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Health and Society (Year 3) > cancer > Flashcards

cancer Flashcards

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1
Q

what is the eurocare report and what did it show?

A

comparing 5 year cancer survival in patients across Europe ->UK performing less well
-Lower than european average for colorectal cancer mortality.

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2
Q

what are the potential causes of poor performance in the eurocare report? (4)

A
  1. Differences in data collection (registries) -> rejected
  2. Age differences ->but rates were age-standardised
  3. Differences in stage at presentation, social class (↑affluent had ↑survival improvement, deprived have worse rates) + access to treatment.
  4. Greater delay in pathway to diagnosis
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3
Q

what were the consequences and conclusions of EUROCARE-II report?

A

Despite methodological limitations, cancer survival in UK in 80s+90s one of worst in europe.

Expert advisory group to chief medical officer generated “Calman-Hine” report.

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4
Q

what were the recommendations of the Calman-Hine report? (7)

A
  1. All patients should have access to uniformly high quality care.
  2. Public and professional education, to recognise early symptoms.
  3. Patients, families + carers should be given clear info re: treatment options + outcomes.
  4. Cancer services should be patient-centred
  5. 1° care to be CENTRAL to cancer care (1st time this had been suggested!!)
  6. Psychosocial needs of carers + patients to be recognised ->also fairly new
  7. Registration + monitoring of outcomes are to be essential
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5
Q

what are the solutions to the calman hine report findings?

A

3 levels of care

  1. 1° care
  2. Cancer Units Serving DGHs (district general hosps) - Treat common cancers, diagnostic procedures, common surgery, non-complex chemo
  3. Cancer Centres – serving populations of >1m, Treating rare cancers, RTx + complex chemotherapy.

Also recognised ongoing importance of palliative care.

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6
Q

what is the purpose of organising care into 3 levels of care? (4)

A
  1. Bring together commissioners (health authorities, CCGs), providers (GP surgery, community care, hospitals) and local authority + voluntary sectors
  2. Helps to integrate aspects of care + deliver holistic package
  3. Allows targeting of resources where needed most
  4. Promotes alliance between providers
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7
Q

why is there an emphasis on the MDT?

A

Modern management involves many disciplines and allied health professionals, MDT streamlines and co-ordinates care so that it is not fragmented over several sites. ->BETTER OUTCOMES!

  • Doubled NSCLC median survival
  • increase outcomes of ovarian cancer, for patients managed by specialist teams (gynaecologist vs. non-gynaec)
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8
Q

what is the structure of the cancer MDT?

A

CORE: Medical staff (physician, oncologist, radiologist, histopathologist), Specialist nurse, MDT co-ordinator.

EXTENDED: Physio, dietician, palliative care, chaplain

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9
Q

what is the function of the MDT?

A
  1. Discuss all new diagnoses at the site. Decide on management + inform 1° care of it
  2. Designate specialist nurse to patient. Audit. Develop guidelines.
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10
Q

what are the advantages of concentrating specialist care into cancer centres?

A
  1. Centres of excellence which have a very high level of expertise
  2. Often needed only in most complex cases -> therefore inefficient to have this in all 3° centres
  3. For a number of cancers, ↑ volume of surgical procedures -> ↑ outcomes. Better to have fewer centres with ↑ volume of cases.
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11
Q

what are the disadvantages of concentrating specialist care into cancer centres?

A
  1. Possible –ve impact on provision of care in smaller hospitals
  2. Challenging to provide accessible services to more geographically isolated areas
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12
Q

what are cancer networks?

A

-(cf MDT that produce local treatment guidelines) to be organisational model to implement the cancer plan. They drive cancer plan and cancer reform strategy.
•34 Cancer networks -> 12 Strategic clinical networks (SCNs) – cover not just cancer (include CVD, dementia, less staff – Apr 2013
•1° aim -> ↓ inequalities in the care of cancer

“Networks are to ensure that all commissioners and providers of cancer care, the voluntary sector and local authorities within the network work effectively together to deliver high quality care.”

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13
Q

what ways is quality of cancer services measured at local and national levels?

A

• One of the few conditions which we have a population level registry!
• In UK we now have 4 cancer registries
• Responsible for registering ALL cancers occuring in geographical area.
• Prinicple aim is to establish incidence and survival over time, between demographics and social groups – can help ↓ inequality
• Also can be used to track efficacy of screening + primary prevention schemes.
o Can be used to change + improve schemes
• Allows comparison between regions – evaluate quality of care
• Evaluates impact of social + environmental factors ->inform means to ↓inequality
WHAT IS CANCER SURVIVAL + HOW IS IT MEASURED?

