Prevalence of multimorbidity in survivors of 28 cancer sites: an English nationwide cross-sectional study.

Multimorbidity, the presence of a chronic condition in addition to cancer, is of particular importance to cancer survivors. It has an impact on the progression, stage at diagnosis, prognosis, and treatment of cancer patients. Evidence is scarce on the prevalence of specific comorbidities in survivors of different cancers to inform prevention and management of multimorbidity. The objective of this study is to address this evidence gap by using large scale electronic health data from multiple linked UK healthcare databases to examine the prevalence of multimorbidity in 28 cancer sites. For this population-based cross-sectional study, we linked primary and secondary healthcare data from the UK Clinical Research Practice Datalink (CPRD) GOLD dataset and Hospital Episode Statistics (HES). We identified survivors of 28 common cancers aged 18 years or older at diagnosis who survived 2 years of cancer and compared their multimorbidity with matched controls without a history of cancer. To compare prevalence of individual comorbidity, multivariable logistic regression models, adjusted for confounding factors were used. Between January 1, 2010 and December 31, 2020, we identified 347,028 cancer survivors and 804,299 controls matched on age, sex and general practice. Cancer survivors had a higher prevalence of multimorbidity compared to non-cancer controls across all the cancer sites. Hypertension (56.2%), painful conditions (39.8%), osteoarthritis (38.0%), depression (31.8%) and constipation (31.4%) were the five most frequent chronic conditions reported. Compared to the controls, higher odds of constipation were found in survivors of 25 of the 28 cancer sites and higher odds of anaemia were found in 23 cancer sites. Prevalence of constipation, anaemia and painful conditions were higher after cancer diagnosis compared to before diagnosis. Since these comorbidities are not uniformly assessed as part of any of the comorbidity scales, they tend to be underreported among cancer survivors. The elevated risk of certain comorbidities in cancer survivors suggests the potential for preventative efforts in this population to lower disease burden and improve quality of life. Long-term conditions should not be viewed as the inevitable result of cancer diagnosis and treatment. We need to consider integrated management of chronic conditions tailored to specific cancers to improve cancer survivorship.

Ethnic differences in early onset multimorbidity and associations with health service use, long-term prescribing, years of life lost, and mortality: A cross-sectional study using clustering in the UK Clinical Practice Research Datalink.

BACKGROUND: The population prevalence of multimorbidity (the existence of at least 2 or more long-term conditions [LTCs] in an individual) is increasing among young adults, particularly in minority ethnic groups and individuals living in socioeconomically deprived areas. In this study, we applied a data-driven approach to identify clusters of individuals who had an early onset multimorbidity in an ethnically and socioeconomically diverse population. We identified associations between clusters and a range of health outcomes. METHODS AND FINDINGS: Using linked primary and secondary care data from the Clinical Practice Research Datalink GOLD (CPRD GOLD), we conducted a cross-sectional study of 837,869 individuals with early onset multimorbidity (aged between 16 and 39 years old when the second LTC was recorded) registered with an English general practice between 2010 and 2020. The study population included 777,906 people of White ethnicity (93%), 33,915 people of South Asian ethnicity (4%), and 26,048 people of Black African/Caribbean ethnicity (3%). A total of 204 LTCs were considered. Latent class analysis stratified by ethnicity identified 4 clusters of multimorbidity in White groups and 3 clusters in South Asian and Black groups. We found that early onset multimorbidity was more common among South Asian (59%, 33,915) and Black (56% 26,048) groups compared to the White population (42%, 777,906). Latent class analysis revealed physical and mental health conditions that were common across all ethnic groups (i.e., hypertension, depression, and painful conditions). However, each ethnic group also presented exclusive LTCs and different sociodemographic profiles: In White groups, the cluster with the highest rates/odds of the outcomes was predominantly male (54%, 44,150) and more socioeconomically deprived than the cluster with the lowest rates/odds of the outcomes. On the other hand, South Asian and Black groups were more socioeconomically deprived than White groups, with a consistent deprivation gradient across all multimorbidity clusters. At the end of the study, 4% (34,922) of the White early onset multimorbidity population had died compared to 2% of the South Asian and Black early onset multimorbidity populations (535 and 570, respectively); however, the latter groups died younger and lost more years of life. The 3 ethnic groups each displayed a cluster of individuals with increased rates of primary care consultations, hospitalisations, long-term prescribing, and odds of mortality. Study limitations include the exclusion of individuals with missing ethnicity information, the age of diagnosis not reflecting the actual age of onset, and the exclusion of people from Mixed, Chinese, and other ethnic groups due to insufficient power to investigate associations between multimorbidity and health-related outcomes in these groups. CONCLUSIONS: These findings emphasise the need to identify, prevent, and manage multimorbidity early in the life course. Our work provides additional insights into the excess burden of early onset multimorbidity in those from socioeconomically deprived and diverse groups who are disproportionately and more severely affected by multimorbidity and highlights the need to ensure healthcare improvements are equitable.

