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Background: Abiraterone acetate plus prednisolone (herein referred to as abiraterone) or enzalutamide added at the start of androgen deprivation therapy improves outcomes for patients with metastatic prostate cancer. Here, we aimed to evaluate long-term outcomes and test whether combining enzalutamide with abiraterone and androgen deprivation therapy improves survival. Methods: We analysed two open-label, randomised, controlled, phase 3 trials of the STAMPEDE platform protocol, with no overlapping controls, conducted at 117 sites in the UK and Switzerland. Eligible patients (no age restriction) had metastatic, histologically-confirmed prostate adenocarcinoma; a WHO performance status of 0–2; and adequate haematological, renal, and liver function. Patients were randomly assigned (1:1) using a computerised algorithm and a minimisation technique to either standard of care (androgen deprivation therapy; docetaxel 75 mg/m 2 intravenously for six cycles with prednisolone 10 mg orally once per day allowed from Dec 17, 2015) or standard of care plus abiraterone acetate 1000 mg and prednisolone 5 mg (in the abiraterone trial) orally or abiraterone acetate and prednisolone plus enzalutamide 160 mg orally once a day (in the abiraterone and enzalutamide trial). Patients were stratified by centre, age, WHO performance status, type of androgen deprivation therapy, use of aspirin or non-steroidal anti-inflammatory drugs, pelvic nodal status, planned radiotherapy, and planned docetaxel use. The primary outcome was overall survival assessed in the intention-to-treat population. Safety was assessed in all patients who started treatment. A fixed-effects meta-analysis of individual patient data was used to compare differences in survival between the two trials. STAMPEDE is registered with ClinicalTrials.gov (NCT00268476) and ISRCTN (ISRCTN78818544). Findings: Between Nov 15, 2011, and Jan 17, 2014, 1003 patients were randomly assigned to standard of care (n=502) or standard of care plus abiraterone (n=501) in the abiraterone trial. Between July 29, 2014, and March 31, 2016, 916 patients were randomly assigned to standard of care (n=454) or standard of care plus abiraterone and enzalutamide (n=462) in the abiraterone and enzalutamide trial. Median follow-up was 96 months (IQR 86–107) in the abiraterone trial and 72 months (61–74) in the abiraterone and enzalutamide trial. In the abiraterone trial, median overall survival was 76·6 months (95% CI 67·8–86·9) in the abiraterone group versus 45·7 months (41·6–52·0) in the standard of care group (hazard ratio [HR] 0·62 [95% CI 0·53–0·73]; pinteraction=0·71) or between-trial heterogeneity (I 2 p=0·70). In the first 5 years of treatment, grade 3–5 toxic effects were higher when abiraterone was added to standard of care (271 [54%] of 498 vs 192 [38%] of 502 with standard of care) and the highest toxic effects were seen when abiraterone and enzalutamide were added to standard of care (302 [68%] of 445 vs 204 [45%] of 454 with standard of care). Cardiac causes were the most common cause of death due to adverse events (five [1%] with standard of care plus abiraterone and enzalutamide [two attributed to treatment] and one (

PURPOSE Survival in stage I seminoma is almost 100%. Computed tomography (CT) surveillance is an international standard of care, avoiding adjuvant therapy. In this young population, minimizing irradiation is vital. The Trial of Imaging and Surveillance in Seminoma Testis (TRISST) assessed whether magnetic resonance images (MRIs) or a reduced scan schedule could be used without an unacceptable increase in advanced relapses. METHODS A phase III, noninferiority, factorial trial. Eligible participants had undergone orchiectomy for stage I seminoma with no adjuvant therapy planned. Random assignment was to seven CTs (6, 12, 18, 24, 36, 48, and 60 months); seven MRIs (same schedule); three CTs (6, 18, and 36 months); or three MRIs. The primary outcome was 6-year incidence of Royal Marsden Hospital stage ≥ IIC relapse (> 5 cm), aiming to exclude increases ≥ 5.7% (from 5.7% to 11.4%) with MRI ( v CT) or three scans ( v 7); target N = 660, all contributing to both comparisons. Secondary outcomes include relapse ≥ 3 cm, disease-free survival, and overall survival. Intention-to-treat and per-protocol analyses were performed. RESULTS Six hundred sixty-nine patients enrolled (35 UK centers, 2008-2014); mean tumor size was 2.9 cm, and 358 (54%) were low risk (< 4 cm, no rete testis invasion). With a median follow-up of 72 months, 82 (12%) relapsed. Stage ≥ IIC relapse was rare (10 events). Although statistically noninferior, more events occurred with three scans (nine, 2.8%) versus seven scans (one, 0.3%): 2.5% absolute increase, 90% CI (1.0 to 4.1). Only 4/9 could have potentially been detected earlier with seven scans. Noninferiority of MRI versus CT was also shown; fewer events occurred with MRI (two [0.6%] v eight [2.6%]), 1.9% decrease (–3.5 to –0.3). Per-protocol analyses confirmed noninferiority. Five-year survival was 99%, with no tumor-related deaths. CONCLUSION Surveillance is a safe management approach—advanced relapse is rare, salvage treatment successful, and outcomes excellent, regardless of imaging frequency or modality. MRI can be recommended to reduce irradiation; and no adverse impact on long-term outcomes was seen with a reduced schedule.

