Elena Cabeza

Lack of association between diagnostic and therapeutic delay and stage of colorectal cancer

BACKGROUND A recent review suggests that there is no association between diagnostic and therapeutic delays and survival in colorectal cancer patients. However, the effect of tumour stage on the relationship between delay and survival in CRC should be clarified. We review here the evidence on the relationship between diagnostic and therapeutic delays and stage in colorectal cancer. METHODS We conducted a systematic review of Medline, Embase, Cancerlit and the Cochrane Database of Systematic Reviews to identify publications published between 1965 and 2006 dealing with delay, stage and colorectal cancer. A meta-analysis was performed based on the estimation of the odds ratios (OR) and on a random effects model. RESULTS We identified 50 studies, representing 18,649 patients. Thirty studies were excluded due to excessively restricted samples (e.g. exclusion of patients with intestinal obstruction or who died 1-3 months after surgery) or because they studied only a portion of the delay. Of the 37 remaining studies, great variability was noted in connection with the type of classification used for disease stage and the type of measurement used for the delay. Meta-analysis was performed based on 17 studies that included 5209 patients. The combined OR was 0.98 (95% confidence interval (CI): 0.76-1.25), suggesting a lack of association between delay and disease stage. In four studies, cancers of the colon and rectum were dealt with separately, and a meta-analysis was performed using the data for colon cancer (1001 patients) and for rectal cancer (799 patients). In both cases, the combined ORs overlapped 1.0, and showed opposite associations when studied separately: 0.86 (95% CI: 0.63-1.19) for the colon (i.e. more delay is associated with the earlier stage at diagnosis) and 1.93 (95% CI: 0.89-4.219) for the rectum (i.e. less delay is associated with the earlier stage). CONCLUSIONS When colorectal cancers are taken as a whole, there appears to be no association between diagnostic delay and disease stage when diagnosis is made. However, when cancers of the colon and the rectum are studied separately, there may be an opposite association. More studies about this issue are needed with larger and unrestricted samples.

Social disparities in breast and cervical cancer preventive practices.

Knowledge of factors related to the use of preventive practices is essential in order to build strategies to decrease cancer incidence and mortality. The aim of this study is to describe the characteristics of women who periodically use cervical smear and mammography. This is a cross-sectional study based on the 2001 Balearic Health Survey, using a stratified sample of non-institutionalized population resident in the Balearic Islands. The study included 560 women, aged 20 years or over. The variables studied were age, marital status, social class, education, place of residence and birth, self-perceived health status, satisfaction with health services, job status and type of medical coverage. A multivariate analysis was performed using logistic regression models. Thirty-five per cent had regular mammography (72% between 50 and 64 years) and 54% had cervical smears. The probability of having undergone mammography is higher in women between the ages of 50 and 64 years [odds ratio (OR)=11.74; interval confidence (IC): 5.89–23.39] and in those with additional medical coverage (OR=1.97; IC: 1.19–3.27) and much lower in single women (OR=0.22; IC: 0.10–0.49). The probability of having undergone a Pap test increases according to educational level (OR=2.25; IC: 0.98–5.18 for women in the higher level) and social class (OR=1.98; IC: 0.91–4.28 for social class I) and decreases in women older than 65 years (OR=0.15; IC: 0.07–0.35) and in single women (OR=0.29; IC: 0.16–0.50). Age and marital status are factors related to both practices. Socio-economic status remains associated with cervical smear use, while having an additional medical coverage increases the probability of regular mammography.

Incidence trends of traumatic spinal cord injury and traumatic brain injury in Spain, 2000-2009

AIMS The aim of the present study was to estimate the incidence of hospital discharges for traumatic spinal cord injury (TSCI) and traumatic brain injury (TBI) in Spain by injury circumstances (traffic crashes and others), injury severity, gender and age group and to describe its trends over the period 2000-2009. METHODS It is a study of trends that includes hospital discharges with a primary diagnosis of TSCI or TBI. Crude and age-standardised rates were calculated per million inhabitants. Changes in rates between 2000 and 2009 were assessed through calculation of the relative risk adjusted for age, using Poisson regression. RESULTS Between 2000 and 2009 in Spain, 10,274 patients were admitted for traumatic TSCI, and 206,503 for TBI. The annual incidence rate for TSCI was 23.5 per million, that for TBI was 472.6 per million. The overall incidence rate for TSCI fell significantly between 2000 and 2009 by 24.2% (traffic-related 40.9%, other 12.9%), as did that for TBI (23.8% overall, 60.2% traffic-related, with no change for other circumstances). Among people aged 65 years and over, no change was observed for TSCI, incidence of TBI fell significantly when due to traffic crashes, but there was a dramatic increase of 87% in men and 89.3% in women when due to other circumstances. CONCLUSIONS Over the last decade the incidence of these types of injury has fallen significantly when the injury resulted from traffic crashes, and to a lesser extent when from other circumstances. However TBI incidence among people aged 65 and over injured in non-traffic-related circumstances has risen dramatically.

