Block 32 Flashcards
What did the EUROCARE report compare?
Compared 5 year survival in patients across Europe.
What did the EUROCARE report show?
That the UK was performing less well than other European countries.
The UK had a lower average than Europe for colorectal cancer mortality.
Give 4 potential causes of the UKs poor performance in the EUROCARE report.
1) Differences in data collection.
2) Age differences.
3) Differences in pt. stage at presentation, social class and access to treatment.
4) Greater delays in pathways to diagnosis.
What happened as a result of the EUROCARE-II report?
The expert advisory group to the CMO generated the ‘Calman-Hine’ report.
Give 4 recommendations of the Calman-Hine report.
1) All patients should have access to a uniformly high quality of care.
2) Give public and professional education to allow recognition of early symptoms.
3) Give clear information to patients, carers and families about treatment options and outcomes.
4) Cancer services should be patient centred.
5) Primary care should be central to cancer care.
6) Recognise the psychosocial needs of patients and carers.
7) It is essential to register and monitor outcomes.
What were the 3 levels of care suggested to be a solution to inequalities in cancer care in the Calman-Hine report?
1) Primary care.
2) Cancer units serving DGHs.
3) Specialist cancer centres serving populations >1 million.
**The Calman-Hine report also recognised the ongoing importance of palliative care.
1) Describe the roles of cancer units which serve district general hospitals.
2) Describe the roles of specialist cancer centres.
1) Treat common cancers, perform diagnostic procedures, perform common surgeries, give non-complex chemotherapy treatment.
2) Diagnose and treat rare cancers, give complex chemotherapy, perform complex surgeries, give deep X-ray therapy.
Why was the Calman-Hine solution of creating 3 levels of care organised in such a way?
1) Unite commissioners, providers, local authorities and the voluntary sector.
2) Integrate care and deliver holistic care.
3) Target resources to where they are most needed.
4) To promote alliance between providers.
Why is there an emphasis on use of MDTs in cancer treatment?
Modern management involves many disciplines and the skills of different HCPs.
MDTs streamline and coordinate care so that it is not fragmented across different sites.
MDTs provide better outcomes.
1) Which HCPs are involved in the core MDT in cancer care?
2) Which HCPs are involved in the extended MDT in cancer care?
1) Physicians, oncologists, radiologists, histologists, specialist nurses and an MDT coordinator.
2) Physiotherapists, dieticians, palliative care teams and chaplains.
Give 3 roles of MDTS within cancer care.
1) Discuss all new diagnoses within the centre.
2) Decide on case management and inform primary care of updates.
3) Designate a specialist nurse to patients.
4) Audit cancer care processes.
5) Develop guidelines for the management of cancer care.
Give 2 benefits of concentrating specialist cancer care into cancer centres.
1) Better case management of lesser seen cancers due to high quality of expertise.
2) Services often only needed in complex cases, so more efficient than having these resources in all tertiary centres.
Give 2 disadvantages to concentrating specialist cancer care into cancer centres.
1) May mean that fewer services are available in smaller, local hospitals.
2) Geographical inequalities in services provided as it would be challenging to provide easily accessible services to more geographically isolated areas.
Describe the structure and role of cancer networks in the UK.
34 cancer networks and 12 strategic clinical networks in the UK.
Cancer networks produce local treatment guidelines.
Strategic clinical networks deal with cancer, CVD and dementia.
What is the aim of cancer networks?
To decrease inequalities in the care received by patients with cancer.
** Networks ensure that commissioners, provider, local authorities and the voluntary sector work together to deliver high quality care.
What are cancer registries?
A service responsible for registering all cancers that occur within their geographical area. There are 4 in the UK.
Describe 4 roles of the UK cancer registries.
1) Establish incidence and survival between different demographic and social groups.
2) Track efficacy of screening and primary prevention programmes.
3) Compare and evaluate quality of care between regions.
4) Evaluate the impact of social and environmental factors between areas.
What is meant by the term ‘cancer survival’?
The % of the study population who are alive for a given period of time following diagnosis (usually 5 years).
1) What is relative survival?
2) What is observed survival?
1) An estimate of the number of patients expected to survive compared with national mortality date.
2) Actual number of patients still alive after a specified length of time post-diagnosis.
1) What is net cancer specific survival?
2) What is crude probability of death?
1) The probability of surviving cancer in the absence of an other illness.
2) The probability of death from cancer in the presence of other causes of death.
**CPOD: determined by using LE tables and COD information.
What is meant by the following with regards to cancer care:
1) Structure
2) Process
3) Outcome
1) Facilities, resources and organisation of resources (clinics, consultants, nurses, mammogram scanners, GPs).
