Awareness of ovarian cancer risk factors, beliefs and attitudes towards screening: baseline survey of 21,715 women participating in the UK Collaborative Trial of Ovarian Cancer Screening.

BACKGROUND: Women's awareness of ovarian cancer (OC) risks, their attitudes towards and beliefs about screening, together with misunderstandings or gaps in knowledge, may influence screening uptake. METHODS: In total, 21 715 post-menopausal women completed questionnaires before randomisation into the UK Collaborative Trial of Ovarian Cancer Screening. RESULTS: In all, 42.3% correctly identified their lifetime risk of OC; 87.1% knew that a family history of OC increased risk, but only 26.7% appreciated the association with a family history of breast cancer. Although 38.2% acknowledged increased risk post-menopause, only 8.8% were aware that OC diagnoses are highest in women over 65 years. Few (13.7%) recognised the association between pregnancy and reduced OC risk or protective effects of breastfeeding (6.2%). There were common misconceptions; 37.2% thought that an abnormal cervical smear and 26.4% that oral contraception increased the likelihood of OC. Although 84.4% recognised that most ovarian masses are benign, 20.2% thought having had a benign cyst increased OC risk. Most (99.4%) believed that a high uptake of OC screening would reduce mortality and (96.2%) that screen-detected cancers would have an improved prognosis. CONCLUSIONS: The results show a need for improved public understanding about OC risks and provide important information for GPs and health educationalists about initiatives needed for future awareness, prevention and screening programmes.

Tamoxifen for the prevention of breast cancer: psychosocial impact on women participating in two randomized controlled trials.

PURPOSE: The purpose of this study was to evaluate the psychosocial implications of tamoxifen versus placebo in women who are at increased risk of breast cancer. PATIENTS AND METHODS: The 488 women in the psychosocial study were recruited from participants in two placebo-controlled, double-blind, randomized, controlled trials that investigated the efficacy of tamoxifen in the prevention of breast cancer in women who are at high familial risk. During a 5-year period, repeated assessments were made of anxiety, psychological distress, and sexual functioning using standardized questionnaires before treatment at baseline and at 6-month intervals during the trial. RESULTS: Questionnaire completion over 5 years was good, with 71.1% of women returning at least 8 of 10 follow-up assessments. Although scores from individuals showed considerable fluctuation and variation over time, changes in anxiety, mood, and sexual functioning were not associated with treatment group. The number of symptoms reported at 48 months via a self-report checklist were not associated with treatment group, but vasomotor symptoms were more frequent among tamoxifen-treated women. Symptoms of low energy, breast sensitivity, and visual blurring were reported most frequently in the placebo group. CONCLUSION: In general, these results are comparable to those from the National Surgical Adjuvant Breast and Bowel Project psychosocial study despite differences in study populations, methodology, and instruments. The long-term use of tamoxifen and other selective estrogen response modulators as preventive agents in high-risk groups has been questioned, but we found no evidence of treatment-related side effects that affect women's psychosocial and sexual functioning.

Results of an intervention study to improve communication about randomised clinical trials of cancer therapy.

We report results from an intervention study to improve communication during consultations about randomised clinical trials of cancer therapy. Patients, eligible for a trial, completed questionnaires about information preferences and attitudes to trials prior to seeing their doctors, who were either shown these questionnaires (intervention) or not (control). Fifteen doctors participated and invited 265 patients to join one of 40 different randomised clinical trials. Most patients (77.4%) agreed to trial entry and this was predicted by the Patient's Attitudes to Trials questionnaire with an 80.4% accuracy. Accrual, length of consultation, doctor and patient satisfaction were not associated with the intervention. Further research to explore the potential use of written interventions to facilitate communication and accrual to randomised clinical trials is recommended.

Encouraging out-patients to make the most of their first hospital appointment: to what extent can a written prompt help patients get the information they want?

A randomised controlled study in which a written prompt was sent to new patients to help them make the most of their consultation was conducted amongst patients referred to the dermatology, gynaecology and orthopaedic out-patients clinics at the Royal Free Hospital, London. The impact of the help card on patients' expectations, preparation for and experience of their out-patient consultation are discussed. A help card and letter were sent to a random sample of patients before their appointment to encourage them to prepare and prioritize questions to ask the doctor at the consultation. After their consultation, patients were sent a postal questionnaire to complete at home. Analysis of the questionnaires provided quantitative and qualitative data about patients' information requirements and whether they were fulfilled. The results highlight the difficulties out-patients have in asking questions and discussing topics fully at their initial consultation, even when they have thought of questions in advance. Half the patients who were sent a help card said they got more out of their consultation as a result, yet few statistically significant differences between the help card group and the other patients were found.

Achieving continuity of care and carer.

The aims of a new service need to be clarified and agreed to avoid disappointment both for midwives and the women they are caring for. Midwives have different views, expectations and priorities, which may be determined by their previous experience. Providing continuity of care to mixed caseloads is complicated to organise, as women with complications need more time and different skills. The success of any service that aims to provide women with care from a small group of midwives depends on adequate staffing and resourcing.