Multimorbidity in people living with and beyond cancer: a scoping review.

Globally, both cancer incidence and survival are increasing. Early cancer detection and improved treatment means many people with cancer will survive for ten or more years following diagnosis. Multimorbidity, defined as two or more chronic conditions, is up to three times higher in people living with and beyond cancer (LWBC) compared to the general population. This scoping review summarises the research evidence on the association between cancer and multimorbidity in people LWBC. It explores five key domains in people LWBC: 1) prevalence of multimorbidity, 2) association between ethnicity and socio-economic status (SES) and multimorbidity, 3) association between health status and multimorbidity, 4) adverse health consequences of cancer and related treatments, and 5) whether being a cancer survivor impacts treatment received for multimorbidity. It focuses on ten common cancers with high survival rates: prostate, breast, non-Hodgkin lymphoma, bowel/colorectal, kidney, head and neck, bladder, leukaemia, uterine and myeloma. A search of Medline, CINAHL, Embase, PsychINFO and Web of Science databases identified 9,460 articles, 115 of which met the inclusion criteria. Articles were included in the review that involved multimorbidity in adult cancer patients. An evaluation of the evidence was performed, and a summary of findings was generated according to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Extension for Scoping Reviews guidelines. This review included work from 20 countries, most studies were from the US (44%). The results showed that the most common long-term conditions in people LWBC were: hypertension, heart conditions, depression, COPD, and diabetes. The most reported incident comorbidities after a cancer diagnosis were congestive heart failure, chronic pain, and chronic fatigue. Multimorbidity tended to be higher amongst people LWBC from ethnic minority groups and those with lower SES. Quality of life was poorer in people LWBC with multimorbidity. The review identified the need for a uniform approach to measure multimorbidity in cancer patients across the world. Further research is required to compare multimorbidity before and after a cancer diagnosis, to explore the association of multimorbidity with ethnicity and socio-economic status and to determine whether a cancer diagnosis impacts care received for multimorbidity in people LWBC.

What is the evidence behind cancer care reviews, a primary care cancer support tool? A scoping review.

PURPOSE: A "cancer care review" (CCR) is a conversation between a patient recently diagnosed with cancer and primary care practitioner soon after a diagnosis of cancer in the UK. This scoping review aimed to identify: methodology and validated outcome measures used to evaluate CCRs, the impact of CCRs on quality of life or symptoms, and the views of patients, their carers and healthcare professionals on CCRs. METHODS: A scoping review was performed and five databases (MEDLINE, Embase, PsychINFO, Scopus, Web of Science, Google Scholar) were searched systematically from January 2000 to March 2022. RESULTS: Of 4133 articles, ten met the inclusion criteria. These included surveys, qualitative research on stakeholders' views and a small study evaluating group consultation CCRs. There were no studies on methodology to evaluate CCRs or the impact of CCRs on patient quality of life or symptoms. Some primary care professionals felt CCRs were a tick-box exercise, and that they had inadequate time to deliver care, compounded by inadequate primary-secondary care coordination and lack of expertise which was echoed by patients. Interviews with patients found few recalled CCRs and those that recalled CCRs did, did not find them particularly helpful. Partners of patients would welcome CCRs to raise personal health concerns and remain updated on patient care. CONCLUSIONS: Further studies should identify the role that stakeholders believe they should have in CCRs, improve care coordination between primary care and secondary care and how to support caregivers. IMPLICATIONS FOR CANCER SURVIVORS: There is currently insufficient evidence to support the use of CCRs in general practice.

