The considerable burden of childhood cancer, in terms of both morbidity and mortality, has generated extensive aetiological research over recent decades. Despite these efforts, apart from ionizing radiation, the causes of childhood leukaemia and other malignancies remain largely unexplained (Doll, 1989). The identification of risk factors has frequently focused on the vulnerable period of intrauterine growth and development, birth and neonatal life. The population-based Scottish case control study of childhood leukaemia and cancer has investigated potential risk factors occurring in the prenatal and perinatal period based on data abstracted from the hospital records of both mothers and neonates. A key aspect was to test prior hypotheses as well as identify associations for separate diagnostic subgroups and search for patterns of risk within and across distinct subsets of childhood malignancy. SUBJECTS AND METHODSThe cases studied were children (0-14 years) diagnosed with leukaemia or another malignancy during 1991-1994 while living in Scotland. The childhood population of Scotland at the 1991 census was 959 268. Pathological confirmation of diagnosis was required and cross-checks with the Scottish Cancer Registry and the UK National Register of Childhood Cancers (Stiller, 1995) optimized completeness of case ascertainment. Population-based controls matched on age (to within one calendar month), sex and health board area of residence were randomly selected from all eligible children registered for primary care. This sampling frame is considered appropriate representation of the general population in this age group (Roberts et al, 1995). An optimum two controls per case were selected and a full description of the study methodology is published elsewhere (McKinney et al, 1995). Scotland is a participating centre in the UK Children's Cancer Study (UKCCS).The study was approved by the Local Research Ethics Committees of the 15 Health Boards in Scotland. Consultant clinicians or general practitioners gave consent to approach and interview mothers who gave their signed permission for information to be abstracted from their medical notes. In Scotland, 76 hospitals and maternity units gave access to medical records relating to births from 1976 to 1994. Records for births occurring in England and Wales (3.4%) were obtained by post.Information from obstetric, delivery and neonatal records was recorded by two trained abstractors onto a specifically designed and highly structured standard form which has been validated in a previous study (Roman et al, 1997). Consistency and data quality were maximized through a programme of continual monitoring, coding checks and duplicate abstractions by the senior midwife abstractor (EF).Demographic details of the mother were collected at interview. Each child was assigned a deprivation score (five categories representing quintiles of the Scottish population) according to Carstairs and Morris (1991) from the home address at the time of birth and its validated postcode. This was based on 19...

Introduction:Long-term lung cancer survival in England has improved little in recent years and is worse than many countries. The Department of Health funded a campaign to raise public awareness of persistent cough as a lung cancer symptom and encourage people with the symptom to visit their GP. This was piloted regionally within England before a nationwide rollout.Methods:To evaluate the campaign's impact, data were analysed for various metrics covering public awareness of symptoms and process measures, through to diagnosis, staging, treatment and 1-year survival (available for regional pilot only).Results:Compared with the same time in the previous year, there were significant increases in metrics including: public awareness of persistent cough as a lung cancer symptom; urgent GP referrals for suspected lung cancer; and lung cancers diagnosed. Most encouragingly, there was a 3.1 percentage point increase (P<0.001) in proportion of non-small cell lung cancer diagnosed at stage I and a 2.3 percentage point increase (P<0.001) in resections for patients seen during the national campaign, with no evidence these proportions changed during the control period (P=0.404, 0.425).Conclusions:To our knowledge, the data are the first to suggest a shift in stage distribution following an awareness campaign for lung cancer. It is possible a sustained increase in resections may lead to improved long-term survival.

Background:This review of the EUROCARE-4 results attempts to separate out the early and late mortality effects contributing to the widely reported poorer 5-year survival rates for cancer patients in the United Kingdom compared with other European countries for 26 cancer sites.Methods:Patients diagnosed with cancer in 1996–1999 in 23 European countries were included in the analyses. Comparison of 1-year, 5-year and 5∣1-year (i.e. only including those patients who had survived to 1 year) survival estimates between data for England and the ‘European average' was undertaken. This analysis was to highlight the relative contribution of early diagnosis, using 1-year survival as a proxy measure, on 5-year survival for the different sites of cancer. Three groups of cancer sites were identified according to whether the survival differences at 1, 5 and 5∣1 years were statistically significant.Results and conclusions:Breast cancer showed significantly poorer 1- and 5-year survival estimates in England, but the 5∣1-year survival figure was not significantly different. Thus, successful initiatives around awareness and early detection could eradicate the survival gap. In contrast, the 5∣1-year survival estimates remained significantly worse for lung, colorectal and prostate cancers, showing that although early detection could make some difference, late effects such as treatment and management of the patients were also influencing long-term outcome differences between England and Europe.

