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Biomedical subjects

S M Moss

Publications and source records attributed to S M Moss.

At least 37 records · Page 2Linked to original sources

Impact of skin cancer education on general practitioners' diagnostic skills.

Seventeen general practitioners (GPs) were evaluated to assess their ability to recognize malignant, borderline and benign skin lesions before and after a novel, cheap and quick skin cancer educational programme. They were tested without prior warning on two occasions using two sets of 30 clinical slides. Between each test the GPs were given a lecture based on an illustrated booklet of similar lesions. The results showed an improvement in the GPs' diagnostic skills (P < 0.05), but nevertheless a wide variation in diagnostic ability between GPs remained. Our study highlights a simple, effective and inexpensive method for teaching GPs the diagnostic clinical features of skin cancer. Further work is needed to improve their diagnostic accuracy in the long term.

Clinical Competence↗

Rationale for a national multi-centre study of magnetic resonance imaging screening in women at genetic risk of breast cancer.

In 1994, the UK National Health Service identified as a research priority that magnetic resonance imaging (MRI) should be assessed as a screening tool for young, pre-menopausal women who are at a high genetic risk of developing breast cancer. In 1997 a national multicentre study was established to compare MRI with X-ray mammography as a method for screening for breast cancer in this group of women. This paper reviews the relevant literature and describes the rationale that led to the setting up of this study.

Journal Article↗

Protocol for a national multi-centre study of magnetic resonance imaging screening in women at genetic risk of breast cancer.

The protocol of the national multicentre study of Magnetic Resonance Imaging (MRI) as a method of screening for breast cancer in women at genetic risk is described. The sensitivity and specificity of contrast-enhanced MRI will be compared with two-view X-ray mammography in a comparative trial. Approximately 500 women below the age of 50 at high genetic risk of breast cancer will be recruited per year for 3 years, with annual MRI and X-ray examination continuing for up to 5 years. A symptomatic cohort will be measured in the initial phase of the study to ensure consistent reporting between centres. The MRI examination will comprise an initial high-sensitivity screening measurement, followed by a high-specificity measurement in equivocal cases. Retrospective analysis will identify the most specific indicators of malignancy. Sensitivity and specificity, together with diagnostic performance, diagnostic impact and therapeutic impact will be assessed with reference to pathology, follow-up and changes in diagnostic certainty and therapeutic decisions. The psychological impact of screening in this high-risk group will be ascertained.

Journal Article↗

Systemic mycosis due to Aspergillus deflectus in a dog.

A 4-year-old, entire female, German Shepherd Dog was referred with a 3-month history of right foreleg lameness that partially responded to nonsteroidal anti-inflammatory and antimicrobial therapy. The bitch lost weight, was polydipsic and had reduced exercise tolerance. On referral, the animal was in poor condition, pyrexic and exhibited moderate pain on full extension of the right shoulder. Blood, urine and joint fluid were obtained and radiographs were taken of the right shoulder and chest. The bitch was lymphopaenic, hyperfibrinogenaemic, hyperglobulinaemic, mildly azotaemic, mildly proteinuric and isosthenuric. Branching fungal hyphae were present in the urine. On radiography, the thorax contained a large ventral mediastinal mass and the humeral head had extensive areas of radiolucency. An aspirate from the right humeroscapular joint exhibited branched fungal hyphae and numerous neutrophils and macrophages. A diagnosis of disseminated mycosis was made and euthanasia was performed. At necropsy, numerous caseating granulomas were present, especially in the kidneys, adrenal glands, heart and lymph nodes. Extensive osteomyelitis involved the head of the right humerus, the sternebrae and the fifth intervertebral disc. Fungal hyphae were detected in sections of granulomas in all affected organs and a diagnosis of disseminated fungal granulomatosis was made. Aspergillus deflectus was readily isolated from affected lymph nodes, but confirming its identity as A deflectus using standard procedures proved difficult. The identity of the fungus was finally confirmed by sequencing part of the 185 rRNA of the isolate. This is the first report in Australia of a disseminated mycosis caused by A deflectus. Previously, the involvement of A deflectus as a cause of disseminated mycosis was limited to 5 cases from the West Coast of the USA, four of which occurred in German Shepherd Dogs.

