Amy Downing

Socioeconomic background in relation to stage at diagnosis, treatment and survival in women with breast cancer

In a large population-based series of invasive breast cancer patients, we investigated socioeconomic background (SEB) in relation to (a) stage at diagnosis; (b) treatment pattern; and (c) 5-year survival. Women diagnosed during 1998–2000 and resident in the Northern and Yorkshire regions of England were identified from the cancer registry database (N=12 768). Logistic regression and Cox proportional hazards analyses were used to estimate associations between SEB (defined using the Townsend Index for area of residence) and tumour stage, treatment pattern, and survival. Living in a more deprived area was associated with increased likelihood of being diagnosed with stage III or IV disease (age-adjusted odds ratio (OR) 1.13; 95% confidence interval (CI) 1.08–1.18 per quartile increase in Townsend score), and, after adjustment for age and stage, reduced odds of having surgery (OR 0.85; 95% CI 0.80–0.91), and receiving radiotherapy (OR 0.91; 95% CI 0.88–0.94). Amongst patients receiving surgery, those living in more deprived areas had decreased odds of having breast conserving surgery (age plus stage-adjusted OR 0.92; 95% CI 0.89–0.95). Living in a more deprived area was also associated with increased mortality (age- plus stage-adjusted hazard ratio 1.08; 95% CI 1.05–1.11). These effects may operate through several pathways, such as later presentation leading to advanced disease.

Recent trends in cutaneous malignant melanoma in the Yorkshire region of England; incidence, mortality and survival in relation to stage of disease, 1993-2003

The aim of this study was to investigate recent trends in incidence, mortality and survival in patients diagnosed with malignant melanoma (MM) in relation to stage (Breslow thickness). Cases of primary invasive and in situ MM diagnosed between 1st January 1993 and 31st December 2003 in the former Yorkshire Health Authority were identified from cancer registry data. Over the study period, the incidence of invasive MM increased from 5.4 to 9.7 per 100 000 in male subjects and from 7.5 to 13.1 per 100 000 in female subjects. Most of this increase was seen in thin tumours (<1.5 mm). Thin tumours were more likely to be diagnosed in the younger age groups and be classified as superficial spreading melanoma. In situ melanoma rates increased only slightly. Over the same time period, mortality rates have been relatively constant in both male and female subjects. Five-year relative survival varied from 91.8% (95% CI 90.4–93.1) for patients with thin tumours to 41.5% (95% CI 36.7–46.3) for those with thick tumours. In multivariable analyses, Breslow thickness was the most important prognostic factor. Age, sex and level of deprivation were also identified as independent prognostic factors. The trends in incidence suggest that the increase is real, rather than an artefact of increased scrutiny, implying that primary prevention in the Yorkshire area of the UK has failed to control trends in incidence. Mortality, in contrast, appears to be levelling off, indicating that secondary prevention has been more effective.

Health-Related Quality of Life After Colorectal Cancer in England: A Patient-Reported Outcomes Study of Individuals 12 to 36 Months After Diagnosis

PURPOSE This population-level study was conducted to define the health-related quality of life (HRQL) of individuals living with and beyond colorectal cancer (CRC) and to identify factors associated with poor health outcomes. PATIENTS AND METHODS All individuals diagnosed with CRC in England in 2010 and 2011 who were alive 12 to 36 months after diagnosis were sent a questionnaire. This included questions related to treatment, disease status, other long-term conditions (LTCs), generic HRQL (EuroQol-5D), and cancer-specific outcomes (Functional Assessment of Cancer Therapy and Social Difficulties Inventory items). RESULTS The response rate was 63.3% (21,802 of 34,467 patients). One or more generic health problems were reported by 65% of respondents, with 10% of patients reporting problems in all five domains. The reporting of problems was higher than in the general population and was most marked in those age less than 55 years. Certain subgroups reported a higher number of problems, notably those with one or more other LTCs, those with active or recurrent disease, those with a stoma, and those at the extremes of the age range (< 55 and > 85 years). Of respondents without a stoma, 16.3% reported no bowel control. Reversal of a stoma resulted in fewer severe bowel problems but more moderate problems than those who had never had a stoma. A quarter of rectal cancer respondents (25.1%) reported difficulties with sexual matters (compared with 11.2% of colon cancer respondents). CONCLUSION This study demonstrates the success of a national patient-reported outcomes survey. The results have the potential to support system-wide improvement in health outcomes through the identification of particular challenges faced by individuals after treatment for CRC.

