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NOVEMBER 2000 . Dr Mike Painter, President of the Section, outlined the afternoon programme and then welcomed the first speaker Professor P Maguire (Honorary Consultant Psychiatrist, Director of CRC Psychological Medicine Group, Christie Hospital NHS Trust) who was scheduled to speak on "Psychological aspects of screening". Professor Maguire outlined the "benefits" and "disadvantages" of screening for cancer. The benefits are an earlier diagnosis; better prognosis; less aggressive treatment likely; and greater opportunity for treatment choice. The disadvantages or "toxic" effects of screening are that a diagnosis of cancer following screening can lead to the individual being very shocked and a sense of loss of control. Further recall in a sensitised individual may be distressing and professional reassurance may fail. Professor Maguire outlined various studies which had examined the psychiatric morbidity in screened populations. Women in false positive groups and symptomatic benign abnormal groups suffered the most anxiety following screening. At three months the false positive group anxiety levels had returned to former levels. The symptomatic benign and newly detected cancer groups were the most anxious at three months post screening. Interestingly the previously detected cancer group of women actually suffered lower anxiety levels than those two former groups. 29% of women in one study where cancer had been detected following screening were critical of some aspects of communication by professionals. A further study showed that women whose breast cancer was detected by screening compared with self-presentation showed no difference in affective disorder. Women with a previous abnormal mammogram perceived themselves to be at higher risk and were more likely to schedule a further mammogram in the future. There was no difference in their levels of depression compared with the general population. Professor Maguire then discussed the implications for cervical cancer screening. 20% of colposcopy patients remain highly anxious after this procedure and this is thought to be due to an inadequacy in professional counselling. Important communication factors include the clinicians’ ability to ascertain the patients’ concerns and check these out with the patients about what their needs are. Doctors were found in one study to have concerns about undertaking this as they felt by distancing themselves from their patients they could avoid difficult questions and not become too close emotionally; it would also take up too much time in the consultation; and they had received no counselling training. A senior doctor’s study at the Christie Hospital looked at doctors who had received communication training and those who had not. The trained group were much better at eliciting patients concerns and there was no increase in the length of consultations. The doctors also felt a greater level of job satisfaction. Dr Painter then invited questions from the floor. Dr Painter then introduced Dr K Fenton (Consultant in Communicable Disease Surveillance, London) whose topic was "Screening for sexually transmitted infection". Dr Fenton outlined his talk:-
Dr Fenton believed any screening programme should be assessed by Wilson and Junger criteria. (i) Is it an important public health problem? (ii) Is there a detectable pre-clinical phase? (iii) Are there simple and acceptable diagnostic tests? (iv) Is the treatment simple and effective? (v) Does treatment prevent onset of complications? Chlamydia episodes requiring treatment have increased in the UK. This is partly due to greater detection but also a greater true prevalence of the disease. It is the most common curable sexually transmitted infection. In those who have acquired the infection, 70% of women and 50% of men will be symptomatic. Untreated infection can lead to reproductive morbidity in the form of pelvic inflammatory disease. 20% of infertility is thought to be caused by previous chlamydia infection and 43% of ectopic pregnancies are caused by this disease. The highest rates of disease are found in females aged between 16 and 24 and men aged between 20 and 24. London and Yorkshire have high rates nationally. The prevalence in different health care settings varies but the median prevalence is between 4.5% and 5% of the attending populations. Therefore, risk factors include young age; single status; high rates of partner change; ethnic groups; low school leaving age; no previous births; and use of oral contraceptives (this may be due to epithelial changes or less likelihood of barrier methods in sexual intercourse). In 1991 there was a national survey of sexual attitudes and lifestyles. This is now being repeated. Urine testing for chlamydia is being used for the population based prevalence estimate. Diagnostic tests have developed, e.g. NAAT (Nucleic Acid Amplification Tests). These are expensive, approximately £10 per test, compared to traditional methods. In addition, the maintenance of the cold chain is very important given that there is a loss of 5-10% in test sensitivity if urine samples are not kept refrigerated. Effective treatments are available and the antibiotics usually prescribed are tetracycline and erythromycin. Regarding reduction in subsequent complications from the disease, Dr Fenton highlighted the success of the Scandinavian and American screening programmes. In Scandinavia the screening programme includes a multi-faceted approach, including both men and women in contact with health services. Legal notification is required. There has been an increase in public education in schools and an awareness raising in the general public of the disease. Results have shown since the introduction of the screening programme new cases