Multimorbidity in patients living with and beyond cancer: protocol for a scoping review.

INTRODUCTION: The number of people living with and beyond cancer is increasing rapidly. Many of them will experience ongoing physical or psychological sequelae as a result of their original cancer diagnosis or comorbidities arising from risk factors common to cancers and other long-term conditions. This poses the complex problem of managing cancer as a 'chronic' illness along with other existing comorbidities. This scoping review aims to map the literature available on multimorbidity in patients living with and beyond cancer, to explore, quantify and understand the impact of comorbid illnesses to inform work around cancer care in UK primary care settings. METHODS AND ANALYSIS: This review will be guided by Joanna Briggs Institute Reviewer's manual for scoping reviews. A systematic literature search using Medical Subject Heading and text words related to cancer survivors and multimorbidity will be performed in MEDLINE, CINAHL, Embase and Web of Science, from 1990. Results will be described in a narrative style, reported in extraction tables and diagrams, and where appropriate in themes and text. ETHICS AND DISSEMINATION: The scoping review will undertake secondary analysis of published literature; therefore, ethics committee approval is not required. Results will be disseminated through a peer-reviewed scientific journal and presented in relevant conferences. The scoping review will inform understanding of the burden of multimorbidity for cancer survivors, thus allow families, practitioners, clinicians and researchers to take the steps necessary to improve patient-centred care.

Public availability and adherence to prespecified statistical analysis approaches was low in published randomized trials.

BACKGROUND AND OBJECTIVE: Prespecification of statistical methods in clinical trial protocols and statistical analysis plans can help to deter bias from p-hacking but is only effective if the prespecified approach is made available. STUDY DESIGN AND SETTING: For 100 randomized trials published in 2018 and indexed in PubMed, we evaluated how often a prespecified statistical analysis approach for the trial's primary outcome was publicly available. For each trial with an available prespecified analysis, we compared this with the trial publication to identify whether there were unexplained discrepancies. RESULTS: Only 12 of 100 trials (12%) had a publicly available prespecified analysis approach for their primary outcome; this document was dated before recruitment began for only two trials. Of the 12 trials with an available prespecified analysis approach, 11 (92%) had one or more unexplained discrepancies. Only 4 of 100 trials (4%) stated that the statistician was blinded until the SAP was signed off, and only 10 of 100 (10%) stated the statistician was blinded until the database was locked. CONCLUSION: For most published trials, there is insufficient information available to determine whether the results may be subject to p-hacking. Where information was available, there were often unexplained discrepancies between the prespecified and final analysis methods.

Acute Kidney Injury and Risk of Death After Elective Surgery: Prospective Analysis of Data From an International Cohort Study.

