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Take a look at a selection of our recent media coverage:
23rd January 2025
Women are waiting longer for lung transplantation than men, a French retrospective study finds, showing changes to clinical guidelines and policies are needed to address gender inequalities.
Lung transplantation is a highly dynamic segment of solid organ transplant, where gender is known to play a central role, the study authors wrote in ERJ Open Research.
Previous research using US lung transplantation data had found women had a lower chance of receiving a transplant than men and waited longer before transplant.
For this study the authors evaluated the differences between men and women before transplantation, during and immediately after surgery and in the months and years following transplantation using data from the French Cohort in lung transplantation (COLT) database – the first to analyse all three periods of the transplantation pathway.
Overall, 1,710 participants (802 women and 908 men) were included in the study, with analysis showing women waited an average of six weeks longer for transplantation, spending 115 days on the transplant list compared with 73 days for men.
Women were less likely than men to undergo transplantation (91.6% vs 95.6%), the data showed.
At the time of registration on the lung transplant list, women were younger than men (47 years vs 54 years) and they displayed fewer comorbidities, including ischemic heart disease and cardiovascular risk factors.
In both genders, the main underlying disease was COPD/emphysema, followed by cystic fibrosis and interstitial lung disease.
In other differences, pre-transplant anti-human leukocyte antigen (HLA) antibodies were more prevalent in women than in men (46% vs 26%) for both class I and class II, with the number of pre-transplant class I anti-HLA antibodies associated with an increased waiting time.
It was also more common for women to receive lungs from height- and sex-matched donors, despite higher female-waiting list mortality and a higher proportion of male donors, the authors wrote.
They stressed that women with oversized lung transplantation, defined by predicted total lung capacity ratio and weight, did not have worse survival, therefore suggesting that size matching criteria could be less stringent.
Post-transplantation, women had a significantly higher survival rate than men, with 34.4% of female recipients dying compared with 42.7% of male recipients.
Survival rates were also higher among women than men at five years post-transplantation (70% vs 61%).
Study lead author Dr Adrien Tissot of from the Pulmonology Department at Nantes University Hospital, France, said people on the lung transplant waiting list had a poor quality of life and high mortality risk.
‘For these patients, waiting is suffering, and the longer the wait the worse these women are suffering,’ he said.
‘Clinicians, patients and policy makers must acknowledge this gender difference as it’s essential for appropriate action to be taken.’
Dr Tissot suggested early listing for women or revising the allocation policy of donor lung to recipient could be considered.
‘We believe our findings, such as the potential role of size matching and its consequence on access to lung transplantation, and length of time on the waiting list, may also apply in other countries where lung transplantation is performed,’ he said.
Also commenting on the findings, Dr Michael Perch, chair of the European Respiratory Society’s Group on Lung Transplantation and a senior consultant at Rigshospitalet in Copenhagen, Denmark, said there could be several reasons why women waited longer for transplantation, including differences in education and health literacy, socioeconomic differences, immunological factors and donor-recipient size matching.
‘Clinicians and policymakers alike must question why there is a focus on gender and size matching in transplantation when evidence shows that, in lungs, these factors do not determine a woman’s chance of survival, and it ultimately risks an increase of women dying while waiting for a transplant,’ he said.
‘It is unacceptable for women to be waiting longer than men for these lifesaving donations, so effective corrective measures must be introduced.’
2nd January 2025
More needs to be done to protect children with asthma in England, including proper implementation of the new UK-wide joint BTS/NICE/SIGN guidelines, Asthma + Lung UK has said.
The charity warned that children from the most deprived areas are four times more likely to die from an asthma attack and called on the Government to take ‘urgent action’ to prevent child asthma deaths, including tackling poor housing conditions and air pollution and ensuring children get the care they need.
This comes as the recent National Child Mortality Database Report on Child Deaths Caused by Asthma shows that between April 2019 and March 2023, 54 children died due to asthma – one every four weeks.
More than half (56%) of the children who died came from the poorest communities.
Well-known risk factors for asthma attacks were common in a high proportion of the deaths, including overuse of reliever inhalers, emergency hospital admissions and exposure to air pollution and cigarette smoke, the report said.
It found 87% of the children had three or more short-acting beta-2 agonist (SABA) inhalers dispensed in the year before their death, with half of them having 12 or more.
In addition, 65% had attended an emergency department or had an emergency admission in the year before death.
All the children who died lived in areas with air pollution above levels recommended by the World Health Organization.
And smoking by family members was recorded in nearly half (43%) of the cases, despite the national average of adults who smoke in the UK being 13%.
Reviews of the deaths documented multiple missed appointments for asthma reviews in primary, secondary and tertiary care over many years, and children being discharged from services.
Poor compliance with preventer medication was also documented, and there were examples of children who were managing their asthma without adult oversight, the report found.
There were also examples of services failing to follow up and escalate appropriately, including SABA inhalers frequently prescribed by GPs despite children not being brought for reviews.
In some cases, healthcare professionals repeatedly referred children to social care due to missed appointments and non-compliance with treatment, stating their concerns about risk of significant harm and death, but this was not followed up.
