A descriptive study of UK cancer genetics services: an emerging clinical response to the new genetics

The objective was to describe NHS cancer genetic counselling services and compare UK regions. The study design was a cross-sectional study over 4 weeks and attendee survey. The setting was 22 of the 24 regional cancer genetics services in the UK NHS. Participants were individuals aged over 18 attending clinics at these services. Outcome measures were staff levels, referral rates, consultation rates, follow-up plans, waiting time. There were only 11 dedicated cancer geneticists across the 22 centres. Referrals were mainly concerned with breast (63%), bowel (18%) and ovarian (12%) cancers. Only 7% of referrals were for men and 3% were for individuals from ethnic minorities. Referral rates varied from 76 to 410 per million per annum across the regions. Median waiting time for an initial appointment was 19 weeks, ranging across regions from 4 to 53 weeks. Individuals at population-level genetic risk accounted for 27% of consultations (range 0%, 58%). Shortfalls in cancer genetics staff and in the provision of genetic testing and cancer surveillance have resulted in large regional variations in access to care. Initiatives to disseminate referral and management guidelines to cancer units and primary care should be adequately resourced so that clinical genetics teams can focus on the genetic testing and management of high-risk families.

Evidence for inadequate construct validity of the Disease Repercussions Profile in people with rheumatoid arthritis

OBJECTIVE

To re-evaluate the construct validity of the Disease Repercussions Profile (DRP), a measure of handicap in arthritis populations.

METHODS

We used the multitrait-multimethod approach to determine convergent and discriminant validity in a postal survey of randomly selected patients with rheumatoid arthritis who had attended the Wellington Regional Rheumatology Unit since 1988. Respondents (n=142) completed the following self-report instruments: Disease Repercussions Profile, EuroQol EQ-5D, Health Assessment Questionnaire, London Handicap Scale and WHOQOL-BREV.

RESULTS AND CONCLUSIONS

The pattern of correlation supported the construct validity of the dichotomous response question (DRP domain affected or not) for the activity and relationships domain, provided ambiguous support for the appearance and emotion domain and no support for the social and financial domains. There was no support for construct validity of any of the domains on the importance rating part of the DRP. We suggest that the DRP be interpreted cautiously in aggregated group data.

Mortality in England and Wales attributable to current alcohol consumption

STUDY OBJECTIVE

To estimate the number of deaths attributable to current alcohol consumption levels in England and Wales by age and sex.

DESIGN

Epidemiological approach using published relative risks and population data.

SETTING

England and Wales.

MAIN OUTCOME MEASURES

Numbers of deaths by age and sex and years of life lost for alcohol related conditions.

RESULTS

Because of the cardioprotective properties of alcohol, it is estimated that there are approximately 2% fewer deaths annually in England and Wales than would be expected in a non-drinking population. This proportion varies greatly by age and sex and only among men aged over 55 years and women aged over 65 years is there likely to be found a net favourable mortality balance. It is also estimated that there were approximately 75 000 premature years of life lost in England and Wales in 1996 attributable to alcohol consumption. The main causes of alcohol attributable mortality among the young include road traffic fatalities, suicide and alcoholic liver disease.

CONCLUSIONS

At a population level, current alcohol consumption in England and Wales may marginally reduce mortality. However, the benefit is disproportionately found among the elderly. Estimating alcohol attributable mortality by age and sex may be a useful indicator for developing alcohol strategies. More research into the possible effect modifications of pattern of consumption, beverage type, age and gender will enable these estimates to be improved.

