The challenge of using routinely collected data to compare hospital admission rates by ethnic group: a demonstration project in Scotland.

BACKGROUND: Recording patients' ethnic group supports efforts to achieve equity in health care provision. Before the Equality Act (2010), recording ethnic group at hospital admission was poor in Scotland but has improved subsequently. We describe the first analysis of the utility of such data nationally for monitoring ethnic variation. METHODS: We analysed all in-patient or day case hospital admissions in 2013. We imputed missing data using the most recent ethnic group recorded for a patient from 2009 to 2015. For episodes lacking an ethnic code, we attributed known ethnic codes proportionately. Using the 2011 Census population, we calculated rates and rate ratios for all-cause admissions and ischaemic heart diseases (IHDs) directly standardized for age. RESULTS: Imputation reduced missing ethnic group codes from 24 to 15% and proportionate redistribution to zero. While some rates for both all-cause and IHD admissions appeared plausible, unexpectedly low or high rates were observed for several ethnic groups particularly amongst White groups and newly coded groups. CONCLUSIONS: Completeness of ethnicity recoding on hospital admission records has improved markedly since 2010. However the validity of admission rates based on these data is variable across ethnic groups and further improvements are required to support monitoring of inequality.

An evaluation of the impact of large-scale interventions to raise public awareness of a lung cancer symptom.

INTRODUCTION: Long-term lung cancer survival in England has improved little in recent years and is worse than many countries. The Department of Health funded a campaign to raise public awareness of persistent cough as a lung cancer symptom and encourage people with the symptom to visit their GP. This was piloted regionally within England before a nationwide rollout. METHODS: To evaluate the campaign's impact, data were analysed for various metrics covering public awareness of symptoms and process measures, through to diagnosis, staging, treatment and 1-year survival (available for regional pilot only). RESULTS: Compared with the same time in the previous year, there were significant increases in metrics including: public awareness of persistent cough as a lung cancer symptom; urgent GP referrals for suspected lung cancer; and lung cancers diagnosed. Most encouragingly, there was a 3.1 percentage point increase (P<0.001) in proportion of non-small cell lung cancer diagnosed at stage I and a 2.3 percentage point increase (P<0.001) in resections for patients seen during the national campaign, with no evidence these proportions changed during the control period (P=0.404, 0.425). CONCLUSIONS: To our knowledge, the data are the first to suggest a shift in stage distribution following an awareness campaign for lung cancer. It is possible a sustained increase in resections may lead to improved long-term survival.

What is the lifetime risk of developing cancer?: the effect of adjusting for multiple primaries.

BACKGROUND: The 'lifetime risk' of cancer is generally estimated by combining current incidence rates with current all-cause mortality ('current probability' method) rather than by describing the experience of a birth cohort. As individuals may get more than one type of cancer, what is generally estimated is the average (mean) number of cancers over a lifetime. This is not the same as the probability of getting cancer. METHODS: We describe a method for estimating lifetime risk that corrects for the inclusion of multiple primary cancers in the incidence rates routinely published by cancer registries. The new method applies cancer incidence rates to the estimated probability of being alive without a previous cancer. The new method is illustrated using data from the Scottish Cancer Registry and is compared with 'gold-standard' estimates that use (unpublished) data on first primaries. RESULTS: The effect of this correction is to make the estimated 'lifetime risk' smaller. The new estimates are extremely similar to those obtained using incidence based on first primaries. The usual 'current probability' method considerably overestimates the lifetime risk of all cancers combined, although the correction for any single cancer site is minimal. CONCLUSION: Estimation of the lifetime risk of cancer should either be based on first primaries or should use the new method.

An updated report on the incidence and epidemiological trends of keratinocyte cancers in the United Kingdom 2013-2018.

Introduction: The most common cancers in the UK are keratinocyte cancers (KCs): the combined term for basal cell carcinomas (BCCs) and cutaneous squamous cell carcinomas (cSCCs). Registration of KC is challenging due to high numbers and multiplicity of tumours per person. Methods: We provide an updated report on the descriptive epidemiology of trends in KC incidence for the resident populations of UK countries (England, Northern Ireland, Scotland and Wales) using population-based cancer registry and pathology report data, 2013-18. Results: Substantial increases in cSCC incidence in England, Scotland and Northern Ireland can be detected for the period of 2013-18, and the incidence of cSCC also increased in Wales from 2016 to 2018. In contrast, however, the pattern of annual change in the incidence of BCC across the nations differs. In England, the incidence of BCC declined slightly from 2016 to 2018, however, the overall trend across 2013-18 is not statistically significant. In Scotland, the incidence of BCC shows some variability, declining in 2017 before increasing in 2018, and the overall trend across 2013-18 was also not statistically significant. In Northern Ireland, the incidence of BCC increased significantly over the study period, and in Wales, the incidence of BCC increased from 2016 to 2018. One in five people will develop non-melanoma skin cancers (NMSC) in their lifetime in England. This estimate is much higher than the lifetime risk of melanoma (1 in 36 males and 1 in 47 females born after 1960 in the UK), which further highlights the burden of the disease and importance of early prevention strategies. Conclusions: We highlight how common these tumours are by publishing the first ever lifetime incidence of NMSC. Additionally, the first time reporting of the age standardised incidence of KC in Wales further confirms the scale of the disease burden posed by these cancers in the UK. With approximately one in five people developing NMSC in their lifetime, optimisation of skin cancer prevention, management and research are essential.

