The impact of old age on cancer-specific and non-cancer-related survival following elective potentially curative surgery for Dukes A/B colorectal cancer.

Previous studies have suggested that survival following surgery for colorectal cancer is poorer in the elderly. However, the findings were inconsistent and none of the studies adjusted for case mix. The aim of this study was to establish whether there were age-related differences in cancer (colorectal)-specific and non-cancer (colorectal)-related survival in patients undergoing elective potentially curative resection for Dukes stage A/B colorectal cancer. One thousand and forty three patients who underwent elective potentially curative resection for Dukes' A/B colorectal cancer between 1991 and 1994 in 11 hospitals in Scotland were included in the study. Ten year cancer-specific and non-cancer-related survival and the hazard ratios were calculated according to age groups (<64; 65-74/>74 years). On follow-up 273 patients died of their cancer and 328 died of non-cancer-related causes. At 10 years, overall survival was 45%, cancer specific was 70% and non-cancer-related survival was 64%. On multivariate analysis of all factors, age (HR 1.38, 95% CI 1.18-1.62, P<0.001), sex (HR 1.74, 95% CI 1.36-2.23, P<0.001), site (HR 1.42, 95% CI 1.11-1.81, P<0.01) and Dukes' stage (HR 1.71, 1.19-2.47, P<0.01) were independently associated with cancer-specific survival. On multivariate analysis of all factors, age (HR 2.14, 1.84-2.49, P<0.001), sex (HR 1.43, 1.15-1.79, P<0.01) and deprivation (HR 1.30, 1.09-1.55, P<0.01) were independently associated with non-cancer-related survival. The results of this study show that increasing age impacts negatively both on cancer-specific and non-cancer-related survival following elective potentially curative resection for node-negative colorectal cancer. However, the effect of increasing age is greater on the non-cancer-related survival. These results suggest that cancer-specific and non-cancer-related mortality should be considered separately in survival analysis of these cancer patients.

The Counterweight programme: Prevalence of CVD risk factors by body mass index and the impact of 10% weight change.

OBJECTIVES: To examine relationships between body mass index (BMI), prevalence of physician-recorded cardiovascular disease (CVD) risk factors in primary care, and changes in risk with 10% weight change. METHODS: The Counterweight Project conducted a baseline cross-sectional survey of medical records of 6150 obese (BMI ≥ 30 kg/m(2)), 1150 age- and sex-matched overweight (BMI 25 to <30 kg/m(2)), and 1150 age- and sex-matched normal weight (BMI 18.5 to <25 kg/m(2)) controls, in primary care. Data were collected for the previous 18 months to examine BMI and disease prevalence, and then modelled to show the potential effect of 10% weight loss or gain on risk. RESULTS: Obese patients develop more CVD risk factors than normal weight controls. BMI ≥ 40 kg/m(2) exhibits increased prevalence of type 2 diabetes mellitus (DM), odds ratio (OR) men: 6.16 (p < 0.001); women: 7.82 (p < 0.001) and hypertension OR men: 5.51 (p < 0.001); women: 4.16 (p < 0.001). Dyslipidaemia peaked around BMI 35 to <37.5 kg/m(2), OR men: 3.26 (p < 0.001); women 3.76 (p < 0.001) and CVD at BMI 37.5 to <40 kg/m(2) in men, OR 4.48 (p < 0.001) and BMI ≥ 40 kg/m(2) in women, OR 3.98 (p < 0.001). A 10% weight loss from the sample mean of 32.5 kg/m(2) reduced the OR for type 2 DM by 30% and CVD by 20%, while 10% weight gain increased type 2 DM risk by more than 35% and CVD by 20%. CONCLUSION: Obesity plays a fundamental role in CVD risk, which is reduced with weight loss. Weight management intervention strategies should be a public health priority to reduce the burden of disease in the population.

How many cases of Type 2 diabetes mellitus are due to being overweight in middle age? Evidence from the Midspan prospective cohort studies using mention of diabetes mellitus on hospital discharge or death records.