Animals↗

Faecal occult blood screening for colorectal cancer at Nottingham: details of the verification process.

Cause specific mortality statistics derived from death certificates are highly dependent upon the accuracy of certification by the attending physician. In the Nottingham colorectal cancer screening trial, there were 12,624 deaths among the screening group and 12,515 among the control group during the period under consideration. There was no significant difference in all cause mortality rate (excluding deaths due to colorectal cancer) between the two study groups (rate ratio = 1.01, 95% confidence interval = 0.99 to 1.03). Disease specific mortality rates did not differ significantly between the two groups either. Overall, the agreement between verified and certified cause of death was 86%. Using the certified cause of death would have resulted in an underestimation bias of 6.27% for colorectal cancer deaths.

Aged↗

Results from the UK NHS breast screening programme 1994-1999.

OBJECTIVE: To present results from the NHS breast screening programme (NHSBSP) from 1994 through to 1999 and to examine the extent to which interim targets are being achieved. METHODS: Data were collated from all screening programmes in the UK on standard statistical returns. Performance of the screening programme was evaluated using calculated targets based on comparison with the Swedish two counties (STC) randomised controlled trial. RESULTS: In the early years of screening (1988-1993), the NHS programme was detecting more DCIS but considerably less invasive cancers than expected, based on the STC trial. Since the screening year 1993/94 (1 April to 31 March) the standardised detection ratio (SDR) measure of the detection of invasive cancers has increased by 36% from 0.83 to 1.13. The SDR has been greater than 1 since 1996197 suggesting that the NHSBSP has only been screening as efficiently as the STC trial since this date. Uptake for screening has been relatively stable over time at approximately 75%. CONCLUSIONS: The NHSBSP has made considerable advances in performance since its inception in 1988 and screening uptake and age standardised invasive cancer detection rates are (by 1999) well in excess of targets. The early years of screening were characterised by good uptake but a low sensitivity for the detection of invasive cancers. It is anticipated that the screening programme will have an increasing impact on breast cancer mortality, particularly in the 55-69 year age group over the coming years.

Breast Neoplasms↗

Survival of patients with colorectal cancer diagnosed in a randomized controlled trial of faecal occult blood screening.

BACKGROUND: Analysis of survival of subjects with colorectal cancer diagnosed by different modalities can provide insight into the mechanism by which screening has an effect. It can also give an indication of the feasibility of using prognostic indicators as surrogate outcome measures to predict mortality in future studies. METHODS: This paper examines the survival of individuals with colorectal cancer diagnosed in the Nottingham trial and explores the role of selected prognostic factors as possible surrogate outcome measures. RESULTS: Survival was significantly better in subjects with screen-detected cancers than in controls, even after adjusting for tumour stage and accounting for lead-time bias. Survival was inversely related to stage of tumour, with patients with stage A tumours having the best survival. Subjects with well or moderately differentiated tumours had a significantly better survival than those with poorly differentiated tumours. CONCLUSION: Screening for colorectal cancer by means of faecal occult blood testing improved survival among subjects with screen-detected cancers. Differences in prognostic factors largely explain the differences in survival between both non-responders and subjects with interval cancers and those in the control group, but not the improved prognosis for patients with screen-detected cancers. The use of such factors as surrogate outcome measures may therefore be inappropriate.

Aged↗

Interval cancers in a randomized controlled trial of screening for colorectal cancer using a faecal occult blood test.

