly assigned to either (1) twice weekly PRT and three times weekly swallowing exercises by physio- and occupational therapists, respectively, as well as daily home exercises throughout radiotherapy or (2) standard care. Inclusion criteria are patients with cancer in the larynx, pharynx, oral cavity, or unknown primary tumor who are referred to radiotherapy with curative intent. Outcomes are measured at end-of-treatment and two, five, and 12 months post-treatment. Interim results: In 16 months, 321 HNC patients were screened for eligibility. Of these, 131 (41%) were eligible according to inclusion criteria. One-hundred-and-fifteen patients were invited to participate of which 69 (60%) were enrolled in the trial and randomized for either intervention or control group with 10 drop-outs (14%). The six pilot patients adhered more than 90% to the program.

CONCLUSION

Preliminary results show that exercise according to protocol is tolerable and feasible.

Preoperative modifiable risk factors in colorectal surgery: an observational cohort study identifying the possible value of prehabilitation

BACKGROUND

Colorectal cancer (CRC) is the second most prevalent type of cancer in the world. Surgery is the most common therapeutic intervention, and associated with 20-40% reduction in physiological and functional capacity. Postoperative complications occur in up to 50% of patients resulting in higher mortality rates and greater hospital costs. The number and severity of complications is closely related to patients' preoperative performance status. The aim of this study was to identify the most important preoperative modifiable risk factors that could be part of a multimodal prehabilitation program.

METHODS

Prospectively collected data of a consecutive series of Dutch CRC patients undergoing colorectal surgery were analyzed. Modifiable risk factors were correlated to the Comprehensive Complication Index (CCI) and compared within two groups: none or mild complications (CCI <20), and severe complications (CCI ≥20). Multivariate logistic regression analysis was done to explore the combined effect of individual risk factors.

RESULTS

In this 139 patient cohort, smoking, malnutrition, alcohol consumption, neoadjuvant therapy, higher age, and male sex, were seen more frequently in the severe complications group (CCI ≥20). Patients with severe complications had significantly longer hospital stay (16 vs. 6 days, p < 0.001). The risk for severe complications was increased in patients with ASA score III [adjusted odds ratio (OR) 4.4, 95% CI 1.04-18.6], and hemoglobin level <7 mmol/l (adjusted OR 3.3, 95% CI 1.3-8.2). Compared to having no risk factors, more than one risk factor increased OR of severe complications (crude OR 5.2, 95% CI 1.8-15).

CONCLUSION

This study revealed that the risk of getting severe complications increases with the number of risk factors present preoperatively. Several preoperative patient-related risk factors are modifiable. Multimodal prehabilitation may improve patients' preoperative status and should be tested in a multicenter randomized controlled trial. With an international consortium (Copenhagen, Montreal, Paris, Eindhoven) we initiated a randomized controlled trial (NTR5947).

Survival After Early-Stage Breast Cancer of Women Previously Treated for Depression: A Nationwide Danish Cohort Study

Purpose

The aim of this nationwide, register-based cohort study was to determine whether women treated for depression before primary early-stage breast cancer are at increased risk for receiving treatment that is not in accordance with national guidelines and for poorer survival.

Material and Methods

We identified 45,325 women with early breast cancer diagnosed in Denmark from 1998 to 2011. Of these, 744 women (2%) had had a previous hospital contact (as an inpatient or outpatient) for depression and another 6,068 (13%) had been treated with antidepressants. Associations between previous treatment of depression and risk of receiving nonguideline treatment of breast cancer were assessed in multivariable logistic regression analyses. We compared the overall survival, breast cancer–specific survival, and risk of death by suicide of women who were and were not treated for depression before breast cancer in multivariable Cox regression analyses.

Results

Tumor stage did not indicate a delay in diagnosis of breast cancer in women previously treated for depression; however, those given antidepressants before breast cancer had a significantly increased risk of receiving nonguideline treatment (odds ratio, 1.14; 95% CI, 1.03 to 1.27) and significantly worse overall survival (hazard ratio, 1.21; 95% CI, 1.14 to 1.28) and breast cancer–specific survival (hazard ratio, 1.11; 95% CI, 1.03 to 1.20). Increased but nonsignificant estimated risks were also found for women with previous hospital contacts for depression. In subgroup analyses, the association of depression with poor survival was particularly strong among women who did not receive the indicated adjuvant systemic therapy.

