Use of health services among long-term breast cancer survivors in Spain: longitudinal study based on real-world data



This study aimed to evaluate health service utilization in Spain among long-term breast cancer survivors and to compare it with that among women with no history of breast cancer.


Study based on the SURBCAN cohort includes a sample of long-term breast cancer survivors and a sample of women without breast cancer from 5 Spanish regions. Healthcare utilization was assessed through primary care, hospital visits, and tests during the follow-up period (2012 to 2016) by using electronic health records. Annual contact rates to healthcare services were calculated, and crude and multivariate count models were fitted to estimate the adjusted relative risk of healthcare services use.


Data were obtained from 19,328 women, including 6512 long-term breast cancer survivors. Healthcare use was higher among breast cancer survivors (20.9 vs 16.6; p < 0.0001) and decreased from >10 years of survival. Breast cancer survivors who underwent a mastectomy were more likely to have a primary care visit (RR = 3.10 95% CI 3.08–3.11). Five to ten years survivors were more likely to have hospital inpatient visits and imaging test compared to women without breast cancer (RRa = 1.35 95% CI 1.30–1.39 and RRa = 1.27 95% CI 1.25–1.29 respectively).


This study shows higher use of health services in long-term breast cancer survivors than in women without breast cancer regardless of survival time.

Implications for Cancer Survivors

These results help to estimate the health resources needed for the growing group of breast cancer survivors and to identify risk factors that drive higher use of health services.

This is a preview of subscription content, access via your institution.

Figure 1

Data availability

Further details of the data analyzed in this work are available from the corresponding author on request.


  1. 1.

    Cardoso F, Harbeck N, Barrios C, Bergh J, Cortés J, El Saghir N, et al. Research needs in breast cancer. Ann Oncol. 2017;28(2):208–17.

    CAS  Article  Google Scholar 

  2. 2.

    American Cancer Society. Cancer Facts & Figures 2019. Atlanta: American Cancer Society; 2019. Accessed 19 Feb 2020

    Google Scholar 

  3. 3.

    Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424. Erratum in: CA Cancer J Clin. 2020 Jul;70(4):313.

    Article  Google Scholar 

  4. 4.

    Stat Bite: Cancer Survivors In The United States. J Natl Cancer Inst. 2008;100(4):236.

  5. 5.

    Hewitt M, Greenfield S, Stovall E. From cancer patient to cancer survivor: lost in transition. Washington, DC: National Academies Press; 2005.

    Google Scholar 

  6. 6.

    Erikson C, Salsberg E, Forte G, Bruinooge S, Goldstein M. Future simply and demand for oncologist: challenges to assuring access to oncology services. J Oncol Pract. 2007;3(2):79–86.

    Article  Google Scholar 

  7. 7.

    Noone AM, Cronin KA, Altekruse SF, Howlader N, Lewis DR, Petkov VI, et al. Cancer incidence and survival trends by subtype using data from the surveillance epidemiology and end results program, 1992-2013. Cancer Epidemiol Biomark Prev. 2017;26(4):632–41.

    Article  Google Scholar 

  8. 8.

    Baeyens-Fernández JA, Molina-Portillo E, Pollán M, Rodríguez-Barranco M, del Moral R, Arribas-Mir L, et al. Trends in incidence, mortality and survival in women with breast cancer from 1985 to 2012 in Granada, Spain: a population-based study. BMC Cancer. 2018;18(1):781.

    Article  Google Scholar 

  9. 9.

    Engholm G, Ferlay J, Christensen N, Bray F, Gjerstorff ML, Klint A, et al. NORDCAN-a Nordic tool for cancer information, planning, quality control and research. Acta Oncol. 2010;49(5):725–36.

    Article  Google Scholar 

  10. 10.

    Cancer research UK. Accessed 16 March 2020.

  11. 11.

    Runowicz C, Leach C, Henry N, Henry K, MEckey H, Cowens-Alvarado R, et al. American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Cre Guideline. CA Cancer J Clin. 2016;66(1):43–73.

    Article  Google Scholar 

  12. 12.

    Alba E, Cruz J, Barón F, Rodríguez X, Blasco A, Escobar Y, et al. Monográfico SEOM de largos supervivientes en cáncer. Sociedad Española de Oncología Médica. Madrid: 2012. Accessed 31 March 2020.

  13. 13.

