Search

Introduction: There is a growing recognition of the impact of work on health both positive and negative. It is important that all health care professionals are equipped to understand the effects of work and worklessness on health and help patients remain in work or manage a healthy return to work where appropriate. Despite explicit reference to health and work in the General Medical Council’s Outcomes for Graduates, currently, there is not a theme that is integrated across the undergraduate medical curricula. Aim: This study evaluates medical tutors’ and undergraduates’ perspectives of a selection of health and work topics in a teaching pilot to consider the suitability and appropriateness for delivery, integration into the curriculum, tailoring of the resources, and appropriateness and expected attainment of learning objectives. Methods: Qualitative, semi structured interviews and focus groups were carried out with five medical tutors and 36 undergraduates. Interviews and focus groups were recorded, transcribed and thematically analysed. Results: The medical tutors and undergraduates identified suitability of appropriate subject specialties and years of teaching, whether learning objectives were important and if these had been achieved, and recommendations for future delivery. Discussion: Medical tutors were committed to delivering the health and work topics with the flexibility of tailoring the resources to existing subject specialties and with respect to the year of study. Learning objectives were perceived appropriate by tutors, despite ambivalence about their importance from some undergraduates. The resources were identified as having relevance to public health undergraduate teaching and teaching during general practice placements.

BackgroundFor the last few years, English general practices — which are, traditionally, small — have been encouraged to serve larger populations of registered patients by merging or collaborating with each other. Meanwhile, patient surveys have suggested that continuity of care and access to care are worsening.AimTo explore whether increasing the size of the practice population and working collaboratively are linked to changes in continuity of care or access to care.Design and settingThis observational study in English general practice used data on patient experience, practice size, and collaborative working. Data were drawn from the English GP Patient Survey, NHS Digital, and from a previous study.MethodThe main outcome measures were the proportions of patients at practice level reporting positive experiences of both access and relationship continuity of care in the GP Patient Survey. Changes in proportions between 2013 and 2018 among practices that had grown and those that had, roughly, stayed the same size were compared, as were patients’ experiences, categorised by whether or not practices were working in close collaborations in 2018.ResultsPractices that had grown in population size had a greater fall in continuity of care (by 6.6%, 95% confidence interval = 4.3% to 8.9%), than practices that had roughly stayed the same size, after controlling for other factors. Differences in falls in access to care were smaller (4.3% difference for being able to get through easily on the telephone; 1.5% for being able to get an appointment; 0.9% in satisfaction with opening hours), but were statistically significant. Practices collaborating closely with others had marginally worse continuity of care than those not working in collaboration, and no differences in access.ConclusionLarger general practice size in England may be associated with slightly poorer continuity of care and may not improve patient access. Close collaborative working did not have any demonstrable effect on patient experience.

BackgroundImproving care for people with long-term conditions is central to NHS policy. It has been suggested that the Quality and Outcomes Framework (QOF), a primary care pay-for-performance scheme that rewards practices for delivering effective interventions in long-term conditions, does not encourage high-quality care for this group of patients.AimTo examine the evidence that the QOF has improved quality of care for patients with long-term conditions.Design and settingThis was a systematic review of research on the effectiveness of the QOF in the UK.MethodThe authors searched electronic databases for peer-reviewed empirical quantitative research studying the effect of the QOF on a broad range of processes and outcomes of care, including coordination and integration of care, holistic and personalised care, self-care, patient experience, physiological and biochemical outcomes, health service utilisation, and mortality. Because the studies were heterogeneous, a narrative synthesis was carried out.ResultsThe authors identified three systematic reviews and five primary research studies that met the inclusion criteria. The QOF was associated with a modest slowing of both the increase in emergency admissions and the increase in consultations in severe mental illness (SMI), and modest improvements in diabetes care. The nature of the evidence means that the authors cannot be sure that any of these associations is causal. No clear effect on mortality was found. The authors found no evidence that the QOF influences integration or coordination of care, holistic care, self-care, or patient experience.ConclusionThe NHS should consider more broadly what constitutes high-quality primary care for people with long-term conditions, and consider other ways of motivating primary care to deliver it.

Background Swimming-induced pulmonary oedema (SIPE) can affect people with no underlying health problems, but may be life threatening and is poorly understood. The aim of this systematic review was to synthesise the evidence on SIPE incidence, prevalence, risk factors, short- and long-term outcomes, recurrence and effectiveness of interventions to prevent recurrences. Methods We carried out a literature search using bibliographic databases and reference lists. Risk of bias was assessed by adapting existing quality assessment tools including those developed by the National Heart Lung and Blood Institute. Results Nine studies met the inclusion criteria. Quantitative synthesis was not possible because of study heterogeneity. Five studies, which differed from each other in case definition, swimming environment, population characteristics and denominators, reported an incidence of 0.01% of UK triathlons raced over 5 years in unspecified swimming environments (one study, not fully reported, of men and women of unspecified age); 0.5% of river races swum over 3 days in Sweden (one study, of men and women up to the age of 70); and 1.8–26.7% of time trials in the sea around Israel (three studies of male teenage military trainees). One study reported that 1.4% of triathletes in the USA had experienced SIPE. One study found that hypertension, female sex, fish oil use, long course distance and another lower initial lung volumes and flows were risk factors for SIPE. A third study reported that higher mean pulmonary artery pressures and pulmonary artery wedge pressures, and lower tidal volumes were associated with SIPE. Three studies suggested that SIPE symptoms usually resolve within 24 h, although a restrictive deficit in lung function persisted for a week in one small study. We found no studies that reported deaths from SIPE. The single small study of longer-term outcomes reported no difference between affected and unaffected swimmers. Two studies suggested that around 30% of people report recurrences of SIPE. Two very small uncontrolled studies of the effect of sildenafil for recurrence prevention were inconclusive. Conclusions SIPE may be an important public health problem affecting the growing number of recreational open water swimmers. Further research should clarify the frequency of SIPE among recreational open water swimmers, confirm reported risk factors and explore others, explore long-term consequences and test interventions to prevent recurrences. Electronic supplementary material The online version of this article (10.1186/s40798-018-0158-8) contains supplementary material, which is available to authorized users.

BackgroundOver the last 5 years, national policy has encouraged general practices to serve populations of >30 000 people (called ‘working at scale’) by collaborating with other practices.AimTo describe the number of English general practices working at scale, and their patient populations.Design and settingObservational study of general practices in England.MethodData published by the NHS on practices’ self-reports of working in groups were supplemented with data from reports by various organisations and practice group websites. Practices were categorised by the extent to which they were working at scale; within these categories, the age distribution of the practice population, level of socioeconomic deprivation, rurality, and prevalence of longstanding illness were then examined.ResultsApproximately 55% of English practices (serving 33.5 million patients) were working at scale, individually or collectively serving populations of >30 000 people. Organisational models representing close collaboration for the purposes of core general practice services were identifiable for approximately 5% of practices; these comprised large practices, superpartnerships, and multisite organisations. Approximately 50% of practices were working in looser forms of collaboration, focusing on services beyond core general practice; for example, primary care in the evenings and at weekends. Data on organisational models and the purpose of the collaboration were very limited for this group.ConclusionIn early 2018, approximately 5% of general practices were working closely at scale; approximately half of practices were working more loosely at scale. However, data were incomplete. Better records of what is happening at practice level should be collected so that the effect of working at scale on patient care can be evaluated.

