University of Leeds | April 2018 |Women at increased cancer risk shun preventative tamoxifen therapy
A study published in Breast Cancer Research and Treatment shows that only 1 in 7 women who were offered Tamoxifen due to a familial history of cancer decided to take it. This new research sought to highlight that women eligible to take the drug were electing not to, it also aimed to explore the reasons behind such decisions. Researchers also found that patients consulted informal networks such as friends and family before making a decision about whether to take Tamoxifen (via University of Leeds) .
Whether the participants had children also had an impact on the decision, the scientists found those with children were more likely to take the drug. One participant explained that taking the drug might affect her ability to care for her children and parents, so decided not to take it.
The study was conducted in collaboration with scientists at the University Hospitals Southampton, University College London, Queen Mary University, University of Leeds and Northwestern University. The research was funded by Cancer Research UK and Yorkshire Cancer Research.
Purpose Uptake of preventive therapy for women at increased breast cancer risk in England is unknown following the introduction of UK clinical guidelines in 2013. Preventive therapy could create socioeconomic inequalities in cancer incidence if it is more readily accepted by particular socio-demographic groups. In this multicentre study, we investigated uptake of tamoxifen and evaluated socio-demographic and clinical factors associated with initiation. We explored women’s experiences of treatment decision-making using qualitative interview data.
Methods Between September 2015 and December 2016, women (n=732) attending an appointment at one of 20 centres in England to discuss breast cancer risk were approached to complete a survey containing socio-demographic details and nul-
liparity. Of the baseline survey respondents (n equal to 408/732, 55.7% response rate), self-reported uptake of tamoxifen at 3-month follow-up was reported in 258 (63.2%). Sixteen women participated in semi-structured interviews.
Results One in seven (38/258=14.7%) women initiated tamoxifen. Women who had children were more likely to report use of tamoxifen than those without children (OR=5.26; 95%CI: 1.13–24.49, p=0.035). Interview data suggested that women weigh up risks and benefits of tamoxifen within the context of familial commitments, with exposure to significant other’s beliefs and experiences of cancer and medication a basis for their decision.
Conclusions Uptake of tamoxifen is low in clinical practice. There were no socio-demographic differences in uptake, suggesting that the introduction of breast cancer preventive therapy is unlikely to create socioeconomic inequalities in cancer incidence. Women’s decision-making was influenced by familial priorities, particularly having children.
The full article can be downloaded here
NHS England has published three rapid cancer diagnostic and assessment pathways. These documents set out how diagnosis within 14 days and diagnosis within 28 days can be achieved for the colorectal, lung, and prostate cancer pathways:
Implementing a timed colorectal cancer diagnostic pathway:
This handbook sets out how the 28 day standard can be achieved in colorectal cancer patients, in preparation for full monitoring against the standard from April 2020.
Implementing a timed lung cancer diagnostic pathway:
This handbook sets out how the 28 day standard can be achieved for lung cancer patients, in preparation for full monitoring against the standard from April 2020.
Implementing a timed prostate cancer diagnostic pathway:
This handbook sets out how the 28 day standard can be achieved for prostate cancer patients, in preparation for full monitoring against the standard from April 2020.
Aggarwal, A. et al. | Hospital Choice in Cancer Care: A Qualitative Study | Clinical Oncology
- Hospital choice is widening socioeconomic inequities in access to cancer treatment.
- There is a lack of clinical support for patients to choose an alternative cancer treatment centre.
- The absence of hospital-level outcomes means patients are reliant on unreliable quality measures such as reputation.
- Hospital choice enables patient to ‘exit’ care that does not meet their expectations.
There is limited evidence about how patients respond to hospital choice policies, the factors that inform and influence patient choices or how relevant these policies are to cancer patients. This study sought to evaluate hospital choice policies from the perspective of men who received treatment for prostate cancer in the English National Health Service.
Materials and methods
Semi-structured interviews were undertaken with a purposive sample of 25 men across England. Fourteen men had chosen to receive treatment at a cancer centre other than their nearest. Interviews were recorded and analysed concurrently with data collection.