Asthma + Lung UK said there was a ‘pressing need’ to do more to protect the 1.75 million children in England with the condition and called on the Government to ensure proper implementation of the new UK-wide joint BTS/NICE/SIGN asthma guidelines.
This should include provision of basic care in the community, including accurate diagnosis and annual reviews that include an inhaler technique check and written action plan.
Sarah Sleet, chief executive of Asthma + Lung UK, said: ‘A child dying from asthma every month is devastating and unacceptable.
‘More than a decade after the National Review of Asthma Deaths found that two thirds of asthma deaths are avoidable, people with asthma are still not getting the basic care they need and those living in the most deprived parts of the country are most at risk.
‘Bridging this health gap will only be possible if politicians commit to preventing poor lung health in the first place. This means action to cut smoking rates, tackle air pollution and address issues such as poor housing.’
Dr Andy Whittamore, a GP and clinical lead at Asthma + Lung UK, said: ‘Every week I speak to families who are powerless to change the things making their child’s asthma worse, such as living in damp, mouldy housing, or near busy polluted roads.
‘For children from the poorest communities, their chance of good health is determined almost before they’re born. That has to change.’
He added: ‘The new asthma guidelines offer some hope. Recommendations for better treatments and closer follow-up after a flare-up have the potential to keep children with asthma safe.
‘But without adequate funding and an NHS workforce fully upskilled in asthma care, properly implementing them will be impossible.’
A version of this article was originally published by our sister publication Pulse.
4th November 2024
The initiation of biological and targeted synthetic disease-modifying antirheumatic drugs (DMARDs) among patients with newly diagnosed rheumatoid arthritis varies widely with age and ethnicity, researchers have found.
In a new study in England and Wales led by King’s College London (KCL), older patients and patients with Asian heritage were found to be missing out on effective treatments.
The researchers showed that patients over 65 years of age were 60% less likely to be given highly effective biological and targeted synthetic DMARDs to treat symptoms compared to patients aged under 40. Asian women were also less likely to be prescribed these drugs than Asian men and white men.
Socioeconomic status, other health conditions, or the response to conventional treatments did not explain the differences, the researchers said.
Using data from the National Early Inflammatory Arthritis Audit (NEIAA), the researchers identified 6,098 patients enrolled in the audit between May 2018 and April 2022 who had rheumatoid arthritis and 12-month follow-up data available.
Statistical methods were used to examine whether factors such as age, sex, ethnicity, health and economic status were associated with the initiation of biological and targeted synthetic DMARDs within 12 months of initial rheumatology assessment.
The mean age of the patients was 59.2 years, and just under two-thirds were women. The majority of the participants were white (86.2%), 2.5% were Black, 7.9% were Asian and 3.3% were mixed or other ethnicities.
Within 12 months of initial diagnosis, 8.3% of patients started biological and targeted synthetic DMARDs. Patients under 40 were nearly two and half times more likely to start treatment than patients who were over 65 (multivariable-adjusted risk ratio 2.41 [95% CI 1.83–3.19]; p<0.0001), and Asian women were about half as likely to start treatment than white individuals (0.52 [0.36–0.76]; p=0.0007).
The study also found that Black individuals were more likely to be started on biological and targeted synthetic DMARDs than white individuals (1.54 [1.10–2.16]; p=0.012), which was at least partly explained by worse disease severity at diagnosis in these individuals.
The findings highlight the problems of a ‘one-size-fits-all’ approach to treatment and the need for personalised information to be considered. The researchers say equitable access to biological and targeted synthetic DMARDs and quality care for underserved groups is needed.
Lead author Dr Mark Russell, NIHR clinical lecturer in rheumatology at King’s College London, said: ‘Rheumatoid arthritis is a progressive, debilitating condition with no cure. This study highlights marked differences in who gets started on advanced therapies for rheumatoid arthritis.
‘Access to these drugs in England and Wales is defined by need. Despite this, we found that Asian women and older adults were far less likely to be initiated on these treatments. Biologics are incredibly effective at improving quality of life and preventing complications from rheumatoid arthritis.
‘It is therefore crucial to develop a better understanding of what underlies these disparities if we are to ensure all patient groups receive equitable access to the best available care.’
Reference
Russell, M et al. Factors associated with biological and targeted synthetic disease-modifying antirheumatic drug initiation for rheumatoid arthritis in underserved patient groups in England and Wales, UK: a national cohort study. The Lancet Rheumatology 2024; Oct 15: DOI: 10.1016/ S2665-9913(24)00221-2.
30th October 2024
With another successful ESC Congress under its belt, the European Society of Cardiology’s new president Professor Thomas Lüscher speaks to Helen Quinn about the current challenges and opportunities in European cardiology, his highlights from the congress and his thoughts on the future of cardiovascular care.
In September 2024, at the European Society of Cardiology (ESC) annual congress, delegates welcomed Professor Thomas F. Lüscher as their new president and it’s a role he is excited about taking on.
Professor Lüscher is a world-renowned cardiologist, ranking in the top 0.5% globally of most cited scientists and currently a consultant cardiologist and director of research, education and development at the Royal Brompton and Harefield hospitals in London and professor at King’s College London, UK.