BACKGROUND: The sensitivity of unhydrated Haemoccult II has been examined in the context of a randomized controlled trial of faecal occult blood screening for colorectal cancer in Nottingham, UK. METHOD: Both traditional and proportional incidence methods were used to calculate sensitivity separately for both sexes, for two age groups at entry to the trial, for first screen and repeat screens and for three subsites within the large bowel. RESULTS: The traditional method of estimation yielded a sensitivity of 59% whereas the corresponding figure obtained using the proportional incidence method was 54%. The difference between the estimates using the two methods was greatest in subjects aged > or = 65 at entry to the trial and in cancers of the distal colon. CONCLUSIONS: The results suggest that there may be a higher proportion of slower growing tumours in subjects aged > or = 65 and that cancers occurring in the distal colon may have a longer mean sojourn time than cancers proximal to the sigmoid colon.

Adult↗

The risks of screening: data from the Nottingham randomised controlled trial of faecal occult blood screening for colorectal cancer.

AIMS: To determine the harm that ensues from faecal occult blood (FOB) screening for colorectal cancer. METHODS: 150 251 people were randomly allocated either to receive biennial Haemoccult FOB tests (n =75 253) or not to be contacted (n=74 998). Study group patients returning positive tests were offered colonic investigation; 1774 underwent complete investigation of the colon. RESULTS: There was no significant difference in the stage at presentation of interval versus control group cancers. Survival in the interval cancer group was significantly prolonged compared with the control group. Sensitivity for colonoscopy or flexible sigmoidoscopy and double contrast barium enema (DCBE) was 96.7%. There were no complications of DCBE but seven (0.5%) complications of colonoscopy, of which six required surgical intervention. There were no colonoscopy related deaths. No patients without colorectal cancer died within 30 days of colonic investigation. Five patients died within 30 days of surgery for screen detected colorectal neoplasia and a further two died without having surgery. Six patients died after 30 days but within two years of surgery for screen detected benign adenomas or stage A cancers; in all cases the cause of death was not related to colorectal cancer. CONCLUSIONS: There was investigation related morbidity but no mortality and little to support overdiagnosis bias. The group returning falsely negative tests had a better outcome compared with the whole control group. There is a negative side to any screening programme but mortality reduction in this and other trials suggests that a national programme of colorectal cancer screening should be given consideration.

Aged↗

Oral cancer in the UK: to screen or not to screen.

Although oral squamous cell carcinoma accounts for only a small proportion of malignant neoplasms in the UK, oral cancer incidence and mortality rates have been rising in recent years. The natural history of oral cancer is not adequately understood at present and there is very little information about the epidemiology of precancerous lesions in the UK. There are also insufficient data to provide firm evidence that the percentage of cases arising de novo is greater in the UK and the Western world as compared to the Indian subcontinent. Screening for oral cancer by visual examination is simple, inexpensive and causes little discomfort; however, there is no evidence for the effectiveness of screening for oral cancer either in reducing mortality from the disease or in reducing the incidence of invasive disease by detection and treatment of precancerous lesions. There is currently insufficient evidence to recommend population screening for oral cancer in the UK. Measures aimed at primary prevention of the disease may be a more feasible method of disease control at present.

Carcinoma, Squamous Cell↗

Screening for prostate cancer: the current position.

Prostate cancer is a significant and increasing health problem in the UK and elsewhere, and there is considerable interest in the potential for screening. Of the currently available screening tests, measurement of serum levels of prostate specific antigen appears the most promising. However, despite evidence that screening can detect asymptomatic early stage disease, there is, as yet, no evidence that mortality from prostate cancer can be reduced. There are concerns that screening may result in considerable over-diagnosis of non-progressive or slowly developing disease, and the effectiveness of radical treatment of localised disease, which itself will cause some morbidity, remains a subject of debate. Population screening should not currently be recommended. Randomised controlled trials are in progress to assess the effectiveness of screening, but these will take many years to produce results.

Biomarkers, Tumor↗

Efficiency of cancer detection during routine repeat (incident) mammographic screening: two versus one view mammography.

