Differences in cancer incidence by broad ethnic group in England, 2013-2017.

BACKGROUND: Cancer incidence variation between population groups can inform public health and cancer services. Previous studies have shown cancer incidence rates vary by ethnic group in England. Since their publication, the completeness of ethnicity recording in cancer data has improved, and relevant inequalities (e.g. risk factor prevalence and healthcare access) may have changed. METHODS: Age-standardised incidence rates were calculated for Asian, Black, Mixed/Multiple and White ethnic groups in England in 2013-2017, using almost 3 million diagnoses across 31 cancer sites. Rate ratios were calculated with the White ethnic group as reference. Sensitivity analyses used imputed ethnicity for cases with missing data and perturbed population estimates. RESULTS: Incidence rates for most cancer sites and ethnic group and sex combinations were lower in non-White minority ethnic groups compared with the corresponding White group, with particularly low rate ratios (below 0.5) for melanoma skin cancer and some smoking-related cancers (lung, bladder and oesophageal cancers). Exceptions included prostate cancer (2.1 times higher in males of Black ethnicity), myeloma (2.7-3.0 times higher in people of Black ethnicity), several gastrointestinal cancers (1.1-1.9 times higher in people of Black ethnicity, 1.4-2.2 times higher in people of Asian ethnicity), Hodgkin lymphoma (1.1 times higher in males of Asian ethnicity, 1.3 times higher in males of Black ethnicity) and thyroid cancers (1.4 times higher in people of Asian ethnicity, 1.2 times higher in people of Black ethnicity). Sensitivity analyses did not materially alter these results (rate ratios changed by a maximum of 12 percentage points, the direction and significance of results were unchanged in all but two cancer site/sex/ethnic group combinations). CONCLUSIONS: People of non-White minority ethnicity in England generally have lower cancer risk than the White population, though there are a number of notable exceptions. These results should galvanise efforts to better understand the reasons for this variation, and the possible impact on cancer services, patient experiences and outcomes.

The fraction of cancer attributable to modifiable risk factors in England, Wales, Scotland, Northern Ireland, and the United Kingdom in 2015.

BACKGROUND: Changing population-level exposure to modifiable risk factors is a key driver of changing cancer incidence. Understanding these changes is therefore vital when prioritising risk-reduction policies, in order to have the biggest impact on reducing cancer incidence. UK figures on the number of risk factor-attributable cancers are updated here to reflect changing behaviour as assessed in representative national surveys, and new epidemiological evidence. Figures are also presented by UK constituent country because prevalence of risk factor exposure varies between them. METHODS: Population attributable fractions (PAFs) were calculated for combinations of risk factor and cancer type with sufficient/convincing evidence of a causal association. Relative risks (RRs) were drawn from meta-analyses of cohort studies where possible. Prevalence of exposure to risk factors was obtained from nationally representative population surveys. Cancer incidence data for 2015 were sourced from national data releases and, where needed, personal communications. PAF calculations were stratified by age, sex and risk factor exposure level and then combined to create summary PAFs by cancer type, sex and country. RESULTS: Nearly four in ten (37.7%) cancer cases in 2015 in the UK were attributable to known risk factors. The proportion was around two percentage points higher in UK males (38.6%) than in UK females (36.8%). Comparing UK countries, the attributable proportion was highest in Scotland (41.5% for persons) and lowest in England (37.3% for persons). Tobacco smoking contributed by far the largest proportion of attributable cancer cases, followed by overweight/obesity, accounting for 15.1% and 6.3%, respectively, of all cases in the UK in 2015. For 10 cancer types, including two of the five most common cancer types in the UK (lung cancer and melanoma skin cancer), more than 70% of UK cancer cases were attributable to known risk factors. CONCLUSION: Tobacco and overweight/obesity remain the top contributors of attributable cancer cases. Tobacco smoking has the highest PAF because it greatly increases cancer risk and has a large number of cancer types associated with it. Overweight/obesity has the second-highest PAF because it affects a high proportion of the UK population and is also linked with many cancer types. Public health policy may seek to mitigate the level of harm associated with exposure or reduce exposure levels-both approaches may effectively impact cancer incidence. Differences in PAFs between countries and sexes are primarily due to varying prevalence of exposure to risk factors and varying proportions of specific cancer types. This variation in turn is affected by socio-demographic differences which drive differences in exposure to theoretically avoidable 'lifestyle' factors. PAFs at UK country level have not been available previously and they should be used by policymakers in devolved nations. PAFs are estimates based on the best available data, limitations in those data would generally bias toward underestimation of PAFs. Regular collection of risk factor exposure prevalence data which corresponds with epidemiological evidence is vital for analyses like this and should remain a priority for the UK Government and devolved Administrations.