BACKGROUND Men with high-risk non-metastatic prostate cancer are treated with androgen-deprivation therapy (ADT) for 3 years, often combined with radiotherapy. We analysed new data from two randomised controlled phase 3 trials done in a multiarm, multistage platform protocol to assess the efficacy of adding abiraterone and prednisolone alone or with enzalutamide to ADT in this patient population. METHODS These open-label, phase 3 trials were done at 113 sites in the UK and Switzerland. Eligible patients (no age restrictions) had high-risk (defined as node positive or, if node negative, having at least two of the following: tumour stage T3 or T4, Gleason sum score of 8-10, and prostate-specific antigen [PSA] concentration ���40 ng/mL) or relapsing with high-risk features (���12 months of total ADT with an interval of ���12 months without treatment and PSA concentration ���4 ng/mL with a doubling time of

BACKGROUND: We aimed to identify a five-fraction schedule of adjuvant radiotherapy (radiation therapy) delivered in 1 week that is non-inferior in terms of local cancer control and is as safe as an international standard 15-fraction regimen after primary surgery for early breast cancer. Here, we present 5-year results of the FAST-Forward trial.METHODS: FAST-Forward is a multicentre, phase 3, randomised, non-inferiority trial done at 97 hospitals (47 radiotherapy centres and 50 referring hospitals) in the UK. Patients aged at least 18 years with invasive carcinoma of the breast (pT1-3, pN0-1, M0) after breast conservation surgery or mastectomy were eligible. We randomly allocated patients to either 40 Gy in 15 fractions (over 3 weeks), 27 Gy in five fractions (over 1 week), or 26 Gy in five fractions (over 1 week) to the whole breast or chest wall. Allocation was not masked because of the nature of the intervention. The primary endpoint was ipsilateral breast tumour relapse; assuming a 2% 5-year incidence for 40 Gy, non-inferiority was predefined as ≤1·6% excess for five-fraction schedules (critical hazard ratio [HR] of 1·81). Normal tissue effects were assessed by clinicians, patients, and from photographs. This trial is registered at isrctn.com, ISRCTN19906132.FINDINGS: Between Nov 24, 2011, and June 19, 2014, we recruited and obtained consent from 4096 patients from 97 UK centres, of whom 1361 were assigned to the 40 Gy schedule, 1367 to the 27 Gy schedule, and 1368 to the 26 Gy schedule. At a median follow-up of 71·5 months (IQR 71·3 to 71·7), the primary endpoint event occurred in 79 patients (31 in the 40 Gy group, 27 in the 27 Gy group, and 21 in the 26 Gy group); HRs versus 40 Gy in 15 fractions were 0·86 (95% CI 0·51 to 1·44) for 27 Gy in five fractions and 0·67 (0·38 to 1·16) for 26 Gy in five fractions. 5-year incidence of ipsilateral breast tumour relapse after 40 Gy was 2·1% (1·4 to 3·1); estimated absolute differences versus 40 Gy in 15 fractions were -0·3% (-1·0 to 0·9) for 27 Gy in five fractions (probability of incorrectly accepting an inferior five-fraction schedule: p=0·0022 vs 40 Gy in 15 fractions) and -0·7% (-1·3 to 0·3) for 26 Gy in five fractions (p=0·00019 vs 40 Gy in 15 fractions). At 5 years, any moderate or marked clinician-assessed normal tissue effects in the breast or chest wall was reported for 98 of 986 (9·9%) 40 Gy patients, 155 (15·4%) of 1005 27 Gy patients, and 121 of 1020 (11·9%) 26 Gy patients. Across all clinician assessments from 1-5 years, odds ratios versus 40 Gy in 15 fractions were 1·55 (95% CI 1·32 to 1·83, pINTERPRETATION: 26 Gy in five fractions over 1 week is non-inferior to the standard of 40 Gy in 15 fractions over 3 weeks for local tumour control, and is as safe in terms of normal tissue effects up to 5 years for patients prescribed adjuvant local radiotherapy after primary surgery for early-stage breast cancer.FUNDING: National Institute for Health Research Health Technology Assessment Programme.