Cancer survival in England and the influence of early diagnosis: what can we learn from recent EUROCARE results?

BACKGROUND: This review of the EUROCARE-4 results attempts to separate out the early and late mortality effects contributing to the widely reported poorer 5-year survival rates for cancer patients in the United Kingdom compared with other European countries for 26 cancer sites. METHODS: Patients diagnosed with cancer in 1996-1999 in 23 European countries were included in the analyses. Comparison of 1-year, 5-year and 5|1-year (i.e. only including those patients who had survived to 1 year) survival estimates between data for England and the 'European average' was undertaken. This analysis was to highlight the relative contribution of early diagnosis, using 1-year survival as a proxy measure, on 5-year survival for the different sites of cancer. Three groups of cancer sites were identified according to whether the survival differences at 1, 5 and 5|1-years were statistically significant. RESULTS AND CONCLUSIONS: Breast cancer showed significantly poorer 1- and 5-year survival estimates in England, but the 5|1-year survival figure was not significantly different. Thus, successful initiatives around awareness and early detection could eradicate the survival gap. In contrast, the 5|1-year survival estimates remained significantly worse for lung, colorectal and prostate cancers, showing that although early detection could make some difference, late effects such as treatment and management of the patients were also influencing long-term outcome differences between England and Europe.

Entry into clinical trials in breast cancer: the importance of specialist teams. Scottish Breast Cancer Focus Group and Scottish Cancer Therapy Network.

The aim of this study was to identify the factors influencing entry of women with invasive breast cancer into clinical trials in Scotland. Women diagnosed during 1987 and 1993 were identified from cancer registry data records and their case notes reviewed. Entry into clinical trials was recorded, along with clinical and demographic data for 4688 patients. In 1987, the proportion of women entering clinical trials was 12.3% and, allowing for shorter follow-up, this appeared unchanged in 1993. Patients seen by surgeons with a high case load and those referred to an oncologist were approximately seven times and three times, respectively, more likely to enter a clinical trial (P < 0.0001). The area of Scotland (Health Board) where the woman was first treated also influenced study entry (P < 0.0001), whereas social deprivation had no effect (P = 0.93). Older women, especially those over 80 years of age, were less likely to enter studies (P = 0.05). Extending the management of patients by specialist multidisciplinary teams should increase recruitment into clinical trials and help to identify better treatments for women with breast cancer.

Improvements in survival for women with breast cancer in Scotland between 1987 and 1993: impact of earlier diagnosis and changes in treatment.

We investigated changes in survival, and their causes, in women with early breast cancer diagnosed in Scotland. The Scottish Cancer Registry identified 1617 and 2077 such women, without metastases at diagnosis who underwent surgery as part of their primary treatment, diagnosed in 1987 and 1993, respectively. There was a statistically significant 11% improvement in 8-year survival between 1987 and 1993. Survival improved across almost all clinical/pathological, treatment and health care delivery/deprivation categories; improvement was not limited to those women diagnosed through the screening programme. In a multivariate model, improved survival appeared to be explained largely by screening and clinical/pathological prognostic factors. Deprivation also had an adverse effect on survival; however, the geographical variation in survival observed for women diagnosed in 1987 was not apparent by 1993. We did not demonstrate a significant independent effect of surgical caseload on survival. We conclude that survival has increased partly as a consequence of screening and earlier diagnosis, but also due to improvements in the organisation and delivery of care.

Prognostic factors in women with breast cancer: distribution by socioeconomic status and effect on differences in survival.

