Blog posts

The economic burden of breast and cervical cancers in low and middle-income countries

Former Master of Public Health (MPH) student Natasha Kassami wrtes about her MPH research project.

“According to the World Health Organisation (WHO), Non-Communicable Diseases (NCDs) currently constitute the largest share of deaths worldwide (38 million deaths each year) with nearly three quarters of these deaths occurring in low- and middle-income countries (LMICs). Among these, cancers constitute the second largest proportion of NCD deaths and it has been suggested that a disproportionate amount of this burden falls on women in these regions who face the challenge of gender inequality in addition to the lack of access to cancer care, which results from their geographical predisposition.

It is fair to say that for a long time, I was relatively ignorant of the threat NCDs like cancer posed to low-resource populations. My attention was always drawn to infectious diseases like malaria, HIV/AIDS, TB, which have been the focus of public health campaigns in Uganda for many years. Needless to say I had suffered from Malaria countless times as a child in Uganda. My final year MPH dissertation came around the same time the threat of cancer became real to me. It was towards the end of the second semester of my Master’s program that I found out my hero, mentor and the head of my family, my father was being treated for colorectal cancer. His illness was an apt reminder of the significance of the research I was doing for my final year dissertation. That and the constant support and encouragement I received from my supervisors, Dr. Lesong Conteh (Senior Lecturer in Health Economics, Imperial College London) and Dr. Ophira Ginsburg (Medical Officer, World Health Organization, Geneva, Switzerland) and Dr. John Tayu (Assistant Professor, National University of Singapore), prompted me to work tirelessly on the summer project, which was a Systematic review on the ‘Economic Burden of breast and cervical cancers in LMICs’.

The review generated a landscape analysis, of sorts, for the current state of economic literature on the burden of these cancers in LMICs. We focused on these two cancers as they are the predominant causes of cancer morbidity and mortality in women around the world. Through our review, we identified several gaps in the research in low resource settings in comparison to High Income Countries (HICs). For example, while there is a growing evidence base on the cost effectiveness of specific interventions to address breast and cervical cancer in low-income countries (LICs), there is a paucity of studies evaluating the wider economic burden of breast cancer at both the household and the national level. Which suggests that the full economic cost of women’s cancer has not yet been realised. Furthermore, there is little research on the cost of advocacy, primary and secondary prevention of breast cancer in LMICs and the economic implications of a diagnosis in the younger, more productive years of a woman’s life are vast and rarely estimated in the literature.

Through the persistence of my amazing supervisors this study was able to have a greater impact than I could have ever achieved on my own, with its findings contributing to a paper on “The global burden of women’s cancers: a grand challenge in global health” which in turn was part of “The Lancet Series on ‘Health, Equity and Women’s Cancers’. The series, which was spearheaded by Dr. Ginsburg featured contributions of many formidable names in Cancer policy and research. Our paper in the series described the burden of breast and cervical cancer in relation to mortality, incidence survival and their implications on socioeconomically disadvantaged women (a subject Dr. Conteh and I contributed towards). I’m forever indebted to my supervisors for ensuring our work that summer was not shelved away and for pursuing it even after I graduated from the School of Public Health. We are currently working on publishing the original Systematic Review.”

Senator Bernie Sanders highlights a recent Imperial College paper on primary care

US Senator Bernie Sanders shared a recent paper from Imperial College London on his Facebook page. The paper highlighted the importance of expanding universal health coverage to reduce ‘avoidable’ deaths among Brazil’s black and mixed-race populations. The paper was published in the journal PLoS Medicine.

Dr Thomas Hone, Professor Christopher Millett, Professor Azeem Majeed from the Department of Primary Care and Public Health, and the School of Public Health, at Imperial College London and their colleagues from Fiocruz in Brazil analysed mortality data from 2000-2013 to determine the effect of Brazil’s Family Health Strategy (FHS) on avoidable deaths in black and mixed-race Brazilians compared to white Brazilians.

We found that rates of avoidable deaths were between 17% and 23% higher in black and mixed-race populations than in the white population during 2000-2013.

Providing support to the survivors of the Grenfell Tower Fire

Volunteer doctors and lawyers providing support to survivors of the Grenfell Tower disaster have spoken of residents who escaped from the fire but remain, they believe, too frightened to seek medical and legal help for fear of being reported to the Home Office because of their irregular immigration status.

