Components of socioeconomic risk associated with head and neck cancer: a population-based case-control study in Scotland.

The complex associations between socioeconomic circumstances and risk for head and neck cancer are under-explored. We investigated components of social class and their relative influence on the risk of head and neck cancers by studying 103 patients (age range 24-80 years) who had been diagnosed with cancer of the head and neck between April 2002 and December 2004, and 91 controls who were randomly selected from general practitioners' lists. Information about occupation, education, smoking, and alcohol consumption was collected at personal interview. Socioeconomic circumstances were measured at an individual level (education, occupational social class, unemployment), and by area-based measures of deprivation. Odds ratios (OR) and 95% confidence intervals (CI) were computed using unconditional logistic regression and multivariate analyses. People living in the most deprived areas (OR=4.66, 95% CI 1.79-12.18); and those who were unemployed (OR=2.27, 95% CI 1.21-4.26) had a significantly higher risk of cancer than those with high levels of educational attainment (OR=0.17, 95% CI 0.05-0.58). Significance was lost for all measures of social class when adjustments were made for smoking and consumption of alcohol. Smoking was the only significant risk factor (OR=15.53, 95% CI 5.36-44.99) in the multivariate analysis. A high risk of head and neck cancer was consistently associated with poor socioeconomic circumstances, and there were strong links for specific components however smoking dominated the overall profile of risk. We propose a framework for future socioeconomic analyses.

Improved survival from lung cancer in British Columbia compared to Scotland-are different treatment rates the whole story?

To explore possible causes of the poor survival of Scottish lung cancer patients, a retrospective registry-based audit was conducted comparing demography, treatment and survival of 3833 Scottish patients and 2073 from British Columbia (BC). Patients from Scotland were older, had a lower rate of pathological confirmation (74% vs 89%, p<0.001), but more squamous (51% vs 31%, p<0.001) or small cell (SCLC) (18% vs 15%, p=0.005) cancers. Fewer Scottish patients received any treatment (57% vs 66%, p<0.001) or treatment aimed at cure (14% vs 26%, p<0.001). Survival was lower in Scotland (median 3.6 months vs 7.3 months; 5% vs 10% 5-year overall survival, p<0.001), irrespective of treatment intent (potentially curative treatment median survival 20.9 months vs 34.0 months, 5-year overall survival 29% vs 34%, p<0.001; palliative treatment 5.0 months vs 6.3 months (p<0.001) and no treatment 1.4 months vs 2.5 months (p<0.001)). With treatment intent included in a multivariate analysis, the hazard ratio for death for lung cancer patients in Scotland compared to British Columbia was 1.5. Relative survival was higher in BC (38% at 1 year and 12% at 5 years vs 22% and 6%, p<0.001), indicating that life expectancy differences between the two countries was not the explanation. Reduced levels of treatment could only partially explain survival differences and other unknown factors related to lifestyle differences such as diet and smoking, co-morbid diseases, population genetics or cancer biology, may be important and warrant further exploration.

Predicting breast cancer risk: implications of a "weak" family history.

Published guidelines adopted in many countries recommend that women whose family history of breast cancer places them at a risk>or=1.7 times that of the age-matched general population, should be considered for inclusion in special surveillance programmes. However validation of risk assessment models has been called for as a matter of urgency. The databases of the four Scottish Familial Breast Cancer clinics and the Scottish Cancer Registry have been searched to identify breast cancers occurring among 1,125 women aged 40-56, with family histories placing them below the "moderate" level of genetic risk. The observed incidence over 6 years was compared with age-specific data for the Scottish population. Our findings confirm that when there are two affected relatives (one first degree) the relative risk (RR) exceeds 1.7 regardless of their ages at diagnosis. When only one (first degree) relative was affected at any age from 40 to 55, the RR does not reach 1.7 if that relative was a mother but exceeds it if the relative was a sister. The probable explanation is that sisters are more likely than mother/daughter pairs to share homozygosity for a risk allele. Surveillance programmes might therefore accommodate sisters of women affected before age 55. Evidence that "low penetrance" alleles contributing to breast cancer risk may be recessive should be taken into account in strategies for identifying them.

Improved treatment and survival for lung cancer patients in South-East Scotland.

INTRODUCTION: Lung cancer survival in Scotland has historically been poor but many changes to the lung cancer services have been introduced and this study was conducted to investigate the impact of these changes on treatment and survival. METHODS: Data obtained from the Scottish Cancer Registry, South-East Scotland Cancer Network audit and Edinburgh Cancer Centre database were used to conduct a comparison of the management and outcomes of lung cancer patients from South-East Scotland diagnosed in 1995 and in 2002. RESULTS: Data on 971 patients diagnosed in 2002 and 927 in 1995 were analyzed and demonstrated that though the use of treatment overall had not changed (62% in 2002 versus 63% in 1995) the use of potentially curative radiotherapy (15 versus 5% chi p < 0.001) and chemotherapy for non-small cell lung cancer (18 versus 7% chi p < 0.001) had increased, but not resection rates (11 versus 10%). The use of palliative radiotherapy declined (38% versus 31% chi p < 0.001). Patients diagnosed in 2002 had an adjusted hazard of death of 0.7 (95% confidence interval, 0.6-0.8) compared with 1995, with median survival from date of diagnosis of 5.2 versus 4.1 month and 2 year overall survival 15 versus 11% (log rank p = 0.004). Localized disease and younger age were also associated with a reduced hazard of death. CONCLUSIONS: Patients diagnosed with lung cancer in Scotland in 2002 had a reduced hazard of death and improved survival compared with 1995. It is hypothesized that this was due in part to improvements in service organization and increased use of treatments likely to increase survival.

