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Survival with common cancers and heart conditions

Methods
Results
Comment
The heart failure angle

Scotland has produced many excellent people and ideas. Few, if asked, would number among them the Scottish Morbidity Record Scheme. In this scheme, each person admitted to a Scottish hospital since 1981 has been assigned a unique identifying number, used for all subsequent hospital admissions. These are also linked to diagnostic codes, and to the General Register office relating to all deaths in the UK, and the Scottish Cancer Registry. This results in a fantastic tool for examining disease and outcomes. It has been used to examine the five-year survival after initial hospital admission for common cardiac conditions and cancers [1].

Methods


Information for all of Scotland (population about 5 million) for first hospital admissions for 1991 were used. Excluded were patients who had an admission for their index condition in the preceding 10 years, and, for cancer patients, any with an admission for any malignant neoplasm.

All deaths occurring in individuals before their expected age of death, taken from life-expectance tables for age-matched populations in 1991, were defined as premature. The number of expected life-years lost was calculated by subtracting the actual age at death from the expected age of death. Loss of expected life was then calculated as a median for each diagnosis and for a 1000 population.

Results


There were 14,842 initial diagnoses for women of heart failure, myocardial infarction, and breast, lung, bowel and ovarian cancer. There were 16,224 initial diagnoses for men for heart failure, myocardial infarction, and lung, bowel, prostate and bladder cancer. The numbers, mean age and annual incidence are shown in Table 1.

Table 1: After first hospital admission with heart condition or common cancer in Scotland, 1991. Incidence, five year survival, and expected life years lost per person and per 1000 population

Sex/condition Number Mean age Annual incidence per 1000 Five year survival (%) Median expected life-years lost per person Expected life years lost per 1000
Women
Heart failure 3606 76 1.4 25 6.8 5.1
Myocardial infarction 4916 72 1.9 48 7.9 6.7
Lung cancer 2902 62 0.4 5 13.1 6.7
Breast cancer 1490 70 0.8 65 16.5 7.0
Large bowel cancer 1402 72 0.4 35 10.2 3.0
Ovarian cancer 526 64 0.2 30 14.6 2.3
Men
Heart failure 3241 71 1.3 25 8.7 6.8
Myocardial infarction 6932 64 2.8 60 9.7 9.4
Lung cancer 2695 69 0.8 5 14.4 12.3
Large bowel cancer 1385 69 0.6 35 10.3 3.6
Prostate cancer 1211 74 0.5 38 5.6 1.2
Bladder cancer 760 69 0.3 52 6.7 0.9

Also shown are the five-year survivals (read from graphs, so limited accuracy here), and the median expected life years lost to individual patients with a diagnosis and for a population of 1000 (adjusted for the proportion of deaths that were premature).

Common cardiac conditions in men and women were more common than cancers, but were associated with similar five-year survival rates and life years lost. Five-year survival for heart failure in men and women was associated with a low survival rate (25%), even when adjusted for age. The age-specific probability of surviving five years for the population was about 80% for women and 75% for men.

Comment


The fact that common cardiac conditions and cancers are associated with poor outcomes is hardly a matter of surprise. What is interesting here is that we have reasonable numbers in a whole population and with information collected systematically. We can compare societal impacts of the various diseases on mortality directly.

The heart failure angle


There is more than just interesting comparative figures in this paper, though. It also contains an argument why we should probably be doing more about heart failure, and doing more more effectively. In doing so it reviews, for instance, other studies in other developed countries, and demonstrates that survival rates in Scotland were broadly similar to those in the USA, Australia and other European countries. This is not just a Scottish problem.

It goes on to review briefly the burden of the disease, and the benefits of screening and palliative care programs, making comparisons with cancer screening and screening for malignant hypertension. It finally reviews specific initiatives that could be used in heart failure programs.

There is much food for thought here. The authors' interest is in heart failure, and their discussion is worth reading because it is wide ranging and intelligent. They make a point that better results can be achieved with heart failure, and subsequent hospital admissions avoided, by the use of nurse-led, comprehensive management programmes. But those, in PCOs or elsewhere, who have to plan and organise services will find this rewarding and useful background reading. More than anything else, this is one of those papers that makes you sit back and have a quiet think about what you are doing and why.

References:

  1. S Stewart et al. More 'malignant' than cancer? Five-year survival following a first admission for heart failure. European Journal of Heart Failure 2001 2: 315-322.
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