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14
Q

what is survival?

A

% of study population who are alive for a given period of time following diagnosis (usually 5 yrs)

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15
Q

what is relative survival?

A

estimate of number of patients expected to survive, calculated from national mortality data

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16
Q

what is observed survival?

A

actual number alive after specified time post-diagnosis

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17
Q

what is net cancer specific survival?

A

probability of surviving cancer in absence of other illness

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18
Q

what is crude probability of death?

A

probability of death from cancer in presence of other causes of death. Obtained from life expectancy tables/cause of death info.

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19
Q

describe the main issue with death rates and confounding?

A

Confounded massively by age. Two approaches to deal with it:

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20
Q

what are the 2 ways to deal with confounding with age and death rates?

A

indirect standardisation

direct standardisation

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21
Q

describe the role of indirect standardisation in death rates and confounding?

A

How many deaths would we expect in age group? How many were there?
 Observed/expected ratio = STANDARDISED MORTALITY RATE
•SMR = 100% = population experiences mortality rate similar to standard rate
•SMR > 100% = higher than standard rate
SMR < 100% = lower than standard rate

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22
Q

describe the role of direct standardisation in death rates and confounding?

A

Weighted avg of ‘stratum-specific rates’. Weights usually based on ‘standard population’

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23
Q

describe the structure of cancer care?

A

facilities, recources (both human and material), organisation
i.e. clinics, consultants, nurses, mammogram scanners, GPs

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24
Q

describe the measures of cancer outcome?

A

Results, changes in health status, PROMs (i.e. satisfaction)

i.e. mortality rate

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25
Q

describe the role of national cancer research network?

A
  • Established by DoH in 2001 in response to need for integration of research and cancer care
  • Supports prospective cancer trials + trials performed by charity
  • AIM: ↑ speed, quality and integration of research to improve patient care
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26
Q

describe the role of the national cancer research institute?

A
  • Est. 2001 to develop common plans for cancer research and to avoid unnecessary duplication of studies/effort.
  • Invest in facilities + resources for research
  • Maintain cancer research database and analyse new research.
  • Develop research initiatives • Coordinate clinical trials for new drugs
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27
Q

what is an adverse event?

A

unintended event resulting from clinical care + causing patient harm, whether physical or psychological
o Serious ‘NEVER’ events, or non-serious.

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28
Q

what is a near miss?

A

events or omissions arising during clinical care fail to develop further (whether or not due to compensating action), thus preventing injury to patient.
oAlthough no harm comes, they do
show the potential!

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29
Q

give examples of never events?

A
  • Wrong surgical site
  • Retained instrument post-surgery
  • Wrong admin route for chemo
  • Inpatient suicide using collapsible rails
  • Maternal death from post-partum haemorrhage after elective caesarian
  • IV admin of conc. KCl
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30
Q

give examples of adverse events?

A
  • HAI (i.e. pneumonia, UTI)
  • Pressure ulcers
  • Falls
  • Medication SFX (not med. error if known pharmacological risk i.e. gentamicin + neonatal deafness)
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31
Q

what are the most frequently reported events in primary care?

A
  • Failure in diagnosis

* Delay in diagnosis

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32
Q

what are the most frequently reported events in secondary care?

A
  • Negligence - ↑↑obstetrics
  • Error in medication dose
  • Error in medication delivery
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33
Q

describe the prevelence of adverse events in the NHS?

A

10% of hosp admissions result in adverse event.

• 850,000 year. 1.1bn paid out (obstetrics 40% of this).

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34
Q

why do adverse events happen?

A

•Whole range of latent + active failures need to align in order for
the negative outcome to become reality.
-swiss cheese model

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35
Q

what latent failures can contribute to an adverse event?

A

management decision

organisational processes

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36
Q

what work conditions can contribute to adverse events?

A

background factors

  • workload
  • supervision
  • communication
  • equipment
  • knowledge/ability
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37
Q

what active failures can contribute to an adverse event?

A

unsafe acts

  • omissions
  • action slips/failures
  • cognitive failures (memory lapses and mistakes)
  • violations
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38
Q

what are active failures?

A

UNSAFE ACTS BY PEOPLE IN DIRECT PT CONTACT

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39
Q

what is the difference between errors and violations?

A

errors are unintentional whereas violations are intentional

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40
Q

give examples of errors?

A

knowledge based
rule based
skills based

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41
Q

what are knowledge based errors?

A

wrong plan formed due to inadequate knowledge/experience (JD misdiagnosis)

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42
Q

what are rule based errorss?