Systematic review of the prospective cohort studies on meat consumption and colorectal cancer risk: a meta-analytical approach

The relation between meat consumption and colorectal cancer risk remains controversial. In this report, we quantitatively reviewed the prospective observational studies that have analyzed the relation between meat consumption and colorectal cancer. We conducted electronic searches of MEDLINE, EMBASE, and CANCERLIT databases through to the end of June 1999 and manual searches of references from retrieved articles. We used both fixed and random-effects meta-analytical techniques to estimate the overall association and to investigate possible sources of heterogeneity among studies. Thirteen studies were eligible for inclusion in the meta-analysis. Pooled results indicate that a daily increase of 100 g of all meat or red meat is associated with a significant 12-17% increased risk of colorectal cancer. The marginally significant between-study heterogeneity for all meat and red meat was explained by a number of study-level covariates. A significant 49% increased risk was found for a daily increase of 25 g of processed meat. The individual study estimates for processed meat showed no detectable heterogeneity. On the basis of this quantitative review of prospective studies, the overall association between meat consumption and risk of colorectal cancer appears to be positive, with marginal heterogeneity between studies. The finding for processed meat and data from experimental studies suggests that it may also be an important predictor of colorectal cancer risk. However, because only a few of the studies reviewed here attempted to examine the independent effect of meat intake on colorectal cancer risk, the possibility that the overall association may be confounded or modified by other factors cannot be excluded.

Modelling the short term consequences of smoking cessation in England on the hospitalisation rates for acute myocardial infarction and stroke

OBJECTIVES

To estimate the short term event and cost consequences of achieving two smoking cessation targets for England among a cohort of 35-64 year olds, in terms of the number of hospitalised acute myocardial infarctions (AMIs) and strokes avoided.

DESIGN

A spreadsheet model based on previous work and using data for England was constructed to simulate the effects of achieving the target set out in the government's tobacco white paper (target 1). We also examined the consequence of achieving the intensive smoking reduction witnessed in California (target 2).

RESULTS

Target 1 would result in 347 AMI and 214 stroke hospitalisations avoided in the year 2000, and by 2010 this would be 6386 AMI and 4964 strokes avoided. Achieving target 2 would result in 739 AMI and 455 stroke hospitalisations avoided in 2000, and 14 554 AMI and 11 304 strokes avoided by 2010. Achieving target 1 would save pound524 million ( pound423 million discounted at a rate of 2.67% for stroke and 2.31% for AMI) and target 2 would save pound1.14 billion ( pound921 million discounted) in terms of National Health Service costs.

CONCLUSION

In the short term (11 years), reductions in the prevalence of smoking will produce sizeable reductions in both events and hospital costs.

Faith, hope, and charity: an in-depth interview study of cancer patients' information needs and information-seeking behavior

OBJECTIVE: To explore why cancer patients do not want or seek information about their condition beyond that volunteered by their physicians at times during their illness. DESIGN: Qualitative study based on in-depth interviews. SETTING: Outpatient oncology clinics at a London cancer center. PARTICIPANTS: 17 patients with cancer diagnosed in previous 6 months. Main outcome measures Analysis of patients' narratives to identify key themes and categories. RESULTS: While all patients wanted basic information on diagnosis and treatment, not all wanted further information at all stages of their illness. Three overarching attitudes to their management of cancer limited patients' desire for and subsequent efforts to obtain further information : faith, hope, and charity. Faith in their doctor's medical expertise precluded the need for patients to seek further information themselves. Hope was essential for patients to carry on with life as normal and could be maintained through silence and avoiding information, especially too detailed or "unsafe" information. Charity to fellow patients, especially those seen as more needy than themselves, was expressed in the recognition that scarce resources-including information and explanations-had to be shared and meant that limited information was accepted as inevitable. CONCLUSIONS: Cancer patients' attitudes to cancer and their strategies for coping with their illness can constrain their wish for information and their efforts to obtain it. In developing recommendations, the government's cancer information strategy should attend to variations in patients' desires for information and the reasons for them.

H2-receptor antagonists may increase the risk of cardio-oesophageal adenocarcinoma: a case-control study