Background: older women are at high risk of presenting with breast cancer when it has reached a late stage, which may be partly because of poor breast cancer awareness. Aim: the aim of this project was to implement and evaluate a new way of delivering the Promoting Early Presentation (PEP) Intervention during flu vaccination appointments in primary care. The PEP Intervention is a 1–minute intervention, accompanied by a booklet and delivered by primary care health professionals to provide older women with the knowledge, confidence and skills to present promptly on discovering symptoms of breast cancer. Method: health professionals delivered the PEP Intervention to older women at six general practices in south London. The authors measured changes in breast cancer awareness after the intervention and interviewed practice staff about their experiences of using it. Findings: knowledge of breast symptoms and breast checking was greater in women aged 70 years and above after the implementation than before. Health professionals' found it acceptable and feasible to implement. Conclusion: this intervention is a novel way of increasing breast cancer awareness in older women, which could contribute to earlier presentation and diagnosis of breast cancer in the UK.

Background Swimming-induced pulmonary oedema (SIPE) can affect people with no underlying health problems, but may be life threatening and is poorly understood. The aim of this systematic review was to synthesise the evidence on SIPE incidence, prevalence, risk factors, short- and long-term outcomes, recurrence and effectiveness of interventions to prevent recurrences. Methods We carried out a literature search using bibliographic databases and reference lists. Risk of bias was assessed by adapting existing quality assessment tools including those developed by the National Heart Lung and Blood Institute. Results Nine studies met the inclusion criteria. Quantitative synthesis was not possible because of study heterogeneity. Five studies, which differed from each other in case definition, swimming environment, population characteristics and denominators, reported an incidence of 0.01% of UK triathlons raced over 5 years in unspecified swimming environments (one study, not fully reported, of men and women of unspecified age); 0.5% of river races swum over 3 days in Sweden (one study, of men and women up to the age of 70); and 1.8–26.7% of time trials in the sea around Israel (three studies of male teenage military trainees). One study reported that 1.4% of triathletes in the USA had experienced SIPE. One study found that hypertension, female sex, fish oil use, long course distance and another lower initial lung volumes and flows were risk factors for SIPE. A third study reported that higher mean pulmonary artery pressures and pulmonary artery wedge pressures, and lower tidal volumes were associated with SIPE. Three studies suggested that SIPE symptoms usually resolve within 24 h, although a restrictive deficit in lung function persisted for a week in one small study. We found no studies that reported deaths from SIPE. The single small study of longer-term outcomes reported no difference between affected and unaffected swimmers. Two studies suggested that around 30% of people report recurrences of SIPE. Two very small uncontrolled studies of the effect of sildenafil for recurrence prevention were inconclusive. Conclusions SIPE may be an important public health problem affecting the growing number of recreational open water swimmers. Further research should clarify the frequency of SIPE among recreational open water swimmers, confirm reported risk factors and explore others, explore long-term consequences and test interventions to prevent recurrences.

Tidlig diagnostik af kræftsygdomme kræver, at vi ved, hvad der kan anspore eller stå i vejen for lægesøgning hos personer med symptomer på mulig kræft. Denne undersøgelse viser, at personer med godt kendskab til kræftsymptomer og/eller få negative holdninger til kræft angiver, at de ville søge læge hurtigt, hvis de oplevede længerevarende hoste eller blødning fra endetarmen. Resultaterne viser også, at mange negative holdninger til kræft ser ud til at kunne ophæve den positive effekt af kendskab til kræftsymptomer i forhold til forventet hurtig lægesøgning ved blødning fra endetarmen. Det betyder, at hvis man er klar over at blødning fra endetarmen kan være tegn på kræft, men samtidig har mange negative holdninger til kræft, så har man samme lave sandsynlighed for hurtig lægesøgning, som hvis man ikke vidste, at blødning fra endetarmen kan være tegn på kræft. Undersøgelsen bygger på telefoninterviews af 20.814 personer (50+) fra Storbritannien, Australien, Canada, Danmark, Norge og Sverige med hjælp fra den standardiserede interviewguide ”The Awareness and Beliefs about Cancer Measure” (ABC). I ABC spørges bl.a. til, hvorvidt længerevarende hoste og blødning fra endetarmen kan være tegn på kræft, og hvornår man ville søge læge, hvis man oplevede disse symptomer. Kort tid til lægesøgning blev defineret som mindre end en måned for længerevarende hoste og mindre end 1 uge for blødning fra endetarmen. Negative holdninger til kræft blev også målt med ABC i form af vurdering af udsagn som fx ”Kræft er en dødsdom” og ”Jeg ville foretrække ikke at vide det, hvis jeg havde kræft”. Undersøgelsens resultater peger på, at fremtidige kampagner, som har til formål at fremme tidlig diagnostik af kræftsygdomme, skal øge kendskabet til mulige symptomer på kræft og samtidig adressere overdrevent negative holdninger til kræft. BACKGROUND: Understanding what influences people to seek help can inform interventions to promote earlier diagnosis of cancer, and ultimately better cancer survival. We aimed to examine relationships between negative cancer beliefs, recognition of cancer symptoms and how long people think they would take to go to the doctor with possible cancer symptoms (anticipated patient intervals).METHODS: Telephone interviews of 20,814 individuals (50+) in the United Kingdom, Australia, Canada, Denmark, Norway and Sweden were carried out using the Awareness and Beliefs about Cancer Measure (ABC). ABC included items on cancer beliefs, recognition of cancer symptoms and anticipated time to help-seeking for cough and rectal bleeding. The anticipated time to help-seeking was dichotomised as over one month for persistent cough and over one week for rectal bleeding.RESULTS: Not recognising persistent cough/hoarseness and unexplained bleeding as cancer symptoms increased the likelihood of a longer anticipated patient interval for persistent cough (OR = 1.66; 95%CI = 1.47-1.87) and rectal bleeding (OR = 1.90; 95%CI = 1.58-2.30), respectively. Endorsing four or more out of six negative beliefs about cancer increased the likelihood of longer anticipated patient intervals for persistent cough and rectal bleeding (OR = 2.18; 95%CI = 1.71-2.78 and OR = 1.97; 95%CI = 1.51-2.57). Many negative beliefs about cancer moderated the relationship between not recognising unexplained bleeding as a cancer symptom and longer anticipated patient interval for rectal bleeding (p = 0.005).CONCLUSIONS: Intervention studies should address both negative beliefs about cancer and knowledge of symptoms to optimise the effect.