Having been involved with the ESC for many years, Professor Lüscher has chaired various working groups, became vice president in 2003 and then editor-in-chief of the European Heart Journal in 2008 – a position he held for 11 years. He describes the society as ‘a fantastic success story’ that has evolved from ‘a small club of friends into the largest and most influential society in medicine’.
With seven associations, seven councils, 15 working groups, 57 national societies, 47 affiliated national societies, 17 journals, 18 textbooks, an annual congress and nine speciality congresses, the ESC works hard to improve cardiovascular care and patient outcomes throughout Europe.
‘[It’s] an institution that dominates the field in a positive manner by providing guidelines, education and registries to improve the burden of cardiovascular disease. So, it’s a really exciting position I have,’ Professor Lüscher says.
Cardiovascular disease is still the leading cause of morbidity and mortality in Europe, and there are significant challenges facing the field. In the past, support from the EU has favoured oncology over cardiovascular healthcare. To try to change this imbalance, the ESC has responded by putting together a cardiovascular health plan, which has been submitted to the EU Council of Health Ministers to raise the profile of research and increase the quality and equality of care patients receive.
‘We hope this will impact the support for cardiovascular science and education in the future,’ Professor Lüscher says. ‘Europe has had a fantastic history. Most of the interventions have been invented in Europe, starting with pacemakers, atrial fibrillation ablation, percutaneous coronary intervention, transcatheter aortic valve implantation and MitraClip. It’s quite an amazing story.’
Today, however, innovation and development are hampered by regulations, according to Professor Lüscher. At the same time, the Food and Drug Administration in the US has become more lenient and much quicker and effective in approving drugs and trials.
‘I’m concerned that the speed and impressive innovation we have delivered over the last 200 years may be fading a little bit. There has been a bit of a shift from Europe to the US. [There are] a lot of rules and regulations in the EU and the UK,’ explains Professor Lüscher.
A lack of centralised device regulation in Europe is also impeding developments in field. Consequently, the ESC is working constructively with the European Medicines Agency and the Notified Bodies to make Europe fitter for innovation.
For some patients, differences in access to care is one of the main barriers to improving cardiovascular health across the continent. Such inequalities are highlighted in the ESC’s publication ‘Atlas of Cardiology’, which gives a picture of the current state of cardiovascular across Europe and shows vast differences in modern management options for cardiovascular conditions in different countries.
Patients in countries like Germany, Switzerland, Scandinavia and the Netherlands have good access to the latest treatments and medications. In other European countries, access is much more difficult, with many patients – particularly those in Eastern Europe – missing out.
And in the UK, for example, there is a concern that lower social classes have limited access to the latest cardiovascular treatments, Professor Lüscher explains, with deprived areas experiencing worse levels of care and, in turn, worse outcomes.
‘If you have severe heart failure, you might need a left ventricular assist device and in many countries that’s not available. Also, some novel, more expensive drugs are not available in certain countries,’ Professor Lüscher says. ‘There’s a huge heterogeneity in access to treatment across European countries. These are ethical concerns for medicine that, by nature, is a humanistic profession. The ESC tried to address this problem.’
The European Union has tried to overcome these inequalities in care by putting pressure on the prices of medications. There is also pressure on patent durations to make generic therapies available more easily and earlier, which is beneficial in the short term, but it is something that Professor Lüscher worries will obstruct innovations in the long term.
‘In the end, this is an economic problem,’ Professor Lüscher says. ‘There’s a close correlation between gross national product and availability of medical services, and currently in Europe the economy is not doing well. In many countries, we have issues with the economy that reflect on the service for patients.’
There is, however, much to be excited about in the field of cardiology, with many innovations and new research shared at the ESC Congress 2024. For Professor Lüscher, two significant potential developments excited him the most.
The first is the development of genetic tools as therapeutic agents to treat and prevent cardiovascular disease. This cutting-edge approach focuses on the use of antisense oligonucleotides (ASOs) and small interfering RNAs (siRNAs), which can block the production of certain proteins in the body and currently mainly target the liver.
‘The liver has specific receptors, in particular the asialoglycoprotein receptor, mainly expressed in hepatocytes. So, once linked with a GalNac residue, you can direct these double-stranded RNAs specifically to the hepatic cells. Then they bind to the RISC complex within the cell and inhibit the translation of a transcript to a protein over several months,’ Professor Lüscher explains.
This process enables a long-lasting therapeutic approach. There are now siRNAs for PCSK9, which lower low-density lipoprotein (LDL) plasma levels for six months, and others, including a new development for lipoprotein(a). In addition, siRNA therapies can target angiotensinogen to lower blood pressure for several months. Other siRNAs, like those that reduce transthyretin (TTR), help treat ATTR amyloidosis by preventing the formation of harmful amyloid deposits.
Gene editing tools, such as CRISPR-Cas9, are also emerging, which can precisely modify nucleoid acid sequences in the DNA. In animal trials, this tool has been used to permanently block the production of PCSK9, preventing it from binding to LDL receptors and thus lowering cholesterol levels and potentially offering a one-off, lifelong treatment.
‘The long-term vision is that we cure rather than treat. These genetic tools are a completely new chapter in pharmacotherapy,’ Professor Lüscher says.