2) How the system works and how healthcare is provided (the % patients diagnosed at an early stage).
3) Results, changes in health status and PROMS (mortality rate and patient satisfaction).
1) What is the national cancer research network?
2) What does the national cancer research network do?
3) What is the national cancer research institute?
1) An institute established by the DoH in 2001 due to a need for the integration of research and cancer care.
2) It supports prospective cancer trials and trials performed by charity.
3) An institution developed in 2001 to develop common plans for cancer research and to avoid unnecessary duplication or studies/ effort.
State 3 roles of the national cancer research institute.
1) Invest in facilities and resources for research.
2) Maintain a cancer research database and analyse new research.
3) Develop research initiatives.
4) Coordinate clinical trials for new drugs.
Describe the aims of the national cancer research network.
To increase speed quality and integration of research to improve patient care.
Give 3 examples of psychological consequences of cancer treatment.
1) Psychologically demanding (it is supposed to help/ cure but in the short term makes patients feel worse).
2) Causes changes in appearance (loss or weight and hair). The change in body image can cause a loss of self-identification and loss of confidence.
3) Treatment is intense, so leaves little time for socialising and can cause patients to feel isolated which may cause depression.
4) Anxiety about potential side effects of treatment.
What is an adverse event?
An unintended event resulting from clinical care and causing patient harm whether physical or psychological.
What is a near miss?
A situation in which events or omissions, arising during clinical care fail to develop further, whether or not as the result of compensating action, thus preventing injury to a patient
What is a serious incident?
Events where the potential for learning is so great, or the consequences to patients, families and carers, staff or organisations are so significant, that they warrant using resources to investigate and act.
What is a never event?
Never Events are serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers.
Give 3 examples which can be classified as never events.
1) Wrong surgical site.
2) Retained instruments post surgery.
3) Wrong administration route for chemotherapy.
4) Inpatient suicide using collapsable rails.
5) Maternal death from postpartum haemorrhage after elective caesarean.
6) IV administration of concentrated KCl.
What is a standardised mortality ratio (SMR)?
A way of calculating and comparing death rates across different communities, where data is standardised for age and sex in order to allow you to compare like with like data.
What have hospital standardised mortality ratios been used for?
To identify hospitals as poor performing, and then some of the poorest performing hospitals are inspected and put into special measures in order to improve their outcomes.
Give 3 reasons as to why the validity of HSMRs has been disputed.
1) Mistaken concept - not unusual for people to die in hospital.
2) Dependent on non-hospital care - variations in planned places of death, completion of ALDs and available local services.
3) Discrepancies in data vagaries (coding and definitions) - makes it difficult to accurately compare.
4) The relationships between HSMRs and quality of care received has not been demonstrated - there is no real association between high SMRs and high avoidable deaths.
1) What are the most frequently reported adverse events in primary care?
2) What are the most frequently reported adverse events in secondary care?
1) Failure in diagnosis and delay in diagnosis.
2) Negligence (highest in obstetrics), error in medication dosing and error in medication delivery.
In order for a negative outcome to occur, what needs to happen?
A wide range of latent failures and active failures need to align (Swiss cheese model).
What are active failures?
Errors and violations having immediate negative results and are usually caused by an individual.
They are unsafe acts committed by people in direct contact with the patient.
What are latent failures?
Latent failures are caused by circumstances such as scheduling problems, inadequate training, or lack of resources which can result in an active failure.
Give 3 examples of active failures.
1) Omissions
2) Action slips/ failures
3) Cognitive failures (memory lapses or mistakes)
4) Violations
Give 2 examples of latent failures.
1) Management decisions
2) Organisational processes.
3) Poor working environmental conditions.
What are contributory factors?
These are factors that either influenced or caused a single event or chain of events that contributed to the incident. They can be positive or negative.
What is a root cause analysis?
A method of problem solving with a specific framework used for finding the root cause or fault of an incident.
What are the 2 categories of active failures?
Error based and violations.
1) What are the 3 types of error based active failures?
2) What are the 4 types of violations?
1) Knowledge based, rule based and skill based.
2) Routine, situational, reasoned and malicious.
Describe what is meant by the following types of error:
1) Knowledge based
2) Rule based
3) Skills based
1) Forming wrong plans as the result of inadequate knowledge or experience (e.g. Junior doctor misdiagnosis).
2) Misapplication of a rule or guideline to a relatively familiar situation (e.g. using an adult dosage on a child).