A

Misapplication of ‘good rule’/guidline (i.e. applying guidline for 10y/o to neonate)

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43
Q

what are skill based errors?

A

Common. Attention/memory lapse. Unintended deviation from good action/plan.

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44
Q

give examples of types of violations?

A

routine
situational
reasoned
malicious

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45
Q

what are routine violations?

A

normalisation of bad practice

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46
Q

what are situational violations?

A

Context-dependent (i.e. shortcuts when overwhelmed/understaffed)

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47
Q

what are reasoned violations?

A

Deliberate deviation from protocol thought to be in best interest @ time.

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48
Q

what are malicious violations?

A

Deliberate act intended to harm

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49
Q

what are latent errors?

A
  • Things in background which ↑likelihood of mistakes being made
  • Develop over time and lay dormant until combine with other factors  adverse event
  • Can be ID’d and removed before an adverse event occurs!
  • i.e. working environment conditions, staff training, socio-cultural factors
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50
Q

what is the role o monitoring adverse events in relation to quality control?

A
  • Tracks errors, gathering data on most common errors and where.
  • Allows us to target studies as to why and interventions to avoid future occurrences.
  • NEAR MISSES should also be recorded, so that system can change BEFORE an adverse event occurs.
  • Re-audit after intro of new procedure allows analysis of efficacy.
  • Root cause analysis is common approach – structured investigation to ascertain cause and actions necessary to eliminate
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51
Q

what systems are in place to monitor adverse events?

A

•National patient safety agency (NPSA)
o Collect + analyse data re: adverse events
o Learn lessons + feedback to healthcare organisations.
o Specify national goals, support work undertaken to produce solutions to ↓risks

•National reporting and Learning system (NRLS)
o Anonymous reporting of incidents
o Run by the NPSA

•Yellow card system – reporting system for adverse drug rxns, run by Medicines + Healthcare Products Agency (MHRA)
o MHRA also run reporting system for adverse events associated with blood products

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52
Q

describe the process of monitoring adverse events?

A
  • classifying incident
  • establishing teams
  • scoping the problem
  • data gathering
  • information mapping
  • identifying problems
  • analysing problems for contributory factors
  • agreeing root causes
  • recommending and reporting
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53
Q

what are the professional responsibilities if involved (directly or as a witness) in adverse event?

A
  • Report it
  • Assess its seriousness, then LEARN
  • Root cause analysis
  • Open + honest w affected pt (DUTY OF CANDOUR)
  • Take steps to ↓future recurrences.
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54
Q

what are the seven steps to patient safety?

A
  1. Build a safety culture
  2. Lead and support staff
  3. Integrate risk management
  4. Promote reporting
  5. Involve and comm with patients + public
  6. Implement solutions to prevent harm
  7. Learn and share safety systems
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55
Q

give examples of possible psychological consequences of cancer treatment?

A
  • Pyschologically demanding -> supposed to help/cure, though in short-term, makes you feel worse.
  • Loss of weight, hair – changes the individual physically ->body image altered ->ID/sense of self is incongruent with what they see in mirror.
  • Treatment can be intense (every day for months) -> no time for social ventures ->isolated ->depression? • Anxiety about SEs
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56
Q

describe the organisation of blood transfusion service?

A
  • Part of NHS Blood and Transplant; a Special Health Authority who are accountable to the DoH.
  • Test, process and score all blood received
  • Promote donors to donate each12/16 weeks
  • Recruit new donors
  • Provide 50% UK stem cell trasnplants
  • Invest in R&D
  • Manage the supply of blood + deliver -> hospitals
  • Blood Safety and Quality Regulations 2005 – regulates blood storage and transport
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57
Q

what is the aim of blood safety and quality regulations 2005?

A

oBlood only transferred in appropriate clinical scenario
oTransported + packaged in accordance with validated procedures
oVein -> Vein tracability must be maintained – document donation, screening, storage, transfer, transfusion.
oWastage minimised

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58
Q

what is the purpose of screening?

A
  • Limited 1° prevention + treatment opportunities
  • Potential for early diagnosis
  • ↑ Effective treatment (as a result of the above)
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59
Q

what is screening?

A

= Systematic application of a test/inquiry to…
• ID individuals @ risk who warrant further investigation/action
• Amongst persons who have not sought medical attention.
• To ↓ risk of disease or its complications
• Best thought of as secondary prevention.

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60
Q

what is the role of the UK national screening committee criteria?

A

The committee consider the viability, efficacy and appropriateness of programme based on…

  • condition
  • test
  • treatment
  • programme
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61
Q

what criteria must the condition meet for screening?