AIMS: To relate body mass index (BMI) in middle age to development of diabetes mellitus. METHODS: Participants were 6927 men and 8227 women from the Renfrew/Paisley general population study and 3993 men from the Collaborative occupational study. They were aged 45-64 years and did not have reported diabetes mellitus. Cases who developed diabetes mellitus, identified from acute hospital discharge data and from death certificates in the period from screening in 1970-1976 to 31 March 2004, were related to BMI at screening. RESULTS: Of Renfrew/Paisley study men 5.4%, 4.8% of women and 5% of Collaborative study men developed diabetes mellitus. Odds ratios for diabetes mellitus were higher in the overweight group (BMI 25 to < 30 kg/m(2)) than in the normal weight group (BMI 18.5 to < 25 kg/m(2)) and highest in the obese group (BMI >or= 30 kg/m(2)). Compared with the normal weight group, age-adjusted odds ratios for overweight and obese Renfrew/Paisley men were 2.73 [95% confidence interval (CI) 2.05, 3.64] and 7.26 (95% CI 5.26, 10.04), respectively. Further subdividing the normal, overweight and obese groups showed increasing odds ratios with increasing BMI, even at the higher normal level. Assuming a causal relation, around 60% of cases of diabetes could have been prevented if everyone had been of normal weight. CONCLUSIONS: Overweight and obesity account for a major proportion of diabetes mellitus, as identified from hospital discharge and death records. With recent increases in the prevalence of overweight, the burden of disease related to diabetes mellitus is likely to increase markedly. Primordial prevention of obesity would be a major strategy for reducing the incidence of diabetes mellitus in populations.

Measurement of process as quality control in the management of acute surgical emergencies.

BACKGROUND: Quality of care measured by adverse events cannot address errors of process that have no adverse outcomes. The aim of this study was to determine whether process could be used to assess quality of care and whether process analysis could be used to assess interventions designed to improve quality. METHODS: A single-centre prospective cohort study was performed over 12 weeks in an acute surgical admission unit. Data were collected prospectively for the first 24 h of admission on three aspects of process: documentation, general management and presentation-specific criteria. After a period of observation, the impact of three interventions (active observation, increasing awareness and issuing a job description) on the mean number of process errors per patient (process score) was compared. RESULTS: The analysis was based on 566 patients admitted with general surgical pathology. Awareness of being observed failed to improve the process score. Interventions that increased awareness of process reduced the overall process score from 4.79 to 2.38 errors per person (P < 0.001). The mean overall process score in patients with an adverse event was twice that of patients who did not have an adverse event (5.74 (95 per cent confidence interval 4.03 to 7.45) versus 3.43 (3.19 to 3.66)). CONCLUSION: Process can be measured objectively and used as a measure of quality of care. Interventions to increase awareness reduced process error rates and adverse events.

Obesity and use of acute hospital services in participants of the Renfrew/Paisley study.

BACKGROUND: Because overweight and obesity are associated with comorbidities, increasing levels of overweight and obesity may impact on hospital use. METHODS: Body mass index (BMI) in middle age was related to acute hospital use in 7036 men and 8327 women from the Renfrew/Paisley prospective cohort study in Scotland. Participants in this general population study were examined between 1972 and 1976 when aged 45-64 years. Acute hospital admissions and bed days per 1000 person-years were calculated by the World Health Organization BMI categories in the follow-up period to 31 March 2004. RESULTS: Underweight and normal weight men had lower-than-expected admission rates, and overweight and obese men had higher-than-expected admission rates. Obese men had higher-than-expected bed day rates. For women, there was a U-shaped relationship with admission rate, with normal weight women having the lowest admission rate and underweight and obese women having similar high rates. Underweight and obese women had higher-than-expected bed day rates. CONCLUSIONS: Participants who were obese in midlife had more-than-expected acute hospital admissions and in particular more bed days. With levels of obesity increasing since this study was started in the 1970s, if these patterns persist, there may be increasing demand on health service resources.

