Cardiovascular disease in women with breast cancer - a nationwide cohort study.

BACKGROUND: There is increasing concern about cardiovascular disease (CVD) after breast cancer (BC). The aim of this study was to estimate the prevalence of different types of CVD in women diagnosed with BC compared to cancer-free controls as well as the incidence of CVD after BC diagnosis. METHODS: We performed a cohort study based on data from national registries covering the entire Danish population. We followed 16,505 cancer-naïve BC patients diagnosed from 2003 to 2007 5 years before and up to 10 years after BC diagnosis compared to 165,042 cancer-free controls. RESULTS: We found that 15.6% of BC patients were registered with at least one CVD diagnosis in hospital records before BC diagnosis. Overall, BC patients and controls were similar with regard to CVD comorbidity before BC diagnosis. After BC diagnosis, the incidence of all CVD diagnoses combined was significantly higher in BC patients than controls up to approximately 6 years after the index date (BC diagnosis). After 10 years, 28% of both BC patients and controls (without any CVD diagnosis up to 5 years before the index date) had at least one CVD diagnosis according to hospital records. However, the incidence of heart failure, thrombophlebitis/thrombosis and pulmonary heart disease including pulmonary embolism remained higher in BC patients than controls during the entire 10-year follow-up period. After 10 years, 2.7% of BC patients compared to 2.5% of controls were diagnosed with heart failure, 2.7% of BC patients compared to 1.5% of controls were diagnosed with thrombophlebitis/thrombosis, and 1.5% of BC patients compared to 1.0% of controls were diagnosed with pulmonary heart disease according to hospital records. Furthermore, we found that the risk of heart failure and thrombophlebitis/thrombosis was higher after chemotherapy. CONCLUSIONS: Focus on CVD in BC patients is important to ensure optimum treatment with regard to BC as well as possible CVD. Strategies to minimise and manage the increased risk of heart failure, thrombophlebitis/thrombosis and pulmonary heart disease including pulmonary embolism in BC patients are especially important.

The importance of workplace accommodation for cancer survivors - The role of flexible work schedules and psychological help in returning to work.

We investigate whether accommodating job attributes influence the probability of returning to work three years after a cancer diagnosis. Using a combination of Danish administrative data and a survey carried out among Danish breast, colon, and melanoma skin cancer survivors, we find that the probability of returning to work is significantly and positively correlated with a flexible work schedule during and after cancer treatment. The result is robust when controlling for pre-cancer work experience, job seniority, pre-cancer job dissatisfaction, and post-cancer ability to work. Furthermore, we show that the influence of a flexible schedule varies with respect to cancer survivors' ability to work, level of education, and type of cancer.

Mortality from cardiovascular disease in women with breast cancer - a nationwide registry study.

BACKGROUND: Only few existing studies have investigated the mortality from cardiovascular disease (CVD) in women with breast cancer (BC). The aim of this study was to investigate CVD mortality in patients with BC compared with a matched control group without BC using national registry data. MATERIAL AND METHODS: We followed 16,505 Danish women diagnosed with BC in 2003-2007 up to 10 years after BC diagnosis compared with 165,042 matched controls from the general Danish population. The matching criteria included gender, age, region of residence, and education. We performed multivariate Cox regression analyses to investigate the influence of preexisting CVD on mortality. Moreover, we used the cumulative incidence and conditional probability functions to study the risk of CVD-related death in the presence of competing risk, i.e., the risk of dying from other causes than CVD. RESULTS: We found that preexisting CVD increased both overall mortality and CVD mortality in both patients with BC and controls. Furthermore, we found that patients with BC were at lower risk of dying from CVD up to 10 years after BC diagnosis compared with controls. The cumulative incidence of CVD as underlying cause of death was 4.0% in patients with BC and 5.7% in controls after 10 years. The most common CVD-related causes of death were ischemic heart disease including acute coronary syndrome, cerebrovascular accident, heart failure, and atrial fibrillation. DISCUSSION: Our study contributes to the growing body of work on BC and comorbidities and highlights the importance of CVD in individuals with BC. Further studies are needed to confirm our finding that patients with BC are at lower risk of dying from CVD up to 10 years after BC diagnosis compared with a matched control group without BC.

The effect of time to death on health care expenditures: taking into account the endogeneity and right censoring of time to death.