The incidence of oral cancer is increasing in the United Kingdom. There is evidence that early diagnosis and effective treatment improve survival, but the poor 5-year survival rate (50%), which has not improved for several decades, has been attributed to advanced stage at presentation. To investigate the symptoms associated with cancer of the oral cavity and to explore the role of general practitioners (GP) in the identification and referral of patients, we sent 200 patients questionnaires on the route to diagnosis, symptoms, delay in presentation, and outcomes of consultations with their GP. Of 161 respondents, over half (56%) had been referred to secondary care by their GP and a third (32%) by their dentist. The most commonly reported symptoms were a mouth ulcer (32%), a lump in the face or neck (28%), and pain or soreness in the mouth or throat (27%). Fifteen per cent delayed presentation for more than 3 months. After consultation with a GP (n=109), 53% were referred to a specialist, 22% were referred for tests, 12% were told that their symptom was not serious, and 12% were treated for another condition. GPs have an important role in the identification and referral of people with oral cancer, and the clearly recognised symptoms identified in this study can be used to aid assessment and decision-making. Interventions to promote the prompt identification of oral cancer in general practice such as the opportunistic screening of high-risk patients may help to improve the poor survival rates.

BACKGROUND: UK policy aims to improve cancer outcomes by promoting early diagnosis, which for many haematological malignancies is particularly challenging as the pathways leading to diagnosis can be difficult and prolonged. METHODS: A survey about symptoms was sent to patients in England with acute leukaemia, chronic lymphocytic leukaemia (CLL), chronic myeloid leukaemia (CML), myeloma and non-Hodgkin lymphoma (NHL). Symptoms and barriers to first help seeking were examined for each subtype, along with the relative risk of waiting >3 months' time from symptom onset to first presentation to a doctor, controlling for age, sex and deprivation. RESULTS: Of the 785 respondents, 654 (83.3%) reported symptoms; most commonly for NHL (95%) and least commonly for CLL (67.9%). Some symptoms were frequent across diseases while others were more disease-specific. Overall, 16% of patients (n=114) waited >3 months before presentation; most often in CML (24%) and least in acute leukaemia (9%). Significant risk factors for >3 months to presentation were: night sweats (particularly CLL and NHL), thirst, abdominal pain/discomfort, looking pale (particularly acute leukaemias), and extreme fatigue/tiredness (particularly CML and NHL); and not realising symptom(s) were serious. CONCLUSIONS: These findings demonstrate important differences by subtype, which should be considered in strategies promoting early presentation. Not realising the seriousness of some symptoms indicates a worrying lack of public awareness.British Journal of Cancer advance online publication, 1 September 2015; doi:10.1038/bjc.2015.311 www.bjcancer.com.

Background: Cancer survival in the UK and Denmark are lower when compared to similar countries with late diagnosis a possible cause. We aimed to study the relationship between barriers to attending a primary care physician (GP) and anticipated time to help seeking (ATHS) with four cancer symptoms in six countries. Method: A population-based survey measuring cancer awareness and beliefs conducted within the International Cancer Benchmarking Partnership in Australia, Canada, Denmark, Norway, Sweden and UK. Data were collected on perceived barriers to GP consultation (including embarrassment, worry about wasting the doctors time, fear about what the doctor might find and being too busy) and ATHS for persistent cough, abdominal swelling, rectal bleeding and breast changes. Relationships between perceived barriers and ATHS were investigated using multivariable analysis. Results: Among 19,079 respondents, higher perceived barrier scores were associated with longer ATHS intervals for all symptoms studied (p10.84) had between two and three times the odds of longer ATHS. ATHS was low in Australia for all symptoms and highest in Denmark for abdominal bloating. Conclusion: Perceived barriers to help-seeking have a role in delaying GP presentation. Early diagnosis campaigns should address emotional and practical barriers that reduce early presentation with potential cancer symptoms.

Background: Early recognition of symptoms of colorectal cancer enables prompt help-seeking and timely diagnosis that may save lives. We aimed to assess public awareness of symptoms of colorectal cancer, anticipated delay to help-seeking in relation to these symptoms, and knowledge of risk factors and most common types of cancer in the English population.

Background Delay in presentation contributes to poorer survival of older women with breast cancer. Research has shown the effectiveness of the promoting early presentation (PEP) intervention when delivered by radiographers in the NHS Breast Screening Programme. This paper investigates the effectiveness of the intervention when delivered by practice nurses in general practice. Methods The Breast Cancer Awareness Measure was used to compare participants' awareness of breast cancer before, 1 month after and 12 months after the delivery of the PEP intervention. Five hundred and fifty-six women aged over 70 years took part, 308 of whom returned all three surveys. Results The intervention was associated with increased awareness of non-lump breast symptoms and reported breast check frequency. There was a marked increase in breast cancer awareness which persisted for 12 months. Less than 5% of women were classified as ‘breast cancer aware’ before the intervention, rising to over 25% 1 month afterwards. This percentage dropped slightly after 1 year to just below 20%. Conclusion Delivery of the PEP intervention in general practice was very effective at raising the awareness of breast cancer among older women. Primary care settings are well placed to enhance the reach of this kind of intervention to at-risk women.

Objective In a randomized controlled trial, the Promoting Early Presentation intervention increased older women’s breast cancer awareness after two years. We investigated whether this increase was sustained at three years, and the effect on breast screening self-referral. Methods We randomly allocated 867 women attending their final invited breast screening appointment to the Promoting Early Presentation intervention or usual care. We examined breast cancer awareness after three years and breast screening self-referrals after four years. Results Women in the Promoting Early Presentation intervention arm had higher breast cancer awareness at three years than the usual care arm (odds ratio: 10.4; 95% confidence interval: 3.1 to 34.8). There were no differences in proportions self-referring for breast screening between arms, but statistical power was limited. Conclusion The Promoting Early Presentation intervention has a sustained effect on breast cancer awareness in older women. The effect on self-referral for breast screening is unclear.

\ud \ud BACKGROUND: \ud \ud Campaigns aimed at raising cancer awareness and encouraging early presentation have been implemented in England. However, little is known about whether people with low cancer awareness and increased barriers to seeking medical help have worse cancer survival, and whether there is a geographical variation in cancer awareness and barriers in England.\ud \ud METHODS: \ud \ud From population-based surveys (n=35?308), using the Cancer Research UK Cancer Awareness Measure, we calculated the age- and sex-standardised symptom awareness and barriers scores for 52 primary care trusts (PCTs). These measures were evaluated in relation to the sex-, age-, and type of cancer-standardised cancer survival index of the corresponding PCT, from the National Cancer Registry, using linear regression. Breast, lung, and bowel cancer survival were analysed separately.\ud \ud RESULTS: \ud \ud Cancer symptom awareness and barriers scores varied greatly between geographical regions in England, with the worst scores observed in socioeconomically deprived parts of East London. Low cancer awareness score was associated with poor cancer survival at PCT level (estimated slope=1.56, 95% CI: 0.56; 2.57). The barriers score was not associated with overall cancer survival, but it was associated with breast cancer survival (estimated slope=-0.66, 95% CI: -1.20; -0.11). Specific barriers, such as embarrassment and difficulties in arranging transport to the doctor's surgery, were associated with worse breast cancer survival.\ud \ud CONCLUSIONS: \ud \ud Cancer symptom awareness and cancer survival are associated. Campaigns should focus on improving awareness about cancer symptoms, especially in socioeconomically deprived areas. Efforts should be made to alleviate barriers to seeking medical help in women with symptoms of breast cancer.British Journal of Cancer advance online publication 18 August 2016; doi:10.1038/bjc.2016.246 www.bjcancer.com.