Men highlight that the geographical configuration of specialist services, the perceived urgency of the condition and the protocolisation of treatment pathways all limit their choice of a specialist treatment centre. Diseases such as cancer appear not to be well suited to the patient choice model, given the lack of hospital-level outcome data. Men instead use proxy measures of quality, leaving them vulnerable to influence by marketing and media reports. Men wishing to consider other treatment centres need to independently collect and appraise complex treatment-related information, which creates socioeconomic inequities in access to treatments. A positive impact of the choice agenda is that it enables patients to ‘exit care’ not meeting their expectations.
Policy makers have failed to consider the organisational, disease-specific and socio-cognitive factors that influence a patient’s ability to choose their cancer treatment provider. Valid comparative hospital-level performance information is required to guide patients’ choices, otherwise patients will continue to depend on informal sources, which will not necessarily improve their health care outcomes.
Full detail at Clinical Oncology online
The Francis Crick Institute | April 2018 | ‘Killer’ kidney cancers identified by studying their evolution
Three new studies funded by Cancer Research UK have led scientists to better understand that kidney cancer follows a specific evolutionary path. The first two studies involved the analysis of more than 1,000 tumour samples from kidney cancer patients (n equal to 100) to reconstruct the sequence of genetic events that led to the cancer in each patient. Their analysis gave rise to the three evolutionarily distinct types of kidney cancer and each has its own path:
- The first type never acquires the ability to become aggressive
- The second tumour type forms the most aggressive tumours, evolving through a rapid burst of genomic damage early on. This enables the tumour all it needs to spread to other regions of the body.
- The third tumour spreads over a longer period of time and are made of different populations of cancer cells, some of which are aggressive
Dr Samra Turajlic lead author of the study said: “The outcomes of patients diagnosed with kidney cancer vary a great deal – we show for the first time that these differences are rooted in the distinct way that their cancers evolve.
“Knowing the next step in cancer’s evolutionary trajectory could tailor the treatment choice for individual patients in the next decade. For instance, patients with the least aggressive tumours could be spared surgery and monitored instead, and those with gradually evolving tumours could have the primary tumour surgically removed even after it has spread.”
The Francis Crick Institute have created a video to accompany this press release
The third study found that events that trigger kidney cancer can take place in childhood or adolescence years before the primary tumour is diagnosed.
Dr Peter Campbell, corresponding author of this study said: “We can now say what the initiating genetic changes are in kidney cancer, and when they happen.” (The Francis Crick Institute).
The full news story can be read at The Francis Crick Institute website
All of the articles are published in Cell and can be read by following the links
Turajlic, S. et al |Deterministic Evolutionary Trajectories Influence Primary Tumor Growth: TRACERx Renal
Turajlic, S. et al |Tracking Cancer Evolution Reveals Constrained Routes to Metastases: TRACERx Renal
Turajlic, S. et al | Timing the Landmark Events in the Evolution of Clear Cell Renal Cell Cancer: TRACERx Renal
In the media
BBC News Why some cancers are born to be bad
An update on Public Health England’s progress towards their objectives in the Independent Cancer Taskforce strategy paper | Public Health England
This document outlines Public Health England’s progress on strategic priorities identified in the Independent Cancer Taskforce report, Achieving world-class cancer outcomes: a strategy for England 2015 to 2020.
Full document: PHE progress report on the Independent Cancer Taskforce recommendations
The Mental Health Foundation | April 2018 | Supporting the emotional and mental health needs of people with cancer
The psychological impact of having cancer has been little researched. In response to this The Mental Health Foundation has conducted qualitative research with patients diagnosed with cancer in Scotland. Their research focused on the negative mental health impacts of cancer, how effective support can be delivered, the barriers to support and the unmet mental health support needs.
