Psychosocial morbidity in women with abnormal cervical cytology managed by cytological surveillance or initial colposcopy:longitudinal analysis from the TOMBOLA randomised trial

Objective To compare psychosocial outcomes (follow-up related worries, and satisfaction with follow-up related information and support) over 30 months of two alternative management policies for women with low-grade abnormal cervical cytology.Methods Women aged 20-59 years with low grade cytological abnormalities detected in the NHS Cervical Screening Programme were randomised to cytological surveillance or initial colposcopy. 3399 women who completed psychosocial questionnaires at recruitment, were invited to complete questionnaires at 12, 18, 24 and 30 months. Linear mixed models were used to investigate differences between arms in the two psychosocial outcomes. Each outcome had a maximum score of 100 and higher scores represented higher psychosocial morbidity.Results On average, over 30 months women randomised to colposcopy scored 2.5 points (95%CI -3.6 to -1.3) lower for follow-up related worries than women randomised to cytological surveillance. Women in the colposcopy arm also scored significantly lower for follow-up related satisfaction with information and support (-2.4; -3.3 to -1.4) over 30 months. For both outcomes, the average difference between arms was greatest at 12 and 18 month time-points. These differences remained when the analysis was stratified by post-school education.Conclusions Women with low-grade cytology, irrespective of their management, have substantial initial psychosocial morbidity that reduces over time. Implementation of newer screening strategies which include surveillance, such as primary HPV screening, need to consider the information and support provided to women

Population screening for colorectal cancer: the implications of an ageing population

Population screening for colorectal cancer (CRC) has recently commenced in the United Kingdom supported by the evidence of a number of randomised trials and pilot studies. Certain factors are known to influence screening cost-effectiveness (e.g. compliance), but it remains unclear whether an ageing population (i.e. demographic change) might also have an effect. The aim of this study was to simulate a population-based screening setting using a Markov model and assess the effect of increasing life expectancy on CRC screening cost-effectiveness. A Markov model was constructed that aimed, using a cohort simulation, to estimate the cost-effectiveness of CRC screening in an England and Wales population for two timescales: 2003 (early cohort) and 2033 (late cohort). Four model outcomes were calculated; screened and non-screened cohorts in 2003 and 2033. The screened cohort of men and women aged 60 years were offered biennial unhydrated faecal occult blood testing until the age of 69 years. Life expectancy was assumed to increase by 2.5 years per decade. There were 407 552 fewer people entering the model in the 2033 model due to a lower birth cohort, and population screening saw 30 345 fewer CRC-related deaths over the 50 years of the model. Screening the 2033 cohort cost £96 million with cost savings of £43 million in terms of detection and treatment and £28 million in palliative care costs. After 30 years of follow-up, the cost per life year saved was £1544. An identical screening programme in an early cohort (2003) saw a cost per life year saved of £1651. Population screening for CRC is costly but enables cost savings in certain areas and a considerable reduction in mortality from CRC. This Markov simulation suggests that the cost-effectiveness of population screening for CRC in the United Kingdom may actually be improved by rising life expectancies

Equity in health care financing: The case of Malaysia

Background: Equitable financing is a key objective of health care systems. Its importance is evidenced in policy documents, policy statements, the work of health economists and policy analysts. The conventional categorisations of finance sources for health care are taxation, social health insurance, private health insurance and out-of-pocket payments. There are nonetheless increasing variations in the finance sources used to fund health care. An understanding of the equity implications would help policy makers in achieving equitable financing. Objective: The primary purpose of this paper was to comprehensively assess the equity of health care financing in Malaysia, which represents a new country context for the quantitative techniques used. The paper evaluated each of the five financing sources (direct taxes, indirect taxes, contributions to Employee Provident Fund and Social Security Organization, private insurance and out-of-pocket payments) independently, and subsequently by combined the financing sources to evaluate the whole financing system. Methods: Cross-sectional analyses were performed on the Household Expenditure Survey Malaysia 1998/99, using Stata statistical software package. In order to assess inequality, progressivity of each finance sources and the whole financing system was measured by Kakwani's progressivity index. Results: Results showed that Malaysia's predominantly tax-financed system was slightly progressive with a Kakwani's progressivity index of 0.186. The net progressive effect was produced by four progressive finance sources (in the decreasing order of direct taxes, private insurance premiums, out-of-pocket payments, contributions to EPF and SOCSO) and a regressive finance source (indirect taxes). Conclusion: Malaysia's two tier health system, of a heavily subsidised public sector and a user charged private sector, has produced a progressive health financing system. The case of Malaysia exemplifies that policy makers can gain an in depth understanding of the equity impact, in order to help shape health financing strategies for the nation

Social inequalities in stage at diagnosis of rectal but not in colonic cancer: a nationwide study

We investigated stage at diagnosis in relation to socioeconomic status (SES) among 15 274 patients with colorectal adenocarcinoma diagnosed in 1996–2004 nationwide in Denmark. The effect of SES on the risk of being diagnosed with distant metastasis was analysed using logistic regression models. A reduction in the risk of being diagnosed with distant metastasis was seen in elderly rectal cancer patients with high income, living in owner–occupied housing and living with a partner. Among younger rectal cancer patients, a reduced risk was seen in those having long education. No social gradient was found among colon cancer patients. The social gradient found in rectal cancer patients was significantly different from the lack of association found among colon cancer patients. There are socioeconomic inequalities in the risk of being diagnosed with distant metastasis of a rectal, but not a colonic, cancer. The different risk profile of these two cancers may reflect differences in symptomatology

Evaluation of a service intervention to improve awareness and uptake of bowel cancer screening in ethnically-diverse areas

The Policy Research Unit in Cancer Awareness, Screening and Early Diagnosis receives funding for a research programme from the UK Department of Health Policy Research Programme (grant no. 106/0001). It is a collaboration between researchers from seven institutions (the Queen Mary University of London, the UCL, the King’s College London, the London School of Hygiene and Tropical Medicine, the Hull York Medical School, the Durham University and the Peninsula Medical School)