BACKGROUND: We have developed the Promoting Early Presentation (PEP) Intervention to equip older women with the knowledge, skills, confidence and motivation to present promptly with breast symptoms, and thereby improve survival from breast cancer. The PEP Intervention consists of a 10-min interaction between a radiographer and an older woman, supported by a booklet. Our previous report showed that at 1 year, the PEP intervention increased the proportion who were breast cancer aware compared with usual care. METHODS: We randomised 867 women aged 67-70 years attending for their final routine appointment on the National Health Service Breast Screening Programme to receive the PEP Intervention, a booklet alone or usual care. The primary outcome was breast cancer awareness measured using a validated questionnaire asking about knowledge of breast cancer symptoms, knowledge that the risk of breast cancer increases with age and breast checking behaviour. RESULTS: At 2 years, the PEP Intervention increased the proportion who were breast cancer aware compared with usual care (21 vs 6%; odds ratio 8.1, 95% confidence interval 2.7-25.0). CONCLUSIONS: The uniquely large and sustained effect of the PEP Intervention on breast cancer awareness increases the likelihood that a woman will present promptly should she develop breast cancer symptoms up to many years later.

Background: Ethnic differences in cancer symptom awareness and barriers to seeking medical help in the English population are not fully understood. We aimed to quantify these differences, to help develop more effective health campaigns, tailored to the needs of different ethnic groups.\ud Methods: Using a large national data set (n=38492) of cross-sectional surveys that used the Cancer Research UK Cancer Awareness Measure, we examined how cancer symptom awareness and barriers varied by ethnicity, controlling for socio-economic position, age and gender. Data were analysed using multivariable logistic regression.\ud Results: Awareness of cancer symptoms was lower in minority ethnic groups than White participants, with the lowest awareness observed among Bangladeshis and Black Africans. Ethnic minorities were more likely than White British to report barriers to helpseeking. South Asians reported the highest emotional barriers, such as lack of confidence to talk to the doctor, and practical barriers, such as worry about many other things. The Irish were more likely than the White British to report practical barriers, such as being too busy to visit a doctor. White British participants were more likely than any other ethnic group to report that they would feel worried about wasting the doctor’s time. Overall, Black Africans had the lowest barriers. All differences were statistically significant (P

Background: During 2001 to 2005, 1-year breast cancer survival was low in ethnically diverse East London. We hypothesised that this was due to low breast cancer awareness and barriers to symptomatic presentation, leading to late stage at diagnosis in women from ethnic minorities. We examined ethnic differences in breast cancer awareness and barriers to symptomatic presentation in East London. Methods: We carried out a population-based survey of 1515 women aged 30+ using the Cancer Research UK Breast Cancer Awareness Measure. We analysed the data using logistic regression adjusting for age group and level of deprivation. Results: South Asian and black women had lower breast cancer awareness than white women. South Asian women, but not black women, reported more emotional barriers to seeking medical help than white women. White women were more likely than non-white women to report worry about wasting the doctor's time as a barrier to symptomatic presentation. Conclusion: Interventions to promote early presentation of breast cancer for South Asian and black women should promote knowledge of symptoms and skills to detect changes, and tackle emotional barriers to symptomatic presentation and for white women tackle the idea that going to the doctor to discuss a breast symptom will waste the doctor's time.

Aim: Until now, there has been no universally accepted and validated measure of breast cancer awareness. This study aimed to validate the new Breast Cancer Awareness Measure (BCAM) which assesses, using a self-complete questionnaire, knowledge of breast cancer symptoms and age-related risk, and frequency of breast checking. Methods: We measured the psychometric properties of the BCAM in 1035 women attending the NHS Breast Screening Programme: acceptability was assessed using a feedback questionnaire (n = 292); sensitivity to change after an intervention promoting breast cancer awareness (n = 576), and test–retest reliability (n = 167). We also assessed readability, and construct validity using the ‘known-groups’ method. Results: The readability of the BCAM was high. Over 90% of women found it acceptable. The BCAM was sensitive to change: there was an increase in the proportion of women obtaining the full score for breast cancer awareness one month after receiving the intervention promoting breast cancer awareness; this was greater among those who received a more intensive version (less intensive version (booklet): 9.3%, 95% confidence interval (CI): 4.5–14.1%; more intensive version (interaction with health professional plus booklet): 30%, 95% CI: 23.4–36.6%). Test–retest reliability of the BCAM was moderate to good for most items. Cancer experts had higher levels of cancer awareness than non-medical academics (50% versus 6%, p = 0.001), indicating good construct validity. Conclusions: The BCAM is a valid and robust measure of breast cancer awareness suitable for use in surveys of breast cancer awareness in the general population and to evaluate the impact of awareness-raising interventions.

Background: The extent to which chronic exposure to outdoor air pollutants influences lung function in adults is unclear. The aim of this study was to measure the association between chronic exposure to outdoor air pollutants and adult lung function. Methods: The relationship between measures of lung function (forced expiratory volume in 1 s (FEV1) and FEV1 as a percentage of forced vital capacity (FVC)) and average exposure to particulate matter

Inner city children make heavy use of accident and emergency (AE) services for asthma. Developing strategies to reduce this requires a better understanding of the risk factors.A case-control study was carried out of children with asthma living in south-east London: 1018 children who attended AE for asthma over 1 year and 394 children who had not attended AE for asthma over the previous year. The main risk factors were socioeconomic status, home environment, routine asthma management and parents' psychological responses to and beliefs about the treatment of asthma attacks.AE attendance was more common in children living in poorer households. No associations were found with home environment or with measures of routine asthma care. Children who had attended outpatients were much more likely to attend AE (odds ratio (OR) 13.17, 95% CI 7.13 to 24.33). Other risk factors included having a parent who reported feeling alone (OR 2.58, 95% CI 1.71 to 3.87) or panic or fear (OR 2.62. 95% CI 1.75 to 3.93) when the child's asthma was worse; and parental belief that the child would be seen more quickly in AE than at the GP surgery (OR 2.48, 95% CI 1.62 to 3.79). Parental confidence in the GP's ability to treat asthma attacks reduced the risk of attending AE (OR 0.30, 95% CI 0.17 to 0.54).There is no evidence that passive smoking, damp homes or poor routine asthma care explains heavy inner city use of AE in children with asthma. Reducing AE use is unlikely to be achieved by improving these, but identifying appropriate settings for treating children with asthma attacks and communicating these effectively may do so.