Dr Paquita de Zulueta, a London GP and Honorary Clinical Senior Lecturer in Primary Care in the School of Public Health at Imperial College London who has been volunteering to help survivors in the Westway, said she and colleagues were aware of at least three patients who were reluctant to go to hospital because of concerns about their immigration status.

The full story can be read on the Guardian Website.

Imperial College academics contribute to a report on the costs of china’s tobacco epidemic

Professor Christopher Millett and Dr Anthony Laverty from the Public Health Policy Unit at Imperial College London contributed to a ground-breaking WHO report which provides an analysis of the current health, social and economic costs and impacts of tobacco use and policies in China. The report highlights the impact of tobacco use on development, with special emphasis on poverty and inequality and the tremendous burden tobacco represents for the poorest and most vulnerable.

China is the epicentre of this epidemic, and thus lies at the heart of global efforts to stop it. China is the world’s largest producer and consumer of tobacco. A staggering 44% of the world’s cigarettes are smoked in China. One million people die of tobacco-related diseases in China every year, many of them in the prime of their productive years.

The report can be viewed on the WHO Website.

Understanding the challenges for GPs in managing overweight & obese children

As part of a research project on the effectiveness of the NCMP (National Child Measurement Programme), a workshop was held in the School of Public Health to evaluate the current use of National Child Measurement Programme feedback by GPs. The aim was to investigate how GPs feel they could add further value to NCMP feedback in the future and any challenges they face incorporating National Child Measurement Programme feedback into their routine clinical work.

The workshop was facilitated by Dr Sonia Saxena & Prof Russell Viner, with participation from Dr Zoe Williams and Dr Rachel Pryke.

In the interactive 2-hour workshop, the audience discussed and came up with different ideas and solutions to overcome barriers faced in monitoring childhood obesity in Primary Care as well as the National Child Measurement Programme feedback. They specifically highlighted the importance of allocating more time for growth and weight checks, improving awareness of appropriate local weight management services and developing an integrated system with BMI centiles entered before consultations.

They also suggested introducing obesity/overweight topics into the CSA examination for GP trainees. Furthermore, attendees underlined the importance of educating GPs on a healthy lifestyle, weight management and specific approaches on how to address these sensitive topics in consultations with families effectively.

Workshop discussions provided a base to develop a short survey on how the National Child Measurement Programme link can better with primary care.

Are diagnoses of dementia being delayed by over-complex referral criteria?

Complex and time-consuming memory clinic referral criteria may be contributing to delays in the diagnosis of dementia, according to a paper published today by the Journal of the Royal Society of Medicine. Around 850,000 people are living with dementia in the UK but the number thought to have dementia substantially exceeds those with a formal diagnosis. Early diagnosis is a priority for the government and the NHS.

Currently GPs are responsible for referring patients for assessment and diagnosis by specialists, usually in dedicated memory clinics which set referral criteria. There is considerable variation in referral criteria, with requirements set by some memory clinics that exceed national guidelines. Requirements can include different combinations of cognitive tests, laboratory blood tests, urine tests and physical examination that vary between clinics.

Lead author Dr Benedict Hayhoe, of the School of Public Health at Imperial College London, says: “GPs have difficulty assessing patients with memory problems in strict accordance with guidance within a 10-minute consultation; in our experience a significant proportion of available consultation time can be taken up by carrying out just one of the brief cognitive tests.” He went on to suggest that, with current workload pressures on primary care, complex criteria involving multiple investigations are likely to provide a significant disincentive for referral.

The authors set out alternative approaches to speed up diagnosis. Dr Hayhoe said: “A primary care led process, perhaps staffed by practice nurses carrying out assessments according to protocols, may speed up diagnosis while reducing pressure on GPs and specialists.” He added that it may also be appropriate to allow some people with memory concerns direct access to memory clinics.

Dr Hayhoe concludes: “A system that discourages or delays referral for dementia is highly counterproductive; an urgent review of this area is necessary to establish a system that effectively supports patients and clinicians in early diagnosis, treatment and prevention“.

The article was reported by a number of media outlets including: The Times, The Express, The Alzheimer’s Society, Pulse and the Jersey Evening Post. The article was also reported by World First, homecare.co.uk, Care Appointments, and the Hippocratic Post.

Preventing delayed diagnosis of cancer: clinicians’ views on main problems and solutions

Delayed diagnosis is a major contributing factor to the UK’s lower cancer survival compared to many European countries. In the UK, there is a significant national variation in early cancer diagnosis. Healthcare providers can offer an insight into local priorities for timely cancer diagnosis. In a study published in the Journal of Global Health, we aimed to identify the main problems and solutions relating to delay cancer diagnosis according to cancer care clinicians.

