Epidemiology of blindness attributable to diabetes in Scotland: change over 20 years in a defined population.

AIMS: To establish the incidence and prevalence of blindness attributable to diabetes in a defined population in Scotland during the period 2000-2009, and to compare these figures with published data from the previous decade in the same population. METHODS: All blind registrations during 2000-2009 in Fife, Scotland, UK were examined and included if diabetic retinopathy/maculopathy was the main cause of blindness. The annual incidence and point prevalence on 31 December 2009 of registered blindness attributable to diabetes were calculated in both the total population and the population with diabetes. These data were compared with figures for the period 1990-1999, using a two-tailed t-test, and subjected to Poisson regression analysis. RESULTS: In the population with diabetes, the mean incidence of blindness attributable to diabetes was 42.7 (sd 24.2, 95% CI 25- 60) per 100 000 per year for 2000-2009, compared with 64.3 for 1990-1999 (P = 0.062). The relative risk of developing blindness per year was 0.894 (95% CI 0.811- 0.988, P = 0.028) for 2000- 2009. The point prevalence on 31 December 2009 was 167 per 100 000 in the population with diabetes, vs 210 on 31 December 1999. CONCLUSION: Compared with the previous decade, the prevalence of blindness attributable to diabetes has decreased in the population with diabetes, with a trend towards a decrease in its incidence. This may be a consequence of an increased denominator population, resulting from better recording of diabetes and changes to the diagnostic criteria. Over the decade 2000-2009, the incidence of blindness attributable to diabetes fell by a mean of 10.6% per year in the population with diabetes.

Assessing and improving out-of-hours palliative care in a deprived community: a rapid appraisal study.

Recent changes to out-of-hours primary care in the UK have generated concerns about care for palliative care patients. The aim of this study was to identify key challenges and improvements to out-of-hours palliative care in a mixed urban and rural deprived area. We integrated data from three sources: interviews with patients and professionals, direct observations of services, and routine statistics. Key issues in the provision of care were the importance of good communication and having information available, the unwieldy process of accessing medical care out of hours, professionals bypassing routine out-of-hours care for palliative care patients, and out-of-hours care being provided by practitioners unaware of local services. We recommend provision to out-of-hours services of an enhanced 'special note' for palliative care patients, to be completed early in the course of the illness and updated regularly. The provision for certain complex patients to bypass NHS24 should be considered if routine care is not satisfactory.

Is anaemia relevant in the referral and diagnosis of colorectal cancer?

OBJECTIVE: Current efforts to improve the outcome from colorectal cancer aim to shorten the delay between referral and diagnosis. Investigation of iron-deficiency anaemia has a high yield for the diagnosis of gastrointestinal malignancy and its presence is included in current referral guidelines. We explored the relationship between anaemia and colorectal cancer. METHOD: We reviewed hospital and laboratory database records of patients diagnosed with colorectal cancer between January 2003 and June 2004. The site of colorectal cancer was correlated with the presence of anaemia at the time of referral. Anaemia was defined according to local practice (Hb < 12.0 g/dl in females and <13.0 g/dl in males), compared with the threshold recommended in current national referral guidelines (Hb < 10 g/dl in females and <11 g/dl in males). RESULTS: Over 18 months, 143 patients were diagnosed with colorectal cancer. Anaemia was present in 48% of males and 50% of females using local practice and 24% of males and 16% of females using national referral guidelines. Those with right-sided and non-rectal cancers were significantly more likely to be anaemic than those with left-sided and rectal cancers, respectively. CONCLUSION: In approximately half of cases the diagnosis of colorectal cancer is not associated with anaemia. Anaemia is more common with proximal lesions but this is not a consistent finding. The current threshold for anaemia at which national guidelines suggest referral also appears to be insensitive.

Modelling the lung function of Caucasians during adolescence as a basis for reference values.

BACKGROUND: In childhood the relationship between lung size and stature changes during the adolescent growth spurt. This is not allowed for in models of lung function based on stature alone. For spirometric indices inclusion of an age x stature interaction (A x St) can overcome the difficulty. AIM: The study tested the hypothesis that this simple, interactive model might also be effective for total lung capacity and its subdivisions and the single breath transfer factor for carbon monoxide. SUBJECTS AND METHODS: Data were available for 695 asymptomatic non-smokers (Caucasians) aged 7-20 years (440 boys, 255 girls). Each lung function index was described using the above model and the fit was compared with that from a linear, power or polynomial model based on stature alone. RESULTS: After allowing for stature, the A x St interaction term was significant for almost all indices. The improved fit was most apparent for the lung function of older adolescent boys. Reference values using the model are reported. CONCLUSIONS: A simple model based on stature and an interaction between stature and age can account for the changing relationship between body habitus during the growth spurt and lung size and transfer factor in a single equation encompassing children and adolescents. Its use is recommended for deriving reference values when the explanatory variables are limited to stature and age.