The interviews identified the post-treatment phase a an especially volatile time for mental wellbeing. To address the unmet need in terms of service provision for mental health during cancer and to strengthen existing programmes, they make the following recommendations:
- There needs to be greater awareness by all service providers of the mental health impacts of cancer and the need to support emotional wellbeing and mental health
- The right support needs to be given at the right time
- Tailored, person-centred support needs to be offered at all stages of the cancer journey
- There must be more collaboration and communication between service providers
- Improve signposting for mental wellbeing services
- Provide clearer and more co-ordinated support pathways after treatment
- Improve the provision of support across Scotland
- More research is needed into how best to tackle social deprivation and co-morbed health inequalities
- More research and awareness is needed to design cancer and wellbeing support services that engage BME communities
- Ensure all people with cancer have access to some level of tumour support (The Mental Health Foundation)
You can download the full document from The Mental Health Foundation
NIHR | April 2018 | Prime minister announces £75 million to support new prostate cancer research
Prostate cancer is the most common cancer in men. It has recently overtaken breast cancer as the third most common cause of cancer deaths in the UK. Now, £75 million funding has been announced by the Prime Minister to support new research into early diagnosis and treatment of prostate cancer. This will be used to complement and extend research undertaken over the past 15 years by the NIHR, Cancer Research UK, Prostate Cancer UK and the Medical Research Council.
New studies will test treatments such as more precise radiotherapy, high-intensity focused ultrasound, and cryotherapy, alongside supportive interventions including exercise and dietary advice.
They will also particularly target groups at higher risk of prostate cancer, such as black men – one in four of whom will develop the disease – men aged 50 or over, and men with a family history of prostate cancer.
Dr Jonathan Sheffield, Chief Executive at the NIHR Clinical Research Network, said:
“Clinical research brings us closer to the development of new treatments for prostate cancer patients.
“The NIHR will work closely with the NHS, life sciences industry, charities and research funders to support the recruitment of 40,000 men into research studies over the next five years. This will provide more opportunities for earlier access to new drugs and therapies, which will ultimately lead to improved diagnoses and care in the future.”
Full story at NIHR
In the media:
ITV News PM announces £75m for prostate cancer research
The Guardian Theresa May launches £75m drive against prostate cancer
The findings of a cluster randomized (1:1) trial have been published in the Journal of Clinical Oncology’s website. The researchers leading the trial sought to compare the effect of a policy adding a clinician- delivered bedside pain assessment and management tool (Edinburgh Pain Assessment and management Tool [EPAT]) to usual care (UC) versus UC alone on pain outcomes.
Employing a two-arm, parallel group, cluster randomized (1:1) trial, the scientists observed pain outcomes in 19 cancer centres in the UK, these centres were randomly assigned to implement EPAT or to continue UC. As part of the trial they enrolled 1,921 patients, with a mean age of 60; 49% of whom were female with a variety of cancer types.
The findings of this multicentre, cluster randomized trial indicate that a policy of integrating systematic pain assessment and management into routine cancer centre care using a simple tool (EPAT) improves pain outcomes for patients with moderate or severe cancer-related pain.
The scientists conclude that the centres employing EPAT had greater improvements in prescribing practice and in the Brief Pain Inventory Short Form pain subscale score. Other pain and distress outcomes and opioid adverse effects did not differ between EPAT and UC.
Pain is suboptimally managed in patients with cancer. We aimed to compare the effect of a policy of adding a clinician-delivered bedside pain assessment and management tool (Edinburgh Pain Assessment and management Tool [EPAT]) to usual care (UC) versus UC alone on pain outcomes.
Patients and Methods
In a two-arm, parallel group, cluster randomized (1:1) trial, we observed pain outcomes in 19 cancer centers in the United Kingdom and then randomly assigned the centers to either implement EPAT or to continue UC. The primary outcome was change in the percentage of study participants in each center with a clinically significant (equal to 2 point) improvement in worst pain (using the Brief Pain Inventory Short Form) from admission to 3 to 5 days after admission. Secondary outcomes included quality of analgesic prescribing and opioid-related adverse effects.
