Sally Tyndel

Self-monitoring of oral anticoagulation: systematic review and meta-analysis of individual patient data

BACKGROUND Uptake of self-testing and self-management of oral anticoagulation [corrected] has remained inconsistent, despite good evidence of their effectiveness. To clarify the value of self-monitoring of oral anticoagulation, we did a meta-analysis of individual patient data addressing several important gaps in the evidence, including an estimate of the effect on time to death, first major haemorrhage, and thromboembolism. METHODS We searched Ovid versions of Embase (1980-2009) and Medline (1966-2009), limiting searches to randomised trials with a maximally sensitive strategy. We approached all authors of included trials and requested individual patient data: primary outcomes were time to death, first major haemorrhage, and first thromboembolic event. We did prespecified subgroup analyses according to age, type of control-group care (anticoagulation-clinic care vs primary care), self-testing alone versus self-management, and sex. We analysed patients with mechanical heart valves or atrial fibrillation separately. We used a random-effect model method to calculate pooled hazard ratios and did tests for interaction and heterogeneity, and calculated a time-specific number needed to treat. FINDINGS Of 1357 abstracts, we included 11 trials with data for 6417 participants and 12,800 person-years of follow-up. We reported a significant reduction in thromboembolic events in the self-monitoring group (hazard ratio 0·51; 95% CI 0·31-0·85) but not for major haemorrhagic events (0·88, 0·74-1·06) or death (0·82, 0·62-1·09). Participants younger than 55 years showed a striking reduction in thrombotic events (hazard ratio 0·33, 95% CI 0·17-0·66), as did participants with mechanical heart valve (0·52, 0·35-0·77). Analysis of major outcomes in the very elderly (age ≥85 years, n=99) showed no significant adverse effects of the intervention for all outcomes. INTERPRETATION Our analysis showed that self-monitoring and self-management of oral coagulation is a safe option for suitable patients of all ages. Patients should also be offered the option to self-manage their disease with suitable health-care support as back-up. FUNDING UK National Institute for Health Research (NIHR) Technology Assessment Programme, UK NIHR National School for Primary Care Research.

What Is the Psychological Impact of Mammographic Screening on Younger Women With a Family History of Breast Cancer? Findings From a Prospective Cohort Study by the PIMMS Management Group

PURPOSE Studies are underway to establish the clinical effectiveness of annual mammographic screening in women younger than 50 years with a family history of breast cancer. This study investigated both the positive and negative psychological effects of screening on these women. PATIENTS AND METHODS Women who received an immediate all-clear result after mammography (n = 1,174) and women who were recalled for additional tests before receiving an all-clear result (false positive; n = 112) completed questionnaires: 1 month before mammography, and 1 and 6 months after receiving final results. The questionnaires included measures of cancer worry, psychological consequences, and perceived benefits of breast screening. RESULTS Women who received an immediate all-clear result experienced a decrease in cancer worry and negative psychological consequences immediately after the result, whereas women who were recalled for additional tests did not. By 6 months this cancer-specific distress had reduced significantly in both groups. Changes in levels of distress were significantly different between the two groups, but in absolute terms the differences were not large. Recalled women reported significantly greater positive psychological consequences of screening immediately after the result, and were also more positive about the benefits of screening compared with women who received an immediate all-clear result. CONCLUSION For women receiving an immediate all-clear result, participating in annual mammographic screening is psychologically beneficial. Furthermore, women who are recalled for additional tests do not appear to be harmed by screening: these womens positive views about mammography suggest that they view any distress caused by recall as an acceptable part of screening.