A

important health problem? Epidemiology + natural Hx should be understood, should be a DETECTABLE RF/disease marker + latent/asymptomatic period. All cost effective 1° preventative measures implemented.

62
Q

what criteria must the test meet for screening programme?

A

simple, safe, precise + validated. Normal distribution of values should be known + cut-off agreed, agreed policy on further management if there is a +ve result.

63
Q

what criteria must the treatment meet for a screening programme?

A

evidence-based effective treatment, agreed policy on who is offered it, clinical management should be optimised prior to implementation

64
Q

what criteria must the programme meet for a screening programme?

A

RCT evidence showing programme effective in ↓mortality/morbidity. Benefit>harm, plan for quality assurance (i.e. NSF) + adequate resources (clinical staff, facilities, equipment, lab staff etc.)

65
Q

why might cancers found on screening have a better prognosis?

A
  • Must distinguish between real benefits and artefactual benefits
  • Length and lead-time biases must be accounted for.
66
Q

what is screened for antenatally and in newborns?

A 
downs syndrome
fetal anomaly ultrasound scan
infectious diseases in pregnancy 
antenatal sickle cell and thalassaemia
newborn and infant physical examination
newborn blood spot
newborn hearing screening
67
Q

what is screened for in adults?

A 
AAA
diabetic retinopathy
breast cancer
cervical cancer
bowel cancer
68
Q

what is sojourn time?

A

time between biological manifestation and clinical (symptomatic) manifestation. Varies with the natural Hx of different diseases (i.e. tumours, long = ↑prognosis + opportunity, short = ↓prognosis, rapid progress)
Slow sojourn time diseases will be disproportionately represented in the population, as fast sojourn are not found as often/as well in screening (↓ chance of catching it).

69
Q

what are the consequences of length bias?

A

•Longer sojourn = easier to catch
•On avg. individuals with disease detected via screening have ↑ prognosis cf clinical pts.
•Comparing those who choose to be screened vs. don’t -> distorted picture
Basing RCT on intention to screen analysis will include all outcomes + assess impact of screening.

70
Q

what is lead time bias?

A

Inherent bias in screening, as ‘disease survival’ is measured from point of detection. Might still die at same age they would have without screening, but have known about disease longer (i.e. longer ‘survival’ with the disease)
 As a result, survival NOT measured; rather deaths prevented.

71
Q

what is the issue of the healthy ‘screenee’?

A
  • People who choose to be screened often also make other health-conscious choices
  • This can exaggerate any beneficial effects a screening programme may be having.
72
Q

what is the difference between colorectal cancer and prostate cancer with regards to screening?

A

o Colorectal well understood, manifests symptomatically very obviously (bleeding polyps), possible 1° prevention.
o Prostate not so (only raised PSA really, but non-specific).

73
Q

describe the difference in screening test for prostate cancer vs colorectal cancer?

A

o Faecal Occult Blood vs. PSA (ultrasound-guided probe + needle).
o Test performance known for FOB, but not for PSA.

74
Q

what is the difference in treatment for prostate cancer and colorectal cancer regarding its suitability for screening?

A 
o	Resection proven for colorectal
o	Prostate (RXT, surveillance, CXT) not sure which is best? SEs: ED, urinary incontinence
75
Q

what is the difference in the potential screening programmes for prostate cancer and colorectal cancer regarding its suitability?

A

o RCTs report benefit to colorectal.

o Prostate RCTs discrepancy between US (no benefit) vs European trial (moderate benefit).

76
Q

who benefits from screening?

A

+ve result doesn’t mean disease, majority are disease free. Some harmed by further investigations. Those few who have disease only small proportion ‘SAVED’ – rest die or survive, but would have anyway!
Large potential for OVERDIAGNOSIS and OVER-TREATMENT

77
Q

what are the ethics of screening?

A

• Screening follows utilitarian ethical logic, benefit/harm at heart of screening.
• Autonomy – properly informed as to risks/benefits?
o What are the objectives of programme? (Down’s syndrome screening, initially to abort?)

78
Q

describe the specificity of PSA testing?

A

• NOT very specific test (↑ also in prostatitis, BPH, UTI, vigorous exercise)

79
Q

what are the advantages of PSA testing?

A
  • May help to pick up sub-clinical prostate cancer

* May be useful to monitor if you are a high risk individual

80
Q

what are the disadvantages of PSA testing?

A
  • ↑ PSA NOT = prostate cancer
  • PSA often normal in those with cancer
  • ↑ -> more tests which would be unneeded -> SEs (pain, infxn)
  • May be diagnosed with slow growing cancer – never have any health implication.
81
Q

describe an ideal test in terms of true/false poisitives/negatives?