Purpose: Outcome data on radiation therapy for prostate cancer in an elderly population are sparse. The CHHiP (Conventional or Hypofractionated High Dose Intensity Modulated Radiotherapy in Prostate Cancer) trial provides a large, prospectively collected, contemporary dataset in which to explore outcomes by age. Methods and Materials: CHHiP participants received 3 to 6 months of androgen deprivation therapy and were randomly assigned (1:1:1) to receive 74 Gy in 37 fractions (conventional fractionation), 60 Gy in 20 fractions, or 57 Gy in 19 fractions. Toxicity was assessed using clinician-reported outcome (CRO) and patient-reported outcome questionnaires. Participants were categorized as aged < 75 years or ≥ 75 years. Outcomes were compared by age group. Results: Of 3216 patients, 491 (15%) were aged ≥ 75 years. There was no difference in biochemical or clinical failure rates between the groups aged < 75 years and ≥ 75 years for any of the fractionation schedules. In the group aged ≥ 75 years, biochemical or clinical failure–free rates favored hypofractionation, and at 5 years, they were 84.7% for 74 Gy, 91% for 60 Gy, and 87.7% for 57 Gy. The incidence of CRO (grade 3) acute bowel toxicity was 2% in both age groups. The incidence of grade 3 acute bladder toxicity was 8% in patients aged < 75 years and 7% in those aged ≥ 75 years. The 5-year cumulative incidence of CRO grade ≥ 2 late bowel side effects was similar in both age groups. However, in the group aged ≥ 75 years, there was a suggestion of a higher cumulative incidence of bowel bother (small or greater) with 60 Gy compared with 74 Gy and 57 Gy. Patient-reported bladder bother was slightly higher in the group aged ≥ 75 years than the group aged < 75 years, and there was a suggestion of a lower cumulative incidence of bladder bother with 57 Gy compared with 74 Gy and 60 Gy in patients aged ≥ 75 years, which was not evident in those aged < 75 years. Conclusions: Hypofractionated radiation therapy appears to be well tolerated and effective in men aged ≥ 75 years. The 57-Gy schedule has potential advantages in that it may moderate long-term side effects without compromising treatment efficacy in this group.

OBJECTIVE: To assess the effects of an expressive writing (EW) intervention on perceptions of emotional support in women completing treatment for early stage breast cancer. METHODS: Women were recruited to the study during their final week of treatment. Of 260 eligible patients, 104 (40%) agreed to participate, and 93 were randomised. Women in the writing group wrote for 20 min on four consecutive days. The control group received normal care. Women's perceptions of emotional support, quality of life (QOL), mood, and healthcare utilisation were assessed at baseline, 1 month, 3 months and 6 months. Interviews were conducted to explore women's experience of writing. RESULTS: Eighty participants completed all follow-ups. There was a significant effect of group on women's perceptions of social support with those in the intervention group being more satisfied with the emotional support they received (p

Background The radiotherapy or ibandronate (RIB) trial was a randomized multicenter nonblind two-arm trial to compare intravenous ibandronate given as a single infusion with single-dose radiotherapy for metastatic bone pain. Methods Four hundred seventy prostate cancer patients with metastatic bone pain who were suitable for local radiotherapy were randomly assigned to radiotherapy (single dose, 8 Gy) or intravenous infusion of ibandronate (6mg) in a noninferiority trial. Pain was measured using the Brief Pain Inventory at baseline and four, eight, 12, 26, and 52 weeks. Pain response was assessed using World Health Organization (WHO) criteria and the Effective Analgesic Score (EAS); the maximum allowable difference was ±15%. Patients failing to respond at four weeks were offered retreatment with the alternative treatment. Quality of life (QoL) was assessed at baseline and four and 12 weeks. Because the trial was designed with a 5% one-sided test, we provide 90% confidence intervals (two-sided) for differences in pain response. Results Overall, pain response was not statistically different at four or 12 weeks (WHO: -3.7%, 90% confidence interval [CI] = -12.4% to 5.0%; and 6.7%, 90% CI = -2.6 to 16.0%, respectively). Corresponding differences using the EAS were -7.5% and -3.5%. However, a more rapid initial response with radiotherapy was observed. There was no overall difference in toxicity, although each treatment had different side effects. QoL was similar at four and 12 weeks. Overall survival was similar between the two groups but was better among patients having retreatment than those who did not. Conclusions A single infusion of ibandronate had outcomes similar to a single dose of radiotherapy for metastatic prostate bone pain. Ibandronate could be considered when radiotherapy is not available.