STUDY OBJECTIVE: To quantify and investigate differences in survival from breast cancer between women resident in affluent and deprived areas and define the contribution of underlying factors to this variation. DESIGN: Analysis of two datasets relating to breast cancer patients in Scotland: (1) population-based cancer registry data; (2) a subset of cancer registration records supplemented by abstraction of prognostic variables (stage, node status, tumour size, oestrogen receptor (ER) status, type of surgery, use of radiotherapy and use of adjuvant systemic therapy) from medical records. SETTING: Scotland. PATIENTS: (1) Cancer registration data on 21,751 women aged under 85 years diagnosed with primary breast cancer between 1978 and 1987; (2) national clinical audit data on 2035 women aged under 85 years diagnosed with primary breast cancer during 1987 for whom adequate medical records were available. MAIN RESULTS: Survival differences of 10% between affluent and deprived women were observed in both datasets, across all age groups. In the audit dataset, the distribution of ER status varied by deprivation group (65% ER positive in affluent group v 48% ER positive in deprived group; under 65 age group). Women aged under 65 with non-metastatic disease were more likely to have breast conservation than a mastectomy if they were affluent (45%) than deprived (32%); the affluent were more likely to receive endocrine therapy (65%) than the deprived (50%). However, these factors accounted for about 20% of the observed difference in survival between women resident in affluent and deprived areas. CONCLUSIONS: Deprived women with breast cancer have poorer outcomes than affluent women. This can only partly be explained by deprived women having more ER negative tumours than affluent women. Further research is required to identify other reasons for poorer outcomes in deprived women, with a view to reducing these survival differences.

Adjuvant ovarian ablation vs CMF chemotherapy in premenopausal breast cancer patients: trial update and impact of immunohistochemical assessment of ER status.

This trial, initiated in 1980, examined the relative values of adjuvant ovarian ablation and chemotherapy comprising cyclophosphamide, methotrexate and 5-fluorouracil (CMF) in premenopausal women with pathological stage II breast cancer. With median follow-up for patients still alive of 13.9 years, there is no difference in survival between women receiving ovarian ablation and CMF (hazard ratio 1.01; 95% CI: 0.74, 1.37). Tumour oestrogen receptor (ER) status was assessed at the time using biochemical ligand-binding assay and retrospectively by immunohistochemistry (IHC). Agreement between these two methods was only fair, but both confirmed the importance of ER status in determining appropriate adjuvant systemic therapy. A statistically significant interaction between IHC quick score and treatment (P=0.001) showed ovarian ablation was more beneficial for patients with a positive quick score, whereas women with a quick score of 0 had a significantly higher risk of death with ovarian ablation (2.33; 95% CI: 1.30, 4.20). We have shown that IHC identifies women with ER 'poor' tumours for whom endocrine manipulation is not appropriate.

Breast cancer in Scotland: changes in treatment and work-load. Scottish Breast Cancer Focus Group and the Scottish Cancer Therapy Network.

Throughout Scotland, the patterns of care of patients with breast cancer were examined for the years 1987 and 1993. Substantial changes in oncological work-load were shown in the intervening period. The number of patients referred to an oncologist (clinical or medical) increased by 52% (from 1076 to 1634), the number of patients receiving postoperative radiotherapy to the breast or chest wall increased by 72% (from 724 to 1248) and the number of patients receiving adjuvant chemotherapy increased by 215% (from 123 to 388). The number of consultant oncologists increased by only 16% (from 32 to 37). If patients are to be treated to the standards expected, then increases in work-load must be matched by appropriate increases in staff.

Postoperative wound complications and systemic recurrence in breast cancer.

Many factors involved in wound healing can stimulate tumour growth in the experimental setting. This study examined the relationship between wound complications and the development of systemic recurrence after treatment of primary breast cancer. One thousand and sixty-five patients diagnosed with operable primary invasive breast cancer between 1994 and 2001 were assessed for development of systemic recurrence according to whether or not a wound complication occurred after surgery, with a median follow-up of 54 months (range 15-119). There were 93 wound complications (9%). There was a statistically significant greater risk of developing systemic recurrence in patients with wound problems than those without (hazard ratio (HR) 2.87; 95% CI: 1.97, 4.18; P<0.0001). This remained in a multivariate analysis after adjustment for case mix variables, including Nottingham Prognostic Index (NPI) and oestrogen-progesterone receptor status (HR: 2.52; 95% CI: 1.69, 3.77; P<0.0001). In the good prognostic NPI group, 4 out of 27 patients (15%) with wound problems vs 11 out of 334 (3%) without wound problems developed systemic recurrence. The corresponding figures were 10 out of 35 (29%) vs 48 out of 412 (12 %) in the moderate prognostic group and 18 out of 29 (62%) vs 75 out of 199 (38%) in the poor prognostic group. In 29 patients NPI could not be calculated. Smokers at the time of diagnosis were more likely to develop metastatic disease than the non-smokers (HR: 1.50; 95% CI: 1.04, 2.15; P=0.03) after adjustment for other factors. The results suggest that patients with wound complications at primary surgery have increased rates of systemic recurrence of breast cancer.

