I focus on three issues central to the economic impacts of changing demographics brought about by trends in life expectancy and in fertility. First, how might people adjust to longer lives when the scope of the state to devote funds to pensions and to health care will come under strain? Second, how great might the strain on the public finances be and how might it be alleviated? Third, how might individuals handle the effects of uncertainty when the ability of the state to offer insurance against risks might be reduced? I focus on the issues for the UK - a country with a set of challenges which is in many ways typical of rich countries. I argue that attempts to offset demographic change and the strains it brings by consistently high immigration or by trying to boost fertility rates of the domestic population are likely to either have undesirable effects in the long run or be ineffective over almost any horizon. Instead, a combination of market forces, and policies which take account of long run fiscal sustainability, will allow ageing populations to adjust.

Way back in 1980, I was hired by a private university as assistant director. This is when my campus public safety career started.

When COVID‐19 hit the country and the world, public safety officials, myself included, quickly realized that there was going to be a significant change to public safety operations.

Abstract Single centre experience of the adoption of self-administered HER2-directed therapy in patients with breast cancer Background: Programs to promote the self-administration of systemic anti-cancer therapy (SACT) offer greater convenience and shared decision making for patients with the opportunity to alleviate pressures on cancer services. Aims and Objective: The aims of this study were to quantify the uptake/acceptability of self-administration (SA) of subcutaneous trastuzumab (sc T), to evaluate safety, patients’ perception of the programme and the chair capacity released as a consequence. Methods: Patients receiving T for the treatment of HER2 +ve breast cancer were offered training in SA. The competency-based training programme, under the supervision of a chemotherapy-trained nurse, consisted of a minimum of 3 training sessions. Patients were also provided with printed and electronic material (via an App) on how to self-administer sc T, with 24/7 contact details in the event of an adverse event or device failure. Once trained and deemed competent, sc T was shipped to the patients’ home in a temperature-controlled environment, in a pre-filled syringe. All patients were assessed by telephone one day before and one day after SA using the Common Terminology Criteria for Adverse Events (CTCAE). Analysis of the total number of administrations of sc T, between February 2022 and June 2023 was conducted. A telephone survey using a validated questionnaire Self-Management Assessment scale (SMASc) was also undertaken. Results Of 46 breast cancer patients receiving single agent sc T, 32 agreed to participate in the program and were trained. 2 patients were undergoing training at data analysis. 6 patients declined and 6 were ineligible for the programme on the basis of inclusion criteria. The median age of the 32 patients that participated was 62, (range 27-77). The average distance from their home address to the cancer centre was 11.7 miles (range 3.5-27.9). 25 (78%) patients were Caucasian, 4 (13%) were Asian and 3 (9%) were of African/Caribbean origin. Patients had received an average of 10 sc injections in the hospital environment (median 5, range 1-103) before starting the training sessions. They required an average of 3 training sessions before sign-off (median 3, range 1-4). In the 32 patients studied, a total of 302 SA injections were delivered median 9 (range 1- 24) No Grade 3 or 4 CTCAE toxicities or infusion-related reactions were reported. During the 17-month period, a total of 302 hours of chair time was saved. 25 of the 32 patients responded to SMASc questionnaires utilising the six-point Likert scale. Patients reported average scores of 5.32 (median 6) and 5.56 (median 6) respectively, for questions relating to having information about their condition and sufficient training to self-administer. They felt that they had sufficient support to participate in the programme (average 5.56 median 6). 80% of the patients would recommend this programme and 88% felt they had benefited. Comments from patients themed around the value of the support provided, ease of administration and time saved. Discussion Programs such as these empower patients and carers to take a more active role in managing their condition with consequent reduced hospital attendance. Safety and acceptability for those patients who agreed to the program has been confirmed. Success of this program with sc T has enabled expansion to incorporate self-administration of Phesgo (sc trastuzumab and pertuzumab) with 31% (14/45) of the current P patient cohort enrolled onto the programme within 2 weeks of roll out and the first patients self-administering their treatment from August 2023. With the continued expansion of SACT treatments, we encourage stakeholders to consider self-administration of SACT as an option. Formulation of treatments conducive to patient self-administration is a key component to this. Citation Format: Wendy Ng, Vikash Dodhia, Amy Guppy, Stephanie Sutherland, Marlgozata Wojtas, Karen Harrold, Adisa Aolat, Tome Tapiwa, David Miles. Single centre experience of the adoption of self-administered HER2-directed therapy in patients with breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-11-01.