Adenocarcinoma of the lower oesophagus and the gastric cardia has shown a dramatic worldwide increase in incidence over the last 25 years, but the cause is unknown. A large number of drugs have been introduced over this period of time, and it has been suggested that drugs that relax the lower oesophageal sphincter (DRLOS) might be causative, and on the other hand that non-steroidal anti-inflammatory drugs (NSAIDS) may be protective. H2-receptor antagonists (H2RAs) may allow achlorhydric reflux to continue without symptoms, and it is postulated that such asymptomatic reflux is uncontrolled by the usual conservative measures and may lead to increased oesophageal damage. H2RAs were first marketed in 1970 and might be the cause of the observed increase of cardio-oesophageal adenocarcinoma (COA). In a case-control study, the records of 56 subjects who died of COA in the period 1 January 1990 to 31 December 1992 were compared with those of 56 age-/sex-matched controls who died of myocardial infarction. They were 28 females and 84 males, mean age 69.8 years. The NHS records containing the lifetime prescription history of each subject were retrieved from the health authority. Each prescription was recorded, omitting drugs taken in the two years before diagnosis. Analysis was performed using conditional logistic regression. Other variables, including the use of antacids, steroids, smoking and alcohol, were also examined. Subjects dying of COA were more likely to have consumed H2RAs (relative risk (RR) 7.50, 95% CI 1.33-42.09, P < 0.02). On the other hand, they were less likely to have consumed NSAIDs (RR 0.16, 95% CI 0.03-0.93, P < 0.04) or DRLOS (RR 0.14, 95% CI 0.02-1.0, P = 0.05). This study supports a protective effect from NSAIDs against COA, but the similar effect of DRLOS is related to the increased use of cardiac drugs in the control group. H2RAs appear to have a harmful effect, which may be related to the worldwide increase in COA. However, the trend may have been apparent before cimetidine was widely available, and it is possible that the cause is multi-factorial.

Cancer patients' information needs and information seeking behaviour: in depth interview study

OBJECTIVES

To explore why cancer patients do not want or seek information about their condition beyond that volunteered by their physicians at times during their illness.

DESIGN

Qualitative study based on in-depth interviews.

SETTING

Outpatient oncology clinics at a London cancer centre.

PARTICIPANTS

17 patients with cancer diagnosed in previous 6 months.

MAIN OUTCOME MEASURES

Analysis of patients' narratives to identify key themes and categories.

RESULTS

While all patients wanted basic information on diagnosis and treatment, not all wanted further information at all stages of their illness. Three overarching attitudes to their management of cancer limited patients' desire for and subsequent efforts to obtain further information: faith, hope, and charity. Faith in their doctor's medical expertise precluded the need for patients to seek further information themselves. Hope was essential for patients to carry on with life as normal and could be maintained through silence and avoiding information, especially too detailed or "unsafe" information. Charity to fellow patients, especially those seen as more needy than themselves, was expressed in the recognition that scarce resources-including information and explanations-had to be shared and meant that limited information was accepted as inevitable.

CONCLUSIONS

Cancer patients' attitudes to cancer and their strategies for coping with their illness can constrain their wish for information and their efforts to obtain it. In developing recommendations, the government's cancer information strategy should attend to variations in patients' desires for information and the reasons for them.

Bed numbers. Inadmissible evidence

Little research has been done on the number of intensive care beds the UK needs, and provision varies widely across the country. There is no indication of systematic under-provision of intensive care unit beds in the UK. There is confusion about appropriate referrals and admissions. Research suggests that with the current number of beds there are 2,100-2,500 avoidable deaths a year. But it is unclear how many of these would be avoided by providing extra beds.

Value of drug-licensing documents in studying the effect of postmenopausal hormone therapy on cardiovascular disease

BACKGROUND

In a previous study of pooled data from published trials, we found no evidence to support the claim that postmenopausal hormone therapy (PHT) is associated with a decrease in cardiovascular disease. The purpose of this study was to see whether reports of clinical trials attached to drug-licensing applications in Finland could be obtained for scientific purposes, whether they are useful for studying cardiovascular events resulting from PHT, and if so, whether these unpublished reports corroborate the results of published reports.

METHODS

Since clinical trials in drug-licensing documents are confidential, we had to obtain special permission from the Ministry of Social Affairs and Health to use the data for research purposes. After permission was granted, we studied the clinical sections of licensing documents for PHT drugs sent by drug companies to the Finnish Drug Agency. We aimed to identify trials that compared PHT and a placebo (or no therapy, or vitamin-mineral drugs), and that reported on cardiovascular and thromboembolic events or superficial phlebitis. New trials were identified and their data were pooled with those of published trials.

