Ethnic differences in the clustering and outcomes of health behaviours during pregnancy: results from the Born in Bradford cohort.

Background: Pregnancy is a time of optimal motivation for many women to make positive behavioural changes. We aim to describe pregnant women with similar patterns of self-reported health behaviours and examine associations with birth outcomes. Methods: We examined the clustering of multiple health behaviours during pregnancy in the Born in Bradford cohort, including smoking physical inactivity, vitamin d supplementation and exposure to second-hand smoke. Latent class analysis was used to identify groups of individuals with similar patterns of health behaviours separately for White British (WB) and Pakistani mothers. Multinomial regression was then used to examine the association between group membership and birth outcomes, which included preterm birth and mean birthweight. Results: For WB mothers, offspring of those in the 'Unhealthiest' group had lower mean birthweight than those in the 'Mostly healthy but inactive' class, although no association was observed for preterm birth. For Pakistani mothers, group membership was not associated with birthweight differences, although the odds of preterm birth was higher in 'Inactive smokers' compared to the 'Mostly healthy but inactive' group. Conclusions: The use of latent class methods provides important information about the clustering of health behaviours which can be used to target population segments requiring behaviour change interventions considering multiple risk factors. Given the dominant negative association of smoking with the birth outcomes investigated, latent class groupings of other health behaviours may not confer additional risk information for these outcomes.

Population mixing and incidence of cancers in adolescents and young adults between 1990 and 2013 in Yorkshire, UK.

PURPOSE: Epidemiological evidence suggests a role for an infectious etiology for cancers in teenagers and young adults (TYAs). We investigated this by describing associations between infection transmission using the population mixing (PM) proxy and incidence of cancers in TYAs in Yorkshire, UK. METHODS: We extracted cancer cases from the Yorkshire Specialist Register of Cancer in Children and Young People from 1990 to 2013 (n = 1929). Using multivariable Poisson regression models (adjusting for effects of deprivation and population density), we investigated whether PM was associated with cancer incidence. We included population mixing-population density interaction terms to examine for differences in effects of PM in urban and rural populations. RESULTS: Nonsignificant IRRs were observed for leukemias (IRR 1.20, 95% CI 0.91-1.59), lymphomas (IRR 1.09, 95% CI 0.90-1.32), central nervous system tumors (IRR 1.06, 95% CI 0.80-1.40) and germ cell tumors (IRR 1.14, 95% CI 0.92-1.41). The association between PM and cancer incidence did not vary in urban and rural areas. CONCLUSIONS: Study results suggest PM is not associated with incidence of cancers among TYAs. This effect does not differ between rural and urban settings.

Incidence and survival of children and young people with central nervous system embryonal tumours in the North of England, 1990-2013.

BACKGROUND: Medulloblastoma and primitive neuroectodermal tumours (PNET) are the most common central nervous system (CNS) embryonal tumours diagnosed in childhood. Survival outcomes are worse for children diagnosed with CNS PNET compared to medulloblastoma. Less is known about survival outcomes in teenagers and young adults (TYA). METHODS: Data were extracted from two population-based cancer registries of children and young people (0-24 years) in the north of England for all diagnoses of medulloblastoma and CNS PNET between 1990 and 2013. Incidence and survival trends were analysed using Poisson and Cox regression. RESULTS: Between 1990 and 2013, 197 medulloblastomas and 58 CNS PNET were diagnosed, age-standardised incidence rates of 3.8 and 1.5 per million, respectively. Medulloblastoma incidence decreased over time while there was no significant change in trend for CNS PNET. The overall 5-year survival rate was 54%. The risk of death was 2.4 times higher (95% confidence interval [CI] 1.6, 3.7) for patients with CNS PNET compared to medulloblastoma, after adjustment for patient characteristics. There was a 39% reduction (95% CI 0.43, 0.87) in the risk of death for patients diagnosed between 2000 and 2013 compared to 1990-1999. Risk of death did not differ for TYA (15-24 years) compared to children aged 5-9 years. CONCLUSIONS: Medulloblastoma incidence decreased over time and differences in survival between medulloblastoma and PNET emerged within the first-year post diagnosis leading to poorer outcomes for children and young adults diagnosed with PNET; however, a significant improvement in survival over time was observed.

