Matthew Barclay

Factors Affecting Short-term Mortality in Women With Ovarian, Tubal, or Primary Peritoneal Cancer Population-Based Cohort Analysis of English National Cancer Registration Data

Objective International studies show lower survival rates in the United Kingdom than other countries with comparable health care systems. We report on factors associated with excess mortality in the first year after diagnosis of primary invasive epithelial ovarian, tubal, and primary peritoneal cancer. Methods Routinely collected national data were used for patients diagnosed in England in 2008 to 2010. A multivariate Poisson model was used to model excess mortality in 3 periods covering the first year after diagnosis, adjusting for various factors including age at diagnosis, route to diagnosis, tumor stage, tumor morphology, and treatment received. Results Of 14,827 women diagnosed as having ovarian cancer, 5296 (36%) died in the first year, with 1673 deaths in the first month after diagnosis. Age older than 70 years, diagnosis after an emergency presentation or by an unknown route, and unspecified or unclassified epithelial morphologies were strongly and independently associated with excess mortality in the first year after diagnosis. Of the 2100 (14%) women who fulfilled all 3 criteria, 1553 (74%) did not receive any treatment and 1774 (85%) died in the first year after diagnosis. In contrast, only 193 (4%) of the 4414 women without any of these characteristics did not receive any treatment, and only 427 (9%) died in the first year after diagnosis. Conclusions Although our results are based on data from England, they are likely to have implications for cancer care pathways worldwide because most of the identified factors are not specific to the UK health care system. Our results suggest the need to increase symptom awareness, promote timely general practitioner referral, and optimize diagnostic and early treatment pathways within secondary care to increase access to treatment for women with advanced-stage invasive epithelial ovarian, tubal, and primary peritoneal cancer. This process should be pursued alongside continued efforts to develop primary prevention and screening strategies.

Adjusted indices of multiple deprivation to enable comparisons within and between constituent countries of the UK including an illustration using mortality rates

Objectives Social determinants can have a major impact on health and as a consequence substantial inequalities are seen between and within countries. The study of inequalities between countries relies on having accurate and consistent measures of deprivation across the country borders. However, in the UK most socioeconomic deprivation measures are not comparable between countries. We give a method of adjusting the Indices of Multiple Deprivation (IMD) for use across the UK, describe the deprivation of each UK country, and show the problems introduced by naïvely using country-specific deprivation measures in a UK-wide analysis of mortality rates. Setting/participants 42 148 geographic areas covering the population of the UK. Outcome measures Adjusted IMD scores based on the income and employment domains of country-specific IMD scores, adjusting for the contribution of other domains. The mortality rate among people aged under 75 years standardised to the UK age structure was compared between country-specific and UK-adjusted IMD quintiles. Results Of the constituent countries of the UK, Northern Ireland was the most deprived with 37% of the population living in areas in the most deprived fifth of the UK, followed by Wales with 22% of the population living in the most deprived fifth of the UK. England and Scotland had similar levels of deprivation. Deprivation-specific mortality rates were similar in England and Wales. Northern Ireland had lower mortality rates than England for each deprivation group, with similar differences for each group. Scotland had higher mortality rates than England for each deprivation group, with larger differences for more deprived groups. Conclusions Analyses of between-country and within-country inequalities by socioeconomic position should use consistent measures; failing to use consistent measures may give misleading results. The published adjusted IMD scores we describe allow consistent analysis across the UK.

Cancer-Related Fatigue in Adolescents and Young Adults After Cancer Treatment: Persistent and Poorly Managed

Cancer-related fatigue is the most prevalent and distressing symptom experienced by adolescents and young adults (AYAs). An electronic survey was undertaken to ascertain current fatigue management and perceptions of its effectiveness. Eighty-five percent of responders (68/80) experienced fatigue, and it was worse more than 1 year after cancer treatment ended, compared to <1 year (p = 0.007). Forty-one percent received no fatigue management. Although advice to exercise was the most frequent intervention, the greatest impact of fatigue was on the ability to exercise and most did not find exercise advice helpful. Early intervention is warranted, supporting AYAs to persevere with increasing activity.