Integrating Patient Reported Outcomes With Clinical Cancer Registry Data: A Feasibility Study of the Electronic Patient-Reported Outcomes From Cancer Survivors (ePOCS) System

Background Routine measurement of Patient Reported Outcomes (PROs) linked with clinical data across the patient pathway is increasingly important for informing future care planning. The innovative electronic Patient-reported Outcomes from Cancer Survivors (ePOCS) system was developed to integrate PROs, collected online at specified post-diagnostic time-points, with clinical and treatment data in cancer registries. Objective This study tested the technical and clinical feasibility of ePOCS by running the system with a sample of potentially curable breast, colorectal, and prostate cancer patients in their first 15 months post diagnosis. Methods Patients completed questionnaires comprising multiple Patient Reported Outcome Measures (PROMs) via ePOCS within 6 months (T1), and at 9 (T2) and 15 (T3) months, post diagnosis. Feasibility outcomes included system informatics performance, patient recruitment, retention, representativeness and questionnaire completion (response rate), patient feedback, and administration burden involved in running the system. Results ePOCS ran efficiently with few technical problems. Patient participation was 55.21% (636/1152) overall, although varied by approach mode, and was considerably higher among patients approached face-to-face (61.4%, 490/798) than by telephone (48.8%, 21/43) or letter (41.0%, 125/305). Older and less affluent patients were less likely to join (both P<.001). Most non-consenters (71.1%, 234/329) cited information technology reasons (ie, difficulty using a computer). Questionnaires were fully or partially completed by 85.1% (541/636) of invited participants at T1 (80 questions total), 70.0% (442/631) at T2 (102-108 questions), and 66.3% (414/624) at T3 (148-154 questions), and fully completed at all three time-points by 57.6% (344/597) of participants. Reminders (mainly via email) effectively prompted responses. The PROs were successfully linked with cancer registry data for 100% of patients (N=636). Participant feedback was encouraging and positive, with most patients reporting that they found ePOCS easy to use and that, if asked, they would continue using the system long-term (86.2%, 361/419). ePOCS was not administratively burdensome to run day-to-day, and patient-initiated inquiries averaged just 11 inquiries per month. Conclusions The informatics underlying the ePOCS system demonstrated successful proof-of-concept – the system successfully linked PROs with registry data for 100% of the patients. The majority of patients were keen to engage. Participation rates are likely to improve as the Internet becomes more universally adopted. ePOCS can help overcome the challenges of routinely collecting PROs and linking with clinical data, which is integral for treatment and supportive care planning and for targeting service provision.

Joint disease mapping using six cancers in the Yorkshire region of England

ObjectivesThe aims of this study were to model jointly the incidence rates of six smoking related cancers in the Yorkshire region of England, to explore the patterns of spatial correlation amongst them, and to estimate the relative weight of smoking and other shared risk factors for the relevant disease sites, both before and after adjustment for socioeconomic background (SEB).MethodsData on the incidence of oesophagus, stomach, pancreas, lung, kidney, and bladder cancers between 1983 and 2003 were extracted from the Northern & Yorkshire Cancer Registry database for the 532 electoral wards in the Yorkshire region. Using postcode of residence, each case was assigned an area-based measure of SEB using the Townsend index. Standardised incidence ratios (SIRs) were calculated for each cancer site and their correlations investigated. The joint analysis of the spatial variation in incidence used a Bayesian shared-component model. Three components were included to represent differences in smoking (for all six sites), bodyweight/obesity (for oesophagus, pancreas and kidney cancers) and diet/alcohol consumption (for oesophagus and stomach cancers).ResultsThe incidence of cancers of the oesophagus, pancreas, kidney, and bladder was relatively evenly distributed across the region. The incidence of stomach and lung cancers was more clustered around the urban areas in the south of the region, and these two cancers were significantly associated with higher levels of area deprivation. The incidence of lung cancer was most impacted by adjustment for SEB, with the rural/urban split becoming less apparent. The component representing smoking had a larger effect on cancer incidence in the eastern part of the region. The effects of the other two components were small and disappeared after adjustment for SEB.ConclusionThis study demonstrates the feasibility of joint disease modelling using data from six cancer sites. Incidence estimates are more precise than those obtained without smoothing. This methodology may be an important tool to help authorities evaluate healthcare system performance and the impact of policies.

Trends in prognostic factors and survival from cutaneous melanoma in Yorkshire, UK and New South Wales, Australia between 1993 and 2003.

