A prognostic survival model for women diagnosed with invasive breast cancer in Queensland, Australia.

PURPOSE: Prognostic models can help inform patients on the future course of their cancer and assist the decision making of clinicians and patients in respect to management and treatment of the cancer. In contrast to previous studies considering survival following treatment, this study aimed to develop a prognostic model to quantify breast cancer-specific survival at the time of diagnosis. METHODS: A large (n = 3323), population-based prospective cohort of women were diagnosed with invasive breast cancer in Queensland, Australia between 2010 and 2013, and followed up to December 2018. Data were collected through a validated semi-structured telephone interview and a self-administered questionnaire, along with data linkage to the Queensland Cancer Register and additional extraction from medical records. Flexible parametric survival models, with multiple imputation to deal with missing data, were used. RESULTS: Key factors identified as being predictive of poorer survival included more advanced stage at diagnosis, higher tumour grade, "triple negative" breast cancers, and being symptom-detected rather than screen detected. The Harrell's C-statistic for the final predictive model was 0.84 (95% CI 0.82, 0.87), while the area under the ROC curve for 5-year mortality was 0.87. The final model explained about 36% of the variation in survival, with stage at diagnosis alone explaining 26% of the variation. CONCLUSIONS: In addition to confirming the prognostic importance of stage, grade and clinical subtype, these results highlighted the independent survival benefit of breast cancers diagnosed through screening, although lead and length time bias should be considered. Understanding what additional factors contribute to the substantial unexplained variation in survival outcomes remains an important objective.

Supportive care needs and psychosocial outcomes of rural versus urban women with breast cancer.

OBJECTIVE: To identify whether supportive care needs vary according to remoteness and area-level socio-economic status and to identify the combinations of socio-demographic, area-level and health factors that are associated with poorer quality of life, psychological distress and severity of unmet supportive care needs. METHODS: Cross sectional data was collected from women with a breast cancer diagnosis (n = 2635) in Queensland, Australia, through a telephone survey including socio-demographic, health, psychosocial and supportive care needs measures. Hierarchical regression and cluster analyses were applied to assess the predictors of unmet need and psychosocial outcomes and to identify socio-demographic and health status profiles of women, comparing their level of unmet needs and psychosocial outcomes. RESULTS: Women living in outer regional areas reported the highest severity of unmet need in the patient care domain. Greater unmet need for health systems and information and patient care was also evident for those in moderately and most disadvantaged areas. Three clusters were identified reflecting (1) older women with poorer health and lower education (19%); (2) younger educated women with better health and private insurance (61%); and (3) physically active women with localised cancer who had completed treatment (20%). Poorer outcomes were evident in the first two of these clusters. CONCLUSIONS: This better understanding of the combinations of characteristics associated with poorer psychosocial outcomes and higher unmet need can be used to identify women with higher supportive care needs early and to target interventions.

Comorbidity prevalence among cancer patients: a population-based cohort study of four cancers.

BACKGROUND: The presence of comorbidity affects the care of cancer patients, many of whom are living with multiple comorbidities. The prevalence of cancer comorbidity, beyond summary metrics, is not well known. This study aims to estimate the prevalence of comorbid conditions among cancer patients in England, and describe the association between cancer comorbidity and socio-economic position, using population-based electronic health records. METHODS: We linked England cancer registry records of patients diagnosed with cancer of the colon, rectum, lung or Hodgkin lymphoma between 2009 and 2013, with hospital admissions records. A comorbidity was any one of fourteen specific conditions, diagnosed during hospital admission up to 6 years prior to cancer diagnosis. We calculated the crude and age-sex adjusted prevalence of each condition, the frequency of multiple comorbidity combinations, and used logistic regression and multinomial logistic regression to estimate the adjusted odds of having each condition and the probability of having each condition as a single or one of multiple comorbidities, respectively, by cancer type. RESULTS: Comorbidity was most prevalent in patients with lung cancer and least prevalent in Hodgkin lymphoma patients. Up to two-thirds of patients within each of the four cancer patient cohorts we studied had at least one comorbidity, and around half of the comorbid patients had multiple comorbidities. Our study highlighted common comorbid conditions among the cancer patient cohorts. In all four cohorts, the odds of having a comorbidity and the probability of multiple comorbidity were consistently highest in the most deprived cancer patients. CONCLUSIONS: Cancer healthcare guidelines may need to consider prominent comorbid conditions, particularly to benefit the prognosis of the most deprived patients who carry the greater burden of comorbidity. Insight into patterns of cancer comorbidity may inform further research into the influence of specific comorbidities on socio-economic inequalities in receipt of cancer treatment and in short-term mortality.