Factors associated with non-participation in a physical activity promotion trial.

BACKGROUND: Non-participation can bias outcome in intervention studies of physical activity. OBJECTIVES: To compare characteristics, knowledge and attitudes to physical activity in participants and non-participants of a physical activity intervention trial in primary care. STUDY DESIGN: Cross-sectional survey. METHODS: Patients aged 40-64 years were recruited opportunistically during surgery visits in an inner city general practice in Newcastle upon Tyne, UK. Attitudes to physical activity, views of its health benefits, and barriers to participation were elicited in interviews with participants, and by postal questionnaire from non-participants. Data held by general practitioners were used to compare anthropometry and lifestyle between groups. RESULTS: Of 842 eligible patients, 276 (33%) refused outright (non-volunteers) and 566 volunteered for the intervention study, of which 353 (42%) attended a baseline assessment and 213 (25%) subsequently defaulted. The initial refusal rate was higher amongst men, smokers and those with addresses in more deprived areas. The response rate to the postal survey of non-volunteers was 45%. Compared with participants, the non-volunteers were more likely to be an adult carer and to report poorer health, and were less likely to have had higher education or to have children living at home. Far more non-volunteers considered that they already did enough exercise to maintain health. Non-volunteers had slightly less knowledge of the benefits of physical activity; attached far less importance to it in maintaining health; were more likely to cite 'fear of leaving their home unattended', 'do not enjoy exercise' and 'poor health' as barriers to exercise; and were less likely to cite 'no one to exercise with' as a barrier to exercise. CONCLUSION: Recruitment of 'hard to engage' individuals requires careful phrasing of the message to focus on their personal goals and to address gaps in their knowledge about physical activity and the principal barriers they perceive. Differential uptake across population subgroups could lead to a widening of health inequalities.

A list of device-specific thresholds for the clinical interpretation of peripheral x-ray absorptiometry examinations.

The UK National Osteoporosis Society (NOS) has recently issued new guidelines on the use of peripheral x-ray absorptiometry (pDXA) devices in managing osteoporosis. The NOS guidelines recommend a triage approach in which patients' bone mineral density (BMD) measurements are interpreted using upper and lower thresholds specific to each type of pDXA device. The thresholds are defined so that patients with osteoporosis at the hip or spine are identified with 90% sensitivity and 90% specificity. Patients with a pDXA result below the lower threshold are likely to have osteoporosis at the hip or spine, patients with a result above the upper threshold are unlikely to have osteoporosis, while those between the two thresholds require a hip and spine BMD examination for a definitive diagnosis. This report presents data from a multicenter study to establish the triage thresholds for a range of pDXA devices in use in the UK. The subjects were white female patients aged 55-70 years who met the normal referral criteria for a BMD examination. For each device, at least 70 women with osteoporosis at the hip or spine and 70 women without osteoporosis were enrolled. All women had hip and spine BMD measurements using axial DXA systems that were interpreted using the National Health and Nutrition Examination Survey (NHANES) reference range for the hip and the manufacturers' reference ranges for the spine. Data are presented for five different devices: the Osteometer DTX-200 (forearm BMD), the Schick AccuDEXA (hand BMD), the GE Lunar PIXI (heel BMD), the Alara MetriScan (hand BMD), and the Demetech Calscan (heel BMD). The clinical measurements were supplemented by theoretical modeling to estimate the age dependence of the triage thresholds and the effect of the correlation coefficient between pDXA and axial BMD on the percentage of women referred for an axial BMD examination. In summary, this study provides thresholds for implementing the new NOS guidelines for managing osteoporosis using pDXA devices. The figures reported apply to postmenopausal white women aged 55-70 years who meet the conventional criteria for a BMD examination. The results confirm that the thresholds are specific to each type of pDXA device and that the NOS triage algorithm requires 40% of women to have an axial DXA examination.

The impact of implementing national hypertension guidelines on prevalence and workload in primary care: a population-based survey of older people.