Adult community health-promoting interventions in primary health care: A systematic review

OBJECTIVE To examine evidence on the effectiveness of health-promoting community interventions carried out in primary health care. METHODS Systematic review of originals and systematic reviews of health-promoting community interventions with the participation of primary health care. A working definition of community activities was used in the inclusion criteria. Databases searched up to 2013: PUBMED, EMBASE, CINHAL, Web of SCIENCE, IBECS, IME, and PSICODOC. No restrictions on year of publication or design. Articles were reviewed by separate researchers to identify risks of bias. RESULTS Fifty-one articles published between 1966 and 2013 were included: 11 systematic reviews and 40 originals that described 39 community interventions. There is evidence on the effectiveness of community interventions in reducing cardiovascular risk factors, encouraging physical exercise, preventing falls and improving self-care among chronic patients compared with usual individual care. The effectiveness of some interventions increases when the community is involved in their development. Most assessments show positive results despite design limitations. CONCLUSIONS The community approach may be more effective than the individual in usual preventive interventions in primary care. There is a lack of evidence on many community interventions in primary care and further research is needed.

Age differences in presentation, diagnosis pathway and management of colorectal cancer

BACKGROUND The gap in survival between older and younger European cancer patients is getting wider. It is possible that cancer in the elderly is being managed or treated differently than in their younger counterparts. This study aims to explore age disparities with respect to the clinical characteristics of the tumour, diagnostic pathway and treatment of colorectal cancer patients. METHODS We conducted a multicenter cross sectional study in 5 Spanish regions. Consecutive incident cases of CRC were identified from pathology services. MEASUREMENTS From patient interviews, hospital and primary care clinical records, we collected data on symptoms, stage, doctors investigations, time duration to diagnosis/treatment, quality of care and treatment. RESULTS 777 symptomatic cases, 154 were older than 80 years. Stage was similar by age group. General symptoms were more frequent in the eldest and abdominal symptoms in the youngest. No differences were found regarding perception of symptom seriousness and symptom disclosure between age groups as no longer duration to diagnosis or treatment was observed in the oldest groups. In primary care, only ultrasound is more frequently ordered in those <65 years. Those >80 years had a significantly higher proportion of iron testing and abdominal XR requested in hospital. We observed a high resection rate independently of age but less adjuvant chemotherapy in Stage III colon cancer, and of radiotherapy in stage II and III rectal cancer as age increases. CONCLUSION There are no relevant age disparities in the CRC diagnosis process with similar stage, duration to diagnosis, investigations and surgery. However, further improvements have to be made with respect to adjuvant therapy.

Conocimientos, creencias y actitudes de la población femenina de Mallorca respecto al cáncer

BACKGROUND: To analyze the knowledge of the facts on the part of the female population of Mallorca with regard to the causes of cancer, the beliefs regarding diagnosis and treatment and their attitude toward prevention. METHODS: A descriptive cross-section study of a random population sample (n=124) of women within the 40-69 age range. The questionnaire includes socio-demographic variables, risk factors, early warning symptoms and beliefs regarding diagnosis and treatment and attitudes toward prevention. RESULTS: Cigarette smoking (92.7%;CI:88.1-97.3) and drinking alcoholic (85.7%; CI:79.4-92.0) are the most well-identified causes. Also the presence of a lump in the breast (92.6%;CI:87.9-97.2) and changes in a mole or wart on the skin (89.7% ; CI:84.2-95.2%). The underestimate the role of the diet (44.4%; CI:35.1-53.8) and overestimate the environmental factors. The knowledge and use of self-examination procedures on the breast are associated directly with the degree of education (p<0.05). Most believe that early diagnosis improves the prognosis (98.4%; CI:94.2-99.5) and that treatment is beneficial (85.2%; CI:78.5-91.9). They consider surgery to be the most highly effective method, and in the event of any doubt they would first see their primary care physician (41.9%; CI:33.2-50.6). It is mainly older women having a low level of completed schooling who get their information regarding cancer above all from the television (43.5%; CI:34.8-52.3). Worthy of special mention is the very small impact of health care personal as a source of information (6.5%; CI:2.1-10.8). CONCLUSIONS: A major knowledge of the facts exists regarding the causes and warning signs, although some misconceptions do exist. In view of future prevention campaigns, educational measures addressed mainly to older women having a low level of completed schooling should be carried out.