A second area of innovation that will continue to be incredibly influential in cardiovascular medicine is the development of artificial intelligence (AI) and machine learning. As part of his presidency, Professor Lüscher has set out his vision for the digital transformation of cardiology in Europe.
Beginning with online consultations, he believes AI has much to offer clinicians and patients. ‘With an algorithm, you can analyse the face of a person, see the pulse, see the wrinkles, see the amount of sweat, and you can make outcome predictions,’ he says.
‘AI analyses any sort of picture, not just faces, but echocardiograms, CT scans, MRIs, nuclear scans, pathology specimens, biopsies – anything that’s visual and can also diagnose patients,’ he adds.
Analysing the human voice is also possible using AI, which can be incredibly helpful for cardiovascular diagnosis by identifying atrial fibrillation and arrhythmias through variations heard in the vocal cords as well as congestion caused by heart failure.
Professor Lüscher believes AI algorithms will become important ‘co-pilots’ for clinicians, prompting them to think about diagnoses they may have missed. Other algorithms can read reports shared as part of a referral, giving summaries and analysing volumes from images in seconds that would otherwise take clinicians significant chunks of time.
‘It makes us faster and more precise, provided the algorithms are good,’ Professor Lüscher says. ‘Algorithms that are not good or false can potentially kill patients. These algorithms have to travel well and work in different geographical areas and countries, otherwise it’s not acceptable.’
As such, the ESC is involved in developing quality standards for algorithms across Europe and only uses algorithms that they can show are well-verified in independent cohorts.
Amidst the innovations and new pathways, there will inevitably be challenges ahead, but there is much to look forward to in cardiology as Professor Lüscher begins his two-year presidential journey.
16th October 2024
Patients who are waiting for planned trauma and orthopaedics and ear, nose and throat services are facing the longest waiting lists in the NHS system, according to a report by the Nuffield Trust and Health Foundation.
As of May 2024, these two specialisms made up almost one fifth of the total waiting list size (11.0% and 8.6% respectively) for planned hospital care. They are waiting an average of 15.4 and 17.6 weeks respectively.
The report said trauma and orthopaedics services are more likely to treat people requiring overnight admission and longer lengths of stay in hospital than other specialities, which limits their capacity to treat patients.
However, it added that the Covid-19 pandemic may have also negatively affected access to these services more than others, as there were ‘greater relative drops’ in the number of admitted patients compared to non-admitted patients.
Oral surgery has the longest median waiting times, with 17.7 weeks, however it is only the thirteenth largest waiting list overall.
The report also highlighted that respiratory medicine and gynaecology services had the largest increases in waiting list sizes over the past 10 years.
Respiratory services, which currently has one of the smaller waiting lists compared to other specialisms, had a 263% increase between May 2014 and May 2024. Gynaecology had the second largest increase, with 223% uplift over the same period.
The report said: ‘For respiratory medicine, this might be a consequence of increasing emergency care needs diverting resources away from planned care as a result of direct Covid-19 infections or exacerbations of respiratory diseases due to changes in the occurrence of respiratory viruses post pandemic, such as respiratory syncytial virus (RSV).
‘In addition, with the emergence of long Covid, the respiratory medicine workforce are caring for a whole new group of patients suffering long-term symptoms following a Covid-19 infection.’
Meanwhile one in 20 waits for gynaecology services were more than 52 weeks, which is the third largest number across the services.
‘The 2022 Elective Recovery Plan for the NHS focused on prioritisation based on clinical need and to reduce long waits over 65 weeks. This has been criticised as not effectively prioritising these services and may have resulted in waits for gynaecological services not improving as much as orthopaedic services which had more of the very longest waiters,’ the report said.
However, it added that waiting lists have increased across all specialities apart from general internal medicine and mental health services.
It comes after health secretary Wes Streeting said the Government plans to get hospitals running like a ‘Formula 1 pit stop’ to deliver up to four times more operations than normal.
The report also looked at waits for emergency services, with patients with psycho-social or behavioural problems waiting longer than other patients, with an average of 11 hours and 59 minutes for those who were admitted and seven hours 19 minutes if not admitted.
It also looked at the demographics of patients waiting longer in A&E and found that more people from deprived areas attend A&E but waiting times are similar across all levels of deprivation.
However, children from Black, Asian and mixed ethnicities were seen to wait longer than white children.
The report said: ‘When we look at the youngest age group (those aged 19 and under), patients of Black ethnicities waited longer – on average three hours and 41 minutes – compared to white children and young people, who waited approximately three hours and 20 minutes on average.
‘Further analysis by 10-year age bands revealed longer waits for Black patients up until the age of 40. Amongst patients who were admitted, Black people of all ages were found to wait longer than white people.’
A version of this article was originally published by our sister publication Healthcare Leader.
14th August 2024
Reducing child poverty between 2024 and 2033 would significantly improve child health and health inequalities, as well as reducing pressure on NHS secondary care services, a study has suggested.
Researchers from the University of Glasgow highlighted how meeting hypothetical future child poverty targets would cut infant deaths, reduce the number of children in care and decrease hospital admissions for children.