A

maximise true +ves/-ves and minimise false ones.

82
Q

what is the true positive rate

A

no. true +ve/total no. with disease = Sensitivity

• Proportion of truly ill people who are ID’d as ill

83
Q

what is the true negative rate?

A

no. true –ve/total no. without disease = Specificity

Proportion of truly healthy people who are ID’d as such

84
Q

describe a test that has a high sensitivity but low specificity?

A

False +ves

•All disease ID’d, but some are actually normal

85
Q

describe a test that has low sensitivity but high specificity?

A

false -ves

• All without disease ID’d, but some with diease missed

86
Q

what is positive predictive value?

A

No. of true +ves /No. who test +ve (false + true)  those who test +ve + actually have disease

87
Q

what is negative predictive value?

A

No. of true –ves/No. who test –ve (false + true)  those who test –ve + really are disease-free

88
Q

what is D-dimer?

A

degradation product of fibrin, indicating fibrin lysis + thus clotting has occurred. Used for DVT

89
Q

what effect does prevalence have on predictive values?

A

↑ Prevalence = ↓ NPV = ↑ PPV and vice versa. (Prevalence DOES NOT CHANGE sensitivity + specificity)

90
Q

in what situations may there be differences in prevelance?

A

May change between 1° ->2° care, across age groups and between countries

91
Q

describe likelihood ratios?

A

a test with two outcomes (+ve/-ve) has two likelihood ratios:
• LR for a +ve test result = LR+ = CHANCE true +ve/CHANCE false +ve = (88/100)/(69/300) = 3.8
• LR for a –ve test result = LR- = false –ve/true -ve
• Approach can be extended for continuous results (i.e. enzyme level)
• Help to assess how chances of disease have changed following a test.

92
Q

the larger the likelihood ratio…

A

↑ chance of disease if test +ve

93
Q

the smaller the likelihood ratio…

A

↓ chance of disease if test –ve

94
Q

what are the aims of the cancer plan 2000?

A

first comprehensive strategy to tackle disease
Save lives; ensure pts get right support, care + treatment; tackle inequality which saw unskilled workers x2 likely to die from cancer; invest in furture via research + workforce to ensure NHS never falls behind again.

95
Q

what is the sequelae of the cancer plan 2000?

A

NICE guidelines on organisation of services for particular cancer, manual of cancer standards (treatment etc.) -> 2004 revised = Manual of Quality Measures, National peer review (centre-centre) to ensure standards.

96
Q

what are the 6 areas of the cancer reform strategy 2007?

A
  • prevention
  • early diagnosis (screening)
  • ensuring better treatment
  • living with and beyond cancer
  • reducing cancer inequalities
  • delivering care in most appropriate settings
97
Q

describe the prevention aspect of the 2007 cancer reform strategy?

A

•Changes to lifestyle (diet, smoking, alcohol, exercise)

98
Q

describe early diagnosis aspect of the cancer reform strategy 2007?

A

• Cervical, breast + bowel (extend programmes), research on feasibility of CT screening for lung cancer.
•National Awareness + Early Diagnosis Initiative – set up to ↑ awareness + develop tool for measuring awareness. NAEDI hypothesis – difficulty in access/unaware = present later = ↓ outcomes, takes into account access, age, ethnicity, SE status etc.
 NAEDI: Achieve early presentation (some pts don’t want to waste time), optimising clincal practice + systems (compare practice data), ↑ GP access to diagnostix, research/monitor/evaluate.
 National audit of cancer diagnosis in 1° care (practice review all cancer cases, adds to focus of cancer care on GP.
 Significant events audits in GP: Asks: what happened? Why? What’s been learned? What’s been changed?
 Decision aiding tools created to aid diagnosis.
 New referral guidelines – focus from systems  symptoms

99
Q

describe the ensuring better treatment aspect of the cancer reform strategy 2007?

A

↓waiting times, training programme for laparoscopic bowel surgery, ↑RTx capacity, all new cancer drugs referred to NICE, CTx audits.

100
Q

describe the living with and beyond cancer aspect of cancer reform strategy 2007?

A

National Cancer Survivor Initiative -> partnership with charities, clinicians + pts to ↑ support + services for survivors -> ended 2013

101
Q

describe the 2 principles of delivering care in most appropriate settings aspect of cancer reform strategy 2007?