The impact of blood loss, obstruction and perforation on survival in patients undergoing curative resection for colon cancer.

BACKGROUND: Previous studies have drawn attention to the high postoperative mortality and poor survival of patients who present as an emergency with colon cancer. However, these patients are a heterogeneous group. The aim of the present study was to establish, having adjusted for case mix, the size of the differences in postoperative mortality and 5-year survival between patients presenting as an emergency with evidence of blood loss, obstruction and perforation. METHODS: The study included 2068 patients who presented with colon cancer between 1991 and 1994 in Scotland. Five-year survival rates and the adjusted hazard ratios were calculated. RESULTS: Thirty-day postoperative mortality following potentially curative resection was consistently higher in patients who presented with evidence of blood loss, obstruction or perforation (all P < 0.005) than in elective patients. Following potentially curative surgery, cancer-specific survival at 5 years was 74.6 per cent compared with 60.9, 51.6 and 46.5 per cent in those who presented with blood loss, obstruction and perforation respectively (all P < 0.001). The corresponding adjusted hazard ratios (95 per cent confidence interval) for cancer-specific survival, relative to elective patients, were 1.62 (1.22 to 2.15), 2.22 (1.78 to 2.75) and 2.93 (1.82 to 4.70) for patients presenting with evidence of blood loss, obstruction or perforation (all P < 0.001). CONCLUSION: Compared with patients who undergo elective surgery for colon cancer, those who present as an emergency with evidence of blood loss, obstruction or perforation have higher postoperative mortality rates and poorer cancer-specific survival.

Carboxyhaemoglobin concentration, smoking habit, and mortality in 25 years in the Renfrew/Paisley prospective cohort study.

OBJECTIVE: To investigate how carboxyhaemoglobin concentration is related to smoking habit and to assess whether carboxyhaemoglobin concentration is related to mortality. DESIGN: Prospective cohort study. SETTING: Residents of the towns of Renfrew and Paisley in Scotland. PARTICIPANTS: The whole Renfrew/Paisley study, conducted between 1972 and 1976, consisted of 7048 men and 8354 women aged 45-64 years. This study was based on 3372 men and 4192 women who were screened after the measurement of carboxyhaemoglobin concentration was introduced about halfway through the study. MAIN OUTCOME MEASURES: Deaths from coronary heart disease (CHD), stroke, chronic obstructive pulmonary disease (COPD), lung cancer, and all causes in 25 years after screening. RESULTS: Carboxyhaemoglobin concentration was related to self reported smoking and for each smoking category was higher in participants who reported inhaling than in those who reported not inhaling. Carboxyhaemoglobin concentration was positively related to all causes of mortality analysed (relative rates associated with a 1 SD (2.93) increase in carboxyhaemoglobin for all causes, CHD, stroke, COPD, and lung cancer were 1.26 (95% confidence interval (CI) 1.19 to 1.34), 1.19 (95% CI 1.13 to 1.26), 1.19 (95% CI 1.13 to 1.26), 1.64 (95% CI 1.47 to 1.84), and 1.69 (95% CI 1.60 to 1.79), respectively). Adjustment for self reported cigarette smoking attenuated the associations but they remained relatively strong. CONCLUSIONS: Self reported smoking data were validated by the objective measure of carboxyhaemoglobin concentration. Since carboxyhaemoglobin concentration remained associated with mortality after adjustment for smoking, carboxyhaemoglobin seems to capture more of the risk associated with smoking tobacco than does self reported tobacco consumption alone. Analysing mortality by self reported cigarette smoking underestimates the strength of association between smoking and mortality.

Childhood IQ of parents related to characteristics of their offspring: linking the Scottish Mental Survey 1932 to the Midspan Family Study.