Recently revised UK and US hypertension guidelines have reduced thresholds for both diagnosis and treatment and differ in their recommendations. We have used data from a random, stratified community-based sample of 4784 people aged 65 years and over to compare the prevalence of treatable hypertension and the potential impact on patients and primary care from using current guidelines. BHS, NICE and JNC7 guidelines were applied to blood pressures obtained from primary care medical records (94%) or measured at a screening clinic (6%). Risk factors were obtained by questionnaire and from medical records, supplemented by epidemiological data. Workload was estimated for a representative practice population of 10 000 patients. Blood pressures were obtained on 4514 patients (94%). Prevalence of treatable hypertension was over 67%. Compared to BHS4, prevalence estimates using NICE guidelines were comparable for men but significantly lower for women (P<0.05). They were significantly higher using JNC7 compared with BHS4 and NICE guidance (P<0.05). A general practice of 10 000 patients could expect 1287 older hypertensive patients using BHS4 guidelines and 1231 patients using NICE guidelines. Under BHS4, an extra 94 patients will require annual, rather than 5-yearly review compared with that using the previous guideline. In conclusion, implementation of BHS4 guidelines, with their revised thresholds for diagnosis, will not add materially to the prevalence of treatable hypertension compared to previous BHS3 guidelines but will have a major impact on practice workload. Use of NICE guidelines in preference to BHS4 will result in GPs treating fewer patients and reviewing untreated patients less often.

Bone density at the os calcis: reference values, reproducibility, and effects of fracture history and physical activity.

AIMS: To establish reference values for bone mineral density (BMD) measured at the os calcis (OC) in healthy UK Caucasian children. Secondary objectives were to assess the reproducibility of the measurement and the effects of fracture history and habitual physical activity. METHODS: A total of 403 children aged 5-18 were studied. Main outcome measures were: BMDoc measured by peripheral DXA, total BMD measured by whole body axial scanner, age, anthropometry, pubertal status, self-reported fracture history, and physical activity (PA) expressed as a three point score. RESULTS: Complete data were available on 171 girls and 123 boys free of a history of fracture. BMDoc was related positively to age, body size, and total BMD, and could be predicted using a proportional model based on height alone (R2: 65% girls, 77% boys). Mean BMDoc appears to plateau in girls at 15 years and attain a value that concurs with the mean peak value in adult women. The 95% limits of agreement in repeated measures were -0.029 to 0.029 g/cm2 (n = 53). Compared with sedentary children, those doing regular sports or PA for more than five hours a week had an increased BMDoc (by about 0.03 g/cm2 or about 7% of the overall mean). A history of fracture (n = 81) was associated with a reduced BMDoc in boys but not in girls, though our study may have been underpowered for a subgroup analysis. CONCLUSIONS: BMDoc can be measured easily and quickly in children older than 5 years and provides an objective measure of areal bone density for clinical and research studies using a reference range derived from its relation to height.

Neonatal accessory digits: a survey of practice amongst paediatricians and hand surgeons in the United Kingdom.

AIM: To describe the management of neonatal accessory digits, comparing views of paediatricians with those of hand surgeons, giving particular emphasis to the form of partial, ulnar duplication of the little finger (ulnar or postaxial polydactyly type B) which has a narrow pedicle. METHODS: Postal questionnaire of management preference using three photographs of ulnar accessory digits of varying complexity. RESULTS: The response rate was 64% in 234 paediatricians and 25% in 260 surgeons. All respondents would intervene in cases of ulnar polydactyly type B with a narrow pedicle: 79% of paediatricians but only 67% of hand surgeons would recommend referral of these cases for specialist assessment, the remainder advocating ligation by the paediatrician in the nursery. Paediatricians and neonatologists working in regional centres or with an on-site specialist service were more likely to refer. There was almost unanimous agreement on the management of the most complex case, but no general consensus on that of the simplest form. CONCLUSION: There is uncertainty and inequality in initial treatment decisions for infants with all but the most complex of accessory digits. Despite published evidence that ligation gives satisfactory results, most respondents in this survey advocate specialist referral, with evidence that the availability of specialist services influences decision making.

Quality of life in patients with established inflammatory bowel disease: a UK general practice survey.