Reducing childhood poverty would particularly benefit children’s health in the most deprived regions, such as the North East, and would likely have beneficial knock-on effects on local authorities and health services, they said.
The findings, published in the Journal of Epidemiology & Community Health, demonstrate the importance of renewed policy efforts to reduce child poverty.
Child poverty is a crucial determinant of population health and health inequalities and is significantly influenced by Government policy. Experiencing childhood poverty is associated with worse outcomes across a wide range of early years health indicators, and the relationship is often causal. The impact of the Covid-19 pandemic and the ongoing cost-of-living crisis has heightened concerns about rising levels of child poverty in the UK.
Using local authority data, combined with published and newly created estimates of the association between childhood poverty and infant mortality, the researchers modelled the effects of different levels of child poverty reduction scenarios on population health and health inequalities in England between 2024 and 2033.
Four indicators of childhood poverty were measured in children under 16 years of age, including infant mortality per 1,000, the number of children in care, those hospitalised for nutritional anaemia and hospital admissions for all-cause emergencies.
The poverty indicators were modelled against three child poverty reduction scenarios between 2024 and 2033. These included low-ambition (15% reduction), medium-ambition (25% reduction) and high-ambition (35% reduction) and were compared with a baseline childhood poverty scenario (15% increase).
The impacts were assessed at national and regional levels to understand how different areas and social strata are affected and how health inequalities occur. Child poverty was defined as the proportion of children under 16 living in families with an income below 60% of the contemporary national average.
All three projected scenarios were shown to significantly improve child health, with the more ambitious targets corresponding to more significant benefits. The benefits associated with the high-ambition target were found to be approximately twice as large as the benefits of the low-ambition target across all four outcomes.
Meeting the high ambition target would be expected to cut the total number of infant deaths by 293, children entering care by 4,696, hospital admissions for nutritional anaemia by 458, and childhood emergency admissions by 32,650 over the next decade.
In comparison, the low ambition target would result in 155 fewer infant deaths, 2,483 fewer children entering care, 242 fewer hospital admissions for nutritional anaemia, and 17,266 fewer childhood emergency admissions.
The improvements would be higher in areas most affected by childhood poverty, the researchers found. In the North East of England, the total number of infant deaths would be projected to fall by 126, compared with a fall of 71 in the least deprived between 2024 and 2033.
The researchers suggested that Government policies should directly tackle childhood poverty to improve childhood health and health inequality. For example, removing the two-child limit on child benefits and targeted income supplementation, such as the Child Tax Credit, alongside other measures to improve early years services.
‘These reductions [in child poverty] would likely translate into significant savings for and relieve pressure on health services,’ the researchers said. ’We highlight that if policymakers were to set and achieve child poverty targets for England, this would likely improve child health, particularly among the most socioeconomically disadvantaged, and “level up“ regional inequalities. Other health impacts we have not been able to quantify are also likely.’
A version of this article was originally published by our sister publication Nursing in Practice.
9th July 2024
Professor Mona Bafadhel tells Katherine Price about developing a new tool that has identified less obvious yet crucial cardiovascular disease risk indicators such as chronic obstructive pulmonary disease. She hopes the tool will impact health inequalities by better predicting at-risk individuals and ensuring previously under-detected populations can access preventative therapies.
Professor Mona Bafadhel is the chair of respiratory medicine at King’s College London and director of the King’s Centre for Lung Health. Her work on chronic obstructive pulmonary disease (COPD) has recently led to her working with colleagues across King’s College London and the Universities of Oxford, Nottingham, Bristol and Edinburgh to support the development of a new cardiovascular disease(CVD) predictive calculator.
COPD is the third leading cause of death worldwide, causing more than three million deaths in 2019. Nearly 90% of deaths in patients under the age of 70 occur in low- and middle-income countries, and it’s estimated that in the UK, at least 4.9% of people over the age of 40 have COPD. By 2050, it’s predicted that global COPD prevalence will approach 600 million cases and become the leading cause of death globally. ‘[This] is an important group of patients,’ stresses Professor Bafadhel.
Among COPD patients, cause of death is often CVD, Professor Bafadhel explains. She and colleague Dr Richard Russell, head of department of the Peter Gorer Department of Immunobiology, were aware of the association between COPD and CVD based on their clinical experience and an increasing body of evidence. However, they wanted to understand more about the link between the two.
CVD is also a leading cause of death globally, responsible for an estimated 17.9 million deaths in 2019. Research into risk factors is abundant, but the tools available in clinical practice to score cardiovascular risk were unable to offer much insight into the CVD risk in a patient with COPD.
‘Indeed, it appears that current risk tools were underestimating the actual cardiovascular risk associated with patients with COPD,’ adds Professor Bafadhel.
The duo liaised with Professor Julia Hippisley-Cox from the University of Oxford and Carol Coupland from the University of Nottingham and others, who designed three iterations of QRISK – the CVD risk score that has been used across the NHS since 2009. It involves measuring patients’ blood pressure, age and medical history to identify those at high risk of developing CVD.
However, even QRISK3 does not capture several conditions that have recently been associated with increased CVD risk, including COPD, meaning it will potentially underestimate risk in these groups, who may subsequently not be offered beneficial interventions.