A

6) DELIVERING CARE IN MOST APPROPRIATE SETTINGS – 2 KEY PRINCIPLES
• care should be delivered locally to max. pt convenience (ease of acces to diagnostic tests)
• services centralised where necessary to improve outcomes
 also shift some inpatient ->outpatient (ambulatory) care

102
Q

did the cancer reform strategy 2007 work?

A

Yes. Survival ↑ for most common cancers, though still behind european avg. HOWEVER still UK inequality i.e. in NSCLC surgical resection rates.

103
Q

what is the independent cancer taskforce 2015?

A

spearhead radical upgrade in prevention + PH, drive ambition to achieve more, pt experience being on par with clinical effiacy, make necessary investments to deliver modern high-qual care.

104
Q

describe the global burden of cancer?

A
  • Lung most common
  • Followed by breast, colorectal + stomach – but only 1/3rd globe has registers
  • Prostate has now replaced stomach as 4th most common (possibly due to ↑hygiene, stomach infx aetiology)
105
Q

what are the most common cancers in the UK?

A
  • Breast most common F
  • Prostate M
  • Then lung, -> bowel. (nb no colorectal on UK lists, whereas v. common globally)
106
Q

how does incidence of cancer alter with age?

A

Incidence ↑ with age – 10% aged 45 -> 60-70% 60+.

107
Q

describe the changes in the incidence of cancer?

A

M -20% lung cancer (↓smoking), -30% bladder (occupational, azo-dyes/paints), +70% melanoma (↑overseas hols in 70s), ↑liver (alcohol)
F - +10% lung cancer (started to smoke later than men).
↑colorectal in MEDCs – diet?
Cancer ↑ follows demographic transition model (↑ageing population ->↑cancer)
SE asia, eastern med + Africa – Cancer still not most common CoD.

108
Q

what are the global causes of cancer death?

A

Lung -> Stomach ->Liver->prostate (despite high incidence, as treatment good + present early).

109
Q

describe the UK common causes of cancer death?

A

Lung -> colorectal -> breast -> prostate. Although incidence of cancer has ↑, deaths have ↓.

110
Q

describe childhood cancers?

A

Differ clinically + histopathologically to adults, comparitively responsive to therapy -> 85% ALL cancers survive >5yrs. Only 1% of all cancers (RARE)
 Peak incidence @ 2-5yrs -> Leukaemias>brain/CNS>lymphomas – Acute Lymphoblastic Leukaemia most common.

111
Q

describe the prevention of childhood cancers?

A

 1° = vaccine, legislation, lifestyle campaigns
 2° = Screening, early detection + diagnosis
 3° = disease management, cure(?), palliative

112
Q
  1. who is invited for mammogram?
  2. who may be invited earlier?
  3. who has the option to self refer for mammograms?
A
  1. All women aged 47-73 invited for a mammogram – rolling programme, so should all go within 3 years of becoming age-eligible.
  2. If genetic predisposition (BRCA1/2 or strong FH) then when aged 40.
  3. Can self-refer after 73 if choose to do so.
113
Q

what views are taken during a mammogram?

A

cranio-caudal and medio-lateral view

114
Q

who has triple assessment and what is it?

A

women recalled from mammogram for further assessment

It’s also where symptomatic referrals are sent from GP (2ww)

Examination + Mammogram + US + biopsy (depending on radiological grading)

115
Q

what is the purpose of the MDT in breast cancer services?

A

discuss results and best option for treatment chosen as well as referral to oncologist for radiotherapy, chemothrapy, hormonal therapy or surgery

116
Q

what are the challenges to breast cancer services? (3)

A
  1. uptake - 75% and declining in london
  2. cost
  3. education - teaching self examination and general understanding of condition
117
Q

how can the quality of breast cancer screening services be assessed? (4)

A
  1. detection rates (sensitivity, PPV, NPV)
  2. compare breast cancer mortality data pre/post screening (beware of bias)
  3. PROMS (patient recorded outcome measures), QALYs (quality adjusted life year)
  4. assess structure such as staffing, time, resources. the process (is it following good practice guidelines) and outcomes (survival)
118
Q

describe the importance of cost effectiveness in national screening programmes? (3)

A
  1. in the UK national screening commitee criteria (is it worth investing in terms of increased QALYs)
  2. need to consider in order to justify the expense as it could be spent elsewhere (opportunity cost)
  3. assessed via QALYs, reduced mortality, lives saved, costs per life saved (NNT X cost)
119
Q

what are the potential psychosocial impacts of a cancer diagnosis and treatment? (6)

A
  1. uncertain prognosis, life on hold, how long left?
  2. stress (affairs in order)
  3. family tension (disagree in treatment pathway)
  4. devastating psychologically
  5. some reticent and introverted to protect family and may need outlet such as councillor
  6. depression, anxiety
120
Q

why is cancer prognosis worse for those of lower SES or BME? (4)

A
  1. less likely to attend screening
  2. ‘risky’ lifestyle choices such as smoking, alcohol, poor diet, less exercise
  3. information inaccessible (eg language difficulty)
  4. services inaccessible (other barriers)
121
Q

what is meant by ‘normal crises’’ (pound et al) with regards to cancer diagnosis?