BACKGROUND: The current understanding of quality of life impairment in inflammatory bowel disease has largely been derived from selected populations and may not reflect the experience of patients in the community, where fewer than half are likely to be under specialist care. AIM: To describe the health-related quality of life in a community-based sample of patients with established inflammatory bowel disease and explore its association with the type and extent of disease, gender, age, material deprivation and other factors. METHODS: Adults with established inflammatory bowel disease were identified systematically from the records of 23 family practices in north-east England. The health-related quality of life was assessed by self-completion of the UK Inflammatory Bowel Disease Questionnaire. RESULTS: Five hundred and fifty-six patients were sent the questionnaire and 409 (74%) gave usable replies. Lower scores (worse quality of life) were significantly associated with female gender, Crohn's disease, more extensive disease (ulcerative colitis) and being under specialist care. The mean health-related quality of life score was significantly lower in patients resident in more deprived districts, independent of the type and extent of disease. CONCLUSIONS: Most patients with established inflammatory bowel disease showed only minor impairment of their health-related quality of life. On average, women and those with Crohn's disease were relatively more affected. Clinicians responsible for the care of patients with inflammatory bowel disease should be aware of these more vulnerable groups.

Errors in general practice: development of an error classification and pilot study of a method for detecting errors.

OBJECTIVE: To describe a classification of errors and to assess the feasibility and acceptability of a method for recording staff reported errors in general practice. DESIGN: An iterative process in a pilot practice was used to develop a classification of errors. This was incorporated in an anonymous self-report form which was then used to collect information on errors during June 2002. The acceptability of the reporting process was assessed using a self-completion questionnaire. SETTING: UK general practice. PARTICIPANTS: Ten general practices in the North East of England. MAIN OUTCOME MEASURES: Classification of errors, frequency of errors, error rates per 1000 appointments, acceptability of the process to participants. RESULTS: 101 events were used to create an initial error classification. This contained six categories: prescriptions, communication, appointments, equipment, clinical care, and "other" errors. Subsequently, 940 errors were recorded in a single 2 week period from 10 practices, providing additional information. 42% (397/940) were related to prescriptions, although only 6% (22/397) of these were medication errors. Communication errors accounted for 30% (282/940) of errors and clinical errors 3% (24/940). The overall error rate was 75.6/1000 appointments (95% CI 71 to 80). The method of error reporting was found to be acceptable by 68% (36/53) of respondents with only 8% (4/53) finding the process threatening. CONCLUSION: We have developed a classification of errors and described a practical and acceptable method for reporting them that can be used as part of the process of risk management. Errors are common and, although all have the potential to lead to an adverse event, most are administrative.

Randomized controlled trial of a single dermatology nurse consultation in primary care on the quality of life of children with atopic eczema.

BACKGROUND: Atopic eczema is mostly managed in primary care but there is often insufficient time for patient education; a nurse practitioner could help with this. OBJECTIVES: To evaluate the effects of a single consultation with a primary care nurse on the quality of life (QOL) of children with atopic eczema aged 0.5-16 years and the impact of the disease on their families. PATIENTS AND METHODS: Children with eczema were invited to join the trial. Volunteers were randomized to a control group or an intervention group who attended the nurse for a single 30-min session. Family impact was determined using the Family Dermatitis Index (FDI), and QOL was assessed using the Infant Dermatitis Quality of Life questionnaire (IDQOL) or, in children aged 4-16 years, the Children's Dermatology Life Quality Index (CDLQI). Baseline scores for family impact and QOL were compared with those at 4 weeks and 12 weeks post-intervention. RESULTS: Two hundred and thirty-five children were recruited over 12 months; 115 were aged 0.5-4 years and 120 were aged 4-16 years. Follow-up data were missing for 38 children (84% completion rate, n = 197). All measures of QOL or family impact at baseline were skewed. The median scores were IDQOL, 5, and CDLQI, 6. About 20% of children had zero scores for the FDI (no impact on family life); median FDI scores were 2 or 3. At baseline the FDI correlated with the IDQOL or CDLQI. In addition, the FDI and IDQOL were related to parental assessment of disease severity. Non-responders had, on average, worse QOL at baseline than those who provided complete data. In the children with complete data, the mean differences in CD < Q1 and 1DQO< scores between intervention and control children were small at 4 and 12 weeks (P > 0.05). The improvement in FDI at 4 weeks was slightly better in intervention than control children (P < 0.06). CONCLUSIONS: The impact on QOL of a single intervention by a dermatology nurse was marginal for family impact at 4 weeks and was not apparent for other measures, either in the short or longer term. The planned sample size was derived from data in hospital patients but in our population disease activity was milder and the effects on QOL were less. On this account the present study was of low statistical power for some measures. Further studies in larger populations using additional outcome measures are required before advocating the wider introduction of nurse specialists.

Body mass, fat percentage, and fat free mass as reference variables for lung function: effects on terms for age and sex.