The purpose of this article is to familiarize the reader with the anatomy of the major pelvic nerves and the clinical features of associated lumbosacral plexopathies. To demonstrate this we illustrate several cases of malignant lumbosacral plexopathy on computed tomography, magnetic resonance imaging, and positron emission tomography/computed tomography. A new lumbosacral plexopathy in a patient with a prior history of abdominal or pelvic malignancy is usually of malignant etiology. Biopsies may be required to definitively differentiate tumour from posttreatment fibrosis, and in cases of inconclusive sampling or where biopsies are not possible, follow-up imaging may be necessary. In view of the complexity of clinical findings often confounded by a history of prior surgery and/or radiotherapy, a multidisciplinary approach between oncologists, neurologists, and radiologists is often required for what can be a diagnostic challenge.

This article was migrated. The article was not marked as recommended. Background: Undergraduate medical training in medical leadership is limited, and there is a general negative perception among medical professionals towards leadership and management. Aims: To improve perceptions of leadership training and encourage leadership activity amongst medical students. Method: A leadership student-selected component (SSC) was designed offering formal leadership education and engagement of students onto leadership and quality improvement projects. The initial cohort consisted of 8 third year medical students. Students were given questionnaires exploring their attitudes and perceptions towards leadership before and after the SSC. Results: The students had no previous formal undergraduate education in leadership. Engagement in the SSC considerably enhanced the perception of leadership and management among students. The students also reported having more confidence in engaging with leadership projects and reported feeling more likely to be involved with leadership projects in future. Conclusions: A formal leadership educational programme which engages students in real leadership and quality improvement work enhances the perception of leadership and inspires students to undertake leadership roles in future.

This article argues the case for a model of conflict management based on a complementary view of two approaches to conflict, resolution and settlement, which have traditionally been presented in the literature as opposed. It employs empirical evidence of complementarity in practice to highlight the failure of this dichotomized theoretical debate. It endorses a theoretical model based on complementarity which both unblocks the paralysis caused by such dichotomization and energizes the prescriptive potential of both approaches. The article first describes and defines the two schools of thought and their respective prescriptions for conflict management, and then considers the potential for complementarity between the two at the theoretical level. Fisher & Keashly's contingency model of intervention (1991) is critiqued, and two descriptive weaknesses are identified: an overdependence on a sequential view of conflict, and an assumption of intra-party cohesion. Evidence for complementarity in practical conflict management strategies in the Northern Ireland conflict is then reviewed. Finally, an expansion of the contingency model based on such empirical study is discussed, in particular a means of building a model which is more flexible and context-responsive through the use of embedded criteria at the prescriptive stage.

SummaryBackgroundIncorporation of a taxane as adjuvant treatment for early breast cancer offers potential for further improvement of anthracycline-based treatment. The UK TACT study (CRUK01/001) investigated whether sequential docetaxel after anthracycline chemotherapy would improve patient outcome compared with standard chemotherapy of similar duration.MethodsIn this multicentre, open-label, phase III, randomised controlled trial, 4162 women (aged >18 years) with node-positive or high-risk node-negative operable early breast cancer were randomly assigned by computer-generated permuted block randomisation to receive FEC (fluorouracil 600 mg/m2, epirubicin 60 mg/m2, cyclophosphamide 600 mg/m2 at 3-weekly intervals) for four cycles followed by docetaxel (100 mg/m2 at 3-weekly intervals) for four cycles (n=2073) or control (n=2089). For the control regimen, centres chose either FEC for eight cycles (n=1265) or epirubicin (100 mg/m2 at 3-weekly intervals) for four cycles followed by CMF (cyclophosphamide 600 mg/m2, methotrexate 40 mg/m2, and fluorouracil 600 mg/m2 at 4-weekly intervals) for four cycles (n=824). The primary endpoint was disease-free survival. Analysis was by intention to treat (ITT). This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN79718493.FindingsAll randomised patients were included in the ITT population. With a median follow-up of 62 months, disease-free survival events were seen in 517 of 2073 patients in the experimental group compared with 539 of 2089 controls (hazard ratio [HR] 0·95, 95% CI 0·85–1·08; p=0·44). 75·6% (95% CI 73·7–77·5) of patients in the experimental group and 74·3% (72·3–76·2) of controls were alive and disease-free at 5 years. The proportion of patients who reported any acute grade 3 or 4 adverse event was significantly greater in the experimental group than in the control group (p