FINDINGS

17 licensing applications for drugs used as PHT were found. The number, type, and quality of reporting of clinical trials varied widely between applications. The trials and their reporting of unanticipated adverse events were mostly inadequate. Six new trials (ie, those fulfilling the inclusion criteria and not included in our earlier report) were found. The new trials added little to the conclusions of previously published studies: the calculated odds ratios of cardiovascular and thromboembolic events for women taking PHT versus those not taking it was 1.97 (95% CI 0.84-4.63), compared with 1.65 (0.65-4.21) in our previous study.

INTERPRETATION

In this case, unpublished trials added only a little to the data available from published trials, mainly due to the type of clinical data used in the licensing applications. The new data did not change the previous conclusion that clinical trials do not support a beneficial effect of PHT on cardiovascular diseases.

Mortality attributable to drinking, drinking too much, or drinking too little: a comparison of methods

BACKGROUND

The existence of a U-shaped relationship between alcohol consumption and all-cause mortality complicates the calculation and interpretation of mortality attributable to alcohol consumption.

METHODS

We used the relationships between all-cause mortality and alcohol consumption from four British cohort studies. For each study we defined a 'sensible drinking level' asthe level with lowest observed mortality. We estimated the fractions of deaths that were attributable to (1) any drinking (compared with not drinking), (2) drinking more than the 'sensible level', and (3) drinking less than the 'sensible level'.

RESULTS

Data from the Doctors' study suggest that on balance 22.3 per cent of deaths are prevented by alcohol consumption, yet the fractions of deaths attributable to drinking more than 8-14 units per week and less than 8-14 units per week are nearly equal (6.5 per cent and 6.4 per cent, respectively). In a sensitivity analysis we show that it is possible for alcohol consumption to prevent deaths overall yet for more deaths to be attributable to drinking above a sensible level than are attributable to drinking below the sensible level.

CONCLUSIONS

The balance of deaths attributable to or prevented by alcohol consumption provides no information about the deaths attributable to drinking above or below sensible levels. Using all-cause data in this way is likely to exaggerate the protective effect of alcohol consumption, so our results are only illustrative.

Conflict between mothers with eating disorders and their infants during mealtimes

BACKGROUND

In a recent study, 20% of the variance in the weight of infants of mothers with eating disorders was accounted for by mealtime conflict.

AIMS

To investigate the antecedents and interactive processes involved in the development of such conflict.

METHOD

Mothers with eating disorders and their 12-month-old infants (n = 34) and a comparison group (n = 24) were videotaped during infant mealtimes. Specific classes of antecedents to conflict episodes were identified. An examination was then made of all such antecedents not leading to conflict and the mother-infant responses to each antecedent.

RESULTS

Within the index group, conflict was less likely when mothers acknowledged infants' cues and were able to put aside their own concerns. The relationship between maternal responses and the evolution of conflictual interaction was confirmed in multiple regression analyses including both index and comparison groups.

CONCLUSIONS

Mothers' and infants' responses to potential antecedents to conflict had an impact on whether mealtime conflict ensued. Conflict arose because maternal eating disorder psychopathology interfered with aspects of responsive parenting.

The impact of patient treatment preferences on the interpretation of randomised controlled trials

Reliable information about aggregate main treatment effects in cancer research comes from randomised controlled trials (RCTs). The possibility of important interactions, such as between treatment preferences and their effects, is necessarily subordinated in the quest for evidence about main treatment effects. If patient preferences can influence the effectiveness of treatments, for which there is some indirect evidence, then those estimates of the treatment's main organic effects from unblind RCTs might be wrong. RCTs clearly disallow patient choice and it is, therefore, important to know the extent of any preference effects in order to interpret the RCT evidence. It may be important to know whether they exist, and where and by how much they affect outcome. It is argued that measuring these effects reliably is methodologically difficult, and will require massive trials each directed at measuring one particular preference effect. Such effects have a slightly fanciful image, particularly in cancer treatment, and may be transient. Given the current uncertainties about their true nature and plausible biological mechanisms, the accumulated evidence is unlikely to provide sufficient justification for investing in such trials, given other current priorities.