The problem with composite indicators

‘The Problem with…’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution.

20 Negative personal emotional impact of caring for the dying – expectations of future doctors. a multicentre study

Background End of life care (EOLC) is a large part of junior doctors’ workload. Negative attitudes may impact on care provided and may be shaped during undergraduate medical training. Aims We investigated: whether medical students expect EOLC to have a negative emotional impact on themselves demographic and psychological factors associated with such expectations. Methods Multicentre cross-sectional online study of 1520 first and 954 final year medical students from 18 universities, (16 UK, 1 New Zealand, 1 Ireland). We assessed attitudes towards EOLC (Sullivan’s statements), age, gender, course year, course type (standard or graduate), spirituality and experience of bereavement as well as psychological variables: death anxiety (Collett Lester Fear of Death Scale, COLFD), empathy (Davis’s Interpersonal Reactivity Index, IRI) and depression (Hospital Depression Scale HADS-D). Factor analysis suggested 3 Sullivan statements formed a ‘negative personal emotional impact score’ (Impact Score, −6 to +6). Students with low/neutral (−6 to +3) and high (+3 to+6) Impact Score were compared (χ2-tests and ANOVA) and regression analyses undertaken. Results Respondents were neutral overall (mean Impact Score=0.3), although with substantial variations. Participants with high Impact Score were likely to be younger, standard course, first-year students, and to have higher depression and distress scores (HADS-D and IRI-Personal-Distress-scale), lower cognitive empathy scores (IRI-Perspective-Taking) and to score more highly on all COLFD sub-scales. Regression analysis showed psychological factors were strongly associated with the Impact Score: COLFD others-dying (1.29;CI: 1.08 to 1.50;p=0.001), IRI-Personal-Distress-scale (0.97;CI: 0.77 to 1.17;p=0.001), HADS-D (0.45;CI: 0.17 to 0.74;p=0.002), and COLFD others-death (0.31;CI: 0.09 to 0.54;p=0.006) scales were the strongest predictors. Conclusions Medical students worry about the possible negative personal emotional impact of EOLC when doctors. While medical education may mitigate such concerns, negative expectations appear related to distress, death anxiety and depression. Measures to improve and support psychological well-being may have a positive impact on medical students’ attitudes toward EOLC.

Time trends in service provision and survival outcomes for patients with renal cancer treated by nephrectomy in England 2000–2010

To describe the temporal trends in nephrectomy practice and outcomes for English patients with renal cell carcinoma (RCC).

Order effects in high stakes undergraduate examinations: an analysis of 5 years of administrative data in one UK medical school

Objective To investigate the association between student performance in undergraduate objective structured clinical examinations (OSCEs) and the examination schedule to which they were assigned to undertake these examinations. Design Analysis of routinely collected data. Setting One UK medical school. Participants 2331 OSCEs of 3 different types (obstetrics OSCE, paediatrics OSCE and simulated clinical encounter examination OSCE) between 2009 and 2013. Students were not quarantined between examinations. Outcomes (1) Pass rates by day examination started, (2) pass rates by day station undertaken and (3) mean scores by day examination started. Results We found no evidence that pass rates differed according to the day on which the examination was started by a candidate in any of the examinations considered (p>0.1 for all). There was evidence (p=0.013) that students were more likely to pass individual stations on the second day of the paediatrics OSCE (OR 1.27, 95% CI 1.05 to 1.54). In the cases of the simulated clinical encounter examination and the obstetrics and gynaecology OSCEs, there was no (p=0.42) or very weak evidence (p=0.099), respectively, of any such variation in the probability of passing individual stations according to the day they were attempted. There was no evidence that mean scores varied by day apart from the paediatric OSCE, where slightly higher scores were achieved on the second day of the examination. Conclusions There is little evidence that different examination schedules have a consistent effect on pass rates or mean scores: students starting the examinations later were not consistently more or less likely to pass or score more highly than those starting earlier. The practice of quarantining students to prevent communication with (and subsequent unfair advantage for) subsequent examination cohorts is unlikely to be required.