As agreed at the previous day’s plenary, the Sub-Committee duly met all day on Wednesday 27 May, to consider in the first instance the four papers from the parties regarding the ongoing deadlock. The paper tabled on Tuesday by the British, Models of Government, was instantly forgotten. Each of the papers tried to define the elements of the impasse. The Nature of the Blockage, another onepage note from the UUP, placed the blame squarely on the SDLP, for two reasons. First, they complained that: ‘John Hume believes that any govt in NI [sic] should not come from or be responsible to the elected assembly.’ Second, in terms of involving the Irish Nationalist identity in a new institution, the SDLP were claiming that ‘their presence in such an institution, even at the highest level, is insufficient to meet this requirement’. Instead, the presence of the Irish government in a local institution, ‘can achieve the objective of obtaining loyalty from Nationalists in NI in a way that the presence of the SDLP cannot’. In UUP eyes, the proposal for externally appointed commissioners ‘is contradictory to their support for para 2 of “common themes” [sic] document’. The reference was to the first theme among 14 identified and agreed during the negotiations of early May. Entitled ‘Constitutional Status and Guarantee’, it read in part: ‘It is accepted by all the talks participants that Northern Ireland is de facto a part of the United Kingdom; that there should be no change in that position without the consent of a majority of the people who live there.’ ‘The SDLP paper’, claimed the UUP, ‘is not consistent with the continued membership of NI within the UK.’

I chose the title of this work carefully: despite some early expectations among participants and the occasional genuine, but limited, breakthrough, the Mayhew talks never truly looked like reaching a settlement. It is much more realistic to see the process as one of building on the previous year’s effort towards developing the process of dialogue. Peter Brooke offered an image to represent this approach: What you are looking at in Northern Ireland in terms of these negotiations are a series of waves advancing up the beach. And the important thing is that one day the wave will reach the top of the beach and you will have achieved your objective. Every wave should get further than the last one, in other words you continue to advance but you must be patient and not frustrated if particular waves are not strong enough to get there. (Bloomfield, 1997, p. 144)

Sir Ninian Stephen convened the first meeting of Strand 2 at 2pm on Monday 6 July, in the Music Room of Lancaster House in London. He sat at the head of the table, with his assistant, the Australian civil servant George Thompson. On their left sat the Alliance delegation (Alderdice, Close, Morrow and Neeson), then the Irish government representatives (Andrews, John Wilson, the Tanaiste and Minister of Defence, Padraig Flynn, Minister of Justice, and Bobby Molloy, the Energy Minister who was standing in for Des O’Malley, the leader of the Progressive Democrats and Minister for Industry and Commerce), and finally the SDLP (Hume, Mallon, McGrady and Hendron). To Stephen’s immediate right sat the UUP delegates (Molyneaux, Nicholson, Maginnis and Chris McGimpsey), then the British government (Mayhew, Hanley, John Chilcott, the Permanent Under- Secretary at the NIO, and David Fell, the head of the Northern Ireland Civil Service), and beside them the DUP (Paisley, Robinson, James McClure and Simpson Gibson). Even the seating was a matter for negotiation, as Stephen recalled

On Tuesday afternoon 10 November, Irish ministers arrived for a brief plenary in which a statement was approved by all parties announcing the end of the talks. For all the argument that had preceded it, the statement was an anodyne affair of little more than 500 words, of which only around 150 words addressed any question of progress achieved or of future dialogue. ‘All parties accepted that nothing would be finally agreed in any of the three strands of the Talks until everything was agreed in the Talks as a whole. We report that the Talks did not reach this stage.’ It was depressingly little to show for six months of work. Mark Brennock commented cogently.