The association between green space and depressive symptoms in pregnant women: moderating roles of socioeconomic status and physical activity.

BACKGROUND: The current study explored the association between green space and depression in a deprived, multiethnic sample of pregnant women, and examined moderating and mediating variables. METHOD: 7547 women recruited to the 'Born in Bradford' cohort completed a questionnaire during pregnancy. A binary measure of depressive symptoms was calculated using a validated survey. Two green space measures were used: quintiles of residential greenness calculated using the normalised difference vegetation index for three neighbourhood sizes (100, 300 and 500 m buffer zones around participant addresses); access to major green spaces estimated as straight line distance between participant address and nearest green space (>0.5 hectares). Logistic regression analyses examined relationships between green space and depressive symptoms, controlling for ethnicity, demographics, socioeconomic status (SES) and health behaviours. Multiplicative interactions explored variations by ethnic group, SES or activity levels. Mediation analysis assessed indirect effects via physical activity. RESULTS: Pregnant women in the greener quintiles were 18-23% less likely to report depressive symptoms than those in the least green quintile (for within 100 m of green space buffer zone). The green space-depressive symptoms association was significant for women with lower education or who were active. Physical activity partially mediated the association of green space, but explained only a small portion of the direct effect. CONCLUSIONS: Higher residential greenness was associated with a reduced likelihood of depressive symptoms. Associations may be stronger for more disadvantaged groups and for those who are already physically active. Improving green space is a promising intervention to reduce risk of depression in disadvantaged groups.

Agreement between routine and research measurement of infant height and weight.

UNLABELLED: In many countries, routine data relating to growth of infants are collected as a means of tracking health and illness up to school age. These have potential to be used in research. For health monitoring and research, data should be accurate and reliable. This study aimed to determine the agreement between length/height and weight measurements from routine infant records and researcher-collected data. METHODS: Height/length and weight at ages 6, 12 and 24 months from the longitudinal UK birth cohort (born in Bradford; n=836-1280) were compared with routine data collected by health visitors within 2 months of the research data (n=104-573 for different comparisons). Data were age adjusted and compared using Bland Altman plots. RESULTS: There was agreement between data sources, albeit weaker for height than for weight. Routine data tended to underestimate length/height at 6 months (0.5 cm (95% CI -4.0 to 4.9)) and overestimate it at 12 (-0.3 cm (95% CI -0.5 to 4.0)) and 24 months (0.3 cm (95% CI -4.0 to 3.4)). Routine data slightly overestimated weight at all three ages (range -0.04 kg (95% CI -1.2 to 0.9) to -0.04 (95% CI -0.7 to 0.6)). Limits of agreement were wide, particularly for height. Differences were generally random, although routine data tended to underestimate length in taller infants and underestimate weight in lighter infants. CONCLUSIONS: Routine data can provide an accurate and feasible method of data collection for research, though wide limits of agreement between data sources may be observed. Differences could be due to methodological issues; but may relate to variability in clinical practice. Continued provision of appropriate training and assessment is essential for health professionals responsible for collecting routine data.

Differences in socioeconomic position, lifestyle and health-related pregnancy characteristics between Pakistani and White British women in the Born in Bradford prospective cohort study: the influence of the woman's, her partner's and their parents' place of birth.