Conclusion

Women previously treated for depression constitute a large subgroup of patients with breast cancer who are at risk for receiving nonguideline breast cancer treatment, which probably contributes to poorer overall and breast cancer–specific survival.

Effect of socioeconomic position on survival after childhood cancer in Denmark

Background One fifth of all deaths among children in Europe are accounted for by cancer. If this is to be reduced there is a need for studies on not only biology and treatment approaches but also on how social factors influence cure rates. We investigated how various socioeconomic characteristics were associated with survival after childhood cancer. Material and methods In a nationwide cohort of 3797 children diagnosed with cancer [hematological cancer, central nervous system (CNS) tumors, non-CNS solid tumors] before age 20 between 1990 and 2009 we identified parents and siblings and obtained individual level parental socioeconomic variables and vital status through 2012 by linkage to population-based registries. Hazard ratios (HR) and 95% confidence intervals (CI) for dying were estimated using multivariate Cox proportional hazard models. Results For all children with cancer combined, survival was slightly but not statistically significantly better the higher the education of the mother or the father, and with maternal income. Significantly better survival was observed when parents were living together compared to living alone and worse survival when the child had siblings compared to none. Young (<20) or older (≥40) maternal age showed non-significant associations, but based on small numbers. For hematological cancers, no significant associations were observed. For CNS tumors, better survival was seen with parents living together (HR 0.70, CI 0.51-0.97). For non-CNS solid tumors, survival was better with high education of the mother (HR 0.66, CI 0.44-0.99) compared to basic and worse for children with one (HR 1.45, CI 1.11-1.89) or two or more siblings (HR 1.29, CI 0.93-1.79) (p for trend 0.02) compared to none. Conclusion The impact of socioeconomic characteristics on childhood cancer survival, despite equal access to protocolled and free-of-charge treatment, warrants further and more direct studies of underlying mechanisms in order to target these as a means to improve survival rates.

Distress after a psychosocial cancer rehabilitation course. Main effects and effect modification in a randomised trial at 12 months of follow-up

BACKGROUND

In 2002, the Danish Cancer Society opened a rehabilitation centre in which cancer patients were offered a free, six-day, multidimensional residential course. Our previous studies of the effects of this course at one and six months of follow-up showed no positive effect on distress. We investigated long-term effects at 12 months of follow-up and whether subgroups with fewer psychosocial resources received more benefit from the intervention than patients with better resources.

MATERIAL AND METHODS

In two Danish counties, 507 patients with breast, prostate, colon or rectum cancer diagnosed within the past two years who had completed primary treatment were randomised to a six-day, multidimensional residential rehabilitation course or to standard care. Of these, 208 patients received the allocated intervention and 244 received the allocated control condition and were included in the analyses. Patients in both groups completed questionnaires at baseline and at one, six and 12 months of follow-up, including the 'Profile of Mood States short form', the 'General Self-efficacy' scale and a question on emotional support. At 12 months of follow-up, 179 participants in the intervention group and 195 in the control group provided data.

RESULTS

No effect of the intervention was found on distress at 12 months of follow-up, even in subgroups with fewer psychosocial resources at baseline, i.e. greater baseline distress, poorer self-efficacy and less emotional support.

CONCLUSION

Multidimensional rehabilitation programmes may not be effective in the treatment of distress. During the past few decades, studies of psychotherapy or psycho-education in cancer patients have shown small to moderate effects. More focused rehabilitation programmes may be more effective.

Social position and referral to rehabilitation among cancer patients

OBJECTIVES

In Denmark, most healthcare services, including cancer treatment and rehabilitation, are offered free of charge by referral from a treating physician; thus, social equality should be expected. In a population-based cohort study of registry-based data, we examined the association between socioeconomic position, measured as educational level, and referral to rehabilitation services among cancer patients.

MATERIAL AND METHODS

Through the Danish Cancer Registry, we identified all people resident in the Municipality of Copenhagen with cancer diagnosed in 2007-2012. Information on all rehabilitation referrals was retrieved from the Municipal Centre for Cancer Rehabilitation for 2009-2012. Information on demographic and socioeconomic characteristics was obtained from national Danish registers. The Cox proportional hazards model was used to investigate associations between educational level and referral to rehabilitation with adjustment for sex, age, diagnosis, disposable income, cohabitation status and number of children living at home at the time of diagnosis.