The new research, utilising several UK primary care databases to assess a cohort of more than 16.5 million UK citizens for derivation and validation of the algorithm, led to the development of QRISK4 or QR4, which showed that COPD was indeed a risk factor. In fact, QR4 outperformed three widely used international CVD scoring models, including QR3, due to the size and validity of the data, accurately identifying more high-risk patients.
‘The accuracy required has to be very vigorous with regard to validation tools and replication models,’ explains Professor Bafadhel. ‘It took a rigorous amount of work as standard because my collaborators Julia and Carol have experience of getting this into patient practice with QRISKs 1, 2 and 3, so we were guided and as sure as we can be that we were doing it even more rigorously for QR4.’
Like QR3, QR4 – if approved – would be a free-to-access web platform into which clinicians can enter details about patient health to generate a percentage risk of them developing CVD in 10 years’ time. Thresholds are also offered to inform clinicians as to when preventative treatment should be offered.
The difference is the inclusion of seven new risk factors. In addition to COPD, this includes learning disabilities, Down syndrome, four cancer types (blood, lung, oral and brain), pre-eclampsia and postnatal depression. While risk factors such as smoking and high cholesterol are well-recognised, this latest research identifies less obvious yet crucial risk indicators and highlights how other significant conditions impact on heart health.
Not only was an increased risk of severe cardiovascular events in patients with COPD identified, but the greatest effect was seen in females – a surprise for Professor Bafadhel.
Evidence previously suggested that COPD most commonly affected men, but more women appear to have COPD than first thought. What’s more, ‘it’s clear actually that women [with COPD] have more susceptibility to cardiovascular risk,’ Professor Bafadhel says, stressing that clinicians need to consider COPD as a diagnosis and confirm it with spirometry, especially in women, to mitigate these cardiovascular risks.
The risk was also highest in younger patients with COPD, which, for Professor Bafadhel, was another sign that conditions such as COPD need to be diagnosed earlier.
Ultimately, the research underlines the importance of prescribing therapies that reduce CVD risk, including optimising inhaled therapies, to reduce mortality.
By integrating these seven risk factors into the QR4 model, the researchers were able to develop a more nuanced and comprehensive tool for predicting CVD, ensuring preventative strategies are more personalised, inclusive and cater to the needs of a broader and more diverse population. It also provides clinicians with the clearest picture yet of individuals’ risk of developing heart and circulatory diseases.
Although the QR4 is based on UK population data, Professor Bafadhel hopes that other countries can use the research and their own population data to assess their own algorithms and tools. For countries with fewer resources, she says available tools can be used, mindful that the data may not be population relevant.
The hope is that, by providing a more accurate CVD risk estimation, QR4 should lead to significant improvements in health outcomes, particularly among populations whose risk may have previously been under-detected. If implemented, it is estimated that optimising the care of COPD patients would save more than 2,500 lives a year in the UK and promote earlier recognition of both COPD and the associated cardiovascular risk.
Professor Bafadhel argues the most important impact of this research would be driving awareness of the interlinked risks of CVD and COPD across the multidisciplinary field, and of how that risk can be modified.
‘We just haven’t had enough investment and funding in [COPD]. People may not know what it is until it’s too late. We really do need to improve the global awareness of it,’ she says.
‘We need to diagnose COPD earlier and be familiar with what COPD is. We need to optimise COPD treatments, including all the available tools we have. And then we need to try and understand what causes that very close association to cardiovascular disease, and of course exacerbations.’
She also highlights the importance of preventing CVD, catastrophic events and deaths by optimising COPD pharmacological treatment as well as primary prevention.
The researchers anticipate that QR4 will supersede QR3, although there is currently no timeline for this. Nevertheless, the next five years are expected to be an exciting time in the COPD field that will further shape understanding of this debilitating condition, according to Professor Bafadhel.
While she and her colleagues are looking at platelets in patients with COPD, other multidisciplinary groups are investigating pulmonary lung-heart events in this group – research Professor Bafadhel hopes will reduce inequalities, raise standards and empower patients to ensure they get the best treatment they need, when they need it.
‘Gone are the days where we think we can’t do anything for a person with COPD,’ she says. ‘We now have multiple tools, from physiotherapy to inhaled treatments, to non-invasive and invasive surgery, and in the next few months, hopefully also biologics in COPD.’
3rd June 2024
While breast cancer mortality has reduced by as much as 40% over the past three decades, and five-year breast cancer survival rates exceed 90% in some countries, these figures mask global inequalities. Dr Carlos Barrios, director of the Latin American Clinical Oncology Research Group in Porto Alegre, Brazil, tells Katherine Price how The Lancet Breast Cancer Commission’s latest report provides a roadmap for change and how clinicians around the world can support it.
Breast cancer cases are increasing globally, and by 2040, it is predicted that there will be three million new diagnoses per year, with people living in low- and middle-income countries (LMICs) disproportionately affected.
‘We need to recognise that there has been unequal progress, and if we keep on doing what we have done so far, that’s not going to change,’ says Dr Carlos Barrios, director of the Latin American Clinical Oncology Research Group in Porto Alegre, Brazil.
