University Hospitals Sussex NHS Foundation Trust is an NHS foundation trust which provides clinical services to people in Brighton and Hove, parts of East Sussex and West Sussex. It is abbreviated as UHSx to avoid confusion with University Hospital Southampton NHS Foundation Trust (UHS).
Purpose Although there are consistent guidelines of standardised glioblastoma patient care, there may be variation in treatments delivered due to differences in patient characteristics or adherence to guidelines across centres. This study explores the variation in treatments for glioblastoma patients across centres in a comprehensive multi-year brain tumour patient cohort in England. Methods We analysed data from the Gliocova project that contains over 50,000 adult brain tumour patients diagnosed between 2013 and 2018 in England. We selected a glioblastoma patient cohort and explored treatment rates, systemic predictors of treatment, variation in treatment across surgical centres and survival rates for different treatment groups. Results We analysed data from 11 359 patients with a histological diagnosis of GBM. Almost 80% of glioblastoma patients received at least some treatment after brain surgery, with 40% receiving the guideline recommended aggressive treatment (47% in the under-70s cohort). Age, sex, deprivation status, comorbidities, surgery type (resection versus biopsy) and ethnicity were identified as systemic predictors of receipt of post-operative treatment. There was also variation in receipt of post-operative treatment (64%-86%) and receipt of aggressive treatment (16%-65%) across centres. Patients receiving aggressive treatment had highest survival (15.6 months); in patients receiving any post operative treatment survival was 12.5 months and in patients receiving surgery only survival was 2.5 months. Conclusion 22% of glioblastoma patients undergoing surgery receive no further treatment and there is variation in post-surgical treatment both at centre and individual patient level. We suggest that centres should measure and report rates of no further treatment as part of standard clinical governance.
Purpose: Since the 2021 World Health Organisation (WHO) classification, glioblastoma could be diagnosed based on classical histological features (hGBM) or molecular criteria (mGBM). However, prior studies included patients who required reclassification as a mGBM, potentially biasing survival analyses. The Histo-Mol GBM collaborative performed an international multicentre retrospective real-world cohort study of glioblastoma patients diagnosed according to WHO CNS 5. Methods: We identified consecutive patients diagnosed in 2021 with IDH wildtype glioblastoma according to WHO CNS 5. Clinicopathological, treatment, and survival data were collected and compared between mGBM and hGBM. Results: 1828 patients diagnosed with glioblastoma were included. 75 mGBM patients (8.4% of tested patients) were identified, with no difference in age (median 61 vs 64, p=0.057), gender (p=0.937), or proportion with performance status 0-1 (82.7% vs 68.3%, p=0.052) compared to hGBM. mGBM patients had an extended interval from MRI to surgery (median 23 vs 14 days, p<0.001) and more frequently underwent biopsy (69.3% vs 30.3%, p<0.001), but equivalent proportions received oncological treatment (80.0% vs 78.7%, p=0.784). Overall survival (OS) from surgery was not different (p=0.063). However, OS from initial MRI, stratified by surgical extent, demonstrated improved OS for mGBM patients (hazard ratio (HR) 0.56, 95% confidence interval (CI): 0.43-0.73). Propensity score matching identified improved survival following resection (HR 0.48, 95% CI: 0.24-0.95; median OS: 26.0 versus 14.0 months, p=0.031) but not biopsy (HR 1.10, 95% CI: 0.71-1.72). Conclusion: In this large real-world cohort, mGBMs had longer OS than hGBMs following resection with implications for prognostication and clinical decision making.
Breast cancer risk is a central concern in shared decision-making when considering menopausal hormone treatment (MHT). Women spend approximately 40% of their lives in menopause, and climacteric symptoms can substantially impair quality of life. MHT is the most effective strategy to treat climacteric symptoms. MHT can consist of the administration of oestrogen only in women who have undergone hysterectomy or a combined treatment of oestrogen and progestogen in women with a uterus. The risk of breast cancer associated with MHT varies with both the individual's baseline risk of breast cancer and the type of treatment. Oestrogen only therapy in women who have undergone hysterectomy appears associated with a lower risk of breast cancer than combined oestrogen and progestogen MHT. Micronised progesterone and dydrogesterone seem associated with a lower risk of breast cancer than progestins, as shown in observational or case-control studies, but no randomised study has addressed this questions. Evaluating baseline risk of breast cancer before prescription of MHT should be considered a minimum standard alongside education on risk factors that can help decrease the risk of breast cancer with or without using MHT. This Review synthesises contemporary randomised and observational evidence, including pharmacologic distinctions, interaction with modifiable risk factors, and implications for better shared decision-making for women considering MHT.
