Health care utilisation and characteristics of long-term breast cancer survivors: Nationwide survey in Denmark

https://doi.org/10.1016/j.ejca.2008.09.027Get rights and content

Abstract

Aim

To investigate long-term female breast cancer survivors’ (BCS’) health care utilisation, health, and employment.

Methods

An age-stratified random sample of 2000 female breast cancer survivors (BCS) 5–15 years after primary surgery without recurrence was drawn from the Danish Breast Cancer Cooperative Group register. A self-administered questionnaire assessed sociodemography, health care utilisation, employment, and health-related quality of life (HRQOL). Associations with breast cancer treatment were investigated.

Results

Response rate was 79%. Significantly more BCS than the general women population reported health care utilisation (61% versus. 56%; age-standardised risk ratio (SRR): 1.10; 95% confidence interval (CI) 1.05–1.15), but significantly fewer BCS were disability pensioners (15% versus 19%; SRR: 0.77; 95% CI 0.64–0.93). ‘Daily activities limited due to sequelae’ were reported by 20%, and ‘stopped working/changed job due to sequelae’ by 11% of BCS.

In multiple logistic regression analysis, radiotherapy (odds ratio (OR) 2.54; 95% CI 1.34–4.80) and endocrine therapy (OR 2.48; 95% CI 1.13–5.45, postmenopausal women only) were significantly related to ‘stopped working/changed job due to sequelae’. Time since surgery 5–10 years (versus >10 years) was significantly associated with ‘daily activities limited due to sequelae’ (OR 2.02; CI 1.43–2.84), which, in turn, was significantly related to poorer HRQOL (all p < 0.05). Chemotherapy, receptor status, and protocol allocation did not show significant associations in any analyses.

Conclusion

Significantly more BCS reported health care utilisation. Radiotherapy, shorter time since surgery, and endocrine therapy predicted daily activity and work limitations due to sequelae.

Introduction

When anticancer treatment is successfully finalised, it is life that matters. However, many cancer survivors are left with mental and physical sequelae,1, 2 functional limitations3, 4 and an increased need of health care5, 6 which often is not met.7 As acute cancer-related symptoms such as pain may change into chronic conditions, and as some sequelae may occur late8, population-based data on long-term sequelae, health, and health care utilisation are of increasing importance to better meet the needs of this population.

Breast cancer is the commonest incident form of malignancy among women in Europe with a 5-year-survival of about 80% in Denmark.9 With one million new cases in the world each year, breast cancer represents a major public health issue,10 and the number of breast cancer survivors (BCS) increases due to improved screening and treatment programmes. However, long-term data on BCS’ health care utilisation beyond 5-years are relatively sparse.

We found previously that long-term BCS frequently reported sequelae such as chronic pain (42%), paraesthesia (47%), swelling of arm/shoulder (25%), phantom pain (19%), and allodynia (15%).1 Interestingly, at the same time this population-based sample of BCS reported a similar to or even slightly better health-related quality of life (HRQOL) compared to the general population data.11

In this study, we aimed at investigating daily activity, employment characteristics, and health care utilisation by BCS using the same nationally representative approach. Some data on BCS could be compared to data from the general population derived from another Danish survey,12 enabling us to identify findings characteristic for BCS.

Section snippets

Study design

Patients diagnosed with breast cancer from 1989 to 1999 were selected from the database of the Danish Breast Cancer Cooperative Group (DBCG) among those who had survived for 5–15 years after primary breast cancer surgery without recurrence or a second cancer. In total, 11,243 women of the DBCG database met the inclusion criteria. The sample design was an age-stratified sample, randomly selecting 500 BCS into each stratum (18–49; 50–59; 60–69; and ⩾70 years). Subsequent analysis led to exclusion

Respondents and non-respondents

Selection of BCS and participation are shown in Fig. 1. Table 1 shows characteristics of responders and non-responders among BCS. High age of participants (⩾70 years) was significantly associated with non-response.

Concerning the data of the general female population sample that we were allowed to access, 7256 women (⩾40 years) were randomly selected, of whom 5208 had completed the interview (72%). The final general population sample included 4865 women, because 343 were excluded due to report

Discussion

Overall, BCS were in contact with the health care system significantly more often than women of the general population, indicating more frequent needs in BCS. The finding that increased health care utilisation is prevalent 5–15 years after breast cancer treatment suggests that breast cancer survival is associated with chronic morbidity. This result is supported by evidence of higher comorbidity in BCS compared to survivors of other cancers2 and compared to women without a cancer history.3, 18

Conclusion

This study identified BCS as a population with chronic morbidity as reflected in the significantly higher prevalence of health care utilisation. While reporting a comparable, high-quality of life, BCS have limitations in daily activities compared to the general women population. Our data suggest that in the long run probably the combination of sociodemographic factors – mainly age, short education, and being single – as well as treatment-related factors – mainly radiotherapy and shorter time

Conflict of interest statement

None declared.

Acknowledgements

The project was financially supported mainly by the Danish Cancer Society. Further funding was also received from the following: ‘Handelsgartner Ove William Buhl Olesen og ægtefælle fru Edith Buhl Olesens’ ‘Mindelegat’, ‘Krista og Viggo Petersens’s Fond’, ‘Beckett– Fonden’, ‘Gangstedfonden’, and ‘Willy og Ingeborg Reinhards Fond’.

References (36)

  • F. Mols et al.

    Quality of life among long-term breast cancer survivors: a systematic review

    Eur J Cancer

    (2005)
  • M. Norredam et al.

    Effect of social class on tumour size at diagnosis and surgical treatment in Danish women with breast cancer

    Soc Sci Med

    (1998)
  • Peuckmann V, Ekholm O, Rasmussen Nk, et al. Chronic pain and other sequelae in long-term breast cancer survivors:...
  • T.N. Chirikos et al.

    Functional impairment and the economic consequences of female breast cancer

    Women Health

    (2002)
  • C. Sweeney et al.

    Functional limitations in elderly female cancer survivors

    J Natl Cancer Inst

    (2006)
  • L.V. van de Poll-Franse et al.

    Increased health care utilisation among 10-year breast cancer survivors

    Support Care Cancer

    (2006)
  • Hoybye MT, Dalton SO, Christensen J, et al. Research in Danish cancer rehabilitation: Social characteristics and late...
  • K. Hodgkinson et al.

    Breast cancer survivors’ supportive care needs 2–10 years after diagnosis

    Support Care Cancer

    (2007)
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