Dorota Juszczyk

Knowledge of lung cancer symptoms and risk factors in the UK: development of a measure and results from a population-based survey

Objectives To develop and validate a Lung Cancer Awareness Measure (Lung CAM) and explore the demographical and social predictors of lung cancer awareness in the general population. Methods study 1 Symptoms and risk factors for lung cancer were identified from the medical literature and health professional expertise in an iterative process. Test–retest reliability, internal reliability, item analyses, construct validity and sensitivity to changes in awareness of the Lung CAM were assessed in three samples (total N=191). Results study 1 The Lung CAM demonstrated good internal (Cronbachs α=0.88) and test–retest reliability (r=0.81, p<0.001). Validity was supported by lung cancer experts scoring higher than equally educated controls (t(106)=8.7, p<0.001), and volunteers randomised to read lung cancer information scoring higher than those reading a control leaflet (t(81)=3.66, p<0.001). Methods study 2 A population-based sample of 1484 adults completed the Lung CAM in a face-to-face, computer-assisted interview. Results study 2 Symptom awareness was low (average recall of one symptom) and there was little awareness of risk factors other than smoking. Familiarity with cancer, and being from a higher socioeconomic group, were associated with greater awareness. Conclusions Using a valid and reliable tool for assessing awareness showed the UK population to have low awareness of lung cancer symptoms and risk factors. Interventions to increase lung cancer awareness are needed to improve early detection behaviour.

Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records.

Objective To determine whether the incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome is higher in general practices that prescribe fewer antibiotics for self limiting respiratory tract infections (RTIs). Design Cohort study. Setting 610 UK general practices from the UK Clinical Practice Research Datalink. Participants Registered patients with 45.5 million person years of follow-up from 2005 to 2014. Exposures Standardised proportion of RTI consultations with antibiotics prescribed for each general practice, and rate of antibiotic prescriptions for RTIs per 1000 registered patients. Main outcome measures Incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome, adjusting for age group, sex, region, deprivation fifth, RTI consultation rate, and general practice. Results From 2005 to 2014 the proportion of RTI consultations with antibiotics prescribed decreased from 53.9% to 50.5% in men and from 54.5% to 51.5% in women. From 2005 to 2014, new episodes of meningitis, mastoiditis, and peritonsillar abscess decreased annually by 5.3%, 4.6%, and 1.0%, respectively, whereas new episodes of pneumonia increased by 0.4%. Age and sex standardised incidences for pneumonia and peritonsillar abscess were higher for practices in the lowest fourth of antibiotic prescribing compared with the highest fourth. The adjusted relative risk increases for a 10% reduction in antibiotic prescribing were 12.8% (95% confidence interval 7.8% to 17.5%, P<0.001) for pneumonia and 9.9% (5.6% to 14.0%, P<0.001) for peritonsillar abscess. If a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then it might observe 1.1 (95% confidence interval 0.6 to 1.5) more cases of pneumonia each year and 0.9 (0.5 to 1.3) more cases of peritonsillar abscess each decade. Mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome were similar in frequency at low prescribing and high prescribing practices. Conclusions General practices that adopt a policy to reduce antibiotic prescribing for RTIs might expect a slight increase in the incidence of treatable pneumonia and peritonsillar abscess. No increase is likely in mastoiditis, empyema, bacterial meningitis, intracranial abscess, or Lemierre’s syndrome. Even a substantial reduction in antibiotic prescribing was predicted to be associated with only a small increase in numbers of cases observed overall, but caution might be required in subgroups at higher risk of pneumonia.

Cervical screening among migrant women: a qualitative study of Polish, Slovak and Romanian women in London, UK

Objective To explore awareness of and participation in cervical screening services in women from Poland, Slovakia and Romania living in London, UK. Methods Three qualitative studies were carried out in London in 2008–2009: an interview study of professionals working with Central and Eastern European migrants (n=11); a focus group study including three Polish, one Slovak and one Romanian focus group; and an interview study of Polish (n=11), Slovak (n=7) and Romanian (n=2) women. Results Awareness of the cervical screening programme was good, but understanding of the purpose of screening was sometimes limited. Some women were fully engaged with the UK screening programme; others used screening both in the UK and their countries of origin; and a third group only had screening in their home countries. Women welcomed the fact that screening is free and that reminders are sent, but some were concerned about the screening interval and the age of the first invitation. Conclusions Migrant women from Poland, Slovakia and Romania living in London vary in their level of participation in the National Health Service Cervical Screening Programme. More needs to be done to address concerns regarding screening services, and to ensure that language is not a barrier to participation.