This paper analyses economic implications of the different ways in which the population structure of countries becomes older: longer lives and declines in fertility both generate ageing populations but have very different impacts upon the aggregate population. If lower fertility persists populations in many countries will decline. Having reviewed the evidence for this, I consider both why fertility rates have fallen and may stay low. I then analyse the economic implications of populations that may stop growing and start to fall, focusing on how this may play out in the UK. I consider policy implications of such a demographic shift. Despite many predictions of the dire consequences of falling populations the economic impacts are likely, on balance, to be positive.

Purpose: Trastuzumab deruxtecan (T-DXd) has been available since April 2021 via the Cancer Drugs Fund for patients with unresectable or metastatic HER2-positive breast cancer who have received 2 or more anti-HER2 therapies, following the results of the phase II DESTINY-Breast01 trial [1]. We examined our local T-DXd use and associated clinical outcomes.

Abstract Introduction Trastuzumab(T) is a humanized monoclonal antibody used in the treatment of HER2-positive breast cancer and is available as a subcutaneous(sc) formulation thereby allowing short and convenient administration. A lack of trained nurses to administer T at home and/or train patients at home to self-administer, together with challenges in maintaining cold-chain delivery have impeded uptake of home administration.1,2 In order to support patients’ ability to self-administer T at home, we have implemented an educational programme that includes nurse-led training, education material, support apps and follow-up telephone clinics. Home delivery of pre-filled syringes was enabled in collaboration with commercial providers for aseptics and logistic. Aim The aim of this service evaluation was to evaluate the utility of this programme from the patients’ perspective and to assess patient satisfaction and impact on quality of life (QOL). Methods A previously validated Self-Injection Assessment Questionnaire (SIAQ)3 was modified to assess patient satisfaction, perceptions and impact of the programme. Patients who had agreed to enrol on the ‘self-administration’ scheme, were asked to complete the questionnaire at baseline, at the third training session and at the second self-administered dose. Approval from a Research Ethics Committee is not required for this service evaluation. Results All 14 patients offered the questionnaire responded to all questions. The median age was 58 years old (age range 43-76), 11 patients were Caucasian, 2 were Asian and one was African/Caribbean. The average distance from their home address to hospital was 10.1 miles (range 4-19). Following completion of the one-to-one nurse training there was an improvement in patient confidence to self-administer sc. T. No differences in ‘feeling in control of their treatment’ or ‘satisfaction of attending hospital appointments’ were noted. Of the 11 patients who reached the self-administration stage, 10 reported that they felt ‘very confident’ and 8 reported that it was ‘very easy’ to give themselves the injection. All patients rated themselves ‘very satisfied’ with self-administration and reported that the nurse training programme helped them to be more confident. 10 patients reported that the App and written information was useful as well as the pre- and post- administration telephone clinics. All patients reported that the self-administration programme had a positive impact on their QOL by reducing the number of hospital visits. In the first 4 months of self-administration each patient reduced their hospital attendance by an average of 8 appointments (median=8) equating to 10 hours of time that would have been spent at hospital. Discussion/Conclusion The subcutaneous T self-administration programme was well received by patients. The nurse training sessions and supportive materials enabled patients to feel more confident about self-administration with no reported incidents or adverse events. This led to fewer hospital visits and improved QOL. This programme was critically dependent on the services of a commercial compounder and homecare provider, emphasizing the importance of joint working between the NHS and commercial sector. Evaluation of this programme will continue and will include other agents, including Phesgo® (sc trastuzumab and pertuzumab) which have more patients and will improve the reliability of the results. References 1. Tjalma, W., Huizing, M., Papadimitriou, K. The smooth and bumpy road of trastuzumab administration: from intravenous (IV) in a hospital to subcutaneous (SC) at home. Facts Views Vis Obgyn, 2017;9(1):51-55. 2. Grady, PA, Gough, LL. Self-management: a comprehensive approach to management of chronic conditions. American Journal of Public Health 2014; 104(8):e25-31. doi:10.2105/AJPH.2014.302041 3. Keininger D, Coteur G. Assessment of self-injection experience in patients with rheumatoid arthritis: psychometric validation of the Self-Injection Assessment Questionnaire (SIAQ). Health Qual Life Outcomes. 2011;9:2. doi:10.1186/1477-7525-9-2