This paper provides new estimates of the impact of the time to death on health care expenditures when the time to death is assumed endogenous. It further proposes estimation methods that take into account the right censoring of time to death. The data consist of twins from Denmark aged over 70 in 1999. The age of death of the mother and the living status of the co-twin are used as instruments for time to death. The results show that IV estimators give estimates higher than those obtained in previous studies when the time to death is assumed exogenous. Furthermore, the estimators proposed in this paper provide estimates that are generally lower compared to the ones obtained with the IV estimator. These results indicate that the impact of time to death has been potentially overestimated in previous studies.

Costs of major intracranial, gastrointestinal and other bleeding events in patients with atrial fibrillation - a nationwide cohort study.

BACKGROUND: Use of oral anticoagulation therapy in patients with atrial fibrillation (AF) involves a trade-off between a reduced risk of ischemic stroke and an increased risk of bleeding events. Different anticoagulation therapies have different safety profiles and data on the societal costs of both ischemic stroke and bleeding events are necessary for assessing the cost-effectiveness and budgetary impact of different treatment options. To our knowledge, no previous studies have estimated the societal costs of bleeding events in patients with AF. The objective of this study was to estimate the 3-years societal costs of first-incident intracranial, gastrointestinal and other major bleeding events in Danish patients with AF. METHODS: The study was an incidence-based cost-of-illness study carried out from a societal perspective and based on data from national Danish registries covering the period 2002-2012. Costs were estimated using a propensity score matching and multivariable regression analysis (first difference OLS) in a cohort design. RESULTS: Average 3-years societal costs attributable to intracranial, gastrointestinal and other major bleeding events were 27,627, 17,868, and 12,384 EUR per patient, respectively (2015 prices). Existing evidence shows that the corresponding costs of ischemic stroke were 24,084 EUR per patient (2012 prices). The average costs of bleeding events did not differ between patients with AF who were on oral anticoagulation therapy prior to the event and patients who were not. CONCLUSIONS: The societal costs attributable to major bleeding events in patients with AF are significant. Intracranial haemorrhages are most costly to society with average costs of similar magnitude as the costs of ischemic stroke. The average costs of gastrointestinal and other major bleeding events are lower than the costs of intracranial haemorrhages, but still substantial. Knowledge about the relative size of the costs of bleeding events compared to ischemic stroke in patients with AF constitutes valuable evidence for decisions-makers in Denmark as well as in other countries.

Societal Costs of First-Incident Ischemic Stroke in Patients with Atrial Fibrillation-A Danish Nationwide Registry Study.

BACKGROUND: Oral anticoagulation therapy reduces the risk of ischemic stroke in patients with atrial fibrillation (AF). However, more data on the costs of stroke in patients with AF are needed to assess how this therapy affects societal costs. OBJECTIVES: The aim of the study was to estimate the average 3-year societal costs of first-incident ischemic stroke in Danish patients with AF, including costs of health care, social care services, and productivity loss. METHODS: The study was designed as an incidence-based cost-of-illness study covering the entire Danish population. All patients with a hospital diagnosis of AF were identified, and propensity score-matched analyses were used to estimate costs attributable to first-incident stroke among patients with AF in the period 2002 to 2012. All data were obtained from nationwide registries. RESULTS: A total of 21,673 patients with AF were identified with a first-incident stroke. The average 3-year costs attributable to stroke were US $30,925 per patient (present value) corresponding to US $19,989 in the incidence year and US $7,683 and US $5,176 1 and 2 years after the stroke, respectively. Health care accounted for 66% of the 3-year costs, with hospitalizations in the incidence year as the main cost driver. After the incidence year, costs of social care services exceeded health care costs. Sensitivity analyses showed that the cost estimates were relatively robust. CONCLUSIONS: The societal costs of first-incident stroke in patients with AF are substantial. This new evidence can be valuable as an input for decision making regarding the treatment of AF and prevention of future strokes.

Labour market participation after breast cancer for employees from the private and public sectors: Educational and sector gradients in the effect of cancer.