Background The incidence of melanoma is rising. Early detection is associated with a more favourable outcome. The factors that influence the timing of a patient’s presentation for medical assessment are not fully understood. The aims of the study were to measure the nature and duration of melanoma symptoms in a group of patients diagnosed with melanoma within the preceding 18 months and to identify the symptoms and barriers associated with a delay in presentation. Methods A questionnaire was distributed to a random sample of 200 of the 963 melanoma patients who had participated in the Cancer Patient Experience Survey 2010 and were known to be alive 1 year later. Data were collected on symptoms, duration of symptoms prior to presentation and the reasons for not attending a doctor sooner. Results A total of 159 patients responded to the questionnaire; 74 (47%) were men; mean age was 62 (range 24–90) years. Of the 149 patients who reported a symptom, 40 (27%) had a delayed presentation (i.e. >3 months). A mole growing bigger was the most common symptom and reporting this symptom was significantly associated with a delayed presentation (odds ratio (OR) 2.04, 95% confidence interval (95% CI) 1.14–5.08). Patients aged ≥65 years were less likely to report a barrier to presentation and were less likely to delay than those under 40, although this was of borderline statistical significance (OR 0.28, 95% CI 0.08–1.00). Conclusions This study highlights that an enlarging mole is a significant symptom influencing the timing of presentation. Increasing public awareness of the signs of melanoma and of the importance of early presentation is desirable. Health professionals should take advantage of the opportunity to educate patients on such symptoms and signs where feasible. Further exploration of the barriers to presentation in younger people should be considered. Electronic supplementary material The online version of this article (doi:10.1186/s12885-016-2978-6) contains supplementary material, which is available to authorized users.

Background: Low cancer awareness may contribute to delayed diagnosis and poor cancer survival. We aimed to quantify socio-demographic differences in cancer symptom awareness and barriers to symptomatic presentation in the English population.Methods: Using a uniquely large data set (n=49 270), we examined the association of cancer symptom awareness and barriers to presentation with age, gender, marital status and socio-economic position (SEP), using logistic regression models to control for confounders.Results: The youngest and oldest, the single and participants with the lowest SEP recognised the fewest cancer symptoms, and reported most barriers to presentation. Recognition of nine common cancer symptoms was significantly lower, and embarrassment, fear and difficulties in arranging transport to the doctor's surgery were significantly more common in participants living in the most deprived areas than in the most affluent areas. Women were significantly more likely than men to both recognise common cancer symptoms and to report barriers. Women were much more likely compared with men to report that fear would put them off from going to the doctor.Conclusions: Large and robust socio-demographic differences in recognition of some cancer symptoms, and perception of some barriers to presentation, highlight the need for targeted campaigns to encourage early presentation and improve cancer outcomes.

Background: Diagnosis may be delayed in young females with cervical cancer because of a failure to recognise symptoms. Aim: To examine the extent and determinants of delays in diagnosis of young females with symptomatic cervical cancer. Design and setting: A national descriptive study of time from symptoms to diagnosis of cervical cancer and risk factors for delay in diagnosis at all hospitals diagnosing cervical cancer in England. Method: One-hundred and twenty-eight patients

Background: Delay in symptomatic presentation leading to advanced stage at diagnosis may contribute to poor cancer survival. To inform public health approaches to promoting early symptomatic presentation, we aimed to identify risk factors for delay in presentation across several cancers.\ud \ud Methods: We surveyed 2371 patients with 15 cancers about nature and duration of symptoms using a postal questionnaire. We calculated relative risks for delay in presentation (time from symptom onset to first presentation >3 months) by cancer, symptoms leading to diagnosis and reasons for putting off going to the doctor, controlling for age, sex and deprivation group.\ud \ud Results: Among 1999 cancer patients reporting symptoms, 21% delayed presentation for >3 months. Delay was associated with greater socioeconomic deprivation but not age or sex. Patients with prostate (44%) and rectal cancer (37%) were most likely to delay and patients with breast cancer least likely to delay (8%). Urinary difficulties, change of bowel habit, systemic symptoms (fatigue, weight loss and loss of appetite) and skin symptoms were all common and associated with delay. Overall, patients with bleeding symptoms were no more likely to delay presentation than patients who did not have bleeding symptoms. However, within the group of patients with bleeding symptoms, there were significant differences in risk of delay by source of bleeding: 35% of patients with rectal bleeding delayed presentation, but only 9% of patients with urinary bleeding. A lump was a common symptom but not associated with delay in presentation. Twenty-eight percent had not recognised their symptoms as serious and this was associated with a doubling in risk of delay. Embarrassment, worry about what the doctor might find, being too busy to go to the doctor and worry about wasting the doctor’s time were also strong risk factors for delay, but were much less commonly reported (

Breast and cervical screening each have a distinct balance of benefits and harms. While they are both likely to reduce mortality, breast screening is associated with a greater relative frequency of serious harms than cervical screening. A unique approach has been adopted in England with respect to providing information on cancer screening with the goal of facilitating informed choice. The new materials provide more detail than previous information about the benefits and harms of screening as well as the scientific uncertainties. While there is a uniform format and the information covers the same key issues in both breast and cervical screening programmes, the emphasis and detail varies according to balance of benefits and harms within these programmes.

There is some evidence that endogenous progesterone and oestrogen levels influence asthma severity in females, but little is known about the effects of hormonal contraceptives. This study aimed to describe how females with asthma perceived the effects of hormonal contraceptives on symptom severity, and to describe the association between asthma severity and current use of hormonal contraceptives. A questionnaire was sent to 891 females with asthma aged 20-30 yrs recruited from general practice registers in South London, UK. It asked about perceptions of the effects of hormonal contraceptives on asthma severity, about current use of hormonal contraceptives, and included an asthma quality of life questionnaire as a measure of asthma severity. About 6% of respondents who had ever used hormonal contraceptives reported that these had influenced asthma severity, -4% reporting worsening and 2% an improvement. There were no significant differences in asthma quality of life score between females currently taking hormonal contraceptives and those not, between those taking combined and progesterone-only preparations, or between users of different progestagen types. This study found no evidence of any important effect of hormonal contraceptives or their components on asthma severity in a group of females with relatively mild asthma.

BackgroundSome young women experience delays in diagnosis of cervical cancer, but little research about ways of studying these delays has been published. A major challenge is that gynaecological symptoms are common in young women, but cervical cancer is rare. This study describes the development and testing of a measure for studying delays in diagnosis in young women with cervical cancer.MethodsProspective development of an interview measure and testing of its ability to reliably and systematically collect relevant data in two large hospitals in London, UK using 27 women aged 18–40 diagnosed with cervical cancer in the previous two years. We developed a semi-structured interview schedule and data extraction form to systematically collect data on symptoms (including nature and duration) and risk factors for delayed diagnosis from young women with cervical cancer. We piloted the measure among young women with cervical cancer (audiorecording it with their permission), refining it iteratively. To complete the measure, we developed a database for managing the data and a manual for using the schedule. Two researchers extracted data from the recorded interviews to assess inter-rater reliability.ResultsThe final interview schedule yielded quantitative data on the nature and duration of symptoms and risk factors for delayed diagnosis. Inter-rater reliability was high. In the pilot, 12 of the 27 women were diagnosed via symptomatic presentation. Median time from the symptom triggering presentation to presentation was one month (interquartile range 0–4 months). Median time from presentation to diagnosis was three months (interquartile range 1–8.5 months).ConclusionsWe have developed a reliable tool for measuring the nature and duration of symptoms in young women with cervical cancer. Pilot data suggest that a substantial proportion of women experience delay between first presentation and diagnosis.