3) Unintended deviation of action from a plan or lack of ability to perform a task (e.g. attention slips and memory lapses).
Describe what is meant by the following types of violation:
1) Routine
2) Situational
3) Reasoned
4) Malicious
1) Normalisation of bad practice.
2) Context -dependent (time pressures, low staffing, lack of supervision).
3) Deliberate deviation from protocol thought to be in the patient’s best interests at the time.
4) A deliberate act intended to cause harm.
What is normalisation of deviance?
Where doing something improperly or wrong becomes the norm and therefore becomes the known way of doing something.
What 3 factors does a human factors approach to error acknowledge?
1) the universal nature of human fallibility
2) the inevitability of error
3) that error is not necessarily due to incompetence
What is done to try and minimise error cause by human factors?
Design aids in the workplace to try and minimise the likelihood of error and/or its consequences.
State 3 changes which have been applied to try and reduce errors caused by human factors.
1) Avoid reliance on memory.
2) Make things visible
3) Review and simplify processes
4) Standardise common processes and procedures
5) Routinely use checklists
6) Decrease reliance on vigilance.
**Basically the idea is to ‘design out error’.
What is the role of monitoring adverse events in relation to quality control? Name 3.
1) Track errors and gather data on the most common errors.
2) Target studies as to why an event has occurred and create interventions to prevent future occurrences.
3) Record near misses so the system can change before an adverse event happens.
4) Re-audit after an intervention to analyse efficacy.
5) Perform root cause analysis to identify actions necessary to eliminate risk of future event.
Name 3 systems which are in place to monitor adverse events and state what they do.
1) National patient safety agency (NPSA): Collect and analyse data about adverse event PLUS learn lessons and feedback to healthcare organisations.
2) National reporting and learning system (NRLS): Allows for anonymous reporting of incidents and is run by the NPSA.
3) Yellow card system: A reporting system for adverse drug reactions and adverse events associated with blood products. Run by the medicines and healthcare products agency (MHRA).
What are the 7 steps to patient safety?
1) Build a safety culture.
2) Lead and support staff.
3) Integrate risk management.
4) Promote reporting of adverse events.
5) Involve and communicate with patients and the public.
6) Implement solutions to prevent patient harm.
7) Learn and share safety systems.
Name 3 ways that patient safety could be improved.
1) Increase nurse and doctor patient ratios.
2) Create a patient safety culture.
3) Electronic early recognition of deteriorating patients.
4) Standardised approaches to high risk patients.
5) Promote safer prescribing.
6) Promote hand hygiene.
Name 5 steps that should be taken when involved (directly or indirectly) when an adverse event occurs.
1) Report it.
2) Assess the seriousness.
3) Analyse why it happened (RCA).
4) Be open and honest with the affected patient (duty of candour).
5) Learn from the event and put in place actions to reduce the risk of a repeat.
What is meant by ‘duty of candour’?
A legal obligation placed upon healthcare professionals to communicate to a patient if something has gone wrong or some harm has been caused.
**You are less likely to get sued if you communicate effectively and apologise then if you try to cover something up.
What is the NHS blood transfusion service?
Part of NHS blood and transplant; a special health authority who are accountable to the DoH.
Name 3 things that the NHS blood transfusion service does.
1) Test, process and store all blood received.
2) Promote donors to donate every 3-4 months.
3) Recruit new donors.
4) Invest in R&D
5) Provide 50% UK stem cell transplants.
What is the purpose of the blood safety and quality regulations of 2005?
They regulate how blood is stored and transported.
State 3 of the blood safety and quality regulations.
1) Blood is only transferred in an appropriate clinical scenario.
2) Blood is transported and packaged in accordance with validated procedures.
3) Vein traceability must be maintained (document donation, screening, storage, transfer and transfusion).
4) Wastage must be minimised.
What is screening?
Systematic application of a test to identify individuals at risk of a particular disease who warrant further investigation amongst persons who have not sought medical attention in order to decrease the risk of that disease or its complications.
Why is screening required?
1) There are limited options for primary prevention and treatment opportunities.
2) Allows the potential for early diagnosis.
3) Allows for earlier treatment and so increases the rate of effective treatment.
What is length bias?
An overestimation of survival duration due to the relative excess of cases detected that are asymptomatically slowly progressing,
What is Sojourn time?
The time between biological manifestation and clinical manifestation of a disease.
What does Sojourn time vary with?
The natural history of diseases.
Some diseases have a long Sojourn time which will give a better prognosis and more opportunities for screening, where as diseases with a short Sojourn time are more rapidly progressing and often have worse prognoses.