Socio-economic deprivation and cancer incidence in England: Quantifying the role of smoking.

BACKGROUND: More deprived populations typically experience higher cancer incidence rates and smoking prevalence compared to less deprived populations. We calculated the proportion of cancer cases attributable to smoking by socio-economic deprivation in England and estimated the impact smoking has on the deprivation gap for cancer incidence. METHODS: Data for cancer incidence (2013-2017), smoking prevalence (2003-2007) and population estimates (2013-2017) were split by sex, age-group and deprivation quintile. Relative risk estimates from meta-analyses were used to estimate the population attributable fraction (PAF) for 15 cancer types associated with smoking. The deprivation gap was calculated using age-specific incidence rates by deprivation quintile. RESULTS: Smoking-related cancer PAFs in England are 2.2 times larger in the most deprived quintile compared to the least deprived quintile (from 9.7% to 21.1%). If everyone had the same smoking prevalence as the least deprived quintile, 20% of the deprivation gap in cancer incidence could have been prevented. If nobody smoked, 61% of the deprivation gap could have been prevented. CONCLUSIONS: The majority of the deprivation gap in cancer incidence could have been prevented in England between 2013-2017 if nobody had smoked. Policy makers should ensure that tobacco control policies reduce overall smoking prevalence by tackling smoking inequalities.

Quality of care management decisions by multidisciplinary cancer teams: a systematic review.

BACKGROUND: Factors that affect the quality of clinical decisions of multidisciplinary cancer teams (MDTs) are not well understood. We reviewed and synthesised the evidence on clinical, social and technological factors that affect the quality of MDT clinical decision-making. METHODS: Electronic databases were searched in May 2009. Eligible studies reported original data, quantitative or qualitative. Data were extracted and tabulated by two blinded reviewers, and study quality formally evaluated. RESULTS: Thirty-seven studies were included. Study quality was low to medium. Studies assessed quality of care decisions via the effect of MDTs on care management. MDTs changed cancer management by individual physicians in 2-52% of cases. Failure to reach a decision at MDT discussion was found in 27-52% of cases. Decisions could not be implemented in 1-16% of cases. Team decisions are made by physicians, using clinical information. Nursing personnel do not have an active role, and patient preferences are not discussed. Time pressure, excessive caseload, low attendance, poor teamworking and lack of leadership lead to lack of information and deterioration of decision-making. Telemedicine is increasingly used in developed countries, with no detriment to quality of MDT decisions. CONCLUSIONS: Team/social factors affect management decisions by cancer MDTs. Inclusion of time to prepare for MDTs into team-members' job plans, making team and leadership skills training available to team-members, and systematic input from nursing personnel would address some of the current shortcomings. These improvements ought to be considered at national policy level, with the ultimate aim of improving cancer care.

Improving decision making in multidisciplinary tumor boards: prospective longitudinal evaluation of a multicomponent intervention for 1,421 patients.

BACKGROUND: Due to its complexity, cancer care is increasingly being delivered by multidisciplinary tumor boards (MTBs). Few studies have investigated how best to organize and run MTBs to optimize clinical decision making. We developed and evaluated a multicomponent intervention designed to improve the MTB's ability to reach treatment decisions. STUDY DESIGN: We conducted a prospective longitudinal study during 16 months that evaluated MTB decision making for urological cancer patients at a university hospital in London, UK. After a baseline period, MTB improvement interventions (eg, MTBs checklist, MTB team training, and written guidance) were delivered sequentially. Outcomes measures were the MTB's ability to reach a decision, the quality of information presentation, and the quality of teamwork (as assessed by trained assessors using a previously validated observational assessment tool). The efficacy of the intervention was evaluated using multivariate analyses. RESULTS: There were 1,421 patients studied between December 2009 and April 2, 2011. All outcomes improved considerably between baseline and intervention implementation: the MTB's ability to reach a decision rose from 82.2% to 92.7%, quality of information presentation rose from 29.6% to 38.3%, and quality of teamwork rose from 37.8% to 43.0%. The MTB's ability to reach a treatment decision was related to the quality of available information (r = 0.298; p < 0.05) and quality of teamwork within the MTB (r = 0.348; p < 0.05). The most common barriers to reaching clinical decisions were inadequate radiologic information (n = 77), inadequate pathologic information (n = 51), and inappropriate patient referrals (n = 21). CONCLUSIONS: Multidisciplinary tumor board-delivered treatment is becoming the standard for cancer care worldwide. Our intervention is efficacious and applicable to MTBs and can improve decision making and expedite cancer care.