Association between age, deprivation and specific comorbid conditions and the receipt of major surgery in patients with non-small cell lung cancer in England: A population-based study.

INTRODUCTION: We investigated socioeconomic disparities and the role of the main prognostic factors in receiving major surgical treatment in patients with lung cancer in England. METHODS: Our study comprised 31 351 patients diagnosed with non-small cell lung cancer in England in 2012. Data from the national population-based cancer registry were linked to Hospital Episode Statistics and National Lung Cancer Audit data to obtain information on stage, performance status and comorbidities, and to identify patients receiving major surgical treatment. To describe the association between prognostic factors and surgery, we performed two different analyses: one using multivariable logistic regression and one estimating cause-specific hazards for death and surgery. In both analyses, we used multiple imputation to deal with missing data. RESULTS: We showed strong evidence that the comorbidities 'congestive heart failure', 'cerebrovascular disease' and 'chronic obstructive pulmonary disease' reduced the receipt of surgery in early stage patients. We also observed gender differences and substantial age differences in the receipt of surgery. Despite accounting for sex, age at diagnosis, comorbidities, stage at diagnosis, performance status and indication of having had a PET-CT scan, the socioeconomic differences persisted in both analyses: more deprived people had lower odds and lower rates of receiving surgery in early stage lung cancer. DISCUSSION: Comorbidities play an important role in whether patients undergo surgery, but do not completely explain the socioeconomic difference observed in early stage patients. Future work investigating access to and distance from specialist hospitals, as well as patient perceptions and patient choice in receiving surgery, could help disentangle these persistent socioeconomic inequalities.

Socioeconomic gaps over time in colorectal cancer survival in England: flexible parametric survival analysis.

BACKGROUND: Despite persistent reports of socioeconomic inequalities in colorectal cancer survival in England, the magnitude of survival differences has not been fully evaluated. METHODS: Patients diagnosed with colon cancer (n=68 169) and rectal cancer (n=38 267) in England (diagnosed between January 2010 and March 2013) were analysed as a retrospective cohort study using the National Cancer Registry data linked with other population-based healthcare records. The flexible parametric model incorporating time-varying covariates was used to assess the difference in excess hazard of death and in net survival between the most affluent and the most deprived groups over time. RESULTS: Survival analyses showed a clear pattern by deprivation. Hazard ratio of death was consistently higher in the most deprived group than the least deprived for both colon and rectal cancer, ranging from 1.08 to 1.17 depending on the model. On the net survival scale, the socioeconomic gap between the most and the least deprived groups reached approximately -4% at the maximum (-3.7%, 95% CI -1.6 to -5.7% in men, -3.6%, 95% CI -1.6 to -5.7% in women) in stages III for colon and approximately -2% (-2.3%, 95% CI -0.2 to -4.5% in men, -2.3%, 95% CI -0.2 to -4.3% in women) in stage II for rectal cancer at 3 years from diagnosis, after controlling for age, emergency presentation, receipt of resection and comorbidities. The gap was smaller in other stages and sites. For both cancers, patients with emergency presentation persistently had a higher excess hazard of death than those without emergency presentation. CONCLUSION: Survival disparities were profound particularly among patients in the stages, which benefit from appropriate and timely treatment. For the patients with emergency presentation, excess hazard of death remained high throughout three years from the diagnosis. Public health measures should be taken to reduce access inequalities to improve survival disparities.

Exploring socioeconomic differences in surgery and in time to elective surgery for colon cancer in England: Population-based study.

