Socioeconomic position and the pre-diagnostic interval among patients diagnosed with head and neck squamous cell carcinoma - a population-based study from DAHANCA.

BACKGROUND: The socioeconomic differences in survival are pronounced for patients diagnosed with head and neck cancer; disease stage at diagnosis is suggested to be a main driver of this association. This nationwide, population-based study investigates socioeconomic differences in the pre-diagnostic interval and disease stage at diagnosis. MATERIAL AND METHODS: Information on patient-reported symptoms, symptom onset and disease-specific factors was obtained from the nationwide population-based Danish Head and Neck Cancer Group (DAHANCA) database for patients diagnosed with head and neck squamous cell carcinoma between 2008 and 2019 in Denmark. Socioeconomic position (SEP) was measured by individual-level education, income and cohabitation status obtained from administrative registers. Socioeconomic differences in the interval from symptom onset to diagnosis were investigated in general linear models with 95% confidence intervals (CIs); overall and by subsite, symptom and comorbidity score. Consultation patterns prior to diagnosis were examined using methods for change-point detection. Associations with advanced-stage disease were estimated in logistic regression models. RESULTS: Patients with low, medium and high SEP had a similar interval from patient-reported symptom onset to diagnosis of 10 weeks. Although this interval varied according to primary symptom and anatomical subsite, no apparent socioeconomic differences were observed within these subgroups. Aligned with the patient-reported symptom onset, a distinct increase in consultation rates was observed at 9 weeks (95% CI [7.3; 10.7]) for patients with low SEP and 7 weeks (95% CI [4.8; 9.2]) for patients with high SEP, with overlapping CIs. Patients with low compared to high SEP had increased odds for advanced-stage glottic and oral cavity squamous cell carcinoma. For the remaining subsites the association varied according to SEP-indicator and TNM-edition. CONCLUSION: The interval from symptom onset to diagnosis and consultation patterns were similar across SEP groups. Still, socioeconomic differences in stage at diagnosis were observed for some - but not all - subsites.

Socioeconomic inequality in cancer in the Nordic countries. A systematic review.

BACKGROUND: Despite structural and cultural similarities across the Nordic countries, differences in cancer survival remain. With a focus on similarities and differences between the Nordic countries, we investigated the association between socioeconomic position (SEP) and stage at diagnosis, anticancer treatment and cancer survival to describe patterns, explore underlying mechanisms and identify knowledge gaps in the Nordic countries. METHODS: We conducted a systematic review of population based observational studies. A systematic search in PubMed, EMBASE and Medline up till May 2021 was performed, and titles, abstracts and full texts were screened for eligibility by two investigators independently. We extracted estimates of the association between SEP defined as education or income and cancer stage at diagnosis, received anticancer treatment or survival for adult patients with cancer in the Nordic countries. Further, we extracted information on study characteristics, confounding variables, cancer type and results in the available measurements with corresponding confidence intervals (CI) and/or p-values. Results were synthesized in forest plots. RESULTS: From the systematic literature search, we retrieved 3629 studies, which were screened for eligibility, and could include 98 studies for data extraction. Results showed a clear pattern across the Nordic countries of socioeconomic inequality in terms of advanced stage at diagnosis, less favorable treatment and lower cause-specific and overall survival among people with lower SEP, regardless of whether SEP was measured as education or income. CONCLUSION: Despite gaps in the literature, the consistency in results across cancer types, countries and cancer outcomes shows a clear pattern of systematic socioeconomic inequality in cancer stage, treatment and survival in the Nordic countries. Stage and anticancer treatment explain some, but not all of the observed inequality in overall and cause-specific survival. The need for further studies describing this association may therefore be limited, warranting next step research into interventions to reduce inequality in cancer outcomes. STUDY REGISTRATION: Prospero protocol no: CRD42020166296.

Socioeconomic position, referral and attendance to rehabilitation after a cancer diagnosis: A population-based study in Copenhagen, Denmark 2010-2015.