The politicians took their well-earned vacations during August. It was largely a quiet month, with some tension evident around seasonal marches in the North, and with Mayhew finally taking the long-threatened step of banning the loyalist paramilitary grouping, the UDA. On 27 August, Northern Ireland reached a depressing milestone as official RUC figures recorded the 3000th violent death of the Troubles.

When the Business Committee reconvened at Stormont on the last Monday of September to agree the agenda for Strand 2 talks on Wednesday, Thursday and Friday, they decided that the first item for the week would be ‘Item 9: Possible institutional arrangements to meet the requirements, including the principles to govern any such arrangements’. Despite DUP pressure, they rejected a proposal to widen the definition of Item 9 so that it could include more discussion of Articles Two and Three. The DUP reaction was to announce the following day that their boycott would continue. Sammy Wilson told the press, ‘We would be there if they were discussing Articles Two and Three, but they are quite clearly not’ (Irish Times 30 September 1992).

On Wednesday morning, 29 April, Sir Patrick Mayhew met briefly with the four party leaders, and then chaired the first Strand 1 plenary meeting. At the suggestion of the two Unionist parties, it was agreed to send Mayhew’s paper ‘Realities and Common Themes’ to a business committee for further revision, so that it could be discussed at the next plenary. Then each party made an opening statement, outlining their view of the ‘problem’ and summarizing their post-Brooke positions. A press embargo was agreed, and the parties also nominated two members each to the Strand 1 business committee with a brief to organize the agenda and the procedural arrangements for the talks. The party leaders were tight-lipped at the brief photocall which followed.

In overall political terms, as in the public view, the Mayhew talks failed, as the Brooke talks a year previously had also failed. The talks agenda expressed the goal of an overall settlement comprising all three strands or relationships. Clearly, no such ambitious result was forthcoming. Indeed, since no single strand reached anything like a definite conclusion, it is hard to claim even a partial success.

British and Irish officials met in Dublin on Monday 15 June to discuss the Strand 2 preliminary meeting, and the agenda for the intergovernmental Strand 3 meeting. Behind the scenes they had, over the previous fortnight, hammered out some of the procedural details of Strand 2 with Thompson and Stephen. Their formal announcement after the meeting indicated that the ‘pre-Strand 2 meeting’ would be held in London, on Wednesday or Friday, and that Strand 3 was likely to happen the following week, probably in London. The vagueness over the dates reflected a tension between the two governments. London was keen to press on with the process. But Dublin, for all its insistence on opening Strand 2, was dealing with a heavy schedule of European and other matters, and was having trouble finding time.

The first week of April 1992 was full of heightened political speculation in the UK. With the general election scheduled for 9 April, pundits focused on the two most interesting outcomes: either a new Labour government for the first time since 1979, or a hung Tory parliament dependent on the nine Ulster Unionist MPs to maintain the Conservative arithmetic at Westminster. Would there be a professed pro-nationalist Labour government in Westminster? Would the Unionists wield influence over a minority Conservative government? Among Northern Ireland Unionists, the former was their worst nightmare, the latter their fondest dream.

The greatest significance of the Brooke Initiative at the time, of course, was that it happened at all. Not since Sunningdale in 1973 had anyone managed to bring unionist and nationalist leaders around a negotiating table to address the constitutional question. That it failed to reach a conclusion surprised few people in Northern Ireland. Almost 20 years of violence, confrontation and protectionism had passed since their political representatives had been called upon to exercise formal negotiating skills: it was not to be expected that they would find it an easy task. But at least the possibility had now been demonstrated. The public knew that it could be done; it would be much more difficult in future for any of the politicians to justify a policy of non-engagement to their electorate. Among at least some of the delegates, too, there was cause for hope. In Eileen Bell’s words The Brooke talks were historic insofar as they were the first time that had happened. I wouldn’t have worried too much at the end of it…. Although we were disappointed that we got nothing concrete at the end of it, we knew, we hoped, a start had been made. We knew that there was already talk about setting up another set of talks. And we hoped, whenever we’d come back to it, that we’d learned from the experience.