Promoción de la salud en atención primaria: si Hipócrates levantara la cabeza…

This article argues for the need to implement community healthcare promotion initiatives in medical practice. Some of the community initiatives introduced in primary care, as well as scientific evidence and associated implementation factors are described. The need for effective coordination between primary care and public health services, working with the community, is underlined. Two specific coordination initiatives are explained by way of example. The first is a project to develop healthcare plans in health centres in the Balearic Islands, by means of a participatory process with the collaboration of citizens, local organisations and the town council (urban planning, mobility, social services, etc.). The second is the Interdepartmental Public Health Plan of Catalonia, which was established to coordinate cross-sectoral healthcare. A specific part of this plan is the COMSalud project, the purpose of which is to introduce a community perspective to health centres and which is currently being piloted in 16 health areas. We review the proposals of a 2008 research study to implement healthcare promotion in primary care, assessing its achievements and shortfalls. The Disease Prevention and Health Promotion Strategy of the Spanish Ministry of Health is recognised as an opportunity to coordinate primary and public health. It is concluded that this change of mentality will require both financial and human resources to come to fruition.

La reforma de la salud pública

Este documento es un resumen ejecutivo de los principales contenidos que se presentaron y debatieron en el encuentro sobre la reforma de la salud pública que se celebró en la Escola d’Estiu de Salut Pública, en Maó (Menorca – Illes Balears), los dı́as 22 y 23 de septiembre de 2008. A este encuentro, organizado por la Direcció General de Salut Pública de la Conselleria de Salut i Consum de les Illes Balears y la Direcció General de Salut Pública del Departament de Salut de la Generalitat de Catalunya, fueron invitados representantes del Ministerio de Sanidad y Consumo del Gobierno de España, los directores generales de salud pública de las 17 comunidades autónomas (CC.AA.) y de la ciudades de Ceuta y Melilla, el Director del Observatorio Europeo de Sistemas de Salud y Polı́ticas de la Organización Mundial de la Salud, algunos representantes de la administración local y expertos relacionados con los procesos de reforma de la salud pública que se están llevando a cabo en los últimos tiempos. Con el fin de agilizar los debates, se acordó restringir el número de participantes a 35. El propósito del encuentro fue intercambiar información y experiencias entre las CC.AA. sobre los procesos de reforma de la salud pública iniciados o que se están planteando, debatir sobre las polı́ticas que articulan dichas reformas, ası́ como conocer y analizar las propuestas de los modelos de funcionamiento y organizativos basándose en experiencias concretas. Recoger los principales contenidos del debate, huyendo de un resumen de lo presentado, es lo que pretende este documento. El contenido del programa se encuentra disponible por si puede ser de interés para algún lector. El encuentro no pretendió en ningún momento lograr un consenso entre los participantes. Por ello, la sı́ntesis de las conclusiones es responsabilidad exclusiva de los organizadores y no representa necesariamente la transcripción literal de las intervenciones, ni tampoco la opinión de todos los asistentes.

Public health reform

Resumen del encuentroEste documento es un resumen ejecutivo de los principalescontenidos que se presentaron y debatieron en el encuentro sobrela reforma de la salud pu´blica que se celebro´ en la Escola d’Estiu deSalut Pu´blica, en Mao´ (Menorca – Illes Balears), los di´as 22 y 23 deseptiembre de 2008.A este encuentro, organizado por la Direccio´ General de SalutPu´blica de la Conselleria de Salut i Consum de les Illes Balears y laDireccio´ General de Salut Pu ´blica del Departament de Salut de laGeneralitat de Catalunya, fueron invitados representantes delMinisterio de Sanidad y Consumo del Gobierno de Espan˜a, losdirectores generales de salud pu´blica de las 17 comunidadesauto ´nomas (CC.AA.) y de la ciudades de Ceuta y Melilla, el Directordel Observatorio Europeo de Sistemas de Salud y Poli´ticas de laOrganizacio ´n Mundial de la Salud, algunos representantes de laadministracio´n local y expertos relacionados con los procesos dereforma de la salud pu´blica que se esta´n llevando a cabo en losu´ltimos tiempos. Con el fin de agilizar los debates, se acordo´restringir el nu´mero de participantes a 35.El propo´sito del encuentro fue intercambiar informacio´nyexperiencias entre las CC.AA. sobre los procesos de reforma de lasalud pu´blica iniciados o que se esta´n planteando, debatir sobrelas poli´ticas que articulan dichas reformas, asi ´como conocer yanalizar las propuestas de los modelos de funcionamiento yorganizativos basa´ndose en experiencias concretas.Recoger los principales contenidos del debate, huyendo de unresumen de lo presentado, es lo que pretende este documento. Elcontenido del programa se encuentra disponible por si puede serde intere´s para algu´n lector