OBJECTIVE: To examine the influence of one view versus two view mammography on cancer detection and recall for further investigation of women attending incident (subsequent) screening. SETTING: All cancers (invasive and in situ) detected as incident cases during the second screening round (January 1994 to January 1997) at the South West London Breast Screening Service were used. This service uses two view mammography and double reading, with arbitration by a third or further readers for all screens. METHODS: Mammograms of cases were mixed with those of controls in a 1:2 ratio in nine test sets; each set was read independently by three film readers. Fourteen readers, each reading from one to four test sets, took part in the study. Initially, the oblique view only was read, then the craniocaudal view was read in addition. Previous films were available to the readers. Data on abnormalities noted on the films and probability of recall were recorded and analysed. RESULTS: 10 of the 14 readers obtained increased sensitivity using two views (p = 0.04), for two readers there was no difference, and for two readers sensitivity decreased. The mean sensitivity increase was 6.1% (p = 0.01). The overall increase in sensitivity from all readings of invasive cancers was 8.9%, with no increase seen for in situ cancers. 11 of the 14 readers obtained an increase in specificity (p = 0.006), two readers showed no increase, and the specificity for one reader was decreased. The mean increase in specificity using two views was 5.7% (p = 0.006). CONCLUSION: This study showed an increase of 8.9% in sensitivity for the detection of invasive cancers when two views are used at incident screening, with a ratio of two control mammograms for every case. This is equivalent to a sample from population screening with a cancer detection rate of 333 per 1000. Such a study is considered to be likely to underestimate the benefit of two views in screening under non-test conditions where the cancer detection rate is of the order of five per 1000. The use of two view mammography for the detection of in situ cancers showed no increased benefit. A randomised controlled trial is needed to obtain a reliable estimate of the increase in cancer detection rate for incident screening in normal populations.

Female↗

A comparison of cancer detection rates achieved by breast cancer screening programmes by number of readers, for one and two view mammography: results from the UK National Health Service breast screening programme.

OBJECTIVE: To determine the increased cancer detection rate, if any, of programmes in the UK National Health Service breast screening programme (NHSBSP) using more than single reading of mammograms. DESIGN: Information on the detection of cancers by individual screening programmes from annual (KC62) returns, supplemented by questionnaire information about the number of readers. SETTING: The 87 NHSBSP programmes from England and Wales for the screening year 1 April 1996 to 31 March 1997. The study includes all programmes for prevalent screens where two views are mandatory, but excludes the four programmes using two view mammography for incident screening. MAIN OUTCOME MEASURES: Cancer detection, invasive cancer detection, and small (< 15 mm) invasive cancer detection by mammographic reading protocol using single reading as the reference level. RESULTS: Programmes collectively using single reading detected the lowest rate of cancers at both prevalent (first) and incident (subsequent) screening. The highest rate of age standardised cancer detection was achieved by programmes using double reading with arbitration. At prevalent screens, where all programmes used two views, those programmes using double reading with arbitration detected 32% (95% confidence interval (CI) 3% to 69%) more small (< 15 mm) invasive cancers than programmes using single reading. At incident screens, where all programmes analysed used one view this increased to 73% (95% CI 40% to 113%). Recall rates showed no obvious difference between single reading and the double reading protocols, being around 7% for prevalent screens and 3.5% for incident screens. DISCUSSION: The results suggest that the increase in cancer detection resulting from increasing the number of readers depends on the number of views, and is higher for one view than two views. Single reading of one view results in a low detection rate of small invasive cancers for most individual programmes. It is, however, recognised that a small number of individual readers may achieve high detection rates with such a protocol. All groups of programmes using different reader/view protocols are on average close to or above target cancer detection rates, except those using single reading of one view (mediolateral oblique) at incident screens.

Breast Neoplasms↗

The quality of histopathology data in a computerised cancer registration system: implications for future audit of care.