We developed and implemented a new priority–setting approach called PRIORITIZE and invited North West London cancer care clinicians to identify and prioritize main causes for and solutions to delayed diagnosis of cancer care. Clinicians identified a number of concrete problems and solutions relating to delayed diagnosis of cancer. Raising public awareness, patient education as well as better access to specialist care and diagnostic testing were seen as the highest priorities. The identified suggestions focused mostly on the delays during referrals from primary to secondary care.

We concluded that many identified priorities were feasible, affordable and converged around common themes such as public awareness, care continuity and length of consultation.

Bringing together physical and mental health within primary care

Reducing fragmentation between different parts of the health system is a key priority for the National Health Service (NHS) and for health systems internationally, if they are to meet the challenges they face. One of the deepest fault-lines in the NHS is the disconnection of mental healthcare from the rest of the system; this has to be addressed as part of efforts to improve integrated care and make care more person centred.

In an article published in the Journal of the Royal Society of Medicine, Preety Das, Chris Naylor and I discuss this issue. Developing integrated approaches towards mental and physical health is increasingly becoming a policy priority; the report of the independent mental health taskforce to the NHS identified this as one of the top three priorities for the next five years. There has been recent investment in integrating mental and physical health within secondary care, for example, liaison psychiatry in acute general hospitals and perinatal mental healthcare. While such investment is also crucial, we believe that there is great unrealised opportunity for integration in developing new approaches to mental health within primary care.

Read the full article in the Journal of the Royal Society of Medicine.

Clinical impact of lifestyle interventions for the prevention of type 2 diabetes

In a study published in the journal BMJ Open, we reviewed the clinical outcomes of combined diet and physical activity interventions for people at high risk of type 2 diabetes. We looked at combined diet and physical activity interventions including ≥2 interactions with a healthcare professional, and ≥12 months follow-up. Our primary outcome measures included glycaemia, diabetes incidence. Secondary outcomes included behaviour change, measures of adiposity, vascular disease and mortality.

We identified 19 recent reviews for inclusion in our study. Most reviews reported that interventions were associated with net reductions in diabetes incidence, measures of glycaemia and adiposity. Small effect sizes and potentially transient effect were reported in some studies, and some reviewers noted that durability of intervention impact was potentially sensitive to duration of intervention and adherence to behaviour change. Behaviour change, vascular disease and mortality outcome data were infrequently reported, and evidence of the impact of intervention on these outcomes was minimal. Evidence for age effect was mixed, and sex and ethnicity effect were little considered.

We concluded that relatively long-duration lifestyle interventions can limit or delay progression to diabetes under trial conditions. However, outcomes from more time-limited interventions, and those applied in routine clinical settings, are more variable, in keeping with the findings of recent pragmatic trials. There is little evidence of intervention impact on vascular outcomes or mortality end points in any context. Hence, ‘real-world’ implementation of lifestyle interventions for diabetes prevention may be expected to lead to modest outcomes.

Priorities for the improvement of medication safety in primary care

Medication error is a frequent, harmful and costly patient safety incident. Research to date has mostly focused on medication errors in hospitals. In this study, we aimed to identify the main causes of, and solutions to, medication error in primary care. The resuls of the study were published in BMC Family Practice.

In the study, we used a novel priority-setting method for identifying and ranking patient safety problems and solutions called PRIORITIZE. We invited 500 North West London primary care clinicians to complete an open-ended questionnaire to identify three main problems and solutions relating to medication error in primary care. 113 clinicians submitted responses, which we thematically synthesized into a composite list of 48 distinct problems and 45 solutions. A group of 57 clinicians randomly selected from the initial cohort scored these and an overall ranking was derived. The agreement between the clinicians’ scores was presented using the average expert agreement (AEA). The study was conducted between September 2013 and November 2014.

The top three problems we identified were incomplete reconciliation of medication during patient ‘hand-overs’, inadequate patient education about their medication use and poor discharge summaries. The highest ranked solutions included development of a standardized discharge summary template, reduction of unnecessary prescribing, and minimisation of polypharmacy. Overall, better communication between the healthcare provider and patient, quality assurance approaches during medication prescribing and monitoring, and patient education on how to use their medication were considered the top priorities.

We identified a range of suggestions for better medication management, quality assurance procedures and patient education. According to clinicians, medication errors can be largely prevented with feasible and affordable interventions.