To help to achieve this aim, Dr Barrios was invited to participate in The Lancet Breast Cancer Commission, an interdisciplinary group of commissioners and patient advocates from high-, middle- and low-income countries across the world seeking to address inequalities in healthcare access and education and counter the perception that this predicted upward trajectory in breast cancer cases is inevitable.
The Commission published a report in April 2024, which Dr Barrios co-authored while also coordinating the working group looking at metastatic breast cancer (MBC). He says the report offers a roadmap for achieving more equal progress on breast cancer care worldwide.
‘The task that was given to us was to try to identify the discrepancies and be transformative – what do we need to do to change this situation?’ he says.
As well as improving representation of participants and research leads from LMICs in trials, many of The Lancet Breast Cancer Commission’s recommendations are for policy change, and Dr Barrios was keen that those responsible for making such changes were explicitly named.
‘Most of the recommendations require a very active and proactive position of policymakers and administrators,’ he explains.
For example, researchers estimate that up to a quarter of breast cancer cases in high-income countries (HICs) could be prevented by modifying risk factors such as alcohol, physical activity and obesity. In addition, identifying those at increased risk is essential for equitable access to personalised prevention strategies, including cheap and effective medications, and early detection programmes. The authors call for stage-shifting as a sustained decline in breast cancer mortality rates can be achieved by diagnosing at least 60% of invasive cancers at less than 2cm in size.
‘More than 50% of that improvement that we see in the mortality is actually driven by early diagnosis and adjuvant therapy,’ says Dr Barrios.
The findings highlight a lack of information in some areas, particularly MBC rates. Relapse is not typically recorded by most national cancer registries, even though 20-30% of patients with early breast cancer relapse.
‘If you don’t have a specific number, it’s very difficult to know the size of the problem and how to devote strategies to these patients,’ says Dr Barrios.
‘We need registry data that tells us actually how many patients we have with metastatic breast cancer, what treatment these patients received, and what the outcomes are of these patients in different places in the world.’
Within the past five years, median survival has reached five years for two of the three main MBC subtypes, which account for approximately 85% of patients with breast cancer, and some subgroups are starting to be considered as having a chronic disease. Dr Barrios and the report authors argue for eradicating social stigma around MBC as a rapidly fatal disease, and for patients to not be excluded from potentially life-extending treatments.
They make the case for at least 70% of registries worldwide to record MBC rates, and for initiatives to promote societal inclusion of people living with MBC, such as, changes to labour laws that empower more flexible working arrangements.
There is also a lack of information around the associated and hidden consequences of breast cancer – the physical, psychological, social and financial costs that are not routinely captured by global health metrics.
The Commission’s UK-based CASCARA pilot study found that a fifth of participants with early breast cancer and a quarter of those with MBC reported difficulty in covering the costs of travel for treatment, for example, and tools are needed to measure these costs and the benefits of addressing them to guide policymakers on interventions.
The report also argues that at least half of patients with MBC should be discussed at multidisciplinary meetings, as well as 80% of patients with a new breast cancer diagnosis. However, while a multidisciplinary approach from diagnosis onwards is essential, as is applying approaches that have worked well in HICs to settings with fewer resources. And this must be tailored to local contexts.
‘Most patients with breast cancer in the world are not going to be treated in institutions where you have the ability for multidisciplinary discussion,’ says Dr Barrios. ‘Most will be managed by physicians [who] work alone, that are outside the capitals, that are not in the tertiary centres.’
As such, telementoring and virtual multidisciplinary meetings are suggested by the Commission to help enable resource sharing between cancer centres and local community hospitals, even between HICs and LMICs, with a vision for technology-enabled data exchange between all stakeholders of the oncology healthcare system and always with a focus centred in the patients’ best interests.
Although many of the recommendations are actions and targets for policymakers, Dr Barrios stresses that clinicians can make a difference by identifying discrepancies around them. ‘See what you can do as a clinician in your everyday clinic to identify patients that may have problems with information or access to healthcare procedures or medications,’ he says.
Better patient communication, for example, is key in improving quality of life, decision-making, body image, and even adherence to therapy – with subsequent positive impacts on survival. The Commission’s report calls for all healthcare professionals to receive communication training and for patient involvement in all stages of breast cancer clinical research, and even provides a framework for patient-centred consultations.
It stresses that healthcare professionals are there to help patients make the decisions that are best for them, which requires the patient to understand the goals, logistics and side effects of treatment, and the clinician to understand the patient’s preferences, values and life goals.
While action from clinicians is crucial, enduring change sits firmly within the power of policymakers. It is hoped that widely sharing the The Lancet Breast Cancer Commission’s report, its findings and recommendations, for example at global oncology conferences, will pave the way to global government and policymaker attention and engagement.
‘The idea here is that we need to have a more significant impact on the national cancer care plans, because that’s where the action will reach the patients,’ says Dr Barrios.
He is optimistic about further improvements in breast cancer care on the horizon, particularly the development of new drugs in the treatment of hormone-receptor-positive disease and antibody-drug conjugates. He says these are ‘revolutionising’ MBC management and will eventually improve cure rates and help patients with early disease as well. He is also keeping a keen eye on research being led by fellow Commission participant Felicia Knaul at the University of Miami into measuring hidden costs and suffering, which he says would be ‘extremely significant’ and transformative for patients and for clinical practice.