    McBride ML, Groome PA, Decker K, et al. Adherence to quality breast cancer survivorship care in four Canadian provinces: a CanIMPACT retrospective cohort study. BMC Cancer. 2019;19(1):659.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Chen YY, Hsieh CI, Chung KP. Continuity of care, follow-up care, and outcomes among breast cancer survivors. Int J Environ Res Public Health. 2019;16(17):3050.

    Article  PubMed Central  Google Scholar 

  15. 15.

    Ong WL, Schouwenburg MG, van Bommel ACM, Stowell C, Allison KH, Benn KE, et al. A Standard Set of Value-Based Patient-Centered Outcomes for Breast Cancer: The International Consortium for Health Outcomes Measurement (ICHOM) Initiative. JAMA Oncol. 2017;3(5):677–85.

    Article  PubMed  Google Scholar 

  16. 16.

    Rubinstein EB, Miller WL, Hudson SV, Howard J, O’Malley D, Tsui J, et al. Cancer survivorship care in advanced primary care practices: a qualitative study of challenges and opportunities. JAMA Intern Med. 2017;177(12):1726–32.

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Jansana A, Posso M, Guerrero I, Prados-Torres A, Del Cura I, Castells X, et al. Health care services use among long-term breast cancer survivors: a systematic review. J Cancer Surviv. 2019;13:477–93.

    Article  Google Scholar 

  18. 18.

    Khan N, Watson E, Rose P. Primary care consultation behaviors of long-term, adult survivors of cancer in the UK. Br J Gen Pract. 2011;61(584):197–9.

    Article  Google Scholar 

  19. 19.

    Nord C, Mykletun A, Thorsen L, Bjøro T, Fosså SD. Self-reported health and use of health care services in long-term cancer survivors. Int J Cancer. 2005;114(2):307–16.

    CAS  Article  Google Scholar 

  20. 20.

    Poll-Franse L, Mols F, Vingerhoets A, Voogd A, Roumen R, Coebergh J. Increased health care utilisation among 10-year breast cancer survivors. Support Care Cancer. 2005;14:436–43.

    Article  Google Scholar 

  21. 21.

    Grunfeld E, Hodgson DC, Del Giudice ME, Moineddin R. Population-based longitudinal study of follow-up care for breast cancer survivors. J Oncol Pract. 2010;6(4):174–81.

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Patnaik JL, Byers T, Diguiseppi C, Denberg TD, Dabelea D. The influence of comorbidities on overall survival among older women diagnosed with breast cancer. J Natl Cancer Inst. 2011;103(14):1101–11.

    Article  Google Scholar 

  23. 23.

    Miller K, Siegel R, Lin C, Mariotto A, Kramer J, Rowland J, et al. Cancer treatment and survivorship statistics, 2016. CA Cancer J Clin. 2016;66(4):271–89.

    Article  Google Scholar 

  24. 24.

    Yan S, Kwan YH, Thumboo J, Low LL. Characteristics and health care utilization of different segments of a multiethnic Asian population in Singapore. JAMA Netw Open. 2019;2(9):e1910878.

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Jutte D, Roos L, Brownell M. Administrative record linkage as a tool for public health research. Annu Rev Public Health. 2011;32(1):91–108.

    Article  Google Scholar 

  26. 26.

    Birkhead GS. Successes and continued challenges of electronic health records for chronic disease surveillance. Am J Public Health. 2017;107(9):1365–7.

    Article  Google Scholar 

  27. 27.

    Jansana A, Del Cura I, Prados-Torres A, Sanz Cuesta T, Poblador-Plou B, Gimeno Miguel A, et al. Use of real-world data to study health services utilisation and comorbidities in long-term breast cancer survivors (the SURBCAN study): study protocol for a longitudinal population-based cohort study. BMJ Open. 2020;10(9):e040253.

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Prados-Torres A, Poblador-Plou B, Gimeno-Miguel A, Calderón-Larrañaga A, Poncel-Falcó A, Gimeno-Feliú LA, et al. Cohort profile: the epidemiology of chronic diseases and multimorbidity. The EpiChron Cohort Study. Int J Epidemiol. 2018;47(2):382–384f.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Bannay A, Chaignot C, Blotière PO, Basson M, Weill A, Ricordeau P, et al. The best use of the Charlson Comorbidity Index with electronic health care databases to predict mortality. Med Care. 2016;54(2):1881–194.

    Article  Google Scholar 

  30. 30.

    Brusselaers N, Lagergren J. The Charlson comorbidity index in Registry-based research. Methods Inf Med. 2017;56(5):401–6.