BACKGROUND: Postoperative acute kidney injury (AKI) is associated with a high mortality rate. However, the relationship among AKI, its associations, and mortality is not well understood. METHODS: Planned analysis of data was collected during an international 7-day cohort study of adults undergoing elective in-patient surgery. AKI was defined using Kidney Disease Improving Global Outcomes criteria. Patients missing preoperative creatinine data were excluded. We used multivariable logistic regression to examine the relationships among preoperative creatinine-based estimated glomerular filtration rate (eGFR), postoperative AKI, and hospital mortality, accounting for the effects of age, major comorbid diseases, and nature and severity of surgical intervention on outcomes. We similarly modeled preoperative associations of AKI. Data are presented as n (%) or odds ratios (ORs) with 95% confidence intervals. RESULTS: A total of 36,357 patients were included, 743 (2.0%) of whom developed AKI with 73 (9.8%) deaths in hospital. AKI affected 73 of 196 (37.2%) of all patients who died. Mortality was strongly associated with the severity of AKI (stage 1: OR, 2.57 [1.3-5.0]; stage 2: OR, 8.6 [5.0-15.1]; stage 3: OR, 30.1 [18.5-49.0]). Low preoperative eGFR was strongly associated with AKI. However, in our model, lower eGFR was not associated with increasing mortality in patients who did not develop AKI. Conversely, in older patients, high preoperative eGFR (>90 mL·minute·1.73 m) was associated with an increasing risk of death, potentially reflecting poor muscle mass. CONCLUSIONS: The occurrence and severity of AKI are strongly associated with risk of death after surgery. However, the relationship between preoperative renal function as assessed by serum creatinine-based eGFR and risk of death dependent on patient age and whether AKI develops postoperatively.

A Prospective International Multicentre Cohort Study of Intraoperative Heart Rate and Systolic Blood Pressure and Myocardial Injury After Noncardiac Surgery: Results of the VISION Study.

BACKGROUND: The association between intraoperative cardiovascular changes and perioperative myocardial injury has chiefly focused on hypotension during noncardiac surgery. However, the relative influence of blood pressure and heart rate (HR) remains unclear. We investigated both individual and codependent relationships among intraoperative HR, systolic blood pressure (SBP), and myocardial injury after noncardiac surgery (MINS). METHODS: Secondary analysis of the Vascular Events in Noncardiac Surgery Cohort Evaluation (VISION) study, a prospective international cohort study of noncardiac surgical patients. Multivariable logistic regression analysis tested for associations between intraoperative HR and/or SBP and MINS, defined by an elevated serum troponin T adjudicated as due to an ischemic etiology, within 30 days after surgery. Predefined thresholds for intraoperative HR and SBP were: maximum HR >100 beats or minimum HR <55 beats per minute (bpm); maximum SBP >160 mm Hg or minimum SBP <100 mm Hg. Secondary outcomes were myocardial infarction and mortality within 30 days after surgery. RESULTS: After excluding missing data, 1197 of 15,109 patients (7.9%) sustained MINS, 454 of 16,031 (2.8%) sustained myocardial infarction, and 315 of 16,061 patients (2.0%) died within 30 days after surgery. Maximum intraoperative HR >100 bpm was associated with MINS (odds ratio [OR], 1.27 [1.07-1.50]; P < .01), myocardial infarction (OR, 1.34 [1.05-1.70]; P = .02), and mortality (OR, 2.65 [2.06-3.41]; P < .01). Minimum SBP <100 mm Hg was associated with MINS (OR, 1.21 [1.05-1.39]; P = .01) and mortality (OR, 1.81 [1.39-2.37]; P < .01), but not myocardial infarction (OR, 1.21 [0.98-1.49]; P = .07). Maximum SBP >160 mm Hg was associated with MINS (OR, 1.16 [1.01-1.34]; P = .04) and myocardial infarction (OR, 1.34 [1.09-1.64]; P = .01) but, paradoxically, reduced mortality (OR, 0.76 [0.58-0.99]; P = .04). Minimum HR <55 bpm was associated with reduced MINS (OR, 0.70 [0.59-0.82]; P < .01), myocardial infarction (OR, 0.75 [0.58-0.97]; P = .03), and mortality (OR, 0.58 [0.41-0.81]; P < .01). Minimum SBP <100 mm Hg with maximum HR >100 bpm was more strongly associated with MINS (OR, 1.42 [1.15-1.76]; P < .01) compared with minimum SBP <100 mm Hg alone (OR, 1.20 [1.03-1.40]; P = .02). CONCLUSIONS: Intraoperative tachycardia and hypotension are associated with MINS. Further interventional research targeting HR/blood pressure is needed to define the optimum strategy to reduce MINS.