RESULTS

A primary cancer was diagnosed in 13 840 people, of whom 2148 (16%) were referred to rehabilitation services during follow-up. In the fully adjusted model, we found education to be a predictor of referral, with a hazard ratio of 1.33 (95% CI 1.19-1.49) for patients with long education and a hazard ratio of 1.15 (95% CI 1.03-1.29) for patients with medium education as compared with patients with short education.

CONCLUSIONS

Our findings suggest that, even after differences in demographics and cancer characteristics are accounted for, referral to rehabilitation services is not equally distributed by social group. Higher educational level is associated with a higher probability of referral to rehabilitation services.

Predictors of continuous tobacco smoking in a clinical cohort study of Danish laryngeal cancer patients smoking before treated with radiotherapy

BACKGROUND

Many cancer patients who are smokers when starting cancer therapy continue smoking despite evidence of tobacco smoking as a risk factor for poor treatment response and secondary primary cancers. Small samples and inconsistent results in previous studies warrant further research to identify predictors of being a continuous smoker during and after radiotherapy.

MATERIAL AND METHODS

In the clinical database of the Danish Head and Neck Cancer Group (DAHANCA), we identified 1455 patients diagnosed with laryngeal cancer between 2000 and 2010, who were all smokers at date of diagnosis and treated with primary radiotherapy. Information on the socio-economic characteristics of the study cohort was obtained from Statistics Denmark the year prior to diagnosis. Logistic regression analyses were applied.

RESULTS

In the cohort of laryngeal cancer patients smoking before starting radiotherapy, 50% still smoked one year after radiotherapy similar to the percentage of smokers during treatment. Being younger than 60 years (OR 1.39, 95% CI 1.00-1.91), commenced smoking before the age of 15 (OR 1.77, 95% CI 1.32-2.38), having a poor WHO Performance status (OR 3.09, 95% CI 1.71-5.61), low income (OR 2.21, 95% CI 1.23-3.98) and living alone (OR 1.56, 95% CI 1.13-2.14) were associated with increased risk of continuous smoking during treatment. Similar findings were found two months and one year after radiotherapy, however, no association with living alone (OR 1.08, 95% CI 0.73-1.59) at the one-year follow-up. Tumor stage and the average number of cigarettes smoked per day before radiotherapy were not associated with being a continuous smoker.

CONCLUSION

Younger patients, who had an early smoking initiation, a poor performance status, low income and lived alone, were most likely to continue smoking. Continuous smoking was not related to the extent of disease.

The role of social position in anxiety and depressive symptoms among Danish cancer survivors

BACKGROUND

Anxiety and depressive symptoms are common among cancer survivors. Studies of a possible association with social position have had divergent results. We examined these associations, social position being measured by education, in Danish cancer survivors approximately two years after diagnosis.

MATERIAL AND METHODS

People aged over 18, living in Denmark and registered for a first cancer in the Danish National Patient Registry between 1 May and 31 August 2010 were contacted; 4346 returned a questionnaire shortly after diagnosis, and 2568 were followed up in 2012. Age, sex and cancer site were derived from the registry; all other information was self-reported, with that on education from the 2010 questionnaire and responses to the Hospital Anxiety and Depression Scale from the 2012 questionnaire. General linear models were used, with adjustment for demographic factors, cancer-specific factors, and comorbidity.

RESULTS

The study population consisted of 1667 people (response rate, 51%). The mean symptom scores were 4.34 (SD 3.77) for anxiety and 2.94 (SD 3.25) for depression. People with medium and higher education had slightly higher anxiety symptom scores (mean differencemedium = 0.41, 95% CI 20.07; 0.88, mean differencehigher = 0.19, 95% CI 20.27; 0.65). Depressive symptom scores were slightly elevated for people with medium education and reduced for those with higher education (mean differencemedium = 0.34, 95% CI 20.07; 0.75, mean differencehigher = 20,11, 95% CI 20.50; 0.29). Female sex, smoking-related cancers and chemotherapy were significantly associated with higher scores for both anxiety and depressive symptoms, but somatic comorbidity and mental disorders at the time of treatment were most strongly, significantly associated with elevated anxiety and depressive symptom scores.