What is selection bias?
Selection bias is the bias introduced by the selection of individuals, groups or data for analysis in such a way that proper randomization is not achieved, thereby ensuring that the sample obtained is not representative of the population intended to be analyzed.
**In screening, there is the concept of ‘healthy screens’ meaning that the sort of person to ‘opt in’ to screening is generally more health aware. This can exaggerate any beneficial effects of a screening programme.
What is lead time bias?
Lead time bias refers to the phenomenon where early diagnosis of a disease falsely makes it look like people are surviving longer.
**Lead time is the extra time that the disease survives depending on how much earlier it was detected. It is inherent bias in screening as ‘disease survival’ is measured from the point of detection.
What is a consequence of lead time bias?
Survival is inevitably longer following diagnosis through screening because of the ‘extra’ Lead Time.
Because of this the appropriate measure of effectiveness is deaths prevented, not survival.
What are the consequences of length bias?
Diseases with a longer sojourn time are ‘easier to catch’ in the screening net.
Individuals with disease detected through screening tend to have a better prognosis than people who present with signs or symptoms.
By comparing prognosis for those screened against those not screened, there will be a distorted picture.
Give 5 examples of NHS screening programmes.
- NHS abdominal aortic aneurysm (AAA) programme
- NHS bowel cancer screening (BCSP) programme
- NHS breast screening (BSP) programme
- NHS cervical screening (CSP) programme
- NHS diabetic eye screening (DES) programme
- NHS fetal anomaly screening programme (FASP)
- NHS infectious diseases in pregnancy screening (IDPS) programme
- NHS newborn and infant physical examination (NIPE) screening programme
- NHS newborn blood spot (NBS) screening programme
- NHS newborn hearing screening programme (NHSP)
- NHS sickle cell and thalassaemia (SCT) screening programme
Why is the test used to screen for colorectal cancer a ‘good’ test?
High sensitivity and specificity (80-90% and 80-98%).
PPV of 2-5%.
Why isn’t the test that could be used to screen for prostate considered a ‘good’ test?
Sensitivity and specificity are not known.
PPV high at 30%.
Why is the treatment for colorectal cancer agreeable in terms of requirements for a screening programme?
Resection is a proven benefit in colorectal cancer and resection in disease of a less advanced stage offers better survival.
Why is the treatment for prostate cancer not agreeable in terms of requirements for a screening programme?
There is no definitive treatment for prostate cancer in terms of which is best (radiotherapy, resection or chemotherapy) and the treatment has side effects such as ED and urinary incontinence.
Why is the screening programme used for colorectal cancer deemed to be ‘good’?
A number of RCTs have reported that screening offers a benefit to patients with colorectal cancer.
Why isn’t the screening programme that could be used for prostate deemed ‘good’?
UK trials and US trials showed no benefit to the screening programme in terms of deaths prevented where as European trials showed a benefit.
Therefore, no definite consensus on the benefit of a screening programme for prostate cancer.
What is good about screening?
Early detection of disease means that the risk of death or illness can be reduced for some people.
What is bad about screening?
Some people are subjected to tests, diagnosis and treatment with no benefit (some can be harmed by further investigations).
Some people get ill or can die despite a negative screening test.
Of those who have the disease, only a small proportion are ‘saved’. The rest will die or survive, but probably would have done anyway.
LARGE POTENTIAL FOR OVER-DIAGNOSIS OR OVER-TREATMENT.
Describe 3 ethical issues of screening.
- Harm and benefits of screening (these issues are at the heart of screening).
- Screening follows a utilitarian logic
- Autonomy - are people properly formed as to the risks and benefits of screening?
- Objectives of the programme (e.g. Down’s syndrome screening had an initial objective to abort pregnancies).
- Screening of infants and children.
What is the main disadvantage with PSA testing?
It is not very specific. PSA raised in prostatitis, BPH, UTI and vigorous exercise as well as in prostate cancer.
Give 2 advantages of PSA testing.
1) May help to pick up subclinical prostate cancer.
2) may be useful to monitor PSA if a patient is a high risk individual.
Give 2 disadvantages of PSA testing.
1) Increased PSA DOES NOT necessarily mean prostate cancer.
2) PSA can often be normal in those with prostate cancer.
3) Increased PSA causes the need for more tests which may be unnecessary (SE’s = pain, infection).
4) May be diagnosed with a slow growing cancer which might never have had any health implications but can be psychologically damaging.
What is the purpose of a clinical test within medicine?
Shifts the probability of belief about whether a diagnosis is likely to be correct or not.