What will be the radiotherapy machine capacity required for optimal delivery of radiotherapy in Scotland in 2015?

AIMS: Lack of radiotherapy capacity has been cited as a reason for poor cancer outcomes reported in the United Kingdom. This modelling study was conducted to ensure sufficient capacity in the future and to aid health service planning. METHODS: The predicted changes in the incidence of each cancer type to 2015 were calculated using the age-period-cohort technique. To develop the model the indications for radiotherapy now and in 2015 were established, as were the fractionation schedules for each clinical scenario. The optimal radiotherapy utilisation rates and required radiotherapy capacity were estimated for 2005 and for 2015. RESULTS: Cancer incidence is expected to rise by 18.9% by 2015. In Scotland, the estimated optimal radiotherapy utilisation rate during initial management is 44.2-47.9%. The model suggested that currently for optimal delivery, the capacity for 195,300-256,300 fractions is required. Due to predicted changes in the patient population, it is anticipated that requirements will increase to between 276,400 and 354,200 fractions per annum by 2015. Based on the current working practices, this is a 20-54% increase in current capacity, or from 5 to 6-7.6 machines per million head of population. CONCLUSIONS: In order to meet the current and projected demand, a marked increase in the provision of radiotherapy machine capacity will be required in Scotland by 2015.

Analysis of referrals to a multi-disciplinary breast cancer genetics clinic: practical and economic considerations.

Analysis of activity was undertaken in an established regional clinic providing risk assessment, counselling, screening and management for women with a family history of breast or ovarian cancer. The objectives were to determine: (1) how closely the route and pattern of referrals matched official guidelines (2) whether the previously recorded socio-economic imbalance among clinic clientele persisted and (3) the economic and practical consequences of committing resources to verification and extension of reported family histories. The findings were: (1) after some years of operation, the proportion of referrals direct from primary care had increased from less than 50% to over 75%, with a concomitant slight decrease in overall referral rate; (2) the socio-economic distribution of patients referred had become less selective and (3) extension and verification of reported family histories led to a redistribution of risk categories, increasing the proportion of referrals judged to be in the "low risk" category, from 25% (based on referral letter alone) to 41% (at the end of the process). The costs associated with this approach are offset by the savings generated and it allows specialised counselling and screening services to be targeted more efficiently.

Impact of a cancer registry-based genealogy service to support clinical genetics services.

In collaboration with the network of genetics clinics in Scotland, a brief questionnaire was designed to gather data prospectively about the impact of information arising from pedigree research provided by Scottish Cancer Registry personnel. Pedigree research in Scotland is facilitated by access to public records of births, deaths, marriages, and historic census returns up to 1901, and enables the construction of accurate and extensive family pedigrees encompassing generations beyond the detailed knowledge of the proband. Subject to existing confidentiality guidelines, linkage of these pedigrees to cancer registration records results in a more comprehensive family history including the age at diagnosis of any cancer, multiple primary cancers, and cancers unreported from death certificates. Of 454 requests for pedigree research completed between 1 April 2002 and 31 March 2003, questionnaires were returned for 425 (94%). The information fed back to genetics clinics led to changes in family history, risk categorisation, and management in 41%, 30%, and 23% of cases, respectively. Management advice altered in both directions, that is, to institute active follow-up and surveillance of clinic attendees and their relatives where none was previously envisaged, and viceversa. The interests of current and future generations of patients concerned about their familial risk of cancer will be served by measures which enable cancer registries to collect data that are as accurate and complete as possible.

National study of cause-specific mortality in rheumatoid arthritis, juvenile chronic arthritis, and other rheumatic conditions: a 20 year followup study.

OBJECTIVE: To quantify risks for cause-specific mortality among hospitalized patients with rheumatoid arthritis (RA), juvenile chronic arthritis (JCA), and 4 other rheumatic conditions in a nationwide, population based cohort over a 20 year period. METHODS: All subjects were identified from Scottish hospital inpatient records from 1981 to 2000 and were followed up by computer linkage to the national registry of deaths. Expected mortality was calculated from national mortality rates and was related to the observed incidence by the standardized mortality ratio (SMR) and the corresponding 95% confidence interval (95% CI). RESULTS: Overall mortality was elevated in each of the 6 rheumatic conditions examined, most notably in JCA (males: SMR 3.4, 95% CI 2.0,5.5; females: SMR 5.1, 95% CI 3.2,7.8). Among patients with RA, there was an increased risk for death in all International Classification of Disease chapters other than those relating to mental disorders. Specific causes of death with an increased risk for subjects with RA included lung cancer [males: 1.4 (1.2,1.5); females: 1.6 (1.5,1.8)], hematopoietic malignancies [M: 1.8 (1.4,2.3); F: 2.0 (1.7,2.3)], coronary artery disease (CAD) [M: 1.6 (1.5,1.7); F: 1.95 (1.9,2.0)], respiratory infections [M: 1.9 (1.7,2.2); F: 2.4 (2.3,2.6)], chronic obstructive pulmonary disease [M: 1.8 (1.6,2.0); F: 2.1 (1.9,2.3)], and renal failure [M: 3.1 (2.5,3.9); F: 3.5 (3.0,4.0)]. Conversely, RA subjects were less likely to die from gastrointestinal tract malignancies [M: 0.82 (0.7,1.0); F: 0.8 (0.7,0.9)]. CONCLUSION: Population studies for primary data collection are required to extend our knowledge about the underlying mechanisms of early mortality in patients with rheumatic conditions.