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.

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.

Validation of a digital photographic method for assessment of dietary quality of school lunch sandwiches brought from home.

BACKGROUND: It is a challenge to assess children's dietary intake. The digital photographic method (DPM) may be an objective method that can overcome some of these challenges. OBJECTIVE: The aim of this study was to evaluate the validity and reliability of a DPM to assess the quality of dietary intake from school lunch sandwiches brought from home among children aged 7-13 years. DESIGN: School lunch sandwiches (n=191) were prepared to represent randomly selected school lunch sandwiches from a large database. All components were weighed to provide an objective measure of the composition. The lunches were photographed using a standardised DPM. From the digital images, the dietary components were estimated by a trained image analyst using weights or household measures and the dietary quality was assessed using a validated Meal Index of Dietary Quality (Meal IQ). The dietary components and the Meal IQ obtained from the digital images were validated against the objective weighed foods of the school lunch sandwiches. To determine interrater reliability, the digital images were evaluated by a second image analyst. RESULTS: Correlation coefficients between the DPM and the weighed foods ranged from 0.89 to 0.97. The proportion of meals classified in the same or an adjacent quartile ranged from 98% (starch) to 100% (fruits, vegetables, fish, whole grain, and Meal IQ). There was no statistical difference between fish, fat, starch, whole grains, and Meal IQ using the two methods. Differences were found for fruits and vegetables; Bland-Altman analyses showed a tendency to underestimate high amounts of these variables using the DPM. For interrater reliability, kappa statistics ranged from 0.59 to 0.82 across the dietary components and Meal IQ. CONCLUSIONS: The standardised DPM is a valid and reliable method for assessing the dietary quality of school lunch sandwiches brought from home.

Equity in the use of publicly subsidized psychotherapy among elderly Danish cancer patients--a register-based cohort study.

UNLABELLED: Approximately 30% of cancer patients suffer from psychological distress, and psychotherapy has been shown to be effective in alleviating it. Based on the 'Behavioral Model of Health Service Use', we investigated equity in the use of publicly subsidized psychotherapy in a cohort of Danish cancer patients. We present descriptive data on patients' use of psychotherapy and examine characteristics of those who used this service. MATERIAL AND METHODS: The study population comprised 3646 participants in the prospective Diet, Cancer and Health cohort, diagnosed with a first cancer between 2003 and 2009, aged 56-80 years. Data on cancer diagnosis, psychotherapy use and comorbid conditions were obtained from registers, whereas data on demographics, social support and health status were obtained from questionnaires. Cox proportional hazards regression was used to identify factors related to use, which were subsequently evaluated with regard to equity. RESULTS: Subsidized psychotherapy was used by 2.3% of the cancer patients. Longer education (> 10 years compared to < 8) was associated with greater likelihood of initiating psychotherapy [hazard ratio (HR), 1.97; 95% confidence interval (CI), 1.06-3.65], as was previous psychotherapy use compared to no previous use (2.86; 1.32-6.20). Patients with partners who did not reliably provide emotional support were significantly more likely to use psychotherapy than those without a partner (2.36; 1.05-5.30), a difference not found for those with partners who did provide support. Further, a higher SF-36 mental component score (0.96; 0.94-0.98, per point increase), and older age were associated with less use (65-69 years: 0.43; 0.21-0.89, 70-74 years: 0.17, 0.07-0.41; > 74 years: 0.07, 0.01-0.57, compared to < 60 years). CONCLUSIONS: The results allow several possible interpretations. We found that mental health plays a role for accessing subsidized psychotherapy, suggesting that use of psychotherapy is predicted by need and thus characterized by equity. However, education and previous psychotherapy use also play a role, suggesting elements of inequity.