A

diagnosis is a continuation/biographical reinforcement of someones normal life

patient may experience crises throughout life such as poverty, ageing, poor housing and a diagnosis is one more in the chain so not a big deal for them

it may be expected eg osteoporosis following life long manual labour

can’t assume that a diagnosis will cause biographical disruption and you need to take into account context, meaning, timing and expectation

122
Q

what are the 3 aspects of disruption?

A
  1. of ‘taken for granted’ assumptions/behaviours (body can’t do certain things anymore)
  2. of biography - self and identity and re-evaluate life plans
  3. response to disruption (demands and resources)
123
Q

what are the risk factors associated with delayed presentation of breast cancer symptoms? (4)

A

age
low SES
low education level
initial symptom was not a lump

124
Q

what are the benefits of smoking cessation? (6)

A

O2 sats increase and peripheries feel warmer

decrease mucous production, less breathing difficulties

increase smell and taste sensation

less susceptible to infection

less CVD risk (within 5 years the risk of MI is same as non smoker)

less risk of throat, oesophageal, lung, bladder cancer risk (within 10 years risk of lung cancer is same as non smoker)

125
Q

what is the quit rate for smoking

  1. without support
  2. with brief opportunistic advice
  3. with brief opportunistic advice and nicotinic replacement therapy
A
  1. 1% per year
  2. 1.7% per year
  3. 3.1% per year
126
Q

what are the models of behaviour change?

A

social cognition theory (self efficacy)

health locus of control

leventhals model of illness

127
Q

describe the social cognition theory (self efficacy)?

A

belief in oneself to be capable of exercising a measure of control over their behaviour, increases likelihood that they will.

Reinforced by social sanctioning of this behaviour too (i.e. scare ads about quitting smoking but fear can go too far and lead to reappraisal which stops promoting behaviour/ continues compromising behaviour.)

128
Q

describe the health locus of control?

A

Attribution theory, attributes blame to various things as cause of event. these can be internal, powerful other, chance or god

129
Q

describe the Leventhal model of illness?

A 
how lay people assess illness:
•ID – what is it?
•Timeline – how long has it been?
•Consequence – bleeding? Loss of function?
•Cause – ‘catch it from someone’?
•Control – can I self-medicate?
130
Q

what are the major theories about predicting and changing health behaviour

A

stages of change (transtheoretical model)

theory of planned behaviour

health belief model

131
Q

describe the stages of change (transtheoretical model)?

A

cycle:

precontemplation -> contemplation -> preparation -> action -> maintenance -> relapse -> precontemplation

132
Q

describe the theory of planned behaviour model?

A

how health behaviours influence intentions

attitude, subjective norm and perceived behavioural control all feed into intention and behaviour

133
Q

describe the health belief model?

A

Takes into account individual perceptions, modifying factors such as demographic, sociopsychosocial etc. as influencing likelihood of undertaking action. With promotion try to: increase perceived susceptibility, severity + benefits; decrease Perceived barriers.

134
Q

what are options for supporting smoking cessation? (4)

A
  1. combination of advice/behavioural support and pharmacotherapy
  2. brief advice
  3. behavioural support - motivational interviewing, CBT, telephone based services
  4. nicotine replacement therapy (buproprion, varenicline)
135
Q

how are smoking cessation services provided?

A
  1. cessation clinics
  2. online ‘quit kit’ request
  3. stop smoking counsellors (specialist trained nurses
136
Q

why are post mortems important? (3)

A
  1. without a medically ID’d cause of death, relatives cannot register the death
  2. contributes to understanding and influencing care of the living
  3. legal requirements for a coroners post mortem
137
Q

how can information from post mortems contribute to understanding and influencing care of the living? (4)

A
  1. Information recorded on certificate underpins national mortality data
  2. monitoring population health (epidemiological research)
  3. Informs authorities of need for intervention and allows targeting of that
  4. Research – tissue pathology allows development of understanding of natural Hx, ID potential tests for investigation of disease presence, ID drug targets.
138
Q

what are the legal requirements for a coroner’s post mortem?