**If a test cannot shift your belief about a patient’s condition, then it is probably not worth doing it.
What is a true positive result?
A positive test result in an individual who does have disease.
What is a false positive result?
A positive test result in an individual who is actually free of disease.
What is a false negative result?
A negative test result in an individual who does have disease.
What is a true negative result?
A negative test result in an individual who does not have the disease.
What makes a good test?
One that maximised true positive and true negatives and minimises false ones.
Define sensitivity.
This is the true positive rate.
The proportion of people with a certain disease who test positive for that disease.
Define specificity.
This is the true negative rate.
The proportion of people without disease who test negative for that disease.
How do you calculate sensitivity?
Number of true positives/ all those with disease.
How do you calculate specificity?
Number of true negatives/ all those without disease.
What will it mean if a test has a high sensitivity but a low specificity?
That all those with disease are identified but there are false positive results.
What will it mean if a test has a low sensitivity but a high specificity?
That all those without disease are identified bu there are false negative results.
1) What is a type 1 error?
2) What is a type 2 error?
1) Rejection of a true null hypothesis.
2) Acceptance of a false null hypothesis.
1) Define positive predictive value.
2) How is positive predictive value calculated?
1) Those who have a positive test and actually have the disease.
2) Number of true positives/ those who test positive.
1) Define negative predictive value.
2) How is negative predictive value calculated?
1) Those who test negative and are actually disease free.
2) Number of true negatives/ number than test negative.
Describe the effect of an increasing prevalence on NPVs and PPVs.
Increasing prevalence = decreasing NPV and increasing PPV.
Describe the effect of a decreasing prevalence on NPVs and PPVs.
Decreasing prevalence = increasing NPV and decreasing PPV.
1) Define incidence.
2) Define prevalence.
1) Incidence is the number of new cases of a condition, symptom, death, or injury that develop during a specific time period, such as a year. Incidence shows the likelihood that a person in a certain population will be affected by that condition.
2) The number of cases of a disease that are present in a particular population at a given time.
Describe the effect of prevalence on sensitivity and specificity.
Prevalence does NOT affect sensitivity and specificity.
Give 3 examples of where prevalence can change.
1) Between primary and secondary care.
2) Across age groups
3) Between countries.
1) How do you calculate incidence?
2) How do you calculate prevalence?
1) Number of new cases in a certain time frame/ total population.
2) Number of cases/ population size.
What can likelihood ratios help you to assess?
How the chances of disease have changed after a test is performed.
What are the 2 likelihood ratios that a test with two outcomes has?
Likelihood ratio for a positive test result (LR+)
Likelihood ratio for a negative test result (LR-)
How do you calculate LR+?
Chance of a true positive/ change of a false positive.
How do you calculate LR-?
Chance of a false negative/ chance of a true negative.
1) What does a larger LR+ mean in terms of chance of disease?
2) What does a smaller LR- mean in terms of chance of disease?
1) The larger the LR+ve greater chance have disease if your test is positive
2) The smaller the LR-ve less chance have disease if your test is negative
1) What does a larger LR+ mean in terms of chance of disease?
2) What does a smaller LR- mean in terms of chance of disease?
1) The larger the LR+ve greater chance have disease if your test is positive
2) The smaller the LR-ve less chance have disease if your test is negative
**Chance of disease before test x LR = chance of disease after test.
What is a nomogram?
It is a way of relating the likelihood ratios to the pre- and post-test probabilities.
1) What is a nomogram?
2) What was special about the NHS cancer plan 2000?
1) It is a way of relating the likelihood ratios to the pre- and post-test probabilities.
2) It was the first ever comprehensive strategy to tackle the disease.
List the sequelae of the NHS cancer plan 2000 (3).
1) Review prevention, screening, diagnosis, treatment and organisation of cancer services.
2) NICE guidance on organisation of services for particular cancers.
3) Creation of manual of cancer standards (revised to manual of quality measures in 2004).
4) National peer reviews (centre to centre) to ensure standards are maintained.
What were the 6 key areas identified in the cancer reform strategy of 2007?
1) Prevention.
2) Earlier cancer diagnosis.
3) Ensuring better treatment.
4) Living with and beyond cancer.
5) Reducing cancer inequalities.
6) Delivering care in the most appropriate settings.
What was the main principle behind the human tissue act of 2004?
That consent is needed for ‘scheduled purposes’ such as storage and use of tissues of the living or deceased. This includes research in connection with disorders or the normal functioning of th human body.
What are the 3 main MRC guidelines on confidentiality?
1) All patient information is to be regarded as confidential.