Body mass index and incident type 1 and type 2 diabetes in children and young adults: a retrospective cohort study

Context: Little is known about the association between obesity and temporal trends in the incidence of diabetes in children and young adults. Objective: We examined the recent incidence of types 1 and 2 diabetes in relation to a high body mass index (BMI) in UK children and young adults. Design: Cohort and nested case-control. Setting: A total of 375 general practices that contribute to the UK Clinical Practice Research Datalink (CPRD). Participants: A total of 369,362 participants aged 2 to 15 years at BMI measurement in CPRD from 1994 to 2013. Intervention: None. Main outcome measures: Incident type 1 diabetes (T1D) and type 2 diabetes (T2D) diagnoses up to age 25 years. Results: A total of 654 incident cases of T2D and 1318 T1D cases were found. The incidence of T2D per 100,000 persons annually increased from 6.4 in 1994 to 1998 to 33.2 in 2009 to 2013; and that for T1D increased from 38.2 to 52.1 per 100,000 persons during the same period. The incidence of T2D increased in both overweight (85th to 95th percentile for age- and sex-specific BMI; P = 0.01) and obese (≥95th percentile; P < 0.01) individuals from 1994 to 2013. Obese individuals, who constituted 47.1% of T2D cases, had a markedly greater risk of incident T2D [odds ratio, 3.75; 95% confidence interval (CI), 3.07 to 4.57], with an incidence rate ratio of 4.33 (95% CI, 3.68 to 5.08) compared with the normal BMI category. No positive linear association was found between obesity (greater BMI) and incident T1D cases. Conclusions: Increasing obesity has contributed to the increasing incidence of T2D but not T1D among UK children and young adults, with a fourfold greater risk of developing T2D in obese individuals.

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

Body-mass index and incidence of type 1 and type 2 diabetes in children and young adults in the UK: an observational cohort study

Abstract Background Obesity, a global health issue at all ages, is a main risk factor for diabetes in adults, but little is known about the associations between obesity and trends in the incidence of the disease in children and young adults. We aimed to examine the recent incidence of type 1 and type 2 diabetes and associations between high body-mass index (BMI) and the incidence of each type of diabetes in children and young adults. Methods We conducted cohort and nested case-control studies within a cohort of participants with a BMI record (369 362 individuals aged 2–15 years) using data from family practices contributing to the UK Clinical Practice Research Datalink between 1994 and 2013. Incident type 1 and type 2 diabetes were defined with medical diagnostic codes, prescriptions for antidiabetic medication, or glycated haemoglobin values of 6·5% or more. Poisson regression was used to test for diabetes incidence rates and trends. We estimated odds ratio for diabetes using data on cases and controls matched for year of birth, sex, and general practice. Findings There were 654 incident cases of type 2 diabetes and 1318 incident cases of type 1 diabetes. The incidence of type 2 and type 1 diabetes increased from 6·4 per 100 000 person-years (95% CI 3·5–10·7, n=14) and 38·2 (30·4–47·2, n=84) in 1994–98 to 33·2 (29·7–37·1, n=320) and 52·1 (47·6–56·9, n=502) in 2009–13, respectively. The incidence of type 2 diabetes continued to increase in overweight (85th–95th percentile for age-specific and sex-specific BMI, p=0·015) or obese (≥95th percentile, p Interpretation Increasing obesity is contributing to the rising incidence of type 2 but not type 1 diabetes among children and young adults in the UK, with a four times greater risk of developing type 2 diabetes in those who are obese. Funding National Institute for Health Research.

Electronically delivered, multicomponent intervention to reduce unnecessary antibiotic prescribing for respiratory infections in primary care: A cluster randomised trial using electronic health records - REDUCE Trial study original protocol

Introduction Respiratory tract infections (RTIs) account for about 60% of antibiotics prescribed in primary care. This study aims to test the effectiveness, in a cluster randomised controlled trial, of electronically delivered, multicomponent interventions to reduce unnecessary antibiotic prescribing when patients consult for RTIs in primary care. The research will specifically evaluate the effectiveness of feeding back electronic health records (EHRs) data to general practices. Methods and analysis 2-arm cluster randomised trial using the EHRs of the Clinical Practice Research Datalink (CPRD). General practices in England, Scotland, Wales and Northern Ireland are being recruited and the general population of all ages represents the target population. Control trial arm practices will continue with usual care. Practices in the intervention arm will receive complex multicomponent interventions, delivered remotely to information systems, including (1) feedback of each practices antibiotic prescribing through monthly antibiotic prescribing reports estimated from CPRD data; (2) delivery of educational and decision support tools; (3) a webinar to explain and promote effective usage of the intervention. The intervention will continue for 12 months. Outcomes will be evaluated from CPRD EHRs. The primary outcome will be the number of antibiotic prescriptions for RTIs per 1000 patient years. Secondary outcomes will be: the RTI consultation rate; the proportion of consultations for RTI with an antibiotic prescribed; subgroups of age; different categories of RTI and quartiles of intervention usage. There will be more than 80% power to detect an absolute reduction in antibiotic prescription for RTI of 12 per 1000 registered patient years. Total healthcare usage will be estimated from CPRD data and compared between trial arms. Ethics and dissemination Trial protocol was approved by the National Research Ethics Service Committee (14/LO/1730). The pragmatic design of the trial will enable subsequent translation of effective interventions at scale in order to achieve population impact. Trial registration number ISRCTN95232781; Pre-results.