Background: Not recognising a symptom as suspicious is a common reason given by cancer patients for delayed help-seeking; but inevitably this is retrospective. We therefore investigated associations between recognition of warning signs for breast, colorectal and lung cancer and anticipated time to help-seeking for symptoms of each cancer.\ud Methods: Computer-assisted telephone interviews were conducted with a population-representative sample (N=6965) of UK adults age greater than or equal to50 years, using the Awareness and Beliefs about Cancer scale. Anticipated time to help-seeking for persistent cough, rectal bleeding and breast changes was categorised as >2 vs less than or equal to2 weeks. Recognition of persistent cough, unexplained bleeding and unexplained lump as cancer warning signs was assessed (yes/no). Associations between recognition and help-seeking were examined for each symptom controlling for demographics and perceived ease of health-care access.\ud Results: For each symptom, the odds of waiting for >2 weeks were significantly increased in those who did not recognise the related warning sign: breast changes: OR=2.45, 95% CI 1.47–4.08; rectal bleeding: OR=1.77, 1.36–2.30; persistent cough: OR=1.30, 1.17–1.46, independent of demographics and health-care access.\ud Conclusion: Recognition of warning signs was associated with anticipating faster help-seeking for potential symptoms of cancer. Strategies to improve recognition are likely to facilitate earlier diagnosis.

Objectives Older women are more likely to delay presentation with breast cancer, which contributes to poorer survival. We evaluated a written intervention that was designed to provide women with the knowledge, motivation, confidence and skills to present promptly with breast cancer symptoms. Methods We assessed acceptability and understanding of the intervention by interviewing 43 women. We used their responses to refine the intervention. We tested the effect of the intervention on breast cancer awareness, confidence and intentions to check breasts and perceived barriers to help-seeking using a self-report questionnaire administered to 61 women prior to and one month after receiving the intervention. Quantitative data were analysed using the McNemar test. Results Women were not made anxious by the intervention and understood its messages. At one month, a greater proportion of women knew that breast cancer risk increases with age, identified ≥5 non-lump symptoms and reported breast checking at least monthly in comparison to before the intervention was implemented. Discussion The intervention does not induce anxiety, is understandable, and appears to increase breast cancer awareness. The results provide justification for a more rigorous trial to test efficacy.

Dette studie understøtter brugen af et særligt spørgeskema til at måle befolkningens viden og holdning til symptomer på kræft, deres forventede aktion ved symptomer, oplevelse af risikofaktorer samt holdning til det at få og have kræft. For at sundhedsvæsenet kan bidrage konstruktivt til, at befolkningen agerer på risici for at udvikle kræft, henvender sig så tidligt som muligt til sundhedsvæsenet med relevante symptomer og tegn på kræft samt har en realistisk forestilling om det at få kræft, var der behov for at have et særligt spørgeskema, der kunne afdække disse forhold. Baseret på et større internationalt samarbejde blev dette spørgeskema udviklet, og denne artikel beskriver udviklingen, og hvorledes spørgeskemaet kan anvendes på tværs af forskellige kulturer og på tværs af forskellige grupper af borgere. Det er med dette skema muligt fx i Danmark at monitorere befolkningens viden og holdning til symptomer, risici og behandling af kræft. OBJECTIVES: To develop an internationally validated measure of cancer awareness and beliefs; the awareness and beliefs about cancer (ABC) measure. DESIGN AND SETTING: Items modified from existing measures were assessed by a working group in six countries (Australia, Canada, Denmark, Norway, Sweden and the UK). Validation studies were completed in the UK, and cross-sectional surveys of the general population were carried out in the six participating countries. PARTICIPANTS: Testing in UK English included cognitive interviewing for face validity (N=10), calculation of content validity indexes (six assessors), and assessment of test-retest reliability (N=97). Conceptual and cultural equivalence of modified (Canadian and Australian) and translated (Danish, Norwegian, Swedish and Canadian French) ABC versions were tested quantitatively for equivalence of meaning (≥4 assessors per country) and in bilingual cognitive interviews (three interviews per translation). Response patterns were assessed in surveys of adults aged 50+ years (N≥2000) in each country. MAIN OUTCOMES: Psychometric properties were evaluated through tests of validity and reliability, conceptual and cultural equivalence and systematic item analysis. Test-retest reliability used weighted-κ and intraclass correlations. Construction and validation of aggregate scores was by factor analysis for (1) beliefs about cancer outcomes, (2) beliefs about barriers to symptomatic presentation, and item summation for (3) awareness of cancer symptoms and (4) awareness of cancer risk factors. RESULTS: The English ABC had acceptable test-retest reliability and content validity. International assessments of equivalence identified a small number of items where wording needed adjustment. Survey response patterns showed that items performed well in terms of difficulty and discrimination across countries except for awareness of cancer outcomes in Australia. Aggregate scores had consistent factor structures across countries. CONCLUSIONS: The ABC is a reliable and valid international measure of cancer awareness and beliefs. The methods used to validate and harmonise the ABC may serve as a methodological guide in international survey research.

Background. Women over 70 with breast cancer have poorer one-year survival and present at a more advanced stage than younger women. Promoting early symptomatic presentation in older women may reduce stage cost effectively and is unlikely to lead to overdiagnosis. After examining efficacy in a randomised controlled trial, we piloted a brief health professional-delivered intervention to equip women to present promptly with breast symptoms, as an integral part of the final invited mammogram at age~70, in the English National Health Service Breast Screening Programme.Methods. We trained mammographers, who then offered the intervention to older women in four breast screening services. We examined breast cancer awareness at baseline and one month in women receiving the intervention, and also in a service where the intervention was not offered.Results. We trained 27 mammographers to deliver the intervention confidently to a high standard. Breast cancer awareness increased 7-fold at one month in women receiving the intervention compared with 2-fold in the comparison service (odds ratio 15.2, 95% confidence interval 10.0 to 23.2).Conclusions. The PEP Intervention can be implemented in routine clinical practice with a potency similar to that achieved in a randomised controlled trial. It has the potential to reduce delay in diagnosis for breast cancer in older women.

Background: The purpose of this study was to explore women's views of the design of a large pragmatic cost-effectiveness randomised controlled trial of the policy of offering a health professional-delivered intervention to promote early presentation with breast symptoms in older women and thereby improve survival, with a view to informing protocol development. The trial will recruit over 100,000 healthy women aged 67+, and outcome data will be collected on those who develop breast cancer. The scale of the trial and the need for long-term follow-up presented a number of design challenges in relation to obtaining consent, ascertaining and contacting participants who developed breast cancer, and collecting outcome data. Methods: Qualitative study involving 69 women participating in 7 focus groups and 17 in-depth interviews. 15 women had a previous diagnosis of breast cancer and 54 did not. Results: The women held strong views and had a good understanding of the rationale of the design of clinical trials. The women recognised that in a very large trial with long-term follow-up it was necessary to incorporate design features to make the trial feasible and efficient. Most strikingly, they supported the idea of opt-out consent and identifying women with breast cancer using routine datasets. Conclusions: This model of user involvement engaged women well with the design challenges of the trial and led to improvements to the protocol. The study strengthens the case for user involvement, in particular through focus groups and in-depth interviews, in the design of trials.