The aim of this study was to compare trends in prognostic factors and survival from cutaneous melanoma between 1993 and 2003 in 2 populations with dramatically different underlying incidence rates [Yorkshire, UK, and New South Wales (NSW), Australia] and to look at whether the greater investment in melanoma prevention and early detection in Australia has resulted in any relative differences in survival. Patients diagnosed with invasive melanoma between 1993 and 2003 in Yorkshire (n = 4,170) and NSW (n = 30,520) were identified from cancer registry databases and prognostic information (age, sex, socioeconomic background, tumour site and Breslow thickness) was extracted. Age‐standardised incidence rates, 5‐year relative survival and relative excess risk of death were calculated. Between 1993–1995 and 2001–2003, the incidence of melanoma increased in both areas. These increases were mainly seen in tumours with thickness ≤1 mm. Five‐year relative survival was 86.9% (95% CI 85.2–88.5) in Yorkshire and 88.6% (95% CI 88.1–89.1) in NSW. Compared with that in NSW, survival in Yorkshire was lower for males and for those living in the most deprived areas. Despite the increase in good prognosis of thin tumours, there was no significant change in survival over the time period in either area. After adjustment for differences in prognostic factors, the relative excess risk of death in Yorkshire compared to that in NSW reduced from 1.36 (95% CI 1.20–1.53) to 1.11 (95% CI 0.99–1.23). Differences in tumour thickness appeared to be the most important factor.

The rising incidence of anal cancer in England 1990-2010: a population-based study.

Although anal cancer is rare, its incidence has been reported to be rising in several countries. This study aimed to determine whether there have been any changes in incidence over time in England.

Temporal and demographic variations in attendance at accident and emergency departments

Objectives: Little has been reported of the demographic and temporal variations in accident and emergency (A&E) attendances despite the importance of this information in planning services. The purpose of this paper to is to explore the variations in attendance patterns across the West Midlands region of the NHS. Methods: The data were obtained from the A&E minimum dataset from a sample of 13 hospitals. Arrival dates and times, age, and sex of all patients attending A&E in the year from 1 April 1999 to 31 March 2000 were analysed to look at the pattern of attendance by hour, day and month, age, and sex. Results: No differences were found in attendance patterns in respect to sex. Attendances by children under 15 years peaked in the evening between 18:00 and 19:59. In contrast, peak attendance in those over 15 years was between 09:00 and 11:59. The percentage of “out of hours” attendances in this dataset was highest in the under 1 age group (58.5%), the 15–24 age group (57.1%), and the 25–44 age group (54.6%). The highest proportion of patients attended A&E on a Monday, while the percentage of weekend attendances decreased with age. In children aged 1–14 years there were more attendances in summer than winter. In those aged under 1 and over 65 there was a winter peak with December having the most attendances. Conclusions: No sex differences were found in the temporal attendance patterns at A&E. However, many differences were found in the attendance of different age groups. These differences are of great importance in the planning of services, and further research is required to explain the reasons behind these variations.

The epidemiology of assault across the West Midlands

Objectives: The purpose of this study is to look at accident and emergency (A&E) attendances and admissions after assault in the West Midlands NHS region across a wide range of acute units. Methods: This study used data from two sources, the A&E Minimum Data Set and the Hospital Episode Statistics database. Analyses were based on data from 12 of the 21 acute trusts in the West Midlands NHS region for the period 1 April 1999 to 31 March 2000. Results: Analyses were performed on 15 969 A&E attendances and 1596 admissions. Some 67.4% of attenders and 84.2% of those admitted were male. The mean age of the patients was between 27 and 29 years. Attendance peaked between 2100 and 0259, especially on Friday and Saturday night. The most common injury was to the head. Some 75.3% of A&E attenders were discharged home. The average stay in hospital was two days and six deaths were recorded. Those living in the most deprived areas were nearly four times more likely to be admitted than those in the least deprived areas (175.9 per 1000 compared with 45.1 per 1000). Conclusions: This study shows assault is predominately a male phenomenon, worst in the evenings and at weekends, and is positively related to deprivation. It is probable that the levels recorded will be an underestimate, however with some additions to the information collected hospital records could create the basis for a comprehensive surveillance system.

Early mortality from colorectal cancer in England: a retrospective observational study of the factors associated with death in the first year after diagnosis

Background:The United Kingdom performs poorly in international comparisons of colorectal cancer survival with much of the deficit owing to high numbers of deaths close to the time of diagnosis. This retrospective cohort study investigates the patient, tumour and treatment characteristics of those who die in the first year after diagnosis of their disease.Methods:Patients diagnosed with colon (n=65 733) or rectal (n=26 123) cancer in England between 2006 and 2008 were identified in the National Cancer Data Repository. Multivariable logistic regression was used to investigate the odds of death within 1 month, 1–3 months and 3–12 months after diagnosis.Results:In all, 11.5% of colon and 5.4% of rectal cancer patients died within a month of diagnosis: this proportion decreased significantly over the study period. For both cancer sites, older age, stage at diagnosis, deprivation and emergency presentation were associated with early death. Individuals who died shortly after diagnosis were also more likely to have missing data about important prognostic factors such as disease stage and treatment.Conclusion:Using routinely collected data, at no inconvenience to patients, we have identified some important areas relating to early deaths from colorectal cancer, which merit further research.