OBJECTIVE: To examine differences between Pakistani and White British women in relation to socioeconomic position, lifestyle and health-related pregnancy characteristics, and to determine whether these differences vary depending on the woman's, her partner's and both of their parents' place of birth. DESIGN: Prospective cohort study. SETTING: Bradford, UK PARTICIPANTS: 3656 Pakistani and 3503 White British women recruited to the Born in Bradford study. MAIN OUTCOME MEASURES: Socioeconomic position (employment status; level of education; receipt of benefits; housing tenure), lifestyle characteristics (body mass index (BMI) at the start of pregnancy; smoking during pregnancy) and health-related pregnancy characteristics (hypertensive disorders of pregnancy; gestational diabetes; fasting glucose, postload glucose and fasting insulin at ∼27 weeks gestation). RESULTS: Fewer Pakistani women were employed (OR 0.17, 95% CI 0.15 to 0.19), the difference being markedly less for UK born women. UK born Pakistani women were more likely, and South Asian born less likely, to be educated post 16 than White British women. Smoking was uncommon among Pakistani women, though the difference comparing UK born Pakistani women to White British women was less than for other groups. BMI was lower among Pakistani compared to White British women (adjusted mean difference -1.12, 95% CI -1.43 to -0.81), the difference being greatest when partners were UK born irrespective of the woman's place of birth. Pakistani women had higher fasting and postload glucose (mean difference 0.20 mmol/L, 95% CI 0.17 to 0.24; 0.37, 95% CI 0.28 to 0.45), higher fasting insulin and were more likely to have gestational diabetes (GDM). CONCLUSIONS: Our results suggest that some socioeconomic, lifestyle and pregnancy characteristics could be beginning to change in response to migration to the UK, with generally beneficial changes, that is, improving education and employment prospects, lower BMI and no evidence that being UK born has further increased the risk of GDM, but some negative, that is, slight increases in smoking.

Diabetes and breast cancer risk: a meta-analysis.

BACKGROUND: The potential of an increased risk of breast cancer in women with diabetes has been the subject of a great deal of recent research. METHODS: A meta-analysis was undertaken using a random effects model to investigate the association between diabetes and breast cancer risk. RESULTS: Thirty-nine independent risk estimates were available from observational epidemiological studies. The summary relative risk (SRR) for breast cancer in women with diabetes was 1.27 (95% confidence interval (CI), 1.16-1.39) with no evidence of publication bias. Prospective studies showed a lower risk (SRR 1.23 (95% CI, 1.12-1.35)) than retrospective studies (SRR 1.36 (95% CI, 1.13-1.63)). Type 1 diabetes, or diabetes in pre-menopausal women, were not associated with risk of breast cancer (SRR 1.00 (95% CI, 0.74-1.35) and SRR 0.86 (95% CI, 0.66-1.12), respectively). Studies adjusting for body mass index (BMI) showed lower estimates (SRR 1.16 (95% CI, 1.08-1.24)) as compared with those studies that were not adjusted for BMI (SRR 1.33 (95% CI, 1.18-1.51)). CONCLUSION: The risk of breast cancer in women with type 2 diabetes is increased by 27%, a figure that decreased to 16% after adjustment for BMI. No increased risk was seen for women at pre-menopausal ages or with type 1 diabetes.

Low abdominoperineal excision rates are associated with high-workload surgeons and lower tumour height. Is further specialization needed?

AIM: Wide variation, independent of disease extent and case mix, has been observed in the rate of use of abdominoperineal excision (APE) for rectal cancer. Previous analyses have, however, been confounded by failure to adjust for the location of the tumour within the rectum. This population-based study sought to examine whether variations in tumour height explained differences in APE use. METHOD: Information was obtained on all individuals who underwent a major resection for a rectal tumour diagnosed between 1998 and 2005 across the Northern and Yorkshire regions of the UK. Median distances from the dentate line were calculated for all tumours excised by APE and compared with rates of use of APE between specialists and nonspecialist surgeons and across hospital trusts. RESULTS: The completeness of pathological reporting of height of tumour within the rectum was variable. A low rate of APE use was associated with a lower median distance of tumours from the dentate line. Specialist colorectal cancer surgeons performed fewer APEs on patients with a tumour located lower in the rectum than nonspecialist surgeons. CONCLUSION: Variations in the height of tumour did not explain the variation in APE use. Specialist high-volume surgeons undertook fewer APEs and those they performed were closer to the dentate line than low-volume nonspecialist surgeons.