Objective To elicit women's preferences for delivery of the National Health Service (NHS) Breast Screening Programme. Design Interview survey. Setting Private households in the UK. Population Five hundred and ninety-seven women aged 45–75 interviewed as part of the National Statistics Omnibus Survey, December 2008 and January 2009. Outcomes Preferred setting (hospital or community) and preferred type of screening unit (mobile or permanent). Rated importance of distance, time, convenience and cost of travelling to a screening unit. Results Forty per cent of women did not mind whether the screening unit was based in a community or hospital setting, and 52% did not mind whether the unit was permanent or mobile. Among those who expressed a preference, 59% preferred a hospital to a community setting, and 62% preferred a permanent to a mobile unit. Many women (63%) said distance to a breast screening unit was an important factor, as was time to travel (58%). Among those with access to a car, 80% regarded the availability of parking as important, but only 40% regarded the cost of car travel as important. Among women with no access to a car, there was a similar pattern for ease of public transport (76%) and cost of public transport (48%). Conclusions Many women were unconcerned about the type and setting of breast screening units. Among those who were concerned, most preferred hospital over community settings and permanent over mobile units, but nonetheless most women said time and distance were important. Well-situated units with advanced publicity about public transport links and parking facilities may encourage greater uptake.

Background: Low cancer awareness contributes to delay in presentation for cancer symptoms and may lead to delay in cancer diagnosis. The aim of this study was to review the evidence for the effectiveness of interventions to raise cancer awareness and promote early presentation in cancer to inform policy and future research.\ud \ud Methods: We searched bibliographic databases and reference lists for randomised controlled trials of interventions delivered to individuals, and controlled or uncontrolled studies of interventions delivered to communities. \ud \ud Results: We found some evidence that interventions delivered to individuals modestly increase cancer awareness in the short term and insufficient evidence that they promote early presentation. We found limited evidence that public education campaigns reduce stage at presentation of breast cancer, malignant melanoma and retinoblastoma. \ud \ud Conclusions: Interventions delivered to individuals may increase cancer awareness. Interventions delivered to communities may promote cancer awareness and early presentation, although the evidence is limited.

Women in the UK have poorer survival rates for breast cancer than many other Western European countries even after taking into account differences in the age distribution of the population. (Berrino et al. 2007). So-called high resolution studies suggest that late stage at diagnosis is largely responsible for the differences in survival rates (Sant et al. 2003). Late stage at diagnosis is almost certainly due to a combination of late presentation by some women and delays in onward referral by some general practitioners. Most delay appears to be due to patient delay (Westcombe et al. 1999), which may be because of late discovery of symptoms or delayed presentation after discovering symptoms.

Background: There is virtually no evidence for the effectiveness of interventions to promote early presentation in breast cancer. We aimed to test the efficacy of an intervention to equip older women with the knowledge, skills, confidence and motivation to detect symptoms and seek help promptly, with the aim of promoting early presentation with breast cancer symptoms. Methods: We randomised 867 women aged 67–70 years attending for their final routine appointment on the UK NHS Breast Screening Programme to receive: a scripted 10-min interaction with a radiographer plus a booklet, a booklet alone or usual care. The primary outcome was whether or not a woman was breast cancer aware based on knowledge of breast cancer symptoms and age-related risk, and reported breast checking. Results: At 1 month, the intervention increased the proportion who were breast cancer aware compared with usual care (interaction arm: 32.8% vs 4.1%; odds ratio (OR): 24.0, 95% confidence interval (CI): 7.7–73.7; booklet arm: 12.7% vs 4.1%; OR: 4.4, 95% CI: 1.6–12.0). At 1 year, the effects of the interaction plus booklet, and the booklet, on breast cancer awareness were largely sustained, although the interaction plus booklet remained much more effective. Conclusions: An intervention to equip older women with the knowledge, skills, confidence and motivation to detect breast cancer symptoms and seek help promptly increases breast cancer awareness at 1 year. Future research will evaluate whether the intervention promotes early presentation and reduces breast cancer mortality.

Background Higher exposure to outdoor air pollution is associated with increased cardiopulmonary deaths, but there is limited evidence about the association between outdoor air pollution and diagnosed cardiovascular disease. Our study aimed to estimate the size of the association between long term exposure to outdoor air pollution and prevalent cardiovascular disease. Methods We carried out a cross-sectional analysis of data on more than 19,000 white adults aged 45 and older who participated in three representative surveys of the English population in 1994, 1998 and 2003, examining the relationship between self-reported doctor-diagnosed cardiovascular disease and exposure to outdoor air pollutants using multilevel regression techniques and meta-analysis. Results The combined estimates suggested that an increase of 1 μg m-3 in concentration of particulate matter less than 10 microns in diameter was associated with an increase of 2.9% (95% CI -0.6% to 6.5%) in prevalence of cardiovascular disease in men, and an increase of 1.6% (95%CI -2.1% to 5.5%) in women. The year-specific analyses showed strongly positive associations in 2003 between odds of cardiovascular disease in both men and women and exposure to particulate matter but not in 1994 or 1998. We found no consistent associations between exposure to gaseous air pollutants and doctor-diagnosed cardiovascular disease. Conclusion The associations of prevalent cardiovascular disease with concentration of particulate matter less than 10 microns in diameter, while only weakly positive, were consistent with the effects reported in cohort studies. The results provide evidence of the size of the association between particulate air pollution and the prevalence of cardiovascular disease but no evidence for an association with gaseous pollutants. We found strongly positive associations between particulate matter and cardiovascular disease in 2003 only, which highlights the importance of replicating findings in more than one population.

There is some evidence that asthmatic women are more likely to have abnormal sex hormone levels. A study was undertaken to determine whether asthma and allergy were associated with irregular menstruation in a general population, and the potential role of asthma medication for this association.A total of 8588 women (response rate 77%) participated in an 8 year follow up postal questionnaire study of participants of the ECRHS stage I in Denmark, Estonia, Iceland, Norway, and Sweden. Only non-pregnant women not taking exogenous sex hormones were included in the analyses (n = 6137).Irregular menstruation was associated with asthma (OR 1.54 (95% CI 1.11 to 2.13)), asthma symptoms (OR 1.47 (95% CI 1.16 to 1.86)), hay fever (OR 1.29 (95% CI 1.05 to 1.57)), and asthma preceded by hay fever (OR 1.95 (95% CI 1.30 to 2.96)) among women aged 26-42 years. This was also observed in women not taking asthma medication (asthma symptoms: OR 1.44 (95% CI 1.09 to 1.91); hay fever: OR 1.27 (95% CI 1.03 to 1.58); wheeze preceded by hay fever: OR 1.76 (95% CI 1.18 to 2.64)). Irregular menstruation was associated with new onset asthma in younger women (OR 1.58 (95% CI 1.03 to 2.42)) but not in women aged 42-54 years (OR 0.62 (95% CI 0.32 to 1.18)). The results were consistent across centres.Younger women with asthma and allergy were more likely to have irregular menstruation. This could not be attributed to current use of asthma medication. The association could possibly be explained by common underlying metabolic or developmental factors. The authors hypothesise that insulin resistance may play a role in asthma and allergy.