This article assesses whether economic injustices that took place in the past still have significant implications for the material welfare of people many years later. That issue is central to the question of how fair is the distribution of wealth and income today. It is also relevant to issues of reparations for past wrongs. I find that in standard neoclassical models of economic growth the lingering effects of injustice from more than 70 years ago are generally small. But effects can last much longer once we allow for impacts of past injustices to be transmitted through human capital accumulation as well as physical capital.

We planned an individual patient data (IPD) meta-analysis of non-inferiority (NI) RCTs to determine if a duration of less than the standard of 12 months (m) of adjuvant trastuzumab is non-inferior for treatment outcomes in HER-2 positive early breast cancer patients. A systematic review identified five NI RCTs, and trial groups agreed a meta-analysis collaboration. PERSEPHONE, PHARE and HORG compared 12m v 6m; SOLD and Short-HER compared 12m v 9weeks[w]. Primary outcome was invasive disease-free survival (IDFS). Secondary outcomes were distant relapse-free survival (DRFS); overall survival (OS) and breast cancer specific survival (BCSS). Analysis was intention-to-treat (ITT). Random effects modelling evaluated prognostic effects of patient and tumour characteristics, treatment and trial. Heterogeneity between studies was assessed using the Cochran's Q statistic. For the comparison of 12m v less (n≈11,500 pts), a 1-sided 2.5% significance was used. For the analyses of 12m v 6m (n≈8,000 pts) and 12m v 9w (n≈3,500 pts), 1-sided 5% significance was utilised. To date, IPD has been obtained from 4 trials and published data has been used from PHARE. For ITT analysis of the primary outcome of IDFS, non-inferiority limits for absolute 2% margins were calculated as 1.19 for all 5 trials, 1.20 for 3 trials comparing 12m v 6m and 1.25 for 2 trials comparing 12m v 9w. For 12m v less (all 5 trials combined), 5-year IDFS rates were 88.46% and 86.87% respectively. The adjusted HR for treatment was 1.14 (95% credibility interval (CI) 0.88-1.47), non-inferiority p=0.37. For 12m v 6m, 5-year IDFS rates were 89.26% and 88.56% respectively. The adjusted HR for treatment was 1.07 (90% CI 0.98-1.17), non-inferiority p=0.02. For 12m v 9w, 5-year IDFS rates were 91.40% and 89.22% respectively. The adjusted HR for treatment was 1.27 (90% CI 1.07-1.49), non-inferiority p=0.56. Cochran's Q is 5.5 for all 5 trials, 0.91 for the 3 trials comparing 12m v 6m and 1.1 for the 2 trials comparing 12m v 9w. Six months trastuzumab is non-inferior to 12months, although nine weeks is not.

This paper addresses a question which is fundamental to the perceived legitimacy of the distribution of resources today: to what extent does unfairness in how assets came to be acquired in the past affect incomes and wealth now? To answer that question requires two things: first, a principle to determine what is, and what is not, a just acquisition of wealth or a just source of income; second, a means of using that principle to estimate what fraction of wealth and income is now unjust. I use a principle put forward by Robert Nozick to provide the first of these things and then use a model of wealth accumulation and economic growth to illustrate its implications for the scale of unfairness today. The greater is depreciation of assets, the higher are saving rates out of labour income and the less important is human capital the more transient are the effects of past economic injustices. I use data on the perceived unfairness of economic outcomes to see if there is any evidence that those features which the model implies should influence the durability of injustice help explain cross-country differences in attitudes towards unfairness.