2) All research using identifiable personal information or anonymous NHS data which is not already in the public domain must be approved by NHS REC.
3) All personal information must be coded and anonymised as far as practically possible.
Name 3 occurrences which motivated the development of research ethics.
1) Nazi experiments.
2) Tuskegee syphilis study.
3) Wakefield claims on correlation between MMR vaccine and autism.
What was the Nuremberg code (1947)?
A set of research ethics principles developed for human experimentation.
Give the 3 principles of the Nuremberg code.
1) Voluntary consent from participants essential.
2) Avoid all unnecessary suffering.
3) Research only to be conducted by qualified persons/
What was the Helsinki Declaration (1964)?
Proposal from the world medical association that key ethics principles, namely the requirement for any human research to be subjected to independent ethical review and oversight by committee.
**Can be beneficial as researchers may be unaware of potential issues and so the committee can consider these.
State 5 general research ethics principles.
1) Will the study be useful?
2) Would the study be possible without humans?
3) Has consent been gained?
4) Make effort to maximise respect for confidentiality/ privacy.
5) Are the selection procedures fair?
6) Has the study been approved by the relevant REC?
What does ‘clinical equipoise’ mean?
This is the assumption that there is not one ‘better’ intervention present during the design of an RCT.
It is based on researchers not knowing which intervention is better in an RCT.
When is approval for a research study needed?
Whenever human participants, human tissues or personal date is being used in the study.
State 3 reasons why approval is needed for research studies.
1) Ensure accordance with research principles.
2) To protect researchers and participants.
3) Decrease cases of negligence.
4) Protect the reputation of institutions.
5) It is a condition for funding to be given.
6) It is a legal requirement.
Who is approval for research studies needed from?
1) NHS REC: for anything using NHS data/ patients (except NHS staff recruited by virtue of a professional role).
2) University REC: usually needed if NHS approval is needed (done by an integrated research application system - IRAS).
Give 3 factors that are considered when committees are deciding whether to grant approval for a research study.
1) Scientific/ ethical importance of a study.
2) Likelihood of the study achieving its aims.
3) Risks vs. benefits of the study.
4) Methods of recruitment, consent and confidentiality.
5) Destruction of samples/ data.
What is valid consent?
INFORMED
VOLUNTARY
CAPACITOUS
How is it ensured that consent received for participation in a research study is:
1) Informed
2) Voluntary
3) Capacitous
1) Patient information sheets about everything involved including risks and procedures.
2) No pressure, no financial inducements, no threats or sanctions.
3) Facilitation of effective decision making:
- avoid jargon
- information sheets
- present information on a level that the patient understands
- give adequate time to contemplate information given
- inform patient that they can withdraw from the study at anytime.
1) What is a proven method for supporting smoking cessation in patients?
2) Give an example of what brief smoking cessation advice would include for a patient who smokes.
3) Name 3 strategies which can be involved in motivational support for patients wanting to give up smoking.
1) Combination of advice/ behavioural support and pharmacotherapy.
2) ‘The best thing you can do for your health is to stop smoking and I would advise you to stop as soon as possible’.
3) Motivational interviewing, CBT and telephone based services.
1) Give 2 options of different drugs used for smoking cessation.
2) Give 3 ways in which smoking cessation services are provided.
1) Buproprion and Varenicline.
2) Cessation clinics, stop smoking counsellors (specialist trained nurses) and online ‘quit kits’ upon request.
Why are post mortem sometimes needed?
Because without a medically identified causes death relatives cannot register the death.
What is the ‘social cognition theory’?
A belief in oneself to be capable of exercising a measure of control over their behaviour and this increases the likelihood that they will be able to.
What is the social cognition theory reinforced by?
Social sanctioning of that certain behaviour (i.e. adverts about quitting smoking).
Name 3 models of behaviour change.
Social cognition theory (self-efficacy)
Health locus of control
Leventhal’s model of illness
Name 3 major theories of predicting and changing health behaviours.
Stages of change model
Theory of planned behaviour
Health belief model
What is the health locus of control/ attribution theory?
Attributes blame to various things (internal, powerful others, chance, god).
What is Leventhal’s model of illness?
A model detailing how lay people assess illness.
What are the 5 main aspects of Leventhal’s model of illness?
1) Identification - what is it?
2) Timeline - how long has it been?
3) Consequence - Bleeding? Loss of function?
4) Cause - caught from someone?
5) Control - can I self medicate?
What are the 5 stages in the ‘stages of change’ model?