General practitioners' views on the implementation of community-led maternity care in south Camden, London.

New recommendations suggesting that maternity care should be increasingly community-based have generated concern regarding the interprofessional cooperation between general practitioners and midwives. In Camden, London, this service was expanded in 1993. Although existing joint antenatal care arrangements between GPs and midwives were not expected to alter significantly, the shift of care from hospital to community midwives, and the expansion of community-led care to women with complications, was expected to have implications for the GPs. A questionnaire-based study asked GPs who provide antenatal care about their role and liaison with other professionals. Most were satisfied with the current arrangements; only a minority felt that their workload, clinical practice, or communication with obstetric teams had altered.

Is community-led maternity care a feasible option for women assessed at low risk and those with complicated pregnancies? Results of a population based study in south Camden, London.

OBJECTIVE: to assess the feasibility of obstetric offering community-led maternity care to most women, both those assessed to be at low obstetric risk and those with complicated pregnancies at 'booking'. Community-led care is defined as appropriate care by community midwives and general practitioners during pregnancy, birth and the puerperium, with routine hospital care kept to a minimum. DESIGN: observational study. SETTING: South Camden, London, UK: University College Obstetric Hospital and community. PARTICIPANTS: 453 women, resident in South Camden, including those 'booked' for home births, who were 'booked' for maternity care at University College Hospital between October 1993 and April 1994. MEASUREMENTS AND FINDINGS: this paper assesses the extent to which community midwives and general practitioners were able to give local women community-led care and describes the amount of care provided to women by their 'named' community midwives and team. Most local women were eligible for community-led care and 85% planned to have it. The majority of care was given by the community midwives, but the amount of hospital input varied. Women who remained at low obstetric risk generally had their antenatal care in the community, only attending hospital for two or three routine assessments and occasional extra referrals. Women attending hospital more frequently usually had a complicated pregnancy. Care given by a woman's 'named' midwives was generally provided antenatally, but care from familiar midwives was less common in labour and postnatally. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: community-led maternity care can be provided to the majority of women, even those with a complicated pregnancy, as long as specialist opinion and facilities are accessible and women are referred as necessary. Although the majority of women had access to local antenatal care from staff they got to know, the 'named' community midwives and teams found it difficult to provide comprehensive care, particularly to the women who developed complications, so priorities need to be established. Further research is needed to compare alternative models of care and their costs.

Are women given enough information by staff during labour and delivery?

A random sample of women who had recently given birth were asked about their experiences in a national postal survey in England and Wales. 76% of the women responded. This paper describes their views on the information given to them by staff during labour and delivery. Findings indicate that although the majority of women were satisfied with the amount of information given, just under a fifth would have liked more explanation from staff during childbirth. Some groups of women were less satisfied than others: first time mothers and multiparae under 30 years old; women not living with a partner and those belonging to ethnic minority groups. Women who experienced an emergency caesarean section, an enema or some forms of pain relief were more likely to be dissatisfied with the quality of information given than others, but most procedures were unrelated to the women's feelings about the amount of explanation given by staff. Women who felt staff had given them enough information during labour and delivery were more likely to say that labour and delivery were managed as they liked than those who wanted more explanation.

Unintended pregnancies and the use of contraception: changes from 1984 to 1989.

PIP: A researcher randomly selected 100 birth registrations in each of 20 areas in England and Wales and sent a questionnaire to the mothers 6 months after birth to determine the 1989 proportion of unplanned pregnancies and contraceptive usage. She compared them with results from a similar survey in 1984. The 1984 and 1989 response rates stood at 79% and 76% respectively. The percentage of unplanned pregnancies between the 2 years rose significantly from 26.7%-31.3% (p.01). The proportion of these mothers who were using some form of contraception at the time of conception decreased only slightly in this period (70.5%- 69.1%). In both years, the mothers who had unintended pregnancies consisted basically of young single women or women with 2 or more children. Further, women who completed full time schooling 18 years were less likely to become pregnancy unintentionally. The percentage of mothers in the 20-24 year old group who had an unplanned pregnancy increased most significantly from 27.4%-44.4% (p.001). The percentage also increased, but less significantly, in the 25-30 year old group from 19.1-26.6% (p.01). In 1984, contraceptive usage rose significantly with age among mothers who had unintended pregnancies (p.001). For example, 37.9% of the teen mothers used a contraceptive at the time of conception while 87% of mothers 35 years did. A smaller proportion of newer mothers were taking oral contraceptives (OCs) at contraception in 1989 (10.4%) than in 1984 (12.9%), but the proportion of them who experienced an unintended pregnancy increased from 47.9% to 68.2%. 81% of 20-24 years old and 68./9% of 25-29 year olds on OCs become pregnant unintentionally in 2989 whereas, in 1984, 47.8% and 44.7% respectively did so. These results demonstrate that contraceptive users often have insufficient knowledge about contraceptives.^ieng