CONCLUSION

No overall significant differences in anxiety or depressive symptom scores were found with length of education. Previous mental disorders and somatic comorbidity are the strongest indicators of higher levels of anxiety and depressive symptoms.

Socioeconomic position and survival after lung cancer: Influence of stage, treatment and comorbidity among Danish patients with lung cancer diagnosed in 2004-2010

BACKGROUND

To address social inequality in survival after lung cancer, it is important to consider how socioeconomic position (SEP) influences prognosis. We investigated whether SEP influenced receipt of first-line treatment and whether socioeconomic differences in survival could be explained by differences in stage, treatment and comorbidity.

MATERIAL AND METHODS

In the Danish Lung Cancer Register, we identified 13 045 patients with lung cancer diagnosed in 2004-2010, with information on stage, histology, performance status and first-line treatment. We obtained age, gender, vital status, comorbid conditions and socioeconomic information (education, income and cohabitation status) from nationwide population-based registers. Associations between SEP and receipt of first-line treatment were analysed in multivariate logistic regression models and those with overall mortality in Cox regression models with stepwise inclusion of possible mediators.

RESULTS

For both low- and high-stage lung cancer, adjusted ORs for first-line treatment were reduced in patients with short education and low income, although the OR for education did not reach statistical significance in men with high-stage disease. Patients with high-stage disease who lived alone were less likely to receive first-line treatment. The socioeconomic difference in overall survival was partly explained by differences in stage, treatment and comorbidity, although some differences remained after adjustment. Among patients with high-stage disease, the hazard ratio (HR) for death of those with low income was 1.12 (95% CI 1.05-1.19) in comparison with those with high income. Among patients with low-stage disease, those who lived alone had a 14% higher risk for dying (95% CI 1.05-1.25) than those who lived with a partner. The differences in risk for death by SEP were greatest in the first six months after diagnosis.

CONCLUSION

Socioeconomic differences in survival after lung cancer are partly explained by social inequality in stage, first-line treatment and comorbidity. Efforts should be made to improve early diagnosis and adherence to first-line treatment recommendations among disadvantaged lung cancer patients.

Association Between Educational Level and Risk of Cancer in HIV-infected Individuals and the Background Population: Population-based Cohort Study 1995-2011

BACKGROUND

Human immunodeficiency virus (HIV)-infected individuals have increased risk of cancer. To our knowledge, no previous study has examined the impact of socioeconomic position on risk and prognosis of cancer in HIV infection.

METHODS

Population-based cohort-study, including HIV-infected individuals diagnosed (without intravenous drug abuse or hepatitis C infection) (n = 3205), and a background population cohort matched by age, gender, and country of birth (n = 22 435) were analyzed. Educational level (low or high) and cancer events were identified in Danish national registers. Cumulative incidences, incidence rate ratios (IRRs), and survival using Kaplan-Meier methods were estimated.

RESULTS

Low educational level was associated with increased risk of cancer among HIV-infected individuals compared to population controls: all (adjusted-IRRs: 1.4 [95% confidence interval {CI}, 1.1-1.7] vs 1.1 [95% CI, .9-1.2]), tobacco- and alcohol-related (2.1 [95% CI, 1.3-3.4] vs 1.3 [95% CI, 1.1-1.6]), and other (1.7 [95% CI, 1.1-2.8] vs 0.9 [95% CI, .7-1.0]). Educational level was not associated with infection-related or ill-defined cancers. One-year-survival was not associated with educational level, but HIV-infected individuals with low educational level had lower 5-year-survival following infection-related and ill-defined cancers.

CONCLUSIONS

Education is associated with risk and prognosis of some cancers in HIV infection, and diverges from what is observed in the background population.

Increased risk for depression after breast cancer: a nationwide population-based cohort study of associated factors in Denmark, 1998-2011

PURPOSE

To investigate the risk for first depression, assessed as incident hospital contacts for depression and incident use of antidepressants, among women with breast cancer.