The objective of the study was to investigate the relationship between childhood IQ of parents and characteristics of their adult offspring. It was a prospective family cohort study linked to a mental ability survey of the parents and set in Renfrew and Paisley in Scotland. Participants were 1921-born men and women who took part in the Scottish Mental Survey in 1932 and the Renfrew/Paisley study in the 1970s, and whose offspring took part in the Midspan Family study in 1996. There were 286 offspring from 179 families. Parental IQ was related to some, but not all characteristics of offspring. Greater parental IQ was associated with taller offspring. Parental IQ was inversely related to number of cigarettes smoked by offspring. Higher parental IQ was associated with better education, offspring social class and offspring deprivation category. There were no significant relationships between parental IQ and offspring systolic blood pressure, diastolic blood pressure, cholesterol, glucose, lung function, weight, body mass index, waist hip ratio, housing, alcohol consumption, marital status, car use and exercise. Structural equation modelling showed parental IQ associated with offspring education directly and mediated via parental social class. Offspring education was associated with offspring smoking and social class. The smoking finding may have implications for targeting of health education.

Empowering primary care to tackle the obesity epidemic: the Counterweight Programme.

OBJECTIVE: To improve the management of obese adults (18-75 y) in primary care. DESIGN: Cohort study. SETTINGS: UK primary care. SUBJECTS: Obese patients (body mass index > or =30 kg/m(2)) or BMI> or =28 kg/m(2) with obesity-related comorbidities in 80 general practices. INTERVENTION: The model consists of four phases: (1) audit and project development, (2) practice training and support, (3) nurse-led patient intervention, and (4) evaluation. The intervention programme used evidence-based pathways, which included strategies to empower clinicians and patients. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation. MAIN OUTCOME MEASURES: Proportion of practices trained and recruiting patients, and weight change at 12 months. RESULTS: By March 2004, 58 of the 62 (93.5%) intervention practices had been trained, 47 (75.8%) practices were active in implementing the model and 1549 patients had been recruited. At 12 months, 33% of patients achieved a clinically meaningful weight loss of 5% or more. A total of 49% of patients were classed as 'completers' in that they attended the requisite number of appointments in 3, 6 and 12 months. 'Completers' achieved more successful weight loss with 40% achieving a weight loss of 5% or more at 12 months. CONCLUSION: The Counterweight programme provides a promising model to improve the management of obesity in primary care.

Impact of anastomotic leakage on long-term survival of patients undergoing curative resection for colorectal cancer.

BACKGROUND: The impact of anastomotic leakage on immediate postoperative mortality in patients undergoing potentially curative resection for colorectal cancer is well recognized. Its impact on long-term survival is less clear. The aim of the present study was to evaluate the relationship between anastomotic leakage and long-term survival in patients undergoing potentially curative resection for colorectal cancer. METHODS: A total of 2235 patients who underwent potentially curative resection for colorectal cancer between 1991 and 1994 in Scotland were included in the study. Five-year survival rates and adjusted hazard ratios were calculated. RESULTS: Fourteen (16 per cent) of the 86 patients with an anastomotic leak died within 30 days of surgery compared with 83 (3.9 per cent) of 2149 without a leak. The 5-year cancer-specific survival rate, including postoperative deaths, was 42 per cent in patients with an anastomotic leak compared with 66.9 per cent in those with no leak (P < 0.001). Excluding postoperative deaths, respective values were 50 and 68.0 per cent (P < 0.001). The adjusted relative hazard ratios, for patients with an anastomotic leak compared with those without a leak, and excluding 30-day mortality, were 1.61 (95 per cent confidence interval (c.i.) 1.19 to 2.16; P = 0.002) for overall survival and 1.99 (95 per cent c.i. 1.42 to 2.79; P < 0.001) for cancer-specific survival. CONCLUSION: Development of an anastomotic leak is associated with worse long-term survival after potentially curative resection for colorectal cancer.

Improvement in survival following surgery for colorectal cancer.