Peter Brooke’s appointment was announced in the 24 July 1989 Cabinet reshuffle. He took up the post four days later. At the time, it was widely interpreted as Prime Minister Thatcher installing a cautious nightwatchman until the general election (which was expected within a year), who could ‘be relied upon not to introduce clever, counterproductive initiatives’. (Irish Times 29 July 1989). Largely free from the stigma which the Unionists had applied to King, Brooke had the potential to operate ‘as a new broom’ (Irish Times 25 July 1989). He appeared to be, as one Unionist politician put it, ‘a safe pair of hands, a man who won’t rock the boat’ (Irish Times 29 July 1989). Chris Ryder described him thus in the Daily Telegraph: Most people thought he was a genial Conservative backslapper who would spend his time lowering pink gins on the 9th hole at one of Ulster’s splendid golf courses or watching cricket…. The emphasis would be on holding the fort. The Unionists would be allowed to simmer in their own intransigence…. Officials in the Northern Ireland Office pressing for a political initiative would be silenced. (10 January 1990)

Brooke began his Initiative in earnest with a keynote speech to a meeting of local business people in Bangor, Co. Down, on 9 January. He remarked that in recent months he had sensed ‘a new mood developing in the electorate of Northern Ireland and their politicians’ (Irish Times 10 January 1990). With his customary caution, he continued, ‘I believed that it was just possible that the will might exist to achieve some political progress in the near future’ (ibid.).

Brooke told journalists on 5 June that there were still some ‘loose ends’ to be tied up (Irish Times 6 June 1990), but that he expected to make a definite statement about the talks soon. The timetable he had in mind aimed for a formal announcement of forthcoming talks during the annual House of Commons debate on Direct Rule on 5 July. In attempting to tie up one loose end in particular, he addressed the question of Dublin and the internal talks: Clearly any talks relating to internal arrangements in Northern Irelandare matters for the British government and for the parties of Northern Ireland…. They are not talks which involve the government of the Republic because they are internal to Northern Ireland itself (ibid.).

On the eve of the first day of Strand 1 bilaterals at Stormont, Brooke commented to the press that the first week’s sessions would be to develop the structure and agenda for the plenary negotiations which would begin in week two. But this would be an ongoing process: ‘As with the agenda, a lot of the structure and the basis will emerge as we go along’ (Irish Times 30 April 1991). It was a statement that proved overly optimistic, if not shortsighted.

In the immediate aftermath of the end of talks, the Unionists steeled themselves for the blame. Popularly, the initial delay and the final breakdown were seen as their responsibility. The British press were largely of one voice in their response to, and reporting of, the end of the Initiative. They criticised Brooke himself for ‘talking up’ his achievement and for basing his hope for future progress on an ‘optimistic but misleading analysis’ of an initiative which ‘lurched from bitter disagreement to reluctant compromise at the eleventh hour, and back to disagreement on almost every aspect conceivable and [had] consequently never been far from terminal breakdown’ (Times 4 July 1991).

On New Year’s Day, Brooke appealed in a BBC radio interview for a period of quiet in which to make progress out of the media spotlight (Irish Times 2 January 1991). Paisley may have failed to hear this plea: two days later he tried to force the pace by going public with some of the details from the Christmas Eve document. Talks could begin as early as February, he claimed in an interview, with Dublin ‘staying on the sidelines’ for five weeks, implying that this effectively meant Dublin’s exclusion from internal talks. Even then, he said, involvement would be subject to evidence of substantial progress by that stage and to the unanimous agreement of the Northern parties. Dublin merely responded that the question of timing was still under discussion (Irish Times 4, 5 January 1991).

Peter Brooke was appointed British Secretary of State for Northern Ireland in July 1989. After preliminary meetings with, and overtures to, the political parties, he launched in January 1990 a concerted effort to bring about negotiations between the Ulster Unionist, Democratic Unionist, Social Democratic and Labour, and Alliance Parties9 on a devolved system of government with an Irish dimension. The process quickly came to be known as the ‘Brooke Initiative’. After a further 15 months of dogged bilateral discussions with Northern parties and the Dublin government, Brooke announced a three-strand framework for negotiations in April 1991. The framework provided for initial internal Northern dialogue on devolution (Strand 1), North-South talks on the form of a subsequent Dublin-Belfast relationship (Strand 2), and talks to reshape the relationship between Britain and the Republic of Ireland (Strand 3). The first seven weeks of the allotted ten-week negotiation span were delayed by wrangling over the structures for Strand 2, and the last three weeks provided a total of eight days of internal Strand 1 negotiations which ended inconclusively in early July 1991. The subsequent months eventually produced one further Strand 1 meeting in March 1992. After the British general election in April 1992, Brooke was replaced as Secretary of State. For reasons of space, I can offer only the briefest of narrative sketches below of the Initiative in Section 1, which I hope will suffice simply to sustain the analysis that follows. (A full history of the Initiative, a fascinating story in itself, is in preparation.)

