Karen Galway

The Incidence of Esophageal Cancer and High-Grade Dysplasia in Barrett's Esophagus: A Systematic Review and Meta-Analysis

Barretts esophagus is a well-recognized precursor of esophageal adenocarcinoma. Surveillance of Barretts esophagus patients is recommended to detect high-grade dysplasia (HGD) or early cancer. Because of wide variation in the published cancer incidence in Barretts esophagus, the authors undertook a systematic review and meta-analysis of cancer and HGD incidence in Barretts esophagus. Ovid Medline (Ovid Technologies, Inc., New York, New York) and EMBASE (Elsevier, Amsterdam, the Netherlands) databases were searched for papers published between 1950 and 2006 that reported the cancer/HGD risk in Barretts esophagus. Where possible, early incident cancers/HGD were excluded, as were patients with HGD at baseline. Forty-seven studies were included in the main analysis, and the pooled estimate for cancer incidence in Barretts esophagus was 6.1/1,000 person-years, 5.3/1,000 person-years when early incident cancers were excluded, and 4.1/1,000 person-years when both early incident cancer and HGD at baseline were excluded. Corresponding figures for combined HGD/cancer incidence were 10.0 person-years, 9.3 person-years, and 9.1/1,000 person-years. Compared with women, men progressed to cancer at twice the rate. Cancer or HGD/cancer incidences were lower when only high-quality studies were analyzed (3.9/1,000 person-years and 7.7/1,000 person-years, respectively). The pooled estimates of cancer and HGD incidence were low, suggesting that the cost-effectiveness of surveillance is questionable unless it can be targeted to those with the highest cancer risk.

Consultation charges in Ireland deter a large proportion of patients from seeing the GP: results of a cross-sectional survey

Objective: To estimate the effect of a consultation charge on the health-seeking behaviour of patients. Methods: Cross-sectional survey of patients carried out in Northern Ireland, where services are free at the point of delivery, and the Republic of Ireland, where 70% of the population are charged a consultation fee to see the general practitioner (GP). Results: There were 11 870 respondents to the survey (response rate 52%). In the Republic of Ireland, 18.9% of patients (4.4% of non-paying patients and 26.3% of paying patients) had a medical problem in the previous year but had not consulted the doctor because of cost; this compares with only 1.8% of patients in Northern Ireland. Because those in the Republic of Ireland on low income are entitled to free care, the effects of the consultation charge were most marked in the middle of the income distribution, with such patients being over four times as likely to have been deterred as those in the most affluent group. However, amongst paying patients, it was the poorest and those with the worst health who were most affected. Compared to the most affluent patients and those without depression, the likelihood of not having seen the GP due to cost was 6.75 (95% confidence interval [CI] 3.79, 11.09) for the poorest patients and 2.01 (95% CI 1.53, 2.52) for those with depression. Conclusion: Even in countries with exemptions for the poor and more vulnerable, a consultation charge can deter a large proportion of poorer and less healthy patients from seeing their GP.

General practitioners perceptions on advance care planning for patients living with dementia

BackgroundAdvance care planning (ACP) facilitates communication and understanding of preferences, nevertheless the use of ACPs in primary care is low. The uncertain course of dementia and the inability to communicate with the patient living with dementia are significant challenges for GPs to initiate discussions on goals of care.MethodsA cross-sectional survey, using a purposive, cluster sample of GPs across Northern Ireland with registered dementia patients was used. GPs at selected practices received the survey instrument and up to four mail contacts was implemented.ResultsOne hundred and thirty-three GPs (40.6%) participated in the survey, representing 60.9% of surveyed practices. While most respondents regarded dementia as a terminal disease (96.2%) only 37.6% felt that palliative care applied equally from the time of diagnosis to severe dementia. While most respondents thought that early discussions would facilitate decision-making during advanced dementia (61%), respondents were divided on whether ACP should be initiated at the time of diagnoses. While most respondents felt that GPs should take the initiative to introduce and encourage ACP, most survey participants acknowledged the need for improved knowledge to involve families in caring for patients with dementia at the end of life and that a standard format for ACP documentation was needed.ConclusionOptimal timing of ACP discussions should be determined by the readiness of the patient and family carer to face end of life. ACP discussions can be enhanced by educational strategies directed towards the patient and family carer that enable shared decision-making with their GP when considering options in future care.