Ten centers were randomly assigned to EPAT, and nine were assigned to UC. We enrolled 1,921 patients and obtained outcome data from 93% (n = 1,795). Participants (mean age, 60 years; 49% women) had a variety of cancer types. For centers randomly assigned to EPAT, the percentage of participants with a clinically significant improvement in worst pain increased from 47.7% to 54.1%, and for those randomly assigned to continue UC, this percentage decreased from 50.6% to 46.4%. The absolute difference was 10.7% (95% CI, 0.2% to 21.1%; P = .046) and it increased to 15.4% (95% CI, 5.8% to 25.0%; P = .004) when two centers that failed to implement EPAT were excluded. EPAT centers had greater improvements in prescribing practice and in the Brief Pain Inventory Short Form pain subscale score. Other pain and distress outcomes and opioid adverse effects did not differ between EPAT and UC.
A systematic integrated approach improves pain outcomes for inpatients in cancer centers without increasing opioid adverse effects.
The full article can be read at Journal of Clinical Oncology, where it has been published online
Reference: DOI: 10.1200/JCO.2017.76.1825 Journal of Clinical Oncology – published online before print March 15, 2018
Oxford University | April 2018 | Weight loss is an important predictor of cancer
A team of scientists from Oxford and Essex Universities conducted a systematic review and meta- analysis to examine all the literature on the association between weight loss and cancer in primary care. This robust study, the first of its kind in this area, demonstrates that unintentional weight loss is the second highest risk factor for colorectal, lung, pancreatic and renal cancers (via Oxford University).
Their analysis of 25 studies, over 11.5 million patients -predominantly in primary care 22 of the studies or 92% – used data coded by clinicians in primary care. Four-fifths of these data defined weight loss as a physician’s coding of the symptom; the remainder collected data directly. An association was identified with weight loss linked with 10 cancer sites: prostate, colorectal, lung, gastro-oesophageal, pancreatic, non-Hodgkin’s lymphoma, ovarian, myeloma, renal tract, and biliary tree.
This also showed that people aged over 60 with unexpected weight loss have more than 3% chance of having cancer in one of the 10 cancer sites. In females in this age group, the average risk across all sites involved was estimated to be up to 6.7%, and in males up to 14.2%.
The authors of the study conclude that a a primary care clinician’s decision to code for weight loss is highly predictive of cancer.
The article has been published in the British Journal of General Practice online ahead of print.
Liu, J., et al | 2018 | An Integrated TCGA Pan-Cancer Clinical Data Resource to Drive High-Quality Survival Outcome Analytics | Cell | 73 | Vol. 2| P. 400-416| e11 | Doi: 10.1016/j.cell.2018.02.052.
Researchers in the US argue that based on the findings of a study that looked at 33 cancer types in more than 10,000 patients, cancers should in future be categorised according to similarities in tumour types; rather than where they are first formed. The researchers suggest they could reclassified into clusters that shared molecules.
For a decade, The Cancer Genome Atlas (TCGA) program collected clinicopathologic annotation data along with multi-platform molecular profiles of more than 11,000 human tumors across 33 different cancer types. TCGA clinical data contain key features representing the democratized nature of the data collection process. To ensure proper use of this large clinical dataset associated with genomic features, we developed a standardized dataset named the TCGA Pan-Cancer Clinical Data Resource (TCGA-CDR), which includes four major clinical outcome endpoints. In addition to detailing major challenges and statistical limitations encountered during the effort of integrating the acquired clinical data, we present a summary that includes endpoint usage recommendations for each cancer type. These TCGA-CDR findings appear to be consistent with cancer genomics studies independent of the TCGA effort and provide opportunities for investigating cancer biology using clinical correlates at an unprecedented scale.
- Generation of TCGA Clinical Data Resource for 11,160 patients over 33 cancer types
- Analysis of clinical outcome endpoints with usage recommendations for each cancer
- Demonstration of data validity and utility for large-scale translational research
In the media: BBC News Reclassify cancers to improve treatment, researchers say
The full article is available from The Cell