Surgical management and outcomes of colorectal cancer liver metastases.

BACKGROUND: This population-based study investigated the frequency of hepatic resections for colorectal cancer metastases across England and their outcome. METHODS: Individuals who underwent surgery for colorectal cancer between January 1998 and June 2004 within the English National Health Service were identified via the National Cancer Data Repository. All episodes of care in the 3 years after the initial operation were examined to determine the frequency of liver resection. Variations in the use of liver resection and survival were assessed. RESULTS: Some 114 155 individuals underwent surgery for colorectal cancer over the study period, of whom 3116 (2.7 per cent) subsequently had one or more hepatic resections. The hepatectomy rate increased from 1.7 per cent in 1998 to 3.8 per cent in 2004. There was significant variation in the rate of liver resection across cancer networks (range 1.1-4.3 per cent) and hospitals (range 0.7-6.8 per cent). The crude 5-year survival rate after liver resection was 44.2 (95 per cent confidence interval (c.i.) 42.4 to 46.1) per cent from the time of hepatectomy and 45.9 (95 per cent c.i. 44.1 to 47.7) per cent from the time of colectomy. This was comparable to the 5-year survival rate of patients with stage III disease (42.2 (95 per cent c.i. 41.7 to 42.7) per cent). CONCLUSION: The rate of resection of liver metastases increased over the study period but varied significantly across the country. Patients who underwent liver resection had 5-year survival comparable to that of patients with stage III colorectal cancer.

Trends in non-metastatic prostate cancer management in the Northern and Yorkshire region of England, 2000-2006.

BACKGROUND: Our objective was to analyse variation in non-metastatic prostate cancer management in the Northern and Yorkshire region of England. METHODS: We included 21,334 men aged > or = 55, diagnosed between 2000 and 2006. Principal treatment received was categorised into radical prostatectomy (11%), brachytherapy (2%), external beam radiotherapy (16%), hormone therapy (42%) and no treatment (29%). RESULTS: The odds ratio (OR) for receiving a radical prostatectomy was 1.53 in 2006 compared with 2000 (95% CI 1.26-1.86), whereas the OR for receiving hormone therapy was 0.57 (0.51-0.64). Age was strongly associated with treatment received; radical treatments were significantly less likely in men aged > or = 75 compared with men aged 55-64 years, whereas the odds of receiving hormone therapy or no treatment were significantly higher in the older age group. The OR for receiving radical prostatectomy, brachytherapy or external beam radiotherapy were all significantly lower in the most deprived areas when compared with the most affluent (0.64 (0.55-0.75), 0.32 (0.22-0.47) and 0.83 (0.74-0.94), respectively) whereas the OR for receiving hormone therapy was 1.56 (1.42-1.71). CONCLUSIONS: This study highlights the variation and inequalities that exist in the management of non-metastatic prostate cancer in the Northern and Yorkshire region of England.

Spatial variation in prostate cancer survival in the Northern and Yorkshire region of England using Bayesian relative survival smoothing.

Primary Care Trust (PCT) estimates of survival lack robustness as there are small numbers of deaths per year in each area, even when incidence is high. We assess PCT-level spatial variation in prostate cancer survival using Bayesian spatial models of excess mortality. We extracted data on men diagnosed with prostate cancer between 1990 and 1999 from the Northern and Yorkshire Cancer Registry and Information Service database. Models were adjusted for age at diagnosis, period of diagnosis and deprivation. All covariates had a significant association with excess mortality; men from more deprived areas, older age at diagnosis and diagnosed in 1990-1994 had higher excess mortality. The unadjusted relative excess risks (RER) of death by PCT ranged from 0.75 to 1.66. After adjustment, areas of high and low excess mortality were smoothed towards the mean, and the RERs ranged from 0.74 to 1.49. Using Bayesian smoothing techniques to model cancer survival by geographic area offers many advantages over traditional methods; estimates in areas with small populations or low incidence rates are stabilised and shrunk towards local and global risk estimates improving reliability and precision, complex models are easily handled and adjustment for covariates can be made.