BACKGROUND: Recent reports based on registry data have shown that survival after surgery for colorectal cancer is improving in the UK. It is not clear whether these improvements are due to earlier presentation or more effective treatment. METHODS: Outcome for 645 patients with colorectal cancer admitted to Glasgow Royal Infirmary between 1974 and 1979 was compared with that for 354 patients admitted between 1991 and 1994. RESULTS: More patients in the later period had Dukes' A or B tumours and fewer had evidence of metastatic spread (P < 0.001); more underwent potentially curative resection (57.6 versus 49.9 per cent; P < 0.001) and fewer underwent palliative diversion. The overall postoperative mortality rate fell from 14.1 to 8.5 per cent (P = 0.017). Overall and cancer-specific 5-year survival after potentially curative resection increased from 40.1 to 60.5 per cent and from 47.3 to 71.7 per cent respectively (both P < 0.001). Compared with the earlier period, the adjusted hazard ratio for cancer-specific survival following potentially curative resection was 0.452 (95 per cent confidence interval 0.329 to 0.622; P < 0.001). CONCLUSION: The observed improvement in survival was mainly due to improvements in the quality of surgery and in perioperative care rather than earlier presentation.

Childhood IQ and all-cause mortality before and after age 65: prospective observational study linking the Scottish Mental Survey 1932 and the Midspan studies.

OBJECTIVES: The objective was to investigate how childhood IQ related to all-cause mortality before and after age 65. DESIGN: The Midspan prospective cohort studies, followed-up for mortality for 25 years, were linked to individuals' childhood IQ from the Scottish Mental Survey 1932. METHODS: The Midspan studies collected data on risk factors for cardiorespiratory disease from a questionnaire and at a screening examination, and were conducted on adults in Scotland in the 1970s. An age 11 IQ from the Scottish Mental Survey 1932, a cognitive ability test conducted on 1921-born children attending schools in Scotland, was found for 938 Midspan participants. The relationship between childhood IQ and mortality risk, adjusting for adulthood socio-economic confounders, was analysed. The effect of adjustment for childhood IQ on the relationship between established risk factors (blood pressure, smoking, height and respiratory function) and mortality was also investigated. RESULTS: For deaths occurring up to age 65, there was a 36% increased risk per standard deviation decrease (15 points) in childhood IQ which was reduced to 29% after adjusting for social class and deprivation category. There was no statistically significant relationship between childhood IQ and deaths occurring after the age of 65. Adjustment for childhood IQ attenuated the risk factor-mortality relationship in deaths occurring up to age 65, but had no effect in deaths occurring after age 65. CONCLUSIONS: Childhood IQ was significantly related to deaths occurring up to age 65, but not to deaths occurring after age 65.

Axillary recurrence in breast cancer.

AIM: To determine whether axillary recurrence reflects inadequate axillary treatment or adverse pathological features. METHODS: The case-records were reviewed of 2122 women aged under 75 years, treated for invasive breast cancer during the time-period 1/1/86-31/12/91 in a geographically defined area. Data were abstracted on operations performed, pathological features, post-operative treatments and details of axillary recurrence. The risk of axillary recurrence was examined by pathological, treatment and patient factors. RESULTS: Axillary recurrence was more than twice as likely after inadequate compared to adequate treatment of the axilla (adequate staging or axillary radiotherapy or clearance). Delayed treatment of the axilla was not as successful as adequate primary treatment: multiple axillary recurrences were twice as common, one third of which were uncontrolled at time of death. Inadequate surgical treatment was associated with increased rates of recurrence despite endocrine therapy, chemotherapy or radiotherapy. Lymphoedema was twice as common if axillary radiotherapy was combined with any axillary surgical procedure. CONCLUSIONS: Axillary recurrence is more common in tumours with adverse pathology but may also result from inadequate axillary treatment. In order to minimise axillary recurrence, optimal treatment of the axilla entails adequate staging (sampling of four or more nodes) and treatment (axillary clearance or radiotherapy and endocrine therapy) in all women.