Initiating advance care planning on end-of-life issues in dementia: Ambiguity among UK and Dutch physicians

BACKGROUND In dementia, advance care planning (ACP) of end-of-life issues may start as early as possible in view of the patients decreasing ability to participate in decision making. We aimed to assess whether practicing physicians in the Netherlands and the United Kingdom who provide most of the end-of-life care, differ in finding that ACP in dementia should start at diagnosis. METHODS In a cross-sectional study, we surveyed 188 Dutch elderly care physicians who are on the staff of nursing homes and 133 general practitioners from Northern Ireland. We compared difference by country in the outcome (perception of ACP timing), rated on a 1-5 agreement scale. Regression analyses examined whether a country difference can be explained by contrasts in demographics, presence, exposure and role perceptions. RESULTS There was wide variability in agreement with the initiation of ACP at dementia diagnosis, in particular in the UK but also in the Netherlands (60.8% agreed, 25.3% disagreed and 14.0% neither agreed, nor disagreed). Large differences in physician characteristics (Dutch physicians being more present, exposed and adopting a stronger role perception) hardly explained the modest country difference. The perception that the physician should take the initiative was independently associated with agreeing with ACP at diagnosis. CONCLUSIONS There is considerable ambiguity about initiating ACP in dementia at diagnosis among physicians practicing in two different European health care systems and caring for different patient populations. ACP strategies should accommodate not only variations in readiness to engage in ACP early among patient and families, but also among physicians.

General practitioners’ perceptions of the barriers and solutions to good quality palliative care in dementia

The general practitioner (GP) is in a pivotal position to initiate and adapt care for their patients living with dementia. This study aimed to elicit GPs’ perceptions of the potential barriers and solutions to the provision of good-quality palliative care in dementia in their practices. A postal survey of GPs across Northern Ireland was conducted with open-ended items soliciting for barriers in their practices and possible solutions; 40.6% (138/340) were returned completed. Barriers to palliative care in dementia were perceived to be a dementia knowledge deficit for healthcare staff and the public, a resource shortfall within the GP practice and community, poor team coordination alongside inappropriate dementia care provision, and disagreements from and within families. These findings have significant implications for educators and clinicians as enhanced dementia education and training were highlighted as a strong agenda for GPs with the suggestions of dementia awareness programmes for the public.

Cancer and serious mental illness – patient, caregiver and professional perspectives: study protocol

AIM To explore the experience of serious mental illness and cancer from the perspective of patients, significant others and healthcare professionals involved in their care. BACKGROUND Serious mental illness is associated with poorer cancer outcomes. Those suffering from this comorbidity receive fewer specialist interventions and die earlier than the general population. Prior qualitative research in this area has comprised of a single study focussing on healthcare professionals and there is little evidence regarding the experiences of patients and caregivers. DESIGN A qualitative exploration using approximately 36 semi-structured interviews. METHODS Semi-structured digitally recorded interviews conducted with: adults living with serious mental illness and diagnosed with cancer; those providing them with informal support and care; and healthcare professionals. Questions will focus on the experience of having cancer and serious mental illness or caring for someone with this comorbidity, experiences of healthcare and priorities for patients and carers. Framework analysis will be used. Research Ethics Committee and Trust Research & Development approval was obtained. A steering group comprising six people with experience of either cancer or mental illness provided feedback and ratified the patient information sheets and interview schedules. DISCUSSION There is a paucity of research addressing stakeholder perspectives on the experience of cancer and of cancer services for people with serious mental illness. Dissemination of findings will inform practice relating to the care of an often neglected population, informing better support for their significant others and the professionals involved in their care.

Patterns of presentation for attempted suicide: analysis of a cohort of individuals who subsequently died by suicide.

All suicides and related prior attempts occurring in Northern Ireland over two years were analyzed, focusing on number and timing of attempts, method, and mental health diagnoses. Cases were derived from coroners records, with 90% subsequently linked to associated general practice records. Of those included, 45% recorded at least one prior attempt (with 59% switching from less to more lethal methods between attempt and suicide). Compared with those recording one attempt, those with 2+ attempts were more likely to have used less lethal methods at the suicide (OR = 2.77: 95% CI = 1.06, 7.23); and those using less lethal methods at the attempts were more likely to persist with these into the suicide (OR = 3.21: 0.79, 13.07). Finally, those with preexisting mental problems were more likely to use less lethal methods in the suicide: severe mental illness (OR = 7.88: 1.58, 39.43); common mental problems (OR = 3.68: 0.83, 16.30); and alcohol/drugs related (OR = 2.02: 0.41, 9.95). This analysis uses readily available data to highlight the persisting use of less lethal methods by visible and vulnerable attempters who eventually complete their suicide. Further analysis of such conditions could allow more effective prevention strategies to be developed.