Optimal loading dose for the initiation of warfarin: a systematic review

BackgroundSelection of the right warfarin dose at the outset of treatment is not straightforward, and current evidence is lacking to determine the optimal strategy for initiation of therapy.MethodsWe included randomized controlled trials in patients commencing anticoagulation with warfarin, comparing different loading dose or different regimens.We searched Medline, EMBASE, the Cochrane Library and the NHS Health Economics Database up to June 2009. Primary outcomes were time to stable INR and adverse events. We summarised results as proportion of INRs in range from date of initiation and compared dichotomous outcomes using relative risks (RR) and calculated 95% confidence intervals (CIs).ResultsWe included 11 studies of 1,340 patients newly initiated on warfarin. In two studies that used single INR measures, a loading dose of 10 mg compared to 5 mg led to more patients in range on day five. However, in two studies which measured two consecutive INRs, a loading dose of 10 mg compared to 5 mg did not lead to more patients in range on day five (RR = 0.86, 95% CI, 0.62 to 1.19, p = 0.37). Patients receiving a 2.5 mg initiation does took longer to achieve the therapeutic range, whilst those receiving a calculated initiation dose achieved target range 0.8 days quicker (4.2 days vs. 5 days, p = 0.007). More elderly patients receiving an age adjusted dose achieved a stable INR compared to the Fennerty protocol (48% vs. 22% p = 0.02) and significantly fewer patients on the age adjusted regimens had high out-of-range INRs. Two studies report no significant differences between genotype guided and 5 mg or 10 mg initiation doses and in the one significant genotype study the control group INRs were significantly lower than expected.ConclusionOur review findings suggest there is still considerable uncertainty between a 10 mg and a 5 mg loading dose for initiation of warfarin. In the elderly, lower initiation doses or age adjusted doses are more appropriate, leading to less higher INRs. Currently there is insufficient evidence to warrant genotype guided initiation, and adequately powered trials to detect effects on adverse events are currently warranted.

Predictors of breast cancer-related distress following mammography screening in younger women on a family history breast screening programme

Objective: This longitudinal study investigated pre‐screening factors that predicted breast cancer‐specific distress among 1286 women who were undergoing annual mammography screening as part of a UK programme for younger women (i.e., under 50) with a family history of breast cancer.

Diagnosed with breast cancer while on a family history screening programme: an exploratory qualitative study

Mammographic screening is offered to many women under 50 in the UK who are at moderate or high risk of developing breast cancer because of their family history of the disease. Little is understood about the impact of screening on the emotional well-being of women with a family history of breast cancer. This qualitative study explores the value that women at increased risk placed on screening, both pre- and post-cancer diagnosis and the impact of the diagnosis. In-depth interviews were undertaken with 12 women, aged 35-50, diagnosed with breast cancer while on an annual mammographic screening programme. Women described the strong sense of reassurance gained from screening prior to diagnosis. This faith in screening was reinforced by early detection of their cancer. Reactions to diagnosis ranged from devastation to relief at having finally developed a long-expected condition. Despite their positive attitudes about screening, not all women wanted to continue with surveillance. For some, prophylactic mastectomy was preferable, to reduce future cancer risk and to alleviate anxieties about the detection of another cancer at each subsequent screen. This study illustrates the positive yet diverse attitudes towards mammographic screening in this group of women with a family history of breast cancer.

Mammographic screening for young women with a family history of breast cancer: knowledge and views of those at risk

Although the effectiveness of mammography for women under the age of 50 years with a family history of breast cancer (FHBC) has not yet been proven, annual screening is being offered to these women to manage breast cancer risk. This study investigates womens awareness and interpretation of their familial risk and knowledge and views about mammographic screening. A total of 2231 women from 21 familial/breast/genetics centres who were assessed as moderate risk (17–30% lifetime risk) or high risk (>30% lifetime risk) completed a questionnaire before their mammographic screening appointment. Most women (70%) believed they were likely, very likely or definitely going to develop breast cancer in their lifetime. Almost all women (97%) understood that the purpose of mammographic screening was to allow the early detection of breast cancer. However, 20% believed that a normal mammogram result meant there was definitely no breast cancer present, and only 4% understood that screening has not been proven to save lives in women under the age of 50 years. Women held positive views on mammography but did not appear to be well informed about the potential disadvantages. These findings suggest that further attention should be paid to improving information provision to women with an FHBC being offered routine screening.