Background: Implementation of new cancer services may lead to socioeconomic differences in uptake and despite reports of more unmet needs among patients with low socioeconomic position studies have found that these patients receive less rehabilitation. We aimed to investigate associations between indicators for socioeconomic position and referral as well as attendance to rehabilitation for cancer. Methods: Through the Danish Cancer Registry, we identified all persons diagnosed with cancer in Copenhagen municipality 2010-2015 and obtained information on referral to and visits at the municipal rehabilitation center from municipal records. We linked the population with information on socioeconomic information and vital status through national registries. Associations were analyzed using multivariate Cox regression models. Results: Among 13,059 persons diagnosed with cancer a total of 2523 were referred for rehabilitation within 2.5 years from diagnosis. Compared to persons with short education, men and women with long education and men with medium education had higher adjusted hazard ratios (HR) for being referred to rehabilitation (Long: HR-men, 1.30 (95% CI: 1.06-1.59) and HR-women, 1.33 (95% CI: 1.15-1.53; Medium: HR-men, 1.23 (95% CI: 1.02-1.49)). Both men and women with children living at home had higher HR of referral (HR-men, 1.23 (95% CI: 1.00-1.52) and HR-women, 1.28 (95% CI: 1.11-1.48)). Among patients referred to rehabilitation, 81% attended a visitation consultation. Long education was associated with attendance in both genders while in men, medium education and in women high income, respectively was associated with attendance. Conclusion: Clear socioeconomic differences in referral and attendance to rehabilitation services indicate that socioeconomic inequality exists in patients' transition from cancer treatment into post-treatment care. Systematic needs assessment and clarification of wish for rehabilitation should be a requisite for all cancer patients independent of their socioeconomic position.

Educational level and the risk of depression after prostate cancer.

Background: The risk of depression is inversely associated with socioeconomic position in the general population; however, studies on the association in cancer populations are limited. The aim was to investigate if shorter education was associated with a higher risk of depression following prostate cancer diagnosis. Material and methods: This is a cohort study among participants in the Danish prospective Diet, Cancer and Health (DCH) study including 2337 men diagnosed with prostate cancer between 1997 and 2014. Primary outcome was indication of moderate to severe depression, defined as either a first hospital contact for depression or first use of antidepressants. The main indicator of socioeconomic position was education categorized into short (<9 years of education), medium (9-12 years) and long (>12 years). We retrieved information on education, depression and cohabitation status from Danish National Registries. Information on stage, primary treatment, lifestyle and anthropometry was obtained from medical records and questionnaires. Data were analyzed using Cox proportional hazards models adjusted for possible confounders and mediators. Results: The hazard of first depression was 1.86-fold higher (95% CI, 1.36-2.54) in prostate cancer patients with short education compared to those with long education. Adjustment for stage and primary treatment did not change the HRs, while adding comorbidity and lifestyle factors resulted in an HR of 1.65 (95% CI, 1.19-2.29). Men with medium education had a non-statistically significant 1.23-fold higher hazard of depression (95% CI, 0.95-1.59) than men with long education in the fully adjusted model. Educational differences were present in the cumulative incidence of first depression among cancer-free DCH study participants, but the level of first depression was substantially lower in this population than in prostate cancer patients. Conclusions: We found indication of social inequality in depression following prostate cancer. Patients and particularly men with short education might benefit from psychosocial intervention and support.

Prolonged hospitalization, primary refractory disease, performance status and age are prognostic factors for survival in patients with diffuse large B-cell lymphoma and transformed indolent lymphoma undergoing autologous stem cell transplantation.

In patients with relapsed diffuse large B-cell lymphoma (DLBCL), high-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is standard treatment. Here, we aim to identify factors associated with survival in patients undergoing ASCT. A total of 369 patients with relapsed DLBCL undergoing ASCT from 2000 to 2012 were identified in the Danish National Lymphoma Registry. Information on clinical and socioeconomic factors was obtained from medical records and national registries. Factors associated with survival were assessed using a Cox's proportional hazards model. Median overall survival was 6.8 years, median progression-free survival was 2.6 years, and treatment-related mortality at Day 100 was 6%. Factors associated with a significant adverse impact on survival were age, primary refractory disease, prolonged hospitalization during salvage treatment, and performance status >0 prior to conditioning therapy. Reconsideration of ASCT for those patients may be required in order to select the right patients for this toxic procedure.