BACKGROUND: Sex specific cross sectional reference values for lung function indices usually employ a linear model with terms for age and stature. The effects of also matching for body mass index (BMI = mass/stature(2)) or its components, fat percentage of body mass (fat%) and fat free mass index (FFMI = fat free mass/stature(2)) were studied. METHODS: The subjects were 458 asymptomatic male and female non-smokers (383 men) and 22 female ex-smokers. Measurements were made of ventilatory capacity, lung volumes, transfer factor (diffusing capacity, single breath CO method), and body composition (skinfold method). Linear and proportional regression models were used. RESULTS: Terms for fat% and FFMI significantly improved the accuracy of reference values for all the primary lung function indices. The improvements in subjects with atypical physiques (fat% and FFMI at the ends of the distributions for the subjects) were in the range 0.3-2.3 SD compared with conventional regression equations. The new partial regression coefficients on age were independent of age related changes in body fat. The coefficient for total lung capacity (TLC) on age in men was now positive. Most differences between the sexes were eliminated. A term for BMI improved the descriptions of subdivisions of TLC but lacked the other advantages. CONCLUSION: Allowance for fat% and FFMI increases the accuracy of reference equations for lung function, particularly for subjects with a lot of fat and little muscle or vice versa. Allowance for BMI is less informative.

Upper aerodigestive tract cancers in former employees at an iron and steel works.

Local concern about numbers of laryngeal cancer cases led to an investigation of the incidence of upper aerodigestive tract (UAT) cancer in an industrial cohort. Males (n = 11 470) who had been directly employed at an iron and steel works in northern England at any time between January 1960 and site closure in September 1983 were followed up for UAT cancers until December 1998. The incidence of UAT and laryngeal cancer was compared to the general population of the region via indirect standardization. Fifty-two members of the cohort developed a UAT cancer during 1960-1998. There were no more UAT cancers than expected [standardized incidence ratio = 97, 95% confidence interval (CI) = 72-127], but slightly more laryngeal cancers than expected (standardized incidence ratio = 118, 95% CI = 78-171), although this estimate was less precise. The lack of complete work histories meant that relationships between cancer incidence and length of service or job categories could not be explored.

Do elderly cancer patients care about cure? Attitudes to radical gynecologic oncology surgery in the elderly.

OBJECTIVE: The aim of this study was to address the hypothesis of no difference between elderly and younger patients' desire for optimal surgery and disease cure. METHODS: The new ARGOSE questionnaire with established instruments was administered to 189 gynecologic cancer patients (95 aged <65, 57 aged 65-74, and 37 aged 75+ years). RESULTS: Disease diagnosis differed between the <65 years and 65+ years cohorts (P < 0.001), but treatment modalities were similar (P = 0.28). Influences of family and friends and past experiences of cancer had little influence on treatment decisions. There was no difference between cohorts in desire for surgery offering a chance of disease cure (P = 0.75), except that the elderly desire cure more if treatment is associated with disfigurement than do the young. (P = 0.029). The elderly believe more strongly than the young that the elderly value cure (P < 0.001). Issues of sexuality and femininity associated with gynecologic cancer and treatment are more important to younger patients (P < 0.001). The elderly support equality of care with relation to age more strongly than the young. However, in a situation of resource limitation, inequality favoring the young is opposed less strongly by the elderly than by the young. Social desirability bias may have influenced this finding. All cohorts reported symptom palliation to be of secondary importance to treatments offering a possibility of cure (P = 0.26). The elderly believe more strongly that doctors should make management decisions (P < 0.001). CONCLUSION: The elderly desire radical surgery and disease cure as strongly as the young. They are less likely to question their doctors' decisions and are therefore vulnerable to physicians' age bias. There is no justification for rationing care on the basis of chronological age.

Can diagnostic laparoscopy be avoided in routine investigation for infertility?