SUMMARY House prices have risen substantially faster than the prices of consumer goods in most G7 countries over the past few decades. This raises major policy issues: such rises affect the distribution of wealth within and between generations, the mobility of labour and financial stability. This paper explores why such rises have happened, and what the policy implications are. The price rises have been greatest in the United Kingdom, where real house prices have risen more than three and a half times since the 1970s, substantially outpacing real income growth. Meanwhile, rental yields have been trending downwards—particularly since the mid-90s. This paper reconciles these observations by analysing the contribution of a number of drivers of house prices. It shows that the rise in house prices relative to incomes between 1985 and 2018 in the United Kingdom can be more than accounted for by the substantial decline in real risk-free interest rates over the period. This is slightly offset by net increases in home-ownership costs from higher rates of tax. Changes in the risk-free real rate are likely to have been a major driver of changes in house prices. We analyse why they have driven house prices up faster in the United Kingdom than in other advanced economies. Our model predicts that a 1% sustained increase in index-linked gilt yields from current rates could ultimately result in a fall in real house prices of around 20%.

Background P + H + docetaxel (DOC) is the standard first-line therapy for HER2-positive LR/mBC, based on results from the phase 3 CLEOPATRA trial. The single-arm PERUSE study (NCT01572038) assessed the safety and efficacy of P + H with investigator-selected taxane in this setting. We present final safety and efficacy results.

Vaccination against the COVID-19 virus began in December 2020 in the UK and is now running at 5% population/week. High Levels of social restrictions were implemented for the third time in January 2021 to control the second wave and resulting increases in hospitalisations and deaths. Easing those restrictions must balance multiple challenging priorities, weighing the risk of more deaths and hospitalisations against damage done to mental health, incomes and standards of living, education outcomes and provision of non-Covid-19 healthcare. Weekly and monthly officially published values in 2020/21 were used to estimate the impact of seasonality and social restrictions on the spread of COVID-19 by age group, on the economy and healthcare services. These plus vaccination program assembled into a model that retrospectively reflected the actual numbers of reported deaths closely both in 2020 and early 2021. It was applied prospectively to the next 6 months to evaluate impact of different speeds of easing social restrictions. The results show vaccinations are significantly reducing the number of hospitalisation and deaths. The central estimate is that relative to a rapid easing the avoided loss of 57,000 life years from a strategy of relatively slow easing over the next 4 months come at a cost in terms of GDP reduction of around £0.4 million/life-year loss avoided. This is over 10 times higher than the usual limit the NHS uses for spending against Quality Adjusted Life Years (QALYs) saved. Alternative assumptions for key factors affecting give significantly different trade-offs between costs and benefits of different speeds of easing. Disruption of non-Covid-19 Healthcare provision also increases in times of higher levels of social restrictions. In most cases, the results favour a somewhat faster easing of restrictions in England than current policy implies. Return of non-Covid-19 healthcare activity to ‘normal’ levels might also improve future health outcomes/mortality.

We analyse housing costs and patterns of residential development over the long term in a dynamic general equilibrium. We show that in a growing economy the speed of travel improvements is crucial to the evolution of land and house prices. We derive a condition for the rate of change in transport efficiency that generates flat land and house prices on a balanced growth path. We present evidence that this condition was satisfied in many countries between the mid-nineteenth century and the mid-twentieth century, but since then passenger transport improvements have slowed down with major implications for how house prices evolve.

This paper analyses the costs and benefits of lockdown policies in the face of COVID-19. What matters for people is the quality and length of lives and one should measure costs and benefits in terms of those things. That raises difficulties in measurement, particularly in valuing potential lives saved. We draw upon guidelines used in the UK for public health decisions, as well as other measures, which allow a comparison between health effects and other economic effects. We look at evidence on the effectiveness of past severe restrictions applied in European countries, focusing on the evidence from the UK. The paper considers policy options for the degree to which restrictions are eased. There is a need to normalise how we view COVID because its costs and risks are comparable to other health problems (such as cancer, heart problems, diabetes) where governments have made resource decisions for decades. The lockdown is a public health policy and we have valued its impact using the tools that guide health care decisions in the UK public health system. The evidence suggests that the costs of continuing severe restrictions in the UK are large relative to likely benefits so that a substantial easing in general restrictions in favour of more targeted measures is warranted.