Precontemplation Contemplation Preparation Action Maintenance
**Patients can get stuck, regress or relapse at any stage.
What does the theory of planned behaviour show?
How health beliefs can influence intentions.
What is the health belief model?
A model taking into account individual perceptions and modifying factors such as demographics or psychosocial factors which can influence the likelihood of undertaking an action.
Give 3 reasons as to why prognosis for disease tends to be worse for those of a lower socio-economic class or BAME groups.
1) Decreased likelihood to attend screening programmes.
2) Increased ‘risky’ lifestyle choices (smoking, alcohol, poor diet, decreased exercise).
3) Information inaccessible (i.e. language barrier/ illiteracy).
4) Services inaccessible.
What did Pound et al. describe ‘normal crises’’ to mean?
That diagnosis is but a continuation/ biographical reinforcement of someone’s normal life.
This means that a patient may have experienced crises throughout life (poverty, ageing, poor housing), so a diagnosis may just be one more crisis in the chain and so not such a big deal to them.
Cannot assume that a new diagnosis will cause biographical disruption as you need to take into account context, meaning, timing and expectations.
What does the biographical disruption theory suggest
That a diagnosis can cause disruption to structures of every day life.
What are the 3 aspects of biographical disruption?
1) ‘taken for granted’ assumptions/ behaviour - the body cannot do certain things anymore.
2) biography/ self-identity - re-evaluation of life plans
3) Response to disruption - demands and resources
**This is a useful concept to understand how people view chronic illness.
Name 4 risk factors associated with delayed presentation of breast cancer symptoms to primary care.
1) Age
2) Lower SES
3) Lower educational level
4) Initial symptom that was not a lump
Name 3 benefits of smoking cessation.
1) Increased O2 sats so peripheries feel warmer.
2) Decreased mucous production = less breathing difficulties.
3) Better smell and taste sensations.
4) Decreased susceptibility to infection.
5) Decreased CVD risk.
6) Decreased risk of throat, oesophageal, lung and bladder cancers.
1) Every year of smoking after 40 years decreases life expectancy by what?
2) How long after quitting smoking does risk of an MI decrease to that of a non-smoker?
3) How long after quitting smoking does risk of lung cancer decrease to that of a non-smoker?
1) By 3 months.
2) 5 years.
3) 10-15 years.
Give 3 ways that post mortems can contribute to understanding an influencing care of the living.
1) Information recorded on death certificate underpins national mortality data.
2) Important in monitoring population health (and for epidemiological research).
3) Inform authorities of need for interventions and allows targeting of interventions.
4) Tissue pathology allows development of understanding of natural history of disease, identification of potential tests for investigation of disease presence and identification of drug targets –> RESEARCH.
What is the role of HM coroner?
To investigate and ascertain cause fo death occurring in suspicious circumstances.
**A body cannot be released until a coroner is satisfied with cause of death.
Why is consent not gained for a post mortem to be carried out?
Because a coroner is required by law to carry out a post-mortem when a death is sudden, suspicious or unnatural.
1) Who is eligible for a mammogram?
2) What is an exception to this eligibility criteria?
3) What views are taken with a mammogram?
1) Women aged 47-73 (all to go within 3 years of becoming age-eligible).
2) If a woman has a genetic predisposition, they are invited for mammogram at age 40.
3) Cranio-caudal and medio-lateral.
1) What is involved in a ‘triple assessment’ for patients with suspected breast cancer?
2) Who undergoes the ‘triple assessment’?
1) Mammogram, examination and USS ± biopsy (depending on radiological grading).
2) Recalled women after screening mammogram or patients referred by GP under 2ww criteria.
What is the basic process at breast cancer MDT meetings?
Patient results are discussed and best options for treatment are chosen.
There is referral to an oncologist.
Treatment options available are radiotherapy, chemotherapy, surgery or hormonal therapy.
What are the 3 main challenges of the breast cancer screening service?
1) Uptake - currently 75%, decreased rates in London/
2) Cost - expensive to run such a wide-reaching service.
3) Education - teaching of self-examination and about breast cancer in general.
Give 3 ways that the quality of a service can be judged.
1) Detection rates (sensitivity, NPV, PPV)
2) Comparative breast cancer mortality data pre-post screening (beware of bias).
3) PROMs (QALYs and surveys of treatment)
4) Look at structure (staffing, time resources), process (following good practice guidelines?) and outcomes (survival, etc).
1) What method is used to look at expenditure for a screening programme to assess its cost effectiveness?
2) How else can cost effectiveness be assessed?
1) Opportunity cost.