Radiotherapy following breast-conserving surgery for screen-detected ductal carcinoma in situ: indications and utilisation in the UK. Interim findings from the Sloane Project.

Use of radiotherapy (RT) after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) varies according to country, precedent and prejudice. Results from a preliminary analysis of the data available within the UK Sloane Project can be appreciated in the context of the uncertainty concerning the selection of adjuvant RT following BCS for DCIS. There was a marked geographical variation in the use of RT within the United Kingdom. However, overall, patients with DCIS treated with BCS were significantly more likely to have RT planned (and given) if they had large (> or =15 mm), intermediate or high-grade tumours or if central comedo-type necrosis was present. Unexpectedly, margin width did not appear to have a significant effect on the decision-making process. However, the Van Nuys Prognostic Index did significantly affect the chances of getting planned RT in the univariate analysis, suggesting that clinicians may be starting to use this scoring system in routine practice to assist in decision making.

Second primary malignancies after treatment for malignant lymphoma.

To determine the incidence and possible causes of second primary malignancies after treatment for Hodgkin's and Non-Hodgkin's lymphoma (HL and NHL). A cohort of 3764 consecutive patients diagnosed with HL or NHL between January 1970 and July 2001 was identified using the Sheffield Lymphoma Group database. A search was undertaken for all patients diagnosed with a subsequent primary malignancy. Two matched controls were identified for each case. Odds ratios were calculated to detect and quantify any risk factors in the cases compared to their matched controls. Mean follow-up for the cohort was 5.2 years. A total of 68 patients who developed second cancers at least 6 months after their primary diagnosis were identified, giving a crude incidence of 1.89% overall: 3.21% among the patients treated for HL, 1.32% in those treated for NHL. Most common were bronchial, breast, colorectal and haematological malignancies. High stage at diagnosis almost reached statistical significance in the analysis of just the NHL patients (odds ratio = 3.48; P = 0.068) after adjustment for other factors. Treatment modality was not statistically significant in any analysis. High stage at diagnosis of NHL may be a risk factor for developing a second primary cancer.

Autoradiographic demonstration of [3H] loperamide binding to opioid receptors in rat and human small intestine.

Loperamide has an anti-diarrhoeal action which has been suggested to be mediated by opioid receptors associated with gut motility. There is now evidence to suggest that loperamide also affects intestinal transport. In this study we have used in vitro autoradiography to localize [3H] loperamide binding sites in both rat and human small intestine and the displacement of [3H] loperamide binding by mu- and delta-selective ligands.

Lung cancer: the importance of seeing a respiratory physician.

Patients with lung cancer present to and are managed by a variety of clinicians. In this study the effect of involvement by a respiratory physician on the diagnosis, staging, treatment and survival of a large unselected group of lung cancer patients was investigated. The study population was derived from the Scottish Cancer Registry. A total of 3,855 patients diagnosed during 1995 with lung cancer were studied. The data were validated and supplemented by references to medical records. The study found that a respiratory physician had been involved in the initial management of 2,901 (75.3%) patients. These patients were found more likely to have had the cancer diagnosis confirmed by histological methods and to have received active treatment with surgery, radiotherapy or chemotherapy. Survival, 1 yr after diagnosis was higher in patients who saw a respiratory physician (24.4 versus 11.1%) and benefit was found to have remained 3 yrs after diagnosis (8.1 versus 3.7%). Although the patients who had not seen a respiratory physician were generally older, and had more extensive disease, after correcting for age, stage and other prognostic factors, the relative hazard ratio of death for those not managed by a respiratory physician was 1.44. The data from this study supports the recommendations of recent lung cancer guidelines for the early involvement by a respiratory physician.

Variation in the survival of women with breast cancer in Scotland. The Scottish Breast Cancer Focus Group and The Scottish Cancer Therapy Network.

We have investigated factors influencing the survival of women with early breast cancer in Scotland. In a retrospective study, clinical, treatment and 'service' factors, e.g. surgical case load, deprivation and geographical area (health board of first treatment) were recorded from hospital records. A total of 2148 women with invasive breast cancer diagnosed in 1987 were identified from the Scottish Cancer Registry, of whom 1619 without metastases at diagnosis underwent surgery as part of their primary treatment. In a multivariate analysis, clinical factors (age, clinical stage, pathological tumour size, node status and oestrogen receptor status) all influenced survival. After allowing for these clinical factors, surgical case load and deprivation did not have statistically significant effects on survival. By contrast, health board did affect survival. This was explained in part by the selection of patients for surgery. There appeared, however, to be a residual effect that may be related to differences in the use of adjuvant systemic treatment among the different health boards. We conclude that, in Scotland, geographical variation in both surgical and non-surgical treatment has a greater effect on variability in survival for women with breast cancer than surgical case load and deprivation.