For employees who get cancer and survive, the probability of returning to work may depend on their ability to work, potential earnings losses if they do not return to work, qualifications and job type, but also on characteristics of the pre-cancer workplace. This paper focuses on differences between public and private sector employees in the effect of breast cancer on the probability of being out of the labour force three years after the diagnosis. We use propensity score weighting methods and a large longitudinal Danish administrative dataset which allows us to control for a wide range of important baseline characteristics such as education, sector of employment, labour market status, income, health, and demographics. We find that the educational gradient in the effect of cancer is significant in the public sector, where the estimated effects are 11.5 and 3.8 percentage points, respectively, for the low- and high-educated. The corresponding estimates for the private sector are 6.2 and 3.2 percentage points and here the educational gradient is only marginally significant. We discuss possible mechanisms behind the large sector gradient for the low-educated.

Cancer stage, comorbidity, and socioeconomic differences in the effect of cancer on labour market participation: a danish register-based follow-up study.

PURPOSE: Socioeconomic inequality in return to work after cancer treatment and rehabilitation have been documented, but less is known about its causes. This paper investigates the role played by breast cancer stage at diagnosis and comorbidity. METHODS: We used the comprehensive Danish Cancer Registry to follow 7372 women aged 30-60, who were in the labour force when diagnosed with breast cancer in 2000-06 and survived at least three years. Controls were 213,276 women without breast cancer. Inequalities in employment outlook were estimated as interaction effects in linear regression between educational attainment and disease on employment. RESULTS: There is significant interaction between education and breast cancer, but it is only marginally affected by including stage and comorbidity in the regression models. Education, breast cancer stage, and comorbidity all have strong effects on later employment, and a considerable amount of the educational effect is mediated by comorbidity and pre-cancer labour market participation and income. CONCLUSION: The result of the study is negative in the sense that the stronger effect of breast cancer on employment among low-educated compared to highly educated individuals is not explained by cancer stage or comorbidity. The fact that comorbidity has little impact on inequality may be due to a different social patterning of most comorbidity compared to breast cancer.

The effect of breast cancer on personal income three years after diagnosis by cancer stage and education: a register-based cohort study among Danish females.

BACKGROUND: The purpose of this study was to investigate whether there is an association between stage of incident breast cancer (BC) and personal income three years after diagnosis. The analysis further considered whether the association differed among educational groups. METHODS: The study was based on information from Danish nationwide registers. A total of 7,372 women aged 30-60 years diagnosed with BC, 48% with metastasis, were compared to 213,276 controls. Generalised linear models were used to estimate the effect of a cancer diagnosis on personal gross income three years after diagnosis, stratified by education and stage of cancer. The models were adjusted for income two years prior to cancer diagnosis and demographic, geographic and co-morbidity covariates. RESULTS: Adjusting for income two years prior to cancer diagnosis and other baseline covariates (see above), cancer had a minor effect on personal income three years after diagnosis. The effect of metastatic BC was a statistically significant reduction in income three years after diagnosis of -3.4% (95% CI -4.8;-2.0), -2.8% (95% CI -4.3;-1.3) and -4.1 (95% CI -5.9;-2.3) among further, vocational and low educated women, respectively. The corresponding estimates for the effect of localised BC were -2.5% (95% CI -3.8; -1.2), -1.6% (95% CI -3.0; -0.2) and -1.7% (95% CI -3.7; 0.3); the latter estimate (for the low-educated) was not statistically different from zero. We found no statistically significant educational gradient in the effect of cancer stage on income. CONCLUSIONS: In a Danish context, the very small negative effect of BC on personal income may be explained by different types of compensation in low- and high-income groups. The public income transfers are equal for all income groups and cover a relatively high compensation among low-income groups. However, high-income groups additionally receive pay-outs from private pension and insurance schemes, which typically provide higher coverage for high-income workers.

Effects of breast and colorectal cancer on labour market outcomes-average effects and educational gradients.

We estimate causal effects of breast and colorectal cancer on labour market outcomes 1-3 years after the diagnosis. Based on Danish administrative data we estimate average treatment effects on the treated by propensity score weighting methods using persons with no cancer diagnosis as control group. We conduct robustness checks using matching, difference-in-differences methods and an alternative control group of later cancer patients. The different methods give approximately the same results. Cancer increases the risks of leaving the labour force and receiving disability pension, and the effects are larger for the less educated. Effects on income are small and mostly insignificant. We investigate some of the mechanisms which may be important in explaining the educational gradient in effects of cancer on labour market attachment.