2) Cost effectiveness assessed by QALYs, decreased mortality, lives saved, cost per life saved (NNT x cost).
**One of the UK National screening committee criteria is cost-efficacy of the programme.
Give 3 psychosocial impacts of cancer diagnosis and treatment.
1) Uncertainty in prognosis (life put on hold, worry about how long is left).
2) Stress (getting affairs in order).
3) Family tension (disagreement in treatment pathway).
4) Devastating psychologically (some patients are irreconcilable).
5) Some are reticent and introverted to protect family (need an outlet –> counsellor?)
6) Depression and anxiety (about condition, what is in store, what will the end be like?)
1) Name the most common cancers globally.
2) Why could have prostate replaced stomach cancer as the 4th most common cancer globally?
3) What are the most common cancers in the UK?
1) Lung, breast, colorectal, prostate
2) Increased hygiene and increased understanding of stomach infection aetiology.
3) Breast (1st in females), prostate (1st in males), lung, bowel.
Describe the changes in incidence of common cancers in men that have happened recently.
Lung cancer: -20% (decrease in smoking).
Bladder cancer: -30% (less occupational exposure).
Melanoma: +70% (increase in overseas holidays since 70s).
Liver cancer: increase (alcohol).
Describe the changes in incidence of common cancers in women that have happened recently.
Lung cancer: +10% (women started to smoke later than men so effects occur later).
1) Which cancer has increased in prevalence in MEDCs?
2) Increases in cancer incidence follow which model?
3) In which areas of the world is cancer not one of the most common cause of death?
1) Colorectal (? due to diet)
2) Demographic transition model (increase in ageing population = increase in cancer).
3) SE Asia, Eastern mediterranean and Africa.
1) What are the most common causes of cancer deaths globally?
2) What are the most common causes of cancer deaths in the UK?
1) Lung, stomach, liver, prostate.
2) Lung, colorectal, breast, prostate.
**In the UK, although incidence of cancer has increased, deaths have decreased.
Describe childhood cancers in comparison to adult cancers.
Differ clinically and histopahtologically
Comparatively responsive to therapy
85% patients with ALL survive >5 years
Form 1% of all cancers (rare).
1) When is peak incidence for childhood cancer?
2) What are the most common childhood cancers?
1) 2-5 years
2) Leukaemia, brain, CNS, lymphoma (ALL is most common).
Give 3 primary prevention methods for cancer.
Vaccines
Legislation
Lifestyle campaigns
Give 3 secondary prevention methods for cancer.
Screening
Early detection
Early diagnosis
Give 3 tertiary prevention methods for cancer.
Disease management
Cure
Palliation
What was involved in prevention in the cancer reform strategy 2007?
Changes to lifestyle (diet, smoking, alcohol, exercise).
What was done for the early diagnosis aspect of the cancer reform strategy 2007?
Extension of screening programmes for cervical, breast and bowel cancer.
Research on feasibility of CT screening fo lung cancer.
What is NAEDI and what is its purpose?
National awareness and early diagnosis initiative. Set up to increase awareness and develop a tool for measuring awareness.
**NAEDI hypothesis: difficulty in access/ awareness = later presentation = worse outcomes.
What were the plans for ensuring better treatment of cancer in the 2007 cancer reform strategy?
Reduce waiting times.
Introduce training programmes for laparoscopic bowel surgery.
Increase radiotherapy capacity.
Refer all new cancer drugs to NICE
What were the 2 principles for delivering care in the most appropriate setting in the cancer reform strategy 2007?
1) Care should be delivered locally wherever possible to maximise patient convenience.
2) Services should be centralised where necessary in order to improve outcomes.
**Some services were also shifted from inpatient to outpatient (ambulatory care).
What were the key principles of NAEDI?
1) Achieve early presentation (some patients don’t want to waste time though).
2) Optimise clinical practice and systems (compare practice data).
3) Increase GP access to diagnostics.
4) Research, monitor and evaluate.
What were the 4 methods used to try and achieve the NAEDI objectives?
1) National audit of cancer diagnosis in primary care.
2) Significant events audit in GP.
3) Decision aid tools to aid diagnosis.
4) New referral guidelines (focus changed from systems to symptoms).
Did the formation of national caner strategies work?
Yes.
Survival increased for most cancers.
UK still behind European average.
Still inequalities across UK.
State 3 things that the independent cancer Taskforce of 2015 did.
1) Spearheaded a radical upgrade in prevention and public health.
2) Drive ambition to achieve more.
3) Want patient experience to be on par with clinical efficacy.
4) Make necessary investments to deliver modern, high-quality care.
