Amanda-Jane Ramirez

Influence of delay on survival in patients with breast cancer: a systematic review

BACKGROUNDnMost patients with breast cancer are detected after symptoms occur rather than through screening. The impact on survival of delays between the onset of symptoms and the start of treatment is controversial and cannot be studied in randomised controlled trials. We did a systematic review of observational studies (worldwide) of duration of symptoms and survival.nnnMETHODSnWe identified 87 studies (101,954 patients) with direct data linking delay (including delay by patients) and survival. We classified studies for analysis by type of data in the original reports: category I studies had actual 5-year survival data (38 studies, 53,912 patients); category II used actuarial or multivariate analyses (21 studies, 25,102 patients); and category III was all other types of data (28 studies, 22,940 patients). We tested the main hypothesis that longer delays would be associated with lower survival, and a secondary hypothesis that longer delays were associated with more advanced stage, which would account for lower survival.nnnFINDINGSnIn category I studies, patients with delays of 3 months or more had 12% lower 5-year survival than those with shorter delays (odds ratio for death 1.47 [95% CI 1.42-1.53]) and those with delays of 3-6 months had 7% lower survival than those with shorter delays (1.24 [1.17-1.30]). In category II, 13 of 14 studies with unrestricted samples showed a significant adverse relation between longer delays and survival, whereas four of five studies of only patients with operable disease showed no significant relation. In category III, all three studies with unrestricted samples supported the primary hypothesis. The 13 informative studies showed that longer delays were associated with more advanced stage. In studies that controlled for stage, longer delay was not associated with shorter survival when the effect of stage on survival was taken into account.nnnINTERPRETATIONnDelays of 3-6 months are associated with lower survival. These effects cannot be accounted for by lead-time bias. Efforts should be made to keep delays by patients and providers to a minimum.

Factors predicting delayed presentation of symptomatic breast cancer: a systematic review

BACKGROUNDnDelayed presentation of symptomatic breast cancer is associated with lower survival. Understanding of the factors that influence delay is important for the development of strategies to shorten delays. We did a systematic review to assess the quality and strength of evidence on risk factors for delays by patients and providers.nnnMETHODSnWe generated hypotheses about the relation between each putative risk factor and delay, against which we tested studies. We did searches to identify papers containing original data related to risk factors for delays by patients (n=86) and providers (n=28). We critically appraised the papers for inclusion in the review according to predefined criteria. The small number of studies of adequate quality did not allow formal meta-analysis. We therefore assigned strength of evidence according to a combination of the number and size of studies supporting, not supporting, or refuting the hypotheses.nnnFINDINGSnMost studies were deemed to be of poor quality and were excluded. Among 23 studies of adequate quality, however, there was strong evidence for an association between older age and delay by patients, and strong evidence that marital status was unrelated to delays by patients. Younger age and presentation with a breast symptom other than a lump were strong risk factors for delays by providers. Moderate evidence was shown for several other factors.nnnINTERPRETATIONnThe strength of the current evidence is inadequate to inform the development of specific strategies to shorten delays by patients or providers. Clarification of the findings of this review through a major programme of primary research is urgently required.

What is a psychological intervention? A metareview and practical proposal

Objective: What do we mean by a ‘psychological intervention’ in the context of cancer care? It is critical to know what treatments are included under this term, if data from diverse treatment trials are to be summarized in order to inform clinical practice. We, therefore, aimed to determine how the term ‘psychological intervention’ has been defined and used to group and compare interventions in reviews of cancer care.

Measuring the quality of MDT working: an observational approach

BackgroundCancer multidisciplinary teams (MDTs) are established in many countries but little is known about how well they function. A core activity is regular MDT meetings (MDMs) where treatment recommendations are agreed. A mixed methods descriptive study was conducted to develop and test quality criteria for observational assessment of MDM performance calibrated against consensus from over 2000 MDT members about the “characteristics of an effective MDT”.MethodsEighteen of the 86 ‘Characteristics of Effective MDTs’ were considered relevant and feasible to observe. They collated to 15 aspects of MDT working covering four domains: the team (e.g. attendance, chairing, teamworking); infrastructure for meetings (venue, equipment); meeting organisation and logistics; and patient-centred clinical decision-making (patient-centredness, clarity of recommendations). Criteria for rating each characteristic from ‘very poor’ to ‘very good’ were derived from literature review, observing MDMs and expert input. Criteria were applied to 10 bowel cancer MDTs to assess acceptability and measure variation between and within teams. Feasibility and inter-rater reliability was assessed by comparing three observers.ResultsObservational assessment was acceptable to teams and feasible to implement. Total scores from 29 to 50 (out of 58) highlighted wide diversity in quality between teams. Eight teams were rated either ‘very good/good’ or ‘very poor/poor’ for at least three domains demonstrating some internal consistency. ‘Very good’ ratings were most likely for attendance and administrative preparation, and least likely for patient-centredness of decision-making and prioritisation of complex cases. All except two characteristics had intra-class correlations of ≥0.50.ConclusionsThis observational tool (MDT-OARS) may contribute to the assessment of MDT performance. Further testing to confirm validity and reliability is required.