Does deprivation affect breast cancer management?

We evaluated whether social deprivation affected decision-making for breast cancer surgery. Of 3419 patients, 53.6% had mastectomy and this was predicted by deprivation, age, tumour size and hospital, all of which retained significance on multivariate analysis, except deprivation. Pathological characteristics and surgical decision-making determined choice of operation not deprivation.

Inadequate treatment of symptomatic breast cancer.

BACKGROUND: Early trials that compared breast and axillary treatments showed differing recurrence rates without significant differences in survival. Consequently, there was a wide range of opinion and practice in the management of breast cancer. The present study explored this variability in surgical management to determine the impact of breast and axillary treatment on recurrence and survival. METHODS: The records of 2776 women with histologically confirmed invasive breast cancer diagnosed between 1986 and 1991 were reviewed. The relationship between adequacy of breast and axillary treatment, recurrence and survival was examined in 2122 women who had surgery with curative intent. A Cox proportional hazards model that included tumour size, node status, grade, socioeconomic status and use of adjuvant therapy was used. RESULTS: Inadequate treatment was associated with a significantly higher risk of local recurrence after breast-conserving surgery (relative hazard ratio (RHR) 4.19 (95 per cent confidence interval (c.i.) 2.73 to 6.43); P < 0.001). Inadequate axillary treatment was associated with a significantly higher risk of regional recurrence (RHR 2.29 (95 per cent c.i. 1.65 to 3.16); P < 0.001). The risk of death from breast cancer was significantly higher if locoregional treatment was inadequate (RHR 1.29 (95 per cent c.i. 1.07 to 1.55); P = 0.008). CONCLUSION: Adequate surgery is fundamental to the optimal treatment of breast cancer. Inadequate surgery resulted in higher recurrence rates despite adjuvant treatments.

Childhood IQ and cardiovascular disease in adulthood: prospective observational study linking the Scottish Mental Survey 1932 and the Midspan studies.

This study investigated the influence of childhood IQ on the relationships between risk factors and cardiovascular disease (CVD), coronary heart disease (CHD) and stroke in adulthood. Participants were from the Midspan prospective cohort studies which were conducted on adults in Scotland in the 1970s. Data on risk factors were collected from a questionnaire and at a screening examination, and participants were followed up for 25 years for hospital admissions and mortality. 938 Midspan participants were successfully matched with their age 11 IQ from the Scottish Mental Survey 1932, in which 1921-born children attending schools in Scotland took a cognitive ability test. Childhood IQ was negatively correlated with diastolic and systolic blood pressure, and positively correlated with height and respiratory function in adulthood. For each of CVD, CHD and stroke, defined as either a hospital admission or death, there was an increased relative rate per standard deviation decrease (15 points) in childhood IQ of 1.11 (95% confidence interval 1.01-1.23), 1.16 (1.03-1.32) and 1.10 (0.88-1.36), respectively. With events divided into those first occurring before and those first occurring after the age of 65, the relationships between childhood IQ and CVD, CHD and stroke were only seen before age 65 and not after age 65. Blood pressure, height, respiratory function and smoking were associated with CVD events. Relationships were stronger in the early compared to the later period for smoking and FEV1, and stronger in the later compared to the earlier period for blood pressure. Adjustment for childhood IQ had small attenuating effects on the risk factor-CVD relationship before age 65 and no effects after age 65. Adjustment for risk factors attenuated the childhood IQ-CVD relationship by a small amount before age 65. Childhood IQ was associated with CVD risk factors and events and can be considered an important new risk factor.

Emergency presentation of colorectal cancer is associated with poor 5-year survival.