BACKGROUND:Skin cancers primarily affect people of White ethnicity and with lighter skin tones, but people of other ethnicities may face diagnostic delays and experience higher mortality, reflecting existing inequities in healthcare. OBJECTIVES:To show incidence data from the National Disease Registration Service (NDRS) cancer registry in England for skin cancers, stratified by the seven broad ethnic groups. METHODS:We used data from the NDRS from 2013 to 2020 to analyse melanoma, acral lentiginous melanoma (ALM), basal cell carcinoma (BCC), cutaneous squamous cell carcinoma (cSCC), cutaneous T-cell lymphoma and Kaposi sarcoma (KS). Tumour records were linked to datasets including census population data, Office for National Statistics (ONS) mortality data, Index of Multiple Deprivation and Hospital Episode Statistics. Ethnicity data were grouped into seven standardized broad ONS categories: White, Asian, Chinese, Black, Mixed, Other and Unknown. European age-standardized rates (EASRs) were calculated using the 2013 European Standard Population and are reported per 100 000 person-years (PY). RESULTS:Ethnic diversity in England increased between the 2011 and 2021 censuses. Proportions of cases with 'Unknown' ethnicity with registry data ranged from 19.2% for BCC to 5.0% for ALM. The EASR (with 95% confidence interval) of melanoma was 33 times higher in the White group (27.3, 27.1-27.5) than in the Asian group (0.82, 0.67-0.99) and 16 times higher in the White than in the Black ethnic group (1.67, 1.37-2.01). Similarly, cSCC was 14 times more common in the White group (61.8, 61.5-62.0) than in the Asian group (4.55, 4.15-4.97) and 13 times more common in the White than in the Black ethnic group (4.73, 4.17-5.34). BCC was 26 times more common in the White group (154, 153-154) than in the Asian group (5.59, 5.16-6.04) and 27 times more common in the White than in the Black ethnic group (5.98, 5.35-6.65). However, the EASR for ALM was highest in the Black ethnic group. ALM was less likely to be referred along the Urgent Suspected Cancer pathway and was more likely to present at a later stage than melanoma overall. The EASR for KS was significantly higher in the Other and Black ethnic groups. CONCLUSIONS:A lack of high-quality published ethnicity data hampers our understanding of health disparities. These findings emphasize the need for better collection of ethnicity data and regular audits to better understand and address the needs of populations underserved by healthcare resources.
The six-month review is a policy recommendation in the United Kingdom involving structured post-stroke follow-up to identify and address the unmet needs of stroke survivors. Differences in the provision of this complex intervention may arise from variations in context. Our study aimed to explore the dynamic interaction between the six-month review and its associated context. A qualitative multiple case study was conducted across three contrasting six-month review services in England selected primarily to reflect variation in provider organisation. Data collection included semi-structured interviews with three stakeholder groups (Service Users, Service Providers, and Service Influencers), direct observations of the review process, and service-related documents. Data analysis utilised a combined deductive and inductive approach. Using the Context and Implementation of Complex Interventions framework, contextual interactions were mapped at the micro, meso and macro levels across the three cases. A cross-case synthesis, guided by complexity theory, identified key patterns of interaction between the six-month review and its context, which were summarised narratively. Data were collected from 36 stakeholders, 17 hours of observation, and 26 service-related documents. Five key patterns of interaction between the six-month review and its context were identified: (1) Access is a dynamic negotiation between service design and contextual barriers, (2) Equitable service provision requires proactive adaptation, (3) Hidden needs stay hidden unless actively unmasked, (4) System levers may trigger unpredictable consequences, and (5) Outcomes are shaped by interdependence with the wider system. The findings demonstrate the multi-level influence that context has on the implementation and delivery of the six-month review. These contextual interactions shape outcomes in varied, unpredictable, and sometimes unintended ways, reflecting the six-month review’s position within a complex system. The identified patterns of interaction provide insight into the six-month review’s underlying mechanisms and may guide future implementation efforts.