Reviewing methodologically disparate data: a practical guide for the patient safety research field.

This article addresses key questions frequently asked by researchers conducting systematic reviews in patient safety. This discipline is relatively young, and asks complex questions about complex aspects of health care delivery and experience, therefore its studies are typically methodologically heterogeneous, non-randomized and complex; but content rich and highly relevant to practice. Systematic reviews are increasingly necessary to drive forward practice and research in this area, but the data do not always lend themselves to 'standard' review methodologies. This accessible 'how-to' article demonstrates that data diversity need not preclude high-quality systematic reviews. It draws together information from published guidelines and experience within our multidisciplinary patient safety research group to provide entry-level advice for the clinician-researcher new to systematic reviewing, to non-biomedical research data or to both. It offers entry-level advice, illustrated with detailed practical examples, on defining a research question, creating a comprehensive search strategy, selecting articles for inclusion, assessing study quality, extracting data, synthesizing data and evaluating the impact of your review. The article concludes with a comment on the vital role of robust systematic reviews in the continuing advancement of the patient safety field.

U.K. parents' decision-making about measles-mumps-rubella (MMR) vaccine 10 years after the MMR-autism controversy: a qualitative analysis.

BACKGROUND AND OBJECTIVES: Public concern about an unsubstantiated link between MMR vaccine and autism stemmed from a 1998 paper by Dr Andrew Wakefield and colleagues, and the substantial media coverage which that work attracted. Though the Wakefield paper is now discredited and an MMR-autism link has never been demonstrated empirically, this concern has manifested in over a decade of suboptimal MMR uptake. Few qualitative studies have explored parents' MMR decision-making since uptake began to improve in 2004. This study updates and adds methodological rigour to the evidence base. METHODS: 24 mothers planning to accept, postpone or decline the first MMR dose (MMR1) for their 11-36 month-old children, described their decision-making in semi-structured interviews. Mothers were recruited via General Practice, parents' groups/online forums, and chain referral. MMR1 status was obtained from General Practice records 6 months post-interview. Interview transcripts were coded and interpreted using a modified Grounded Theory approach. RESULTS: Five themes were identified: MMR vaccine and controversy; Social and personal consequences of MMR decision; Health professionals and policy; Severity and prevalence of measles, mumps and rubella infections; Information about MMR and alternatives. Results indicated that MMR1 acceptors were sympathetic toward Wakefield as a person, but universally rejected his study which sparked the controversy; parents opting for single vaccines expressed the sense that immune overload is not a consideration but that not all three components of MMR are warranted by disease severity; and MMR1 rejectors openly criticised other parents' MMR decisions and decision-making. CONCLUSIONS: This study corroborated some previous qualitative work but indicated that the shrinking group of parents now rejecting MMR comprises mainly those with more extreme and complex anti-immunisation views, whilst parents opting for single vaccines may use second-hand information about the controversy. In response, policymakers and practitioners should revise their expectations of today's MMR decision-makers, and their methods for supporting them.

Attitudinal and demographic predictors of measles, mumps and rubella (MMR) vaccine acceptance: development and validation of an evidence-based measurement instrument.