PATIENTS AND METHODS

Danish national registries were used to identify 1,997,669 women with no diagnosis of cancer or a major psychiatric disorder. This cohort was followed from 1998 to 2011 for a diagnosis of breast cancer and for the two outcomes, hospital contact for depression and redeemed prescriptions for antidepressants. Rate ratios for incident hospital contacts for depression and incident use of antidepressants were estimated with Poisson regression models. Multivariable Cox regression was used to evaluate factors associated with the two outcomes among patients with breast cancer.

RESULTS

We identified 44,494 women with breast cancer. In the first year after diagnosis, the rate ratio for a hospital contact for depression was 1.70 (95% CI 1.41 to 2.05) and that for use of antidepressants was 3.09 (95% CI 2.95 to 3.22); these rate ratios were significantly increased after 3 and 8 years, respectively. Comorbidity, node-positive disease, older age, basic and vocational educational levels, and living alone were associated with use of antidepressants.

CONCLUSION

Women with breast cancer are at long-term increased risk for first depression, including both severe episodes leading to hospital contact and use of antidepressants. Clinicians should be aware that the risk is highest in women with comorbid conditions, node-positive disease, and age of 70 years or more. We found no clear association between type of surgery or adjuvant treatment and risk for depression.

Pre-diagnostic anthropometry and survival after colorectal cancer diagnosis in Western European populations

General and abdominal adiposity are associated with a high risk of developing colorectal cancer (CRC), but the role of these exposures on cancer survival has been less studied. The association between pre-diagnostic anthropometric characteristics and CRC-specific and all-cause death was examined among 3,924 men and women diagnosed with CRC between 1992 and 2009 in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. Multivariable Cox proportional hazards models were used to calculate hazard ratios (HRs) and corresponding 95% confidence intervals (CIs). Over a mean follow-up period of 49 months, 1,309 deaths occurred of which 1,043 (79.7%) were due to CRC. In multivariable analysis, pre-diagnostic BMI ≥ 30 kg/m(2) was associated with a high risk for CRC-specific (HR = 1.26, 95% CI = 1.04-1.52) and all-cause (HR = 1.32, 95% CI = 1.12-1.56) death relative to BMI <25 kg/m(2). Every 5 kg/m(2) increase in BMI was associated with a high risk for CRC-specific (HR = 1.10, 95% CI = 1.02-1.19) and all-cause death (HR = 1.12, 95% CI = 1.05-1.20); and every 10 cm increase in waist circumference was associated with a high risk for CRC-specific (HR = 1.09, 95% CI = 1.02-1.16) and all-cause death (HR = 1.11, 95% CI = 1.05-1.18). Similar associations were observed for waist-to-hip and waist-to-height ratios. Height was not associated with CRC-specific or all-cause death. Associations tended to be stronger among men than in women. Possible interactions by age at diagnosis, cancer stage, tumour location, and hormone replacement therapy use among postmenopausal women were noted. Pre-diagnostic general and abdominal adiposity are associated with lower survival after CRC diagnosis.

Beyond treatment - Psychosocial and behavioural issues in cancer survivorship research and practice

The population of cancer survivors has grown steadily over the past several decades. Surviving cancer, however, is not synonymous with a life free of problems related to the disease and its treatment. In this paper we provide a brief overview of selected physical and psychosocial health problems prevalent among cancer survivors, namely pain, fatigue, psychological distress and work participation. We also address issues surrounding self-management and e-Health interventions for cancer survivors, and programmes to encourage survivors to adopt healthier lifestyles. Finally, we discuss approaches to assessing health-related quality of life in cancer survivors, and the use of cancer registries in conducting psychosocial survivorship research. We highlight research and practice priorities in each of these areas. While the priorities vary per topic, common themes that emerged included: (1) Symptoms should not be viewed in isolation, but rather as part of a cluster of interrelated symptoms. This has implications for both understanding the aetiology of symptoms and for their treatment; (2) Psychosocial interventions need to be evidence-based, and where possible should be tailored to the needs of the individual cancer survivor. Relatively low cost interventions with self-management and e-Health elements may be appropriate for the majority of survivors, with resource intensive interventions being reserved for those most in need; (3) More effort should be devoted to disseminating and implementing interventions in practice, and to evaluating their cost-effectiveness; and (4) Greater attention should be paid to the needs of vulnerable and high-risk populations of survivors, including the socioeconomically disadvantaged and the elderly.