The Prevention of Respiratory Insufficiency after Surgical Management (PRISM) Trial. Report of the protocol for a pragmatic randomized controlled trial of CPAP to prevent respiratory complications and improve survival following major abdominal surgery.

BACKGROUND: Over 300 million patients undergo surgery worldwide each year. Postoperative morbidity - particularly respiratory complications - are most frequent and severe among high-risk patients undergoing major abdominal surgery. However, standard treatments, like physiotherapy or supplemental oxygen, often fail to prevent these. Preliminary research suggests that prophylactic continuous positive airways pressure (CPAP) can reduce the risk of postoperative respiratory complications. However, without evidence from a large clinical effectiveness trial, CPAP has not become routine care. This trial aims to determine whether early postoperative CPAP reduces the incidence of respiratory complications and improves one-year survival following major intra-peritoneal surgery. METHODS: This is an international multicenter randomized controlled trial with open study group allocation. The participants are aged 50 years and over undergoing major elective intra-peritoneal surgery. The intervention is CPAP for at least four hours, started within four hours of the end of surgery. RESULTS: The primary outcome is a composite of pneumonia, re-intubation, or death within 30 days of randomization. All participants with a recorded outcome will be analyzed on an intention-to-treat basis. The primary analysis will use a mixed-effects logistic regression model, which includes center as a random-intercept, and will be adjusted for the minimization factors and other pre-specified covariates. Trial Registration: ISRCTN 56012545. CONCLUSIONS: This is the first proposed clinical effectiveness trial of postoperative CPAP to prevent respiratory complications of which we are aware. The large sample size and multicenter international design will make the result generalizable to a variety of healthcare settings.

Variation in haemodynamic monitoring for major surgery in European nations: secondary analysis of the EuSOS dataset.

BACKGROUND: The use of cardiac output monitoring may improve patient outcomes after major surgery. However, little is known about the use of this technology across nations. METHODS: This is a secondary analysis of a previously published observational study. Patients aged 16 years and over undergoing major non-cardiac surgery in a 7-day period in April 2011 were included into this analysis. The objective is to describe prevalence and type of cardiac output monitoring used in major surgery in Europe. RESULTS: Included in the analysis were 12,170 patients from the surgical services of 426 hospitals in 28 European nations. One thousand four hundred and sixteen patients (11.6 %) were exposed to cardiac output monitoring, and 2343 patients (19.3 %) received a central venous catheter. Patients with higher American Society of Anesthesiologists (ASA) scores were more frequently exposed to cardiac output monitoring (ASA I and II, 643 patients [8.6 %]; ASA III-V, 768 patients [16.2 %]; p < 0.01) and central venous catheter (ASA I and II, 874 patients [11.8 %]; ASA III-V, 1463 patients [30.9 %]; p < 0.01). In elective surgery, 990 patients (10.8 %) were exposed to cardiac output monitoring, in urgent surgery 252 patients (11.7 %) and in emergency surgery 173 patients (19.8 %). A central venous catheter was used in 1514 patients (16.6 %) undergoing elective, in 480 patients (22.2 %) undergoing urgent and in 349 patients (39.9 %) undergoing emergency surgery. Nine hundred sixty patients (7.9 %) were monitored using arterial waveform analysis, 238 patients (2.0 %) using oesophageal Doppler ultrasound, 55 patients (0.5 %) using a pulmonary artery catheter and 44 patients (2.0 %) using other technologies. Across nations, cardiac output monitoring use varied from 0.0 % (0/249 patients) to 27.5 % (19/69 patients), whilst central venous catheter use varied from 5.6 % (7/125 patients) to 43.2 % (16/37 patients). CONCLUSIONS: One in ten patients undergoing major surgery is exposed to cardiac output monitoring whilst one in five receives a central venous catheter. The use of both technologies varies widely across Europe. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01203605. Date of registration: 15.09.2010.