Diagnosed with breast cancer whilst on a family history screening programme: an exploratory qualitative study

Mammographic screening is offered to many women under 50 in the UK who are at moderate or high risk of developing breast cancer because of their family history of the disease. Little is understood about the impact of screening on the emotional well-being of women with a family history of breast cancer. This qualitative study explores the value that women at increased risk placed on screening, both pre- and post-cancer diagnosis and the impact of the diagnosis. In-depth interviews were undertaken with 12 women, aged 35–50, diagnosed with breast cancer while on an annual mammographic screening programme. Women described the strong sense of reassurance gained from screening prior to diagnosis. This faith in screening was reinforced by early detection of their cancer. Reactions to diagnosis ranged from devastation to relief at having finally developed a long-expected condition. Despite their positive attitudes about screening, not all women wanted to continue with surveillance. For some, prophylactic mastectomy was preferable, to reduce future cancer risk and to alleviate anxieties about the detection of another cancer at each subsequent screen. This study illustrates the positive yet diverse attitudes towards mammographic screening in this group of women with a family history of breast cancer.

Predictors of cancer worry following mammography in younger women on a family history breast screening programme [Abstract]

Background:This correlational study examined the value of the HAPA theory at predicting weight-loss in a weight-loss trial. Methods:Participants (N¼22) undergoing an 8-week weight-loss programme were recruited from aprivate hospital. Baseline questionnaires measured demographics, height, weight, self-efficacy,risk-perception, outcome-expectancies and intentions. Findings:Questionnaires at 4 and 8 weeks measured weight-loss behaviours – physical activity,dietary variables, effort and weight. The HAPA was able to significantly predict weight-loss(RAˆ2¼0.57,p¼0.027). Self-efficacy and risk-perceptions were significantly related to intention(r¼0.80,p50.001 andr¼�0.48,p50.01 respectively). Intentions were significantly related to weight-loss behaviour was significantly related toweight-loss (r¼0.73,p50.01). The study provides evidence for the predictive value of the HAPAat predicting weight-loss. Discussion:Findings build on current knowledge of the cognitions and behaviours involved insuccessful weight-loss and may contribute to the development of interventions designed to increaseweight-loss in the overweight and clinically obese population.Background: Previous reports of this prospective study highlight the psychological benefits of a breast screening programme for younger women with a family history of breast cancer. The present paper identified risk factors for cancer worry in these women. Methods: 1286 women completed questionnaires one month prior to screening (T1), and one (T2)and six (T3) months after screening results. Breast cancer worry, perceived risk, cognitive appraisals, coping, and dispositional optimism were measured. Findings: T1 cancer worry explained 56/61% and 54/57% of the variance in worry at T2 and T3 respectively. Other salient predictors included high perceived risk of breast cancer, appraisals of high relevance and threat associated with the family history, and low perceived ability to cope emotionally. A false positive screening result, pessimistic personality, and religion/substance use coping predicted outcomes at T2 but not T3. Discussion: Interventions to ameliorate high levels of cancer worry and negative appraisals are needed.Background: Personal disclosures of patients may influence how they are evaluated by others. These evaluations may be influenced by the information the patient provides but also by the recipients needs. Methods: In an experimental study, healthy female participants (N = 61) listened to a female cancer patient’s testimonial (25 minutes) in which the patient told about either her negative emotions during radiation therapy or coping strategies she used. The dependent variable was participant’s evaluation of the patient. Findings: The results showed a main effect of condition, meaning that patients who told about their coping were perceived as more sympathetic, courageous and realistic. As indicated by a significant interaction, this effect was especially strong in participants with a strong inclination to compare themselves to others. Discussion: These data show that the personal information that patients provide to others influences how others perceive them. This may have consequences for the others’ motivation to provide social support.Background: Ovarian cancer is known as the “silent killer”. A prospective psychological evaluation study (PsyFOCS) is underway in partnership with the UK Familial Ovarian Cancer Screening Study, which aims to determine the clinical effectiveness of ovarian screening for high risk women. Methods: Prior to screening, 991 women completed the Illness Perception Questionnaire (adapted for ovarian cancer risk), Impact of Event Scale (IES), and Hospital Anxiety and Depression Scale. Findings: Over one third of women were moderately or highly distressed about their risk according to IES scores. Hierarchical multiple regression showed that negative emotional representations (p<.001), higher anxiety (p<.001), stronger ovarian cancer screening control beliefs (p<.01), and past ovarian cancer screening recall (p<.05) were associated with higher pre-screening distress. Discussion: The association between ovarian cancer screening control beliefs and distress suggests that more distressed women may place greater faith in screening as a means of controlling genetic risk.