Unacceptable variation in abdominoperineal excision rates for rectal cancer: time to intervene?

OBJECTIVE: To determine the variation in the rates of use of abdominoperineal excision (APE) by cancer network, hospital trust and surgeon across England between 1998 and 2004 and determine if any variation could be explained by differences in patient characteristics such as stage of disease, age, gender or socioeconomic deprivation. DESIGN: Retrospective study of a population-based dataset comprised of cancer registry and hospital episode statistics data. SETTING: All NHS providers of rectal cancer surgery within England. PATIENTS: 31,223 patients diagnosed with rectal cancer and receiving a major abdominal procedure within the NHS in England between 1998 and 2004. MAIN OUTCOME MEASURE: Rates and odds of use of APE were determined in relation to patient case-mix and each patient's managing surgeon, trust and cancer network. RESULTS: The rate of use of APE decreased from 30.5% in 1998 to 23.0% in 2004. Males, the economically deprived and those managed by surgeons operating on fewer than seven rectal cancer cases per year were all significantly more likely to receive an APE. There were also significant variations in the odds of receiving an APE over time and between individual surgeons and hospital trusts independently of patient case-mix. CONCLUSIONS: Over the study period the use of APE decreased but statistically significant variation was observed in its application independently of case mix. Reducing this variation will remove inequalities, reduce colostomy rates, and improve outcomes in rectal cancer. Rates of APE use could be a national performance measure.

The future burden of cancer in England: incidence and numbers of new patients in 2020.

We estimated the future cancer incidence rates and the future numbers of cancer cases in England up to 2020 using cancer registration data for 1974-2003, and the official population projections from ONS up to 2023. Data were analysed using an age-period-cohort model as developed for the Nordic countries. We predict that for all cancers combined there will be relatively little change in age-standardised incidence rates in 2020. The number of new cancer cases per year in England is, however, predicted to increase by 33%, from 224,000 in 2001 to 299,000 cases in 2020. This increase is mainly due to the anticipated effects of population growth and ageing; cancer patients in 2020 will be older than today's cancer population.

Social class inequalities in perinatal outcomes: Scotland 1980-2000.

OBJECTIVE: To examine social class inequalities in adverse perinatal events in Scotland between 1980 and 2000 and how these were influenced by other maternal risk factors. DESIGN: Population based study using routine maternity discharge data. SETTING: Scotland. PARTICIPANTS: All women who gave birth to a live singleton baby in Scottish hospitals between 1980 and 2000 (n=1,282,172). MAIN OUTCOME MEASURES: Low birth weight (LBW), preterm birth, and small for gestational age (SGA). RESULTS: The distribution of social class changed over time, with the proportion of mothers with undetermined social class increasing from 3.9% in 1980-84 to 14.8% in 1995-2000. The relative index of inequality (RII) decreased during the 1980s for all outcomes. The RII then increased between the early and late 1990s (LBW from 2.09 (95%CI 1.97, 2.22) to 2.43 (2.29, 2.58), preterm from 1.52 (1.44, 1.61) to 1.75 (1.65, 1.86), and SGA from 2.28 (2.14, 2.42) to 2.49 (2.34, 2.66) respectively). Inequalities were greatest in married mothers, mothers aged over 35, mothers taller than 164 cm, and mothers with a parity of one or more. Inequalities were also greater by the end of the 1990s than at the start of the 1980s for women of parity one or more and for mothers who were not married. CONCLUSION: Despite decreasing during the 1980s, inequalities in adverse perinatal outcomes increased during the 1990s in all strata defined by maternal characteristics.