The failure of suicide prevention in primary care: family and GP perspectives – a qualitative study

BackgroundAlthough Primary care is crucial for suicide prevention, clinicians tend to report completed suicides in their care as non-preventable. We aimed to examine systemic inadequacies in suicide prevention from the perspectives of bereaved family members and GPs.MethodsQualitative study of 72 relatives or close friends bereaved by suicide and 19 General Practitioners who have experienced the suicide of patients.ResultsRelatives highlight failures in detecting symptoms and behavioral changes and the inability of GPs to understand the needs of patients and their social contexts. A perceived overreliance on anti-depressant treatment is a major source of criticism by family members. GPs tend to lack confidence in the recognition and management of suicidal patients, and report structural inadequacies in service provision.ConclusionsMental health and primary care services must find innovative and ethical ways to involve families in the decision-making process for patients at risk of suicide.

Findings from a systematic review: 'Cancer and people with Serious Mental Illness'.

Background: Survival from cancer is poorer in the UK than other European countries. Critical illness may be a potential determinant of cancer outcomes but its role has not been described before. We assessed the incidence of admission to intensive care units (ICU) following cancer diagnosis to quantify the risk of critical illness among cancer patients. Method: We took data for solid cancer registrations in the West of Scotland region, UK, between 2000–2009 from the Scottish Cancer Registry. Linked hospital, ICU, and mortality records provided details of hospital admissions, deaths, sociodemographics and comorbidities. We assessed the incidence of admission to ICU within two years of cancer diagnosis and explored differences in hospital mortality by patient characteristics. Results: 6,121 (5.2%,95% CI 5.0–5.3%) out of 118,571 incident cancer patients developed a critical illness and were admitted to ICU within 2 years. Risk of critical illness was highest at ages 60–69 and higher in men. The cumulative inci-dence of critical illness was greatest for small intestinal (17.2%,95% CI 13.3–21.8%) and colorectal cancers (16.5%,15.9–17.1%). The risk following breast cancer was low (0.8%,95% CI 0.7–1.0%). Mortality in ICU was 14.1% (95% CI 13.3–15.0%), and during the hospital stay 24.6% (23.5– 25.7%). Mortality was greatest among emergency medical admissions and lowest among elective surgical patients. The risk of critical illness did not vary by socio-economic circumstances but mortality was higher among patients from deprived areas. Conclusions: About one in 20 cancer patients experiences a critical illness resulting in ICU admission within two years of cancer diagnosis. They experience high mortality which may make a significant contribution to cancer outcomes. The UK has lower provision of ICU than countries in which cancer survival is better. It is important to determine whether provision of ICU resources might reduce critical illness mortality among cancer patients.Aim: To explore the experience of serious mental illness and cancer from the perspective of patients, significant others and health care professionals involved in their care. Background: Serious mental illness is associated with poorer cancer outcomes. Those suffering from this comorbidity receive fewer specialist interventions and die earlier than the general population. Prior qualitative research in this area has comprised of a single study focussing on healthcare professionals, and there is little evidence regarding the experiences of patients and caregivers. Design: A qualitative exploration using approximately 36 semi-structured interviews. Methods: Semi-structured digitally recorded interviews conducted with: adults living with serious mental illness and diagnosed with cancer; those providing them with informal support and care; and healthcare professionals. Questions will focus on the experience of having cancer and serious mental illness or caring for someone with this comorbidity, experiences of healthcare, and priorities for patients and carers. Framework analysis will be used. Research Ethics Committee and Trust Research & Development approval was obtained. A steering group comprising six people with experience of either cancer or mental illness provided feedback and ratified the patient information sheets and interview schedules. Discussion: There is a paucity of research addressing stakeholder perspectives on the experience of cancer and of cancer services for people with serious mental illness. Dissemination of findings will inform practice relating to the care of an often neglected population, informing better support for their significant others and the professionals involved in their care. Summary Statement Why this study is needed: • People with serious mental illness experience poorer cancer outcomes than the general population, with mortality rates around double those for patients without mental illness. There are indications that this is linked to service-related factors. • There has been no research that directly consults patients with comorbid cancer and serious mental illness, or their informal caregivers, about their experiences of cancer and of cancer care. There has only been one study directly consulting healthcare professionals about this issue.