A

Role of HM Coroner is to investigate and ascertain cause of deaths occurring in suspicious circumstances.

Body can’t be release until after coroner satisfied with cause of death

139
Q

in what situations should a death be referred to a coroner? (18)

A
  1. Cannot readily be certified as being due to natural causes.
  2. The deceased was not seen by a doctor within the 14 days prior.
  3. Element of suspicious circumstances.
  4. There is any history of violence.
  5. Death linked to an accident
  6. Question of self-neglect or neglect by others.
  7. Death occurred or the illness arisen during/shortly after being detained in custody.
  8. Detained under the Mental Health Act.
  9. Death is linked with an abortion.
  10. May have been contributed to by actions of the deceased himself (Hx of drug or solvent abuse, self-injury or overdose)
  11. Receiving war pension/industrial disability pension unless death shown to be unconnected.
  12. Due to industrial disease or related to deceased’s employment (however long ago)
  13. During an operation/before full recovery from anaesthetic/related to anaesthetic (24hrs)
  14. Related to a medical procedure or treatment. 15. Due to lack of medical care.
  15. Unusual or disturbing features to the case.
  16. Occurs within 24 hours of admission
  17. It may be wise to report death where there is an allegation of medical mismanagement.
140
Q

what are ethical/legal issues surrounding consent for post mortem?

A
  1. Consent must be obtained – what if refused prior to death, but would normally require coroner investigation?
  2. Consent of nominated rep – do they know what’s in best interest? What if they consent against the patient’s wishes?
  3. If no nominated rep – person in a ‘qualifying relationship’ – issue as above
141
Q

what has motivated improved ethics regarding research?

A
  1. Nazi experiments
  2. Tuskegee syphilis study (left untreated even when penicillin became available),
  3. Wakefield: Autism + MMR
142
Q

what is the nuremberg code?

A

Set of research ethics principles for human experimentation. Includes: voluntary consent of participants essential, avoid all unnecessary suffering, conducted only be qualified persons

143
Q

what is the helsinki decleration (1964)?

A

World Medical Association – Proposes key ethical principles, namely requirement for any human research to be subjected to independent ethical review and oversight by committee (article 13). Helps as researchers may be unaware of potential issues.

144
Q

what considerations should be made with regards to research ethics prior to undertaking the research? (6)

A
  1. Useful? In a therapeutic method are risks > benefit (non- maleficence vs. beneficence? Already known? No need to subject more to research?
  2. Possible without humans?
  3. Got consent? Informed + voluntary + competent = valid
  4. Make effort to maximise respect for confidentiality/privacy
  5. Selection procedures fair, or some groups unfairly burdened? (Justice). Is there clinical EQUIPOISE? Wrt what is best practice? Do we really not know which is better?
  6. Been approved by relevant research ethics committee?
145
Q

when is approval needed for a research trial?

A

Whenever human participants, tissue +/- personal data are used.

146
Q

why is approval needed in research trials? (6)

A
  1. Ensures accordance with principals
  2. Protects researchers + participants
  3. ↓negligence
  4. Protects reputation of institution
  5. Condition for funding
  6. Legally required.
147
Q

from whom is approval for a research trial needed?

A
  1. NHS REC approval needed for anything using NHS data/pts except for NHS staff recruited by virtue of professional role.
  2. Uni approval usually needed if NHS is. Done by Integrated research application system (IRAS).
148
Q

what is considered when getting approval for a research trial?

A
  1. Scientific/ethical importance of study
  2. Likelihood of achieving aims
  3. Risk vs. benefit
  4. Methods of recruitment, consent, confidentiality
  5. Destruction of samples/data.
149
Q

what are the important aspects of consent when recruiting for a research trial?

A
  1. Informed (via pt info sheets about EVERYTHING involved, risks, procedures etc)
  2. Voluntary – no pressure, no financial inducements to cause abnormal pt risk behaviour, no threats/sanctions

(+ Competency)
3.Facilitate decision-making: Avoid jargon, info sheets, present on a level they understand, adequate time to digest info, told can withdraw at any time.

150
Q

what is stated in the human tissue act 2004?

A

Consent needed for ‘scheduled purposes’ = storage + use of tissues of living/deceased, including research ‘in connection with disorders or functioning of the human body.

151
Q

what are the MRC guidelines surrounding confidentiality in research trials?

A
  1. All pt info regarded as confidential
  2. All research using identifiable personal info, or anon. NHS data which is not already in public domain must be approved by NHS REC.
  3. All personal info must be coded AND anonymised as far as practicably possible.

Health and Society (Year 3) (6 decks)

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