have dropped dramatically and there have also been a dramatic drop in the incidents of pelvic inflammatory disease and rates of admission to hospital for ectopic pregnancy. The USA has seen similar changes since the introduction of their screening programme. Given this evidence, Dr Fenton outlined areas of uncertainty that are holding back the introduction of a national screening programme in the UK. Experts are still unsure of the full natural history; there does appear to be a spontaneous clearance of the disease; diagnostic tests are expensive; contact tracing can be problematic; it is unknown what the appropriate target populations are for screening; and there is a need for greater public awareness of the disease. The Department of Health are piloting opportunistic screening in the Wirral and Portsmouth to establish a model that is appropriate for extending nationally. The groups targeted include women aged 16-24, in particular those that are attending for termination of pregnancy and fitting of an IUD. Also populations attending sexual health clinics and genito-urinary medicine clinics are included. The two pilots have given quite different results and the acceptability is still being examined. Men are often not included in national screening programmes as chlamydia is more damaging to women and the most cost-effective strategy therefore is to target this gender. There is an argument for primary and secondary prevention and consequently involving men in sexual health programmes. Dr Painter invited questions from the floor. Dr Painter then welcomed Mrs Julia Patnick (National Co-ordinator, NHS Cancer Screening Programmes, Sheffield) to present her topic "Breast and cervical screening". Mrs Patnick covered the epidemiology of female common causes of cancer. She then went on to brief the audience about the history of the breast cancer screening programme which has been operational now for ten years. Initially it was estimated that 1,250 lives would be saved a year, however, there have been problems in evaluating the mortality effects of service screening. The quality of the screening programme has improved significantly. A recent paper in the BMJ analysed the reduction in mortality and concluded that up to 300 lives per year were saved that were attributable to screening. Other lives have been saved but this is attributable to better treatment, in particular tamoxifen, chemotherapy and earlier presentation of women following symptomatic disease. Mrs Patnick reinforced that it will be a further 5-10 years before we can really assess the full effect of the breast cancer screening programme. She then proceeded to cover cervical cancer screening where the incidence of this disease is declining and mortality is reducing by about 5% each year. It is thought the screening programme saves about 2,000 new cases of cervical cancer each year and saves 1,300 lives each year. An important aspect about this particular screening programme is that coverage is more important than frequency of screening. She outlined the percentage reduction in incidence with different screening frequencies. These were:-
Most districts operate on a three yearly cycle given the cost benefit analysis. She highlighted some recent studies on breast cancer screening populations where it has been found that if women have a partner they are more likely to attend and that attendance is often linked with self esteem. An interesting finding in the breast cancer screening population is that half of women attending have used HRT and one-third of the population are currently using it when they attend. The hard to reach groups include poor women, women from ethnic minorities (though these two factors are often inter-linked) and women with learning disabilities. There is some evidence that practices are cohersing women into having smears and this is not on! The National Cancer Plan is to be welcomed and includes further investment and reform in cancer services. It is important that women have an informed choice and are fully aware of the pros and cons of cervical cancer and breast cancer screening programmes. She highlighted the current patient information leaflets which have just been launched. Mrs Patnick ended her talk by highlighting the colorectal cancer screening pilot which is currently being undertaken in Warwickshire. Dr Painter then invited questions from the floor. The speakers were warmly thanked by the audience for the quality of their presentations. The meeting then closed.
Lower social classes suffer more years of disability before they die - up to 13 year gap in disability - free life expectancy. Have higher sickness and death rates from many causes from birth to old age. Female and male -increasing mortality with decreasing social class. Not just adults same relationship in children. Percentage of individuals reporting their health as not good by income quintiles –clear gradient. Mental health - life not worth living by class and ethnic group - highest in all families with no full-time worker. The impact of income on food consumption: Families with one child. Poor families consume less fruit and vegetables. Cluster effect of social deprivation -reinforces effects. Accumulation of risk over a life cycle. Absolute poverty is insufficient to encapsulate the state people find themselves in the UK, therefore poverty now seen as the absence of a range of resources -material, cultural and social, i.e. resources are below the-average, i.e. relative poverty. Lack of freedom to be able to do what you are capable of doing. Poverty increase since 1979 -10%
Increasing children in low-income households. UK compared to other European counties - UK highest proportion of households with children with no working adults. Changes in real incomes of rich and poor in UK.