    Article  Google Scholar 

  31. 31.

    Snyder CF, Frick KD, Peairs KS, Kantsiper ME, Herbert RJ, Blackford A, et al. Comparing care for breast cancer survivors to non-cancer controls: a five-year longitudinal study. J Gen Intern Med. 2009;24:469–74.

    Article  Google Scholar 

  32. 32.

    Kendell C, Decker KM, Groome PA, McBride ML, Jiang L, Krzyzanowska MK, et al. Use of physician services during the survivorship phase: a multi-province study of women diagnosed with breast cancer. Curr Oncol. 2017;24(2):81–9.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Clèries R, Ameijide A, Buxó M, Martínez JM, Marcos-Gragera R, Vilardell ML, et al. Long-term crude probabilities of death among breast cancer patients by age and stage: a population-based survival study in Northeastern Spain (Girona-Tarragona 1985-2004). Clin Transl Oncol. 2018;20:1252–60.

    Article  Google Scholar 

  34. 34.

    Hofvind S, Holen, Aas T, Roman M, Sebuødegård S, Akslen LA. Women treated with breast conserving surgery do better than those with mastectomy independent of detection mode, prognostic and predictive tumor characteristics. Eur J Surg Oncol. 2015;41(10):1417–22.

    CAS  Article  Google Scholar 

  35. 35.

    Miret C, Domingo L, Louro J, Barata T, Baré M, Ferrer J, et al. Factors associated with readmissions in women participating in screening programs and treated for breast cancer: a retrospective cohort study. BMC Health Serv Res. 2019;19(1):940.

    Article  Google Scholar 

  36. 36.

    Clèries R, Buxó M, Yasui Y, Marcos-Gragera R, Martínez JM, Ameijide A, et al. Estimating long-term crude probability of death among young breast cancer patients: a Bayesian approach. Tumori. 2016;102(6):555–61.

    Article  Google Scholar 

  37. 37.

    Dal Maso L, Guzzinati S, Buzzoni C, Capocaccia R, Serraino D, Caldarella A, et al. Long-term survival, prevalence, and cure of cancer: a population-based estimation for 818 902 Italian patients and 26 cancer types. Ann Oncol. 2014;25(11):2251–60.

    CAS  Article  Google Scholar 

  38. 38.

    Virgo KS, Lerro CC, Klabunde CN, Earle C, Ganz PA. Barriers to breast and colorectcancer survivorship care: perceptions of primary care physicians and medical oncologists in the United States. J Clin Oncol. 2013;31(18):2322–36.

    Article  Google Scholar 

  39. 39.

    Baena-Cañada JM, Ramírez-Daffós P, Cortés-Carmona C, Rosado-Varela P, Nieto-Vera J, Benítez-Rodríguez E. Follow-up of long-term survivors of breast cancer in primary care versus specialist attention. Fam Pract. 2013;30(5):525–32.

    Article  Google Scholar 

  40. 40.

    Urquhart R, Folkes A, Babineau J, Grunfeld E. Views of breast and colorectal cancer survivors on their routine follow-up care. Curr Oncol. 2012;19(6):294–301.

    CAS  Article  Google Scholar 

  41. 41.

    Khan NF, Carpenter L, Watson E, Rose PW. Cancer screening and preventative care among long-term cancer survivors in the United Kingdom. Br J Cancer. 2010;102:1085–90.

    CAS  Article  Google Scholar 

  42. 42.

    Grunfeld E, Julian JA, Pond G, Maunsell E, Coyle E, Folkes A, et al. Evaluating survivorship care plans: results of a randomized, clinical trial of patients with breast cancer. J Clin Oncol. 2011;29(36):4755–62.

    Article  Google Scholar 

  43. 43.

    Jones T, Duquette D, Underhill M, Ming C, Menderlsohn-Victor K, Anderson B, et al. Surveillance for cancer recurrence in long-term young breast cancer survivors randomly selected from a statewide cancer registry. Breast Cancer Res Treat. 2018;169:141–52.

    Article  Google Scholar 

  44. 44.

    Field TS, Doubeni C, Fox MP, Buist DSM, Wei F, Geiger AM, et al. Under Utilization of Surveillance Mammography among Older Breast Cancer Survivors. J Gen Intern Med. 2007;23:158–63.

    Article  Google Scholar 

  45. 45.

    Bouvard B, Chatelais J, Soulié P, Hoppé E, Saulnier P, Capitain O, et al. Osteoporosis treatment and 10 years' oestrogen receptor+ breast cancer outcome in postmenopausal women treated with aromatase inhibitors. Eur J Cancer. 2018;101:87–94.