OBJECTIVE: To determine whether routine testing for serum Chlamydia trachomatis antibodies, considered in combination with a woman's clinical features, may avoid the need for diagnostic laparoscopy in routine investigation for infertility. DESIGN: Retrospective case notes analysis. SETTING: Secondary level care infertility clinic. POPULATION: Eighty women who had undergone both laparoscopy and serum Chlamydia trachomatis antibody testing. METHODS: Ascertainment of any history of suspected pelvic inflammatory disease, pelvic pain, cervical intraepithelial neoplasia, pelvic surgery or appendicectomy; any abnormality on clinical pelvic examination; the findings at laparoscopy; the result of serum Chlamydia trachomatis antibody testing by enzyme-linked immunosorbent assay (ELISA) screening with microimmunofluorescence (MIF) confirmatory diagnostic testing. The usefulness of clinical features, the serum Chlamydia trachomatis antibody test and these two variables combined in the detection of tubal disease and pelvic pathology of relevance to infertility were measured statistically. MAIN OUTCOME MEASURES: Specificity, sensitivity, positive predictive value, negative predictive value and likelihood ratio for each of the tests. RESULTS: The combination of any positive clinical feature with a positive test for serum Chlamydia trachomatis antibodies detects tubal disease with sensitivity 92%, specificity 70%, positive predictive value 72%, negative predictive value 91% and likelihood ratio 3 x 1; it detects bilateral tubal obstruction with sensitivity 84%, specificity 51%, positive predictive value 35%, negative predictive value 91% and likelihood ratio 1 x 7; it detects pelvic pathology relevant to infertility with sensitivity 76%, specificity 71%, positive predictive value 80%, negative predictive value 65% and likelihood ratio 2 x 6. The negative predictive value for pelvic pathology from the use of clinical features in addition to the chlamydia antibody test is not significantly higher than that from the chlamydia antibody test alone (53%). CONCLUSIONS: A policy of selective laparoscopy in routine investigation for infertility, based on the result of the test for serum Chlamydia trachomatis antibodies and a woman's clinical features, is not supported.

Identification of women with reduced bone density at the lumbar spine and femoral neck using BMD at the os calcis.

We assessed the clinical usefulness of bone density measurements at the os calcis as a screening tool to identify patients with low bone density at the lumbar spine and femoral neck. Bone mineral density (BMD) was recorded in 443 women (mean age 60 years) referred to a bone densitometry service. Measurements were made at the lumbar spine and femoral neck using a Lunar DPXL and at the right os calcis using a Peripheral Instantaneous X-ray Imaging (PIXI) dual-energy X-ray absorptiometry system. Average T-scores derived using the manufacturer's data were: 1.59 for the lumbar spine, -1.41 for the femoral neck and -0.87 for the os calcis. The prevalence of osteoporosis using WHO criteria (T-scores of -2.5 or less) was 36% for the lumbar spine or femoral neck but only 9.7% for the os calcis. BMD of the os calcis correlated with that at the lumbar spine (r = 0.69, p < 0.001) and femoral neck (r = 0.67, p < 0.001). The area under the receiver operator characteristics curve was 0.836 (standard error 0.020) for the os calcis related to osteoporosis at the lumbar spine or femoral neck. Optimal accuracy was obtained at a T-score of < or = -1.3 (BMD 0.39 g/cm2) when the sensitivity was 69.6% (95% confidence interval 65.3, 73.9%) and specificity 82.6% (95% confidence interval 79.1, 86.1%). However, the probability of diagnosing low bone density from a given BMD at the os calcis varied by age and site scanned. Accordingly, for informing management strategies, the choice of a single cutoff BMD at the os calcis may not be appropriate and several thresholds may be adopted based on age, the site of interest (lumbar spine or femoral neck) and consideration of associated clinical features. Thus, the use of heel bone density scanners could reduce the number of axial bone density measurements required. The advantages of portability, low cost and shorter scan times should reduce the cost of detection and provide a greater opportunity for identification of women at risk of fracture.

Attitudes to radical gynecological oncology surgery in the elderly: a pilot study.

Does age-related inequality of cancer care reflect patient preference or physician prejudice? We hypothesize no difference between elderly and younger patients' desire for optimal surgery and disease cure, and psychological adaptation to cancer. A newly developed questionnaire to assess attitudes to radical gynecological surgery in the elderly (ARGOSE) and a battery of established instruments were administered to 54 gynecological cancer patients (32 aged 65 + years; and 22 aged < 65 years) by structured interview. Disease diagnosis differed between cohorts (P = 0.007), but treatment modalities were similar (P = 0.46). There was no difference between cohorts in desire for optimal surgery and disease cure. Trends suggest the young consider a patient's age is less important than do the elderly, but the elderly may oppose age-related economic rationing of treatment more than the young. Furthermore, elderly individuals tend to perceive their seniors too elderly for treatment, but not themselves. The elderly believe more strongly that doctors should make management decisions. Perceptions of change in body image after cancer treatment did not differ between cohorts. The influence of age in determining attitudes is complex. A larger study with increased power is indicated to examine trends revealed in this pilot study.