Limiting long term illness -higher class more
likely to keep job. How does inequality and poverty 'cause' poor health? 1. Lack of financial resources 2. Psychosocial stress 3. Behavioural change "The most health damaging effects of inequality are those that exclude people from taking part in society denying them self-respect and dignity." Wilkinson 1996
Strategies for improving inequalities Acheson Inquiry adopted a socio-economic model of determinants of health. Evidence on areas for policy development. Three Priority areas: 1. Health inequalities impact assessment of policies. 2. High priority for families with children. 3. Reduce income inequality and improve living standards of poor households.
Practical tools/guidance: 1. HIA methods. 2. Target setting for equity. 3. Equitable formulas for resource allocation. 4. Benchmarks of fairness/equity audits. 5. Organisational development research. Only reduce inequalities by levelling up not levelling down. Universalism vs targeted. Professor Whitehead took questions from the audience. Dr. Joyce Leeson gave the vote of thanks.
MARCH 2001 The President, Dr M J Painter, opened the meeting and introduced the speakers. The first talk was given by Dr Gunjit Bandesha (Specialist Registrar West Pennine Health Authority) whose lecture was entitled: - "Community participation – fad, fact or fantasy?" Dr Bandesha introduced the definition of community participation as a contested concept but that it encompassed - social and environmental justice in the
developing world Importance: Alma Ata Community major arena to address inequalities. Community participation = collective action (not consumerism = individual action). Dr Bandesha discussed the benefits and limitations. She then discussed her master (MPH) dissertation, which evaluated a community participation project in an Ashton-under-Lyne South Asian, Pakistan Bangladeshi, Indian Community by exploring lay and professional views on community participation and health gain. Emerging Themes: Professionals Partnerships. Clinicians (GPs) threatened/not involved. Culture - barrier to participation "pathologising of culture". Lay No perception of power. Many do not wish to participate (75%). Trust ie. project for their benefit. Culture - inhibited from participating because of ignorance etc. Skills required for participation work is different from clinical skills. Health gain
1. Psychological benefits noted by lay
informants. MFA Network 1991 describes participation as an ‘onion’. Outer
layer = isolated individuals From a professional point of view, no improvements in health services or lifestyle improvement. Therefore would be deemed a failure. Would need to see it in broader context. The second speaker, Dr Alex Stewart (Specialist Registrar, Wirral Health Authority) spoke on: - "Of airs, waters and places" Dr Stewart began by stressing the importance of iodine deficiency worldwide and in Western Europe (20% ‘at risk’). Problems encountered Pregnancy and birth 1992 – Framework for planning iodine deficiency prevention programs. Most have focussed on providing iodised salt. In many communities it has wiped out iodine deficiency – not all. Dr Stewart showed a world map illustrating who are ‘at risk’ with no climatological or epidemiological pattern. Who says soil become iodine deficient due to leaching from snow and high rainfall? – no proof. He described the environment scientist knowledge of the iodine cycle. Null hypothesis – no relationship between environmental iodine and endemic goitre. Mapped in England and Wales
Endemic goitre (stock: 12-13 yrs:
1920’s)
(monthly by 15 months) 1990 More towns than cities had goitre and more
counties than towns (? related to incomes at this time.)
Soil Iodine No pattern emerges. Large differences existing in small areas Water Iodine Pattern suggests until deep well water removed (as 300 m down and known to be high). There is no link between goitre and environmental iodine. Weaknesses in
study Data spread over 50 years – but 3
data sets show similar information.
Few environmental points Goitre Marked belt in 1927 England and Wales. Rural/urban gradient. Iodine deposition
Fairly even. Soil and Water Iodine pattern unlike goitre. A population who is iodine deficient does not mean an environment that is iodine deficient. Dr Stewart suggested that he should research further environmental iodine and look at socio economic factors and other non dietary interventions. Questions were taken from the audience. Dr Peter Elton gave the vote of thanks. After the meeting a dinner was held in honour of the two speakers at the University Refectory.
APRIL 2001 The President of the Section, Dr M J Painter, opened the meeting and introduced the evening's speaker, Ms Suzi Leather whose lecture was entitled: - "Food standards"
Ms Leather is the Deputy Chair of the Food Standards Agency, which was set up in April 2000. Its aim is to make sure the food we eat is safe and to offer us independent, balanced advice. She explained that a 'Consumer Attitudes to Food' survey was carried out six months after the Agency was created. It revealed the views of more than 3,000 people across the UK and the issues that really matter to them. The greatest level of concern is over safety issues, which highlighted widespread confusion among consumers about food labelling. Members of the audience listened attentively and a lively question and answer session took place. A vote of thanks was given to Ms Leather for a most interesting, topical lecture.
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MANCHESTER
MEDICAL SOCIETY