    CAS  Article  PubMed  Google Scholar 

  46. 46.

    Recalde M, Manzano-Salgado CB, Díaz Y, Garcia-Gil MDM, Marcos-Gragera R, Ribes-Puig J. Validation of cáncer diagnoses in electronic health records: results from the Information System for Research in Primary Care (SIDIAP) in Northeast Spain. Clin Epidemiol. 2019;11:1015–24.

    Article  Google Scholar 

  47. 47.

    Cantarero-Prieto D, Pascual-Sáez M, Gonzalez-Prieto N. Effect of having private health insurance on the use of health care services: the case of Spain. BMC Health Serv Res. 2017;17:716.

    Article  Google Scholar 

  48. 48.

    Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J, Rosso S, Coebergh JWW, Comber H, et al. Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012. Eur J Cancer. 2013;49:1374–03.

    CAS  Article  Google Scholar 

Download references


Anna Jansana is a Ph.D. candidate at the Methodology of Biomedical Research and Public Health program, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain (European Higher Education Area Doctoral Program in Methodology of Biomedical Research and Public Health in Department of Pediatrics, Obstetrics and Gynecology, Preventive Medicine and Public Health, Universitat Autónoma de Barcelona (UAB), Bellaterra, Barcelona, Spain).

The authors acknowledge the dedication and support of the SURBCAN Study Group (alphabetical order): IMIM (Hospital del Mar Medical Research Institute), Barcelona: Mercè Abizanda, Xavier Castells, Mercè Comas, Laia Domingo, Talita Duarte, Anna Jansana, Javier Louro, and María Sala. Hospital Costa del Sol, University of Malaga: María del Carmen Martínez, Cristóbal Molina, María del Carmen Padilla, and Maximino Redondo. Grupo EpiChron de Investigación en Enfermedades Crónicas, del Instituto Aragonés de Ciencias de la Salud, Aragón: Antonio Gimeno, Manuela Lanzuela, Beatriz Poblador, and Alexandra Prados. Primary Care Research Unit. Gerencia de Atención Primaria, Hospital Universitario 12 de Octubre, Madrid: Ángel Alberquilla, Isabel del Cura, Antonio Díaz, Teresa Sanz, Guillermo Pérez, Ana María Muñoz, Francisco Javier Salamanca, and Óscar Toldos. Grupo de investigación en servicios sanitarios y cronicidad de la Fundación Miguel Servet, Navarra: Javier Baquedano, Rossana Burgui, Javier Gorricho, Berta Ibáñez, Conchi Moreno, and Ibai Tamayo.


This work was supported by Carlos III Health Institute [PI16/00244] and [PI19/00056] and by FEDER (European Regional Development Fund/European Social Fund) and by the Research Network on Health Services in Chronic Diseases [RD16/0001/0013].

Author information




MS, AJ, LD, BI, IDC, AP, and MR made substantial contributions to the design and conception of the study. AD, TS, and IDC took responsibility for the data acquisition of the Madrid sub-cohort; BP, AG, and ML for the Aragon sub-cohort; MP, MCM, and CM for the Costa del Sol sub-cohort; JG, JB, CM, and RB for the Navarre sub-cohort; and MS, AJ, JL, TDS, MC, LD, and MA for the Hospital del Mar sub-cohort. AJ took responsibility for data analysis, interpretation, and drafting the article.

MS, LD, MC, XC, BI, AP, MR, IDC provided advice for the study design, critical interpretation of the study, and gave final approval of the version to be published. All of the authors have read and approved the manuscript.

Corresponding author

Correspondence to Maria Sala.

Ethics declarations

Ethics approval and consent to participate

This article does not contain any studies with human participants or animals performed by any of the authors. This project was accepted by the Clinical Research Ethics Committee of Parc de Salut Mar (n°2016/6835/I).

Informed consent

For this type of study, formal consent is not required.

Conflict of interest

The authors declare no conflict of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information


(DOC 84 kb).


(DOCX 24 kb).


(DOCX 22 kb).

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Jansana, A., Domingo, L., Ibañez, B. et al. Use of health services among long-term breast cancer survivors in Spain: longitudinal study based on real-world data. J Cancer Surviv (2021).

Download citation


  • Breast cancer
  • Health services research
  • Cancer survivors
  • Primary care
  • Survival care
  • Real-world data