BACKGROUND: Previous studies have reported that emergency presentation of colorectal cancer is associated with poor outcome. Many of these studies were small and most were not adjusted for case mix. The aim of this study was to establish, after adjusting for case mix, the magnitude of the differences in postoperative mortality and survival between patients undergoing elective surgery and those presenting as an emergency. METHODS: Three thousand two hundred patients who underwent surgery for colorectal cancer between 1991 and 1994 in Scotland were studied. Five-year survival rates and adjusted hazard ratios were calculated. RESULTS: Some 1603 (72.4 per cent) of 2214 elective patients had a potentially curative resection compared with 632 (64.1 per cent) of 986 patients who presented as an emergency (P < 0.001). Following curative resection, the postoperative mortality rate was 2.8 per cent after elective and 8.2 per cent after emergency operation (P < 0.001). Overall survival at 5 years was 57.5 per cent after elective and 39.1 per cent after emergency curative surgery (P < 0.001); cancer-specific survival at 5 years was 70.9 and 52.9 per cent respectively (P < 0.001). The adjusted hazard ratio for overall survival after emergency relative to elective surgery was 1.68 (95 per cent confidence interval (c.i.) 1.49 to 1.90; P < 0.001) and that for cancer-specific survival was 1.90 (95 per cent c.i. 1.62 to 2.22; P < 0.001). CONCLUSION: Following apparently curative resection for colorectal cancer, there was an excess of both cancer-related and intercurrent deaths in patients who presented as an emergency.

Influence of volume and specialization on survival following surgery for colorectal cancer.

BACKGROUND: Previous studies have shown that significant surgeon-related differences in survival exist following surgery for colorectal cancer. It is not clear whether these differences were due to differences in caseload or degree of specialization. METHODS: Outcome in 3200 patients who underwent resection for colorectal cancer between 1991 and 1994 was analysed on the basis of caseload and degree of specialization of individual surgeons. Five-year survival rates, and the corresponding hazard ratios adjusted for case mix, were calculated. RESULTS: Cancer-specific survival rate at 5 years following curative resection varied among surgeons from 53.4 to 84.6 per cent; the adjusted hazard ratios varied from 0.48 to 1.55. Cancer-specific survival rate at 5 years following curative resection was 70.2, 62.0 and 65.9 per cent for surgeons with a high, medium and low case volume respectively. There were no consistent differences in the adjusted hazard ratios by volume. Cancer-specific survival rate at 5 years following curative resection was 72.7 per cent for those treated by specialists and 63.8 per cent for those treated by non-specialists; the adjusted hazard ratio for non-specialists was 1.35 (95 per cent confidence interval 1.13 to 1.62; P = 0.001). CONCLUSION: The differences in outcome following apparently curative resection for colorectal cancer among surgeons appear to reflect the degree of specialization rather than case volume. It is likely that increased specialization will lead to further improvements in survival.

Increased mortality from breast cancer and inadequate axillary treatment.

BACKGROUND: The assessment of axillary nodal status remains divisive: inaccurate staging may result in untreated axillary disease, and appropriate adjuvant therapy not being delivered. The impact of inadequate axillary treatment on survival remains controversial. We analyse the impact of failure to adequately assess the axillary nodal status on survival. METHODS: All women with confirmed breast cancer in a 15-year period were identified, and the original pathology reports examined, and details of radiotherapy obtained. The survival of women by axillary sample size was compared to a reference group of women and corrected for nodal status, tumour size, age, deprivation category and speciality of treating surgeon. FINDINGS: Sampling less than four nodes is associated with a significantly increased risk of death. This cannot be due to understaging the extent of axillary disease nor is fully explainable by differential prescription of adjuvant therapies. We conclude that the survival of the women studied may have been adversely effected by inadequate axillary treatment.

Incidence of malignant neoplasms among HIV-infected persons in Scotland.

Among 2574 persons diagnosed with HIV throughout Scotland and observed over the period 1981-1996, cancer incidence compared to the general population was 11 times higher overall; among homosexual/bisexual males, it was 21 times higher and among injecting drug users, haemophiliacs and heterosexuals it was five times higher, mostly due to AIDS-defining neoplasms. However, liver, lung and skin cancers (all non-AIDS-defining) were also significantly increased.