Electronic linkage between pathology data sources and other information systems has not realised its full potential benefits due to the poor quality of histopathology coding. This study showed that 38% of a sample of 158 pathology reports were coded accurately. Of the incorrectly coded reports, 25% had the potential to distort published cancer incidence figures. The incidence figures of the most common cancers are less likely to be affected by coding errors. Areas in which all errors, both topographical and morphological, could have significant impact include examining resource allocation at directorate level and adjusting outcome indicators for casemix. This study concludes that electronic linkage between histopathology systems and cancer registries is not sufficient to improve the quality of registration data. As cancer registries become more dependent on computerised information provided through hospital information systems, registries need to be aware of poor quality data and put in place appropriate quality assurance measures specifically tailored to support electronic cancer registration. Purchasers and providers need to be aware that incomparable datasets could be produced if other bodies use computerised pathology datasets without first validating the data.

England↗

Use of two view mammography compared with one view in the detection of small invasive cancers: further results from the National Health Service breast screening programme.

OBJECTIVE: To examine further the effect of using two view mammography in comparison with one view mammography in the detection of small (< 15 mm) invasive cancers for programmes in the National Health Service breast screening programme (NHSBSP). The study is in two parts: first the effect on the small invasive cancer detection rate for programmes that changed from using one view to two views for first (prevalent) screens, and secondly the effect on the small invasive cancer detection rate for programmes that used two views for subsequent (incident) screens compared with programmes that used one view. SETTING: Screening programme data from the NHSBSP. METHODS: Data were collated from all screening programmes in the United Kingdom on standard "Korner" returns (KC62 forms) for the screening years 1 April 1994 to 31 March 1995 and 1 April 1995 to 31 March 1996. The comparison between one and two view mammography was made using indirectly age standardised invasive cancer detection rates. RESULTS: For prevalent (first) screens, programmes changing from one view mammography in 1994/95 to two views in 1995/96 reported a 45% (95% confidence interval (CI) 25% to 68%) increase in the detection of invasive cancers of < 15 mm. In comparison, programmes that were already using two views in 1994/95 showed no change in 1995/96. For incident (subsequent) screens the small number of programmes that have opted to use two views reported 25% (95% CI 1% to 55%) more invasive cancers of < 15mm than programmes using one view in 1995/96, and 42% (95% CI 11% to 81%) more in 1994/95. CONCLUSIONS--These results confirm the benefit of using two view mammography in the detection of small invasive cancers, and provide evidence that this effect is seen in subsequent screens as well as the first screen.

Adult↗

Influence of number of views and mammographic film density on the detection of invasive cancers: results from the NHS Breast Screening Programme.

The National Health Service Breast Screening Programme (NHSBSP) has recommended the adoption of two view mammography at the prevalent screen, and the use of a target film density in the range 1.4-1.8. The aim of this study was to review the impact of number of views and optical density on the detection of invasive cancers. The last four annual returns for screening centres in the NHSBSP have been analysed retrospectively for 2827342 women aged 50-64 years attending their first (prevalent) screening examination. The detection of invasive cancers was assessed in relation to the number of views and film density using the age adjusted, Standardized Detection Ratio measure of screening performance. Typical film densities were reported for each screening year by local physicists, and the average value for all mammography sets at each programme calculated, and found to vary from 0.85 to 1.85. The mean film density across the NHSBSP rose progressively from 1.30 (SD = 0.21) in 1991/2 to 1.57 (SD = 0.12) in 1994/5. Programmes using single view mammography (MLO) and an optical density less than 1.4 detected 76% (95% CI 74-79%) of the expected invasive cancers. Programmes using two view mammography (MLO and CC) and an optical density equal to or greater than 1.4 detected 95% (95% CI 92-98%) of the expected invasive cancers. In 1994/95 when more programmes used the recommended screening modes, the NHSBSP detected 96% (95% CI 92-101%) of the expected invasive cancers at prevalent screening. The detection of invasive cancers was highest where programmes used two views with a film density in the range 1.4-1.8. The results provide evidence of the benefit of the recommended protocol for prevalent screening and indicate that from 1995/96 when all programmes will be using the recommended protocol, it is likely that the detection rates and interval cancer rates from prevalent screens in the NHSBSP will be close to the figures in the Swedish-Two County Trial.

Breast Neoplasms↗