BACKGROUND AND OBJECTIVE: Parents' attitudes toward MMR vaccine and measles, mumps and rubella infections relate to their child's MMR status, therefore improving these attitudes is central to improving current suboptimal MMR uptake. However, no study has yet combined evidence-based, comprehensive and psychometrically validated assessment of these attitudes with reliable objective MMR status data, in order to identify through multivariate analyses the strongest attitudinal predictors of MMR uptake for interventions to target. The present study fills this lacuna by developing and testing a robust evidence-based MMR attitudes measurement instrument. DESIGN: Cross-sectional self-administered postal/telephone questionnaire with objective behavioural outcome. SETTING AND PARTICIPANTS: 535 parents of children aged 5-18 in London and north-west England, UK (response rate 18.1%). Recruitment via Primary Care Trust records, age-stratified purposive sample with suboptimally immunised cases oversampled. MAIN OUTCOME MEASURES: Parents' responses to evidence-based measurement instrument comprising 20 attitude/previous behaviour items (collapsing to 5 scales) and 7 demographic items, and their children's PCT-recorded 5th birthday status for MMR dose 1 (on-time, late or none) and MMR dose 2 (on-time or none). RESULTS: The attitudes measurement instrument was psychometrically robust: content valid, and demonstrating good or acceptable internal consistency (Cronbach's alpha=0.55-0.75 for all scales), test-retest reliability (Pearson's correlation >0.60-0.80, p<0.01 to <0.001 for all scales and 11 individual items), concurrent/construct validity (t-tests for difference between MMR status groups p<0.05 for four scales and thirteen individual items), and predictive/criterion validity (OR=0.66, 95% confidence interval=0.48-0.92 to OR=1.97, 95% CI=1.18-3.31 for three scales and five individual items). Black and minority ethnicity (OR=1.94, 95% CI=1.15-3.30 to OR=4.15, 95% CI=2.40-7.19), positive MMR attitudes (OR=1.63, 95% CI=1.00-2.66 to OR=1.97, 95% CI=1.18-1.31), and positive social attitudes (OR=1.64, 95% CI=1.23-2.40 to OR=1.72, 95% CI=1.13-2.38) independently predicted uptake for both MMR doses. MMR status groups differed most strongly on preference for single measles, mumps and rubella vaccines (6-9% variance in status explained), previous MMR acceptance/rejection (5-9%), and wishing to protect others through vaccinating one's own child (6-8%). CONCLUSIONS: The measurement instrument is robust on multiple validity and reliability dimensions, and is appropriate for use in research and practice as a tool for designing and evaluating interventions. Parents appear to act in line with their attitudes toward MMR vaccine, though attitudes toward measles infection bore little relation to MMR uptake. This study indicates populations and attitudes to be prioritized in MMR uptake improvement interventions.

Omission bias and vaccine rejection by parents of healthy children: implications for the influenza A/H1N1 vaccination programme.

2009 H1N1 influenza A ("swine flu") vaccine has been offered to healthy UK children aged 6 months-5 years since December 2009, though around 50% of parents plan to reject the vaccine. This study examined whether such parents exhibit omission bias (preference for errors arising from inaction over errors arising from action). One-hundred and forty-two parents completed an online questionnaire in which they rated (a) probability of occurrence, (b) symptoms and (c) duration of a hypothetical disease and a hypothetical vaccine adverse event (VAE). Almost all attributes were rated significantly less favourably when relating to VAE than to disease (p<0.01 for 17 of 22 outcomes), despite the attributes being objectively identical. These data suggest that any vaccine is at a disadvantage in many parents' consciousness in comparison with the infection itself, and that minor safety concerns could have disproportionately detrimental effects on vaccine uptake. Behavioural science offers strategies to ameliorate the impact of this bias and these should be explored further.

Factors underlying parental decisions about combination childhood vaccinations including MMR: a systematic review.

Suboptimal childhood vaccination uptake results in disease outbreaks, and in developed countries is largely attributable to parental choice. To inform evidence-based interventions, we conducted a systematic review of factors underlying parental vaccination decisions. Thirty-one studies were reviewed. Outcomes and methods are disparate, which limits synthesis; however parents are consistently shown to act in line with their attitudes to combination childhood vaccinations. Vaccine-declining parents believe that vaccines are unsafe and ineffective and that the diseases they are given to prevent are mild and uncommon; they mistrust their health professionals, Government and officially-endorsed vaccine research but trust media and non-official information sources and resent perceived pressure to risk their own child's safety for public health benefit. Interventions should focus on detailed decision mechanisms including disease-related anticipated regret and perception of anecdotal information as statistically representative. Self-reported vaccine uptake, retrospective attitude assessment and unrepresentative samples limit the reliability of reviewed data - methodological improvements are required in this area.