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 invest...

Background: With a growing population of cancer survivors in Denmark, the evaluation of health‐related quality of life (HRQoL) has become increasingly important. We describe variations in HRQoL between educational groups in a national population of cancer survivors.Methods: We conducted a cross‐sectional questionnaire study among breast, prostate, lung, and colon cancer survivors diagnosed in 2010–2019 in Denmark. We used the EORTC QLQ‐C30 to assess HRQoL including physical, role, emotional, cognitive, social functioning, and symptoms (fatigue, nausea and vomiting, pain, dyspnea, insomnia, appetite loss, constipation, diarrhea, and financial difficulties). Information on educational level and clinical data were extracted from national registers and clinical databases. Levels of impaired functioning and severe symptoms were identified using newly established thresholds for clinical importance. Multivariate logistic regression was used to examine associations between education and HRQoL. All statistical tests were 2‐sided.Results: In total, 27,857 (42%) participated in the study. Up to 72% and 75% of cancer survivors with short education (≤9 years) reported impaired functioning and severe symptoms, respectively. Cancer survivors with short compared to long education (>12 years) were more likely to report impaired functioning and severe symptoms, with for example significantly higher odds ratios (ORs) for impaired physical function (breast OR = 2.41, 99% CI = 2.01–2.89; prostate OR = 1.81, 99% CI = 1.48–2.21; lung OR = 2.97, 99% CI = 1.95–4.57; and colon cancer OR = 1.69, 99% CI = 1.28–2.24).Conclusions: Cancer survivors with short education are at greater risk of impaired HRQoL than survivors with long education 2–12 years after diagnosis. This underscores the need for systematic screening and symptom management in cancer aftercare, in order to reach all cancer survivors, also cancer survivors with short education.

Background: Many cancer survivors experience late effects after cancer. Comorbidity, health literacy, late effects, and help-seeking behavior may affect healthcare use and may differ among socioeconomic groups. We examined healthcare use among cancer survivors, compared with cancer-free individuals, and investigated educational differences in healthcare use among cancer survivors. Methods: A Danish cohort of 127,472 breast, prostate, lung, and colon cancer survivors from the national cancer databases, and 637,258 age- and sex-matched cancer-free individuals was established. Date of entry was 12 months after diagnosis/index date (for cancer-free individuals). Follow-up ended at death, emigration, new primary cancer, December 31st, 2018, or up to 10 years. Information about education and healthcare use, defined as the number of consultations with general practitioner (GP), private practicing specialists (PPS), hospital, and acute healthcare contacts 1–9 years after diagnosis/index date, was extracted from national registers. We used Poisson regression models to compare healthcare use between cancer survivors and cancer-free individuals, and to investigate the association between education and healthcare use among cancer survivors. Results: Cancer survivors had more GP, hospital, and acute healthcare contacts than cancer-free individuals, while the use of PPS were alike. One-to-four-year survivors with short compared to long education had more GP consultations (breast, rate ratios (RR) = 1.28, 95% CI = 1.25–1.30; prostate, RR = 1.14, 95% CI = 1.10–1.18; lung, RR = 1.18, 95% CI = 1.13–1.23; and colon cancer, RR = 1.17, 95% CI = 1.13–1.22) and acute contacts (breast, RR = 1.35, 95% CI = 1.26–1.45; prostate, RR = 1.26, 95% CI = 1.15–1.38; lung, RR = 1.24, 95% CI = 1.16–1.33; and colon cancer, RR = 1.35, 95% CI = 1.14–1.60), even after adjusting for comorbidity. One-to-four-year survivors with short compared to long education had less consultations with PPS, while no association was observed for hospital contacts. Conclusion: Cancer survivors used more healthcare than cancer-free individuals. Cancer survivors with short education had more GP and acute healthcare contacts than survivors with long education. To optimize healthcare use after cancer, we need to better understand survivors’ healthcare-seeking behaviors and their specific needs, especially among survivors with short education.

The number of cancer survivors is increasing worldwide, largely due to ageing populations, advances in early detection and cancer treatment. ¹ The 5-year prevalences of cancer survivors in Denmark have increased by almost 200% from 2000 to 2020, and close to 6% of the Danish population have been diagnosed with cancer. ² Extensive research has established that globally, but also in countries with equal and free access to health care, there is social inequality in stage at cancer diagnosis, treatment provided and survival. ³ Since the introduction of cancer treatment by surgery, then radiation and later systemic chemotherapy, late effects have been a part of the aftermath accompanying survival. Late effects are defined as physiological and psychological symptoms or disorders which occur during or after end of treatment and which may become long-term or chronic. ¹ Little is known about social inequality in late effects. A Danish national study of 458 646 adult cancer survivors showed a significantly increased risk of other diseases in all but one of 11 major diagnostic groups, such as diseases in the nervous system and endocrine, cardiovascular, metabolic and respiratory disorders, for cancer survivors across cancer types up to 17 years after treatment compared with cancer-free individuals. This cohort study included only cancer survivors free of the diseases in the diagnostic group prior to the date of the cancer diagnosis. ⁴ A prospective cohort from the USA of more than 12 000 people observed a 37% higher risk of cardiovascular disease and up to 52% higher risk of heart failure in adult cancer survivors compared with cancer-free individuals, depending on cancer type and treatment. ⁵ Additionally, systematic reviews and meta-analyses found that up to 49% of cancer survivors suffer from fatigue ⁶ and 47% suffer from pain. ⁷ A Danish nationwide study reported that 57% have impaired sex life. ⁸ Furthermore, a systematic review of 20 studies of psychological symptoms among long-term cancer survivors showed that 21% reported having depression, ⁹ and another systematic review of 43 studies on mood disorders among long-term cancer survivors found a prevalence of anxiety of 18%. ¹⁰ An American population-based cohort study found that 20% of breast cancer survivors have lymphoedema 2 years after diagnosis. ¹¹ Late effects comprise several other conditions, including sleep problems, peripheral neuropathy, cognitive impairments, physical limitations, problems with body image, psychological issues and reduced quality of life, as well as familial, financial and employment problems. ^{12, 13} Thus, physical, psychological and social complications after cancer and cancer treatment should be considered. Not all late effects can be measured objectively, which makes it crucial to include the patient’s perspective. ¹⁴