Does the method of detection of breast cancer affect subsequent psychiatric morbidity

The aim of this prospective study was to compare the prevalence of psychiatric morbidity following diagnosis of breast cancer between a group of women presenting with screen-detected cancer and a group presenting with symptomatic disease. Psychiatric symptoms were elicited using the Structured Clinical Interview (SCID) and classified according to DSM-III criteria. 61 (46%) of 132 women interviewed experienced an episode of psychiatric disorder between 1 month before diagnosis and 12 months post-diagnosis. There was no association between detection by screening of breast cancer and psychiatric disorder (Odds Ratio (OR) 0.8, 95% Confidence Interval (CI) 0.4-1.8 P=0.7). The occurrence of an episode of psychiatric disorder was associated with a previous history of treatment for psychological problems (OR 2.4, 95% CI 1.1-5.5, P=0.02). The results suggest there is no increased risk of developing psychiatric morbidity associated with the detection of cancer through the National Breast Screening Programme.

Do the UK public realise that colorectal cancer is a common cancer

Dear Sir, Colorectal cancer (CRC) is one of the top three most commonly diagnosed cancers among women and men. However, it is widely acknowledged that it receives less attention than other cancers. Breast cancer gets the most public attention because of its high incidence and iconic status [1]. Lung cancer attracts attention because of its established link with smoking [2], and prostate cancer is sometimes presented as the neglected ‘male equivalent’ of breast cancer [3]. Recognition of the high incidence of CRC is particularly important in the UK because the new national screening programme based on biennial Faecal Occult Blood (FOB) Testing has recently been introduced. In the first 28 months of the screening programme, uptake in England was only around 55% (von Wagner C, Baio G, Raine R, Snowball J, Morris S, Atkin W, Obichere A, Handley G, Logan R, Rainbow S, Smith S, Halloran S, Wardle J, submitted). This contrasts with uptake of around 74% in breast screening [4] and 80% in cervical screening [5]. Lack of awareness of CRC’s high prevalence may contribute to low uptake of CRC screening [6,7]. One study has demonstrated that informing people that CRC is common and often asymptomatic can lead to increased awareness of risk and a decision to be screened in up to 50% of those who had initially declined the test [8]. Awareness that CRC is a common cancer has been found to be low in several studies using a recognition-based methodology [9–11], and may be even lower if measured using open recall questions [12]. We report findings from research using a populationbased UK sample investigating awareness of the high incidence of CRC using an open response format. Data were collected as part of the Office for National Statistics (ONS) Opinions Survey in September and October 2008. This uses stratified random probability sampling and a computer-assisted, face-to-face interview. Respondents were asked about common male and female cancers using the following questions: ‘What do you think is the most [then second then third most] common cancer in women [men]’. Both men and women were asked the questions for both sexes. Responses were recorded verbatim. Of 3652 households invited to participate, interviews were completed with one person from each of 2216 households (61% response rate), of whom 2208 (968 males and 1240 females) completed the questions on common cancers (99.6%). Awareness that CRC is a common female cancer was extremely low (16%), with men less likely to identify it as a common female cancer (12%) than women (20%). Older respondents were more likely to name CRC as a common female cancer than younger respondents (22% at ‡ 65 years vs 9% at 16–24). There were no other demographic differences. Awareness that CRC is a common male cancer was higher (40%). Again, women had higher awareness than men (43% vs 36%) and the youngest respondents were the least likely to name CRC as one of the top three (19% at age 16–24). Awareness was higher in respondents who were married and from higher socioeconomic and white ethnic backgrounds. The most frequently reported female cancers (in any order) were: breast cancer (94%), cervical cancer (60%) and lung cancer (34%) (Fig. 1). The fourth and fifth most frequently mentioned cancers were ovarian cancer (19%) and skin cancer (18%). CRC, named by 16% of respondents, was sixth in the list. The most frequently reported male cancer was lung (70%), followed by prostate (65%) and CRC (40%). However, 29% of respondents identified testicular cancer as being in the top three, and 13% identified skin cancer (see Fig. 2). As far as we are aware, this is the first population-based study assessing awareness of CRC in relation to other common cancers in which respondents were simply asked to name common cancers. The results show that the British are largely unaware of the high incidence of CRC, and significantly less aware than they are of the other ‘top three’ cancers. Over 80% of respondents failed to identify CRC as being among the top three female cancers and 60% failed to identify it as a common male cancer. Although awareness was somewhat higher in older age groups, who are the target for CRC screening, it was still relatively low, despite information being available in the leaflet that accompanies the screening invitation. Lack of public awareness of CRC might be partly due to media under-reporting relative to the disease burden. The media prefers to focus on positive cancer stories, and with relatively high mortality, CRC performs poorly. CRC may also be associated with embarrassment because of difficulties with discussing a private body area and its functioning [13], which could contribute to low levels of media coverage. However, the new UK government’s commitment to CRC screening, including the introduction of flexible sigmoidoscopy screening (based on evidence from

Can we reduce burnout amongst cancer health professionals

Cancer doctors, in common with doctors generally, are at particular risk of poor mental health, compared with the general working population. This includes both work-related burnout and more pervasive psychiatric problems such as clinical depression and anxiety. In 2002, about a third of United Kingdom (UK) hospital consultants were estimated to experience psychiatric morbidity compared with 15% of the general working population. In this issue, Blanchard and colleagues confirm high levels of burnout exist amongst junior oncology doctors in France. Whether working in cancer care in itself increases the risk of poor mental health amongst doctors is unclear. A large cohort study of UK consultants reported higher levels of estimated psychiatric morbidity amongst medical, clinical and surgical oncologists compared with other specialty groups. By contrast other studies have reported comparably high rates of poor mental health in other high pressured specialty groups. The high levels of poor mental health amongst doctors as a professional group matters not only because of the consequences for them and their family, but also because of the impact it has on their ability to deliver high quality patient care. Hospital consultants, including cancer consultants with poor mental health are twice as likely to report harmful consumption of alcohol, being irritable with patients, being irritable with colleagues, reducing their standards of care at work