Objectives: To quantify the documentation of vital signs in children attending accident and emergency (A&E) for asthma and to assess whether indicators of severity were used appropriately. Methods: Records of all children aged 3 to 14 attending A&E for the treatment of asthma in four London hospitals over a three month period were examined for documentation of heart rate, respiratory rate, peak expiratory flow rate, oxygen saturation, and fraction of inspired oxygen. The relation between severity indicators and whether the child was admitted or not was examined. Results: There were 255 attendances in 229 children. Heart rate, respiratory rate, and oxygen saturation were recorded on most attendances (94.5%, 85.5%, and 96.8%) but fraction of inspired oxygen and peak flow were recorded in few children (48.6% and 48.5%). Heart rate and respiratory rate were higher and oxygen saturation lower in children who were admitted compared with those who were not. Conclusions: Assessment of airways obstruction is inadequate in children but when measured may be used appropriately to guide admission. There is a need for interventions to improve assessment of children attending A&E for asthma.

Background: In July 1995 the volcano on the West Indian island of Montserrat erupted after being inactive for several hundred years. Since then, clouds of ash have been released intermittently from the volcano. Some of this ash is

Introduction and aims Older women are more likely to delay presentation in breast cancer,1 which in turn contributes to poorer survival.2 We have developed a health professional-delivered intervention to promote early presentation in older women with breast symptoms (Promoting Early Presentation (PEP) Intervention) to be delivered when they attend for their final routine mammogram. We aimed to evaluate its efficacy in an randomized controlled trial (RCT) and adapt it for use in routine clinical practice. Methods We randomised 867 women attending for their final round of screening on the NHS Breast Screening Programme to receive either the PEP Intervention delivered by a radiographer or usual care. We measured breast cancer awareness at baseline and 2 years post-randomisation. We are adapting and piloting the PEP Intervention to be suitable for adoption in routine practice across the NHS Breast Screening Programme. Results In the RCT, the PEP Intervention increased the proportion breast cancer aware at 2 years compared with usual care (21% vs 6%, OR: 8.1, 95% CI: 2.7 to 25.0). We have adapted the intervention so that it can be delivered feasibly while maintaining consistent quality. Conclusions We have demonstrated the efficacy of the PEP Intervention in an RCT. We plan to evaluate its effectiveness in routine practice by implementing it in three breast screening services, and measuring feasibility, costs and health outcomes (comparing these with health outcomes in control services). Our findings will provide the data needed to inform possible implementation across the entire NHS Breast Screening Programme.

Background: While ovarian cancer is recognised as having identifiable early symptoms, understanding of the key determinants of symptom awareness and early presentation is limited. A population-based survey of ovarian cancer awareness and anticipated delayed presentation with symptoms was conducted as part of the International Cancer Benchmarking Partnership (ICBP). Methods: Women aged over 50 years were recruited using random probability sampling (n = 1043). Computer-assisted telephone interviews were used to administer measures including ovarian cancer symptom recognition, anticipated time to presentation with ovarian symptoms, health beliefs (perceived risk, perceived benefits/barriers to early presentation, confidence in symptom detection, ovarian cancer worry), and demographic variables. Logistic regression analysis was used to identify the contribution of independent variables to anticipated presentation (categorised as

Introduction and aims Delayed presentation in breast cancer leads to more advanced stage at diagnosis and ultimately poorer survival. Delays in presentation are associated with low breast cancer awareness. Breast Cancer Care delivers the Train the Trainer: Breast Health Promotion programme to train people across England to deliver messages to increase breast cancer awareness: knowing how breasts normally look and feel and what breast changes to look for; encouraging regularly looking and feeling for breast changes; early symptomatic presentation and breast screening uptake. We measured trainees9 knowledge and confidence to deliver these messages in a before and after observational design. Methods We recruited 126 trainees attending nine courses over 6 months. Trainees included volunteers, community workers and health professionals. They completed the Cancer Research UK Breast Cancer Awareness Measure at baseline and 1 and 6 months after attending. We also collected information about recipients of the breast cancer awareness messages during the 6 months after training. Results At baseline, 46% trainees identified five or more non-lump symptoms of breast cancer; 21% identified a 70-year-old woman as at higher risk of breast cancer than a 30 or 50 year old. 50% reported looking and feeling their breasts at least monthly. These proportions are higher than the general population (18%, 14% and 23% respectively).1 Follow-up will finish in March 2011. Conclusion Breast cancer awareness at baseline was higher than in the general population. We will present 1-month follow-up data at the meeting. The findings will provide the rationale for future investment and improvements in the programme.

Objective To determine the effect of home blood pressure\ud monitoring on blood pressure levels and proportion of people\ud with essential hypertension achieving targets.\ud Design Meta-analysis of 18 randomised controlled trials.\ud Participants 1359 people with essential hypertension allocated\ud to home blood pressure monitoring and 1355 allocated to the\ud "control" group seen in the healthcare system for 2-36 months.\ud Main outcome measures Differences in systolic (13 studies),\ud diastolic (16 studies), or mean (3 studies) blood pressures, and\ud proportion of patients achieving targets (6 studies), between\ud intervention and control groups.\ud Results Systolic blood pressure was lower in people with\ud hypertension who had home blood pressure monitoring than\ud in those who had standard blood pressure monitoring in the\ud healthcare system (standardised mean difference 4.2 (95%\ud confidence interval 1.5 to 6.9) mm Hg), diastolic blood pressure\ud was lower by 2.4 (1.2 to 3.5) mm Hg, and mean blood pressure\ud was lower by 4.4 (2.0 to 6.8) mm Hg. The relative risk of blood\ud pressure above predetermined targets was lower in people with\ud home blood pressure monitoring (risk ratio 0.90, 0.80 to 1.00).\ud When publication bias was allowed for, the differences were\ud attenuated: 2.2 ( − 0.9 to 5.3) mm Hg for systolic blood pressure\ud and 1.9 (0.6 to 3.2) mm Hg for diastolic blood pressure.\ud Conclusions Blood pressure control in people with\ud hypertension (assessed in the clinic) and the proportion\ud achieving targets are increased when home blood pressure\ud monitoring is used rather than standard blood pressure\ud monitoring in the healthcare system. The reasons for this are\ud not clear. The difference in blood pressure control between the\ud two methods is small but likely to contribute to an important\ud reduction in vascular complications in the hypertensive\ud population.

Former professor of primary medical care Southampton University (b Aberdeen 1922; q Aberdeen 1951; MA, MD, FRCGP), died from lung cancer on 22 June 2003.​2003. Figure 1 After active service in north Africa, Italy, and Palestine, John Forbes returned to Aberdeen in 1946, determined to read medicine. He was a general practitioner for 16 years in Bicester, researching and writing his MD in his spare time. In 1969 John was appointed senior lecturer at the newly forming Southampton Medical School—which took its first students in 1971—becoming professor of primary medical care in 1972. Determined to produce doctors who understood the social context of illness, he developed new ways of teaching medicine. One of these was the early medical contact scheme, in which general practitioners took first year students into patients' homes. He leaves a wife, June; four children; and five grandchildren.