BACKGROUND: A persistent socioeconomic gap in colon cancer survival is observed in England. Provision of cancer care may also vary by socioeconomic status (SES). We investigated population-based data to explore differential surgical care by SES. METHODS: We analysed a retrospective cohort of patients diagnosed with colon cancer in England (2010-2013). We examined patterns of presentation and surgery by SES, and whether socioeconomic differences exist in the length of time from diagnosis to elective major resection using linear regression. RESULTS: Among a total of 68 169 patients with colon cancer, 21.0 % (3138/14 917) in the most affluent group had emergency presentation (EP) whereas 27.9 % (2901/10 386) in the most deprived. Among 45 332 (66.5 %) patients who underwent resection, the proportion of patients receiving urgent surgery (surgery before or ≤ 7 days of diagnosis) was higher in the most deprived group (39.9 %, 2685/6733) than the most affluent (35.4 %, 3595/10 146). Days from diagnosis to elective surgery (surgery > 7 days after diagnosis) ranged from 33.9 (95 % CI 33.1-34.8) in stage II to 38.2 (95 % CI 36.8-39.7) in stage I, but no socioeconomic differences in time were seen in all stages. CONCLUSIONS: Time to elective surgery for colon cancer did not differ by SES, whereas a higher proportion among deprived patients tended to be diagnosed through EP and to receive urgent surgery. These results suggest that the waiting time target may not be an appropriate measure to assess access to cancer care. Reducing both EP and urgent surgery should be a key policy target.

Reproducibility, reliability and validity of population-based administrative health data for the assessment of cancer non-related comorbidities.

BACKGROUND: Patients with comorbidities do not receive optimal treatment for their cancer, leading to lower cancer survival. Information on individual comorbidities is not straightforward to derive from population-based administrative health datasets. We described the development of a reproducible algorithm to extract the individual Charlson index comorbidities from such data. We illustrated the algorithm with 1,789 laryngeal cancer patients diagnosed in England in 2013. We aimed to clearly set out and advocate the time-related assumptions specified in the algorithm by providing empirical evidence for them. METHODS: Comorbidities were assessed from hospital records in the ten years preceding cancer diagnosis and internal reliability of the hospital records was checked. Data were right-truncated 6 or 12 months prior to cancer diagnosis to avoid inclusion of potentially cancer-related comorbidities. We tested for collider bias using Cox regression. RESULTS: Our administrative data showed weak to moderate internal reliability to identify comorbidities (ICC ranging between 0.1 and 0.6) but a notably high external validity (86.3%). We showed a reverse protective effect of non-cancer related Chronic Obstructive Pulmonary Disease (COPD) when the effect is split into cancer and non-cancer related COPD (Age-adjusted HR: 0.95, 95% CI:0.7-1.28 for non-cancer related comorbidities). Furthermore, we showed that a window of 6 years before diagnosis is an optimal period for the assessment of comorbidities. CONCLUSION: To formulate a robust approach for assessing common comorbidities, it is important that assumptions made are explicitly stated and empirically proven. We provide a transparent and consistent approach useful to researchers looking to assess comorbidities for cancer patients using administrative health data.

No Difference in Mood and Quality of Life in DHEA-S Deficient Adults with Addison's Disease vs. Type 2 Diabetes Patients with Normal DHEA-S Levels: Implications for Management of These Conditions.

Patients with Addison's disease have relatively high rates of depression and anxiety symptoms compared with population-based reference samples. Addison's disease results in deficiency of dehydroepiandrosterone (DHEA) and DHEA-sulfate (DHEA-S). There is considerable debate about the specific effects of DHEA deficiency on energy level and mood. We measured emotional well-being in 16 patients with Addison's disease and a group of 16 hospital attendees with type 2 diabetes. Participants completed the General Health Questionnaire-28 (GHQ-28), the Hospital Anxiety and Depression Scale (HADS), the World Health Organization's quality of life assessment (WHOQOL-BREF) and the Holmes-Rahe life event scale. DHEA-S was low in Addison's patients (Addison's men: 0.5 ± 0.1 µmol/l [normal range: 2.1-10.8] compared with diabetes men: 3.2 ± 1.2 µmol/l; Addison's women: 0.4 ± 0.01 µmol/l [normal range: 1.0-11.5] compared with diabetes women: 2.2 ± 0.71 µmol/l). Testosterone levels were similar in both groups studied. There were no differences in emotional well-being and quality of life (QOL) between patients with Addison's disease and Type 2 Diabetes Mellitus as measured by GHQ-28 (Addison's: 22.4 ± 2.6, Diabetes: 19.6 ± 2.7), HADS Depression (Addison's: 5.4 ± 0.9, Diabetes: 4.5 ± 1.4), HADS Anxiety and WHOQOL-BREF. There were no gender differences in affective symptomatology within the Addison's group. Life event scores were above average in both groups (Addison's: 195 ± 39.6, Diabetes: 131 ± 43.8), but not significant for difference between groups as was GHQ-28 total score. Both groups scored highly on the GHQ-28 and the life event scale, indicative of poorer health perceptions than the general population. This could be due to the chronicity of both disorders. We have not identified any specific effects of DHEA-S deficiency on mood or QOL.