Throughout the theoretical literature on conflict management, a dichotomy is apparent. Almost every scholar, in reviewing thinking on the subject, describes a bipolar differentiation in approaches, both in descriptive and prescriptive thinking. The distinctions, and their labels, differ of course from writer to writer, but a general acceptance of two different strands of thought is recurrent.

Complementarity between the two practical approaches in Northern Ireland is more than merely a hypothesis advanced in an academic study. Practitioners from within the approaches themselves make implicit or explicit acknowledgement of an underlying complementarity. The review in Chapters 2 and 3 of the history of these approaches may give the impression of two largely discrete processes in independent operation, which Chapter 5’s analysis of the Brooke Initiative in the main does little to contradict. Chapter 6’s examination of recent development trends in community relations, however, contains a significant thread of argument which challenges that view. The consequent argument to be proposed here is that such a view is — and will be increasingly — challenged by the movement from within the cultural approach to address constituencies and/or issues which were formerly the preserve of the structural approach. It should be pointed out that this challenge is to the structural approach, rather than to the structures themselves; that is, it is directed towards the policy areas in which the structural approach operates.

My aim here is not to make yet another contribution to the already swollen numbers of academic analyses of Northern Ireland. Nor do I claim that what follows is in any way a comprehensive review of the conflict there. I wish merely to sketch an overview of those elements of the conflict which are most pertinent to the argument I want to develop in later chapters. There are many excellent analyses already in existence, and I will simply enlist the help of extant scholarly work, rather than try to replace it with further analysis.

In the Introduction, I referred to peacemaking initiatives in Northern Ireland since 1968, both at the political and the community level. The processes involved at the two levels can be differentiated into structural and cultural processes respectively (Ruane and Todd, 1990).

In Chapter 3, I traced the development of cultural initiatives from the late 1960s to the late 1980s, noting the gradual development of a coherent approach and a constituency of practitioners. After the failure of the flawed structural attempt to address intercommunal relationships in the Community Relations Commission (1969–74), the approach grew out of the strength of informal initiatives at community level, moving from simple contact work in the 1970s to focused community relations work in the 1980s. As Chapter 3 noted, by 1986 the realisation was growing that the approach could benefit from a more strategic and higher profile format.

This chapter aims to relate the information gathered from the foregoing discussion of Northern Ireland practice (Chapters 5–7) to the theoretical debate from Chapter 4 on a model of complementarity in conflict management.

Kevin Boyle remarked to the Opsahl Commission in 1993 that, around the dinner tables of England, Northern Ireland is not considered a polite topic for conversation. He spoke as one of the large number of people recently referred to in an Irish Sunday paper as Northern Irish Professional People Living in England, or ‘nipples’. Few of them would disagree. His tone was one of resignation. His point was that, when mainland political or social problems surface, British society at large loses interest in, and accords little importance to, Northern Ireland. Most of Professor Boyle’s fellow nipples would endorse his views with little surprise, and look with sanguine resignation at those British dinner tables. But they, and their compatriots in Northern Ireland, share a suspicion that the same disinterest applies to the British Cabinet table too. And on that point, they are less forgiving.

We undertook a retrospective review of patients presenting with apparently localised prostatic carcinoma to a single practitioner for consideration of radiation therapy to clarify the characteristics of those patients who might benefit from the use of neo-adjuvant androgen deprivation. Of 133 patients referred between January 1989 and June 1994, 85 were considered suitable for radical therapy, of whom 31 were treated with hormone therapy prior to radiotherapy, frequently on the basis of an elevated PSA. Increasing PSA levels (p = 0.0016) and Gleason grade (p = 0.026) were independent variables for relapse. It was possible to define three prognostic groups of patients, on the basis of initial PSA and Gleason grade. Those of intermediate risk (PSA10 micrograms/l, Gleason score 8-10; PSA 10-25 micrograms/l, Gleason 5-7 or 8-10; PSA25 micrograms/l, Gleason score 2-4) had a superior duration of disease-free survival if given initial hormone therapy. This group of patients is potentially the most likely to benefit from such an approach and should be enrolled in prospective randomised studies of neoadjuvant androgen deprivation.