Study objective-To quantify and investigate diVerences in survival from breast cancer between women resident in aZuent and deprived areas and define the contribution of underlying factors to this variation. Main results-Survival diVerences of 10% between aZuent and deprived women were observed in both datasets, across all age groups. In the audit dataset, the distribution of ER status varied by deprivation group (65% ER positive in aZuent group v 48% ER positive in deprived group; under 65 age group). Women aged under 65 with nonmetastatic disease were more likely to have breast conservation than a mastectomy if they were aZuent (45%) than deprived (32%); the aZuent were more likely to receive endocrine therapy (65%) than the deprived (50%). However, these factors accounted for about 20% of the observed diVerence in survival between women resident in aZuent and deprived areas. Conclusions-Deprivedwomen with breast cancer have poorer outcomes than aZuent women. This can only partly be explained by deprived women having more ER negative tumours than aZuent women. Further research is required to identify other reasons for poorer outcomes in deprived women, with a view to reducing these survival diVerences. (J Epidemiol Community Health 2001;55:308-315) Women with breast cancer from lower socioeconomic groups have relatively lower survival than aZuent women and this diVerence in outcomes seems independent of the measure of socioeconomic status used.1 The clinical importance of this observation depends on the magnitude of the diVerence in survival. A recent review of cancer registration data from England and Wales indicated a diVerence of 5%-10% both for absolute and relative survival between the aZuent and deprived groups depending on the period of diagnosis 2

Background: Cancer incidence varies by socioeconomic group and these variations have been linked with environmental and lifestyle factors, differences in access to health care and health seeking behaviour. Socioeconomic variations in cancer incidence by region and age are less clearly understood but they are crucial for targeting prevention measures and health care commissioning.

Many factors involved in wound healing can stimulate tumour growth in the experimental setting. This study examined the relationship between wound complications and the development of systemic recurrence after treatment of primary breast cancer. One thousand and sixty-five patients diagnosed with operable primary invasive breast cancer between 1994 and 2001 were assessed for development of systemic recurrence according to whether or not a wound complication occurred after surgery, with a median follow-up of 54 months (range 15-119). There were 93 wound complications (9%). There was a statistically significant greater risk of developing systemic recurrence in patients with wound problems than those without (hazard ratio (HR) 2.87; 95% CI: 1.97, 4.18; Po0.0001). This remained in a multivariate analysis after adjustment for case mix variables, including Nottingham Prognostic Index (NPI) and oestrogenprogesterone receptor status (HR: 2.52; 95% CI: 1.69, 3.77; Po0.0001). In the good prognostic NPI group, 4 out of 27 patients (15%) with wound problems vs 11 out of 334 (3%) without wound problems developed systemic recurrence. The corresponding figures were 10 out of 35 (29%) vs 48 out of 412 (12 %) in the moderate prognostic group and 18 out of 29 (62%) vs 75 out of 199 (38%) in the poor prognostic group. In 29 patients NPI could not be calculated. Smokers at the time of diagnosis were more likely to develop metastatic disease than the non-smokers (HR: 1.50; 95% CI: 1.04, 2.15; P ¼ 0.03) after adjustment for other factors. The results suggest that patients with wound complications at primary surgery have increased rates of systemic recurrence of breast cancer.

Background:The ‘lifetime risk' of cancer is generally estimated by combining current incidence rates with current all-cause mortality (‘current probability' method) rather than by describing the experience of a birth cohort. As individuals may get more than one type of cancer, what is generally estimated is the average (mean) number of cancers over a lifetime. This is not the same as the probability of getting cancer.Methods:We describe a method for estimating lifetime risk that corrects for the inclusion of multiple primary cancers in the incidence rates routinely published by cancer registries. The new method applies cancer incidence rates to the estimated probability of being alive without a previous cancer. The new method is illustrated using data from the Scottish Cancer Registry and is compared with ‘gold-standard' estimates that use (unpublished) data on first primaries.Results:The effect of this correction is to make the estimated ‘lifetime risk' smaller. The new estimates are extremely similar to those obtained using incidence based on first primaries. The usual ‘current probability' method considerably overestimates the lifetime risk of all cancers combined, although the correction for any single cancer site is minimal.Conclusion:Estimation of the lifetime risk of cancer should either be based on first primaries or should use the new method.

Relationships between the rate of bone resorption (measured by urinary N-telopeptide (Ntx) excretion) and a range of skeletal complications have been evaluated in patients with metastatic bone disease. A total of 121 patients had monthly measurements of Ntx during treatment with bisphosphonates. All skeletal-related events, plus hospital admissions for bone pain and death during the period of observation, were recorded. Data were available for 121 patients over the first 3-month period of monitoring (0 -3 months) and 95 patients over the second 3-month period (4 -6 months). N-telopeptide levels were correlated with the number of skeletal-related events and/or death (r ¼ 0.62, Po0.001 for 0 -3 months and r ¼ 0.46, Po0.001 for 4 -6 months, respectively). Patients with baseline Ntx values X100 nmol mmol À1 creatinine (representing clearly accelerated bone resorption) were 19.48 times (95% CI 7.55, 50.22) more likely to experience a skeletal-related event/death during the first 3 months than those with Ntx o100 (Po0.001). In a multivariate logistic regression model, Ntx was highly predictive for events/death. This study is the first to indicate a strong correlation between the rate of bone resorption and the frequency of skeletal complications in metastatic bone disease. N-telopeptide appears useful in the prediction of patients most likely to experience skeletal complications and thus benefit from bisphosphonate treatment.