Temperature taking: children's preferences.

Children aged between six and 15 years on two paediatric wards of one NHS trust were invited to take part in a study to find out whether they preferred digital underarm thermometry or tympanic thermometry. The study was conducted as part of the Nursing and Midwifery Research and Practice Development Project for the Southern Derbyshire Acute Hospitals NHS Trust. In the six to ten year age group (n = 39), 74 per cent of the children preferred the tympanic thermometer, as did 91 per cent in the 11-15 year age group (n = 44). Children/young people in both age groups commented that the tympanic thermometer was quicker and more comfortable. All children over two years now have their temperature taken using the tympanic thermometer, with the exception of those for whom it would not be medically appropriate or who express dislike for this method.

A comparison of self-reported quality of life between patients with epilepsy and neurocardiogenic syncope.

Epilepsy and neurocardiogenic syncope share a final common pathway of loss of consciousness and consequent social disruption. We compared 52 patients with syncope, 96 with epilepsy and 100 controls. Epilepsy and syncope patients expressed significantly higher levels of anxiety and depression and reported significantly less good quality of life (QoL) compared with controls. There were no significant differences on any of the QoL parameters measured between the syncope and epilepsy patients. These findings suggest the main contributor to poor QoL in epilepsy may be the unpredictable loss of control that is the hallmark of the condition.

Recognition of emotion with temporal lobe epilepsy and asymmetrical amygdala damage.

PURPOSE: Impairments in emotion recognition occur when there is bilateral damage to the amygdala. In this study, ability to recognize auditory and visual expressions of emotion was investigated in people with asymmetrical amygdala damage (AAD) and temporal lobe epilepsy (TLE). METHODS: Recognition of five emotions was tested across three participant groups: those with right AAD and TLE, those with left AAD and TLE, and a comparison group. Four tasks were administered: recognition of emotion from facial expressions, sentences describing emotion-laden situations, nonverbal sounds, and prosody. RESULTS: Accuracy scores for each task and emotion were analysed, and no consistent overall effect of AAD on emotion recognition was found. However, some individual participants with AAD were significantly impaired at recognizing emotions, in both auditory and visual domains. CONCLUSIONS: The findings indicate that a minority of individuals with AAD have impairments in emotion recognition, but no evidence of specific impairments (e.g., visual or auditory) was found.

Long-term negative impact on quality of life in patients with successfully treated Cushing's disease.

OBJECTIVE: A cohort of pituitary tumour patients, who had undergone definitive treatment within a 15-year period at a single neuroscience centre, were investigated as to whether there were differences in psychological well-being and psychosocial functioning, dependent on endocrine pathology and treatment variables. DESIGN: A detailed assessment of 114 patients with benign pituitary tumours in relation to primary diagnosis and mode of treatment was carried out. Psychological rating scales used were: the Hospital Anxiety and Depression Scale--UK version (HADS-UK), the World Health Organization Quality of Life Scale--abbreviated version (WHOQOL-BREF), General Health Questionnaire 28 (GHQ-28), the Functional Assessment of Cancer Therapy (FACT) and the Social Adjustment Scale--modified (SAS1 and SAS2; the former completed by the patient and the latter by another person who knows the patient well). All Cushing's patients were biochemically cured as defined by a normal 24-h urine free cortisol excretion within the previous 6 months. RESULTS: Patients with treated Cushing's disease had significantly impaired psychological well-being and psychosocial functioning across all tested domains compared with all other pituitary tumours, where scores were similar. When participants with Cushing's disease were excluded, patients who had undergone transfrontal surgery scored significantly higher on GHQ and HADS ratings than transsphenoidally treated patients. CONCLUSION: Cushing's disease even when biochemically stable has long-term adverse effects on mood and social functioning. We hypothesize that this may be related to irreversible changes in central neural function. Further studies are necessary to define the precise pathways involved.