Dr Barrios and his co-authors hope that application of the recommendations set out in The Lancet Breast Cancer Commission’s report will not only lead to improvements in breast cancer rates, treatment and outcomes in a more equal way, but have a positive impact across the cancer field, healthcare and society as a whole.
‘[These] solutions and strategies could be applicable to other diseases, and also empowering women in general,’ says Dr Barrios. ‘If we make women more participatory in the process, this will have much broader implications for women in society overall.’
1st May 2024
Cholesterol-lowering drugs are less frequently prescribed to women compared to men, despite European Society of Cardiology (ESC) guidelines recommending statins for all patients with chronic coronary syndrome, new research has revealed.
Recommendations for target levels of low-density lipoprotein (LDL) cholesterol are the same for women and men, but previous studies have shown that women are less likely to meet these target levels.
This new retrospective observational study, presented at the recent ESC Preventive Cardiology 2024 congress, considered whether women and men actually receive the same treatments, as is outlined in ESC guidelines.
Electronic health records were used to obtain data on cholesterol levels of 1,037 men and 415 women with a chronic coronary syndrome diagnosed between 2012 and 2020, and who had never had a heart attack. The median age was 68 years in men and 70 years in women.
Information on dispensed medications was obtained from the Swedish National Prescribed Drug Registry and participants were followed up for three years following their diagnosis.
At the end of the third year of follow-up, just 54% of women were treated with cholesterol-lowering drugs compared with 74% of men. Additionally, 5% of women were treated with statin plus ezetimibe compared with 8% of men.
Dr Nina Johnston, study author and cardiologist at Uppsala University in Sweden, said: ‘Cholesterol-lowering drugs save lives and prevent heart attacks, and should be prescribed to all patients with coronary artery disease. Unfortunately, our study shows that women are missing out on these essential medications.
During the study, the researchers also examined treatments and cholesterol levels of women and men diagnosed with a chronic coronary syndrome at different ages: less than 60, 60-69.9, 70-79.9 and 80 years or older.
In all age groups, prescription of cholesterol-lowering treatment was found to be highest at diagnosis and declined over the following three years. This decline was steeper in women compared with men.
For example, in patients under 60 years of age, 65% of women and 79% of men were treated with cholesterol-lowering treatment the week after diagnosis, compared with 52% of women and 78% of men three years later. Achievement of LDL cholesterol targets was also lower in women than men.
Dr Johnston added: ‘Our findings should be a wake-up call about the undertreatment of women with heart disease. Equal prescribing practices are needed so that women receive all recommended therapies and are protected from adverse outcomes.’
The researchers are currently investigating factors which may explain the observed sex differences.
23rd April 2024
Many people with breast cancer are not receiving the treatment they should, with inequalities in care leading to many groups being ‘systematically left behind, ignored and forgotten’, according to a new report.
This comes despite considerable advances in breast cancer research and treatment over the last three decades, which has led to a more than 40% reduction in breast cancer mortality in some high-income countries.
People living with metastatic breast cancer are particularly disadvantaged since rates of this type of cancer are unrecorded, and the needs of this population are unmet. The findings of The Lancet Breast Cancer Commission suggested that systematic recording of cancer rates must be established and call for increased prevention strategies and personalised treatment.
Current predictions suggest there will be three million new cases a year of breast cancer worldwide by 2040 and a million deaths, with people living in low- and middle-income countries disproportionately affected.
Tackling breast cancer gaps and inequities should be achieved through ‘global collaboration, and communication and empowerment’, the researchers said, stating that The Lancet Breast Cancer Commission is a ‘forward-looking and optimistic road map’ to address urgent challenges in breast cancer care and reduce breast cancer rates.
The findings highlighted a lack of information around rates of metastatic breast cancer, despite statistics showing that 20-30% of early breast cancers experience relapse.
Often, the physical, psychological, social and financial costs of breast cancer were found to be ‘immense but under-recognised’ since current global health metrics do not capture them.
Professor Charlotte Coles, professor of breast cancer clinical oncology and deputy head of department of oncology at the University of Cambridge, said: ‘Recent improvements in breast cancer survival represent a great success of modern medicine. However, we can’t ignore how many patients are being systematically left behind.’
She added: ‘We hope that, by highlighting these inequities and hidden costs and suffering in breast cancer, they can be better recognised and addressed by healthcare professionals and policymakers in partnership with patients and the public around the world.’
In response to the findings, the researchers established a UK-based pilot study that provides a snapshot of the economic burden and care needs of people affected by breast cancer. Nearly all of the 606 people living with breast cancer and carers surveyed experienced physical or wellbeing issues related to breast cancer, such as losing a job whilst undergoing treatment or experiencing sexual dysfunction.
Many cancer patients were also found to experience financial difficulty as a result of their illness, with 27% of patients with early breast cancer and 35% with metastatic breast cancer reporting money problems. A fifth of participants with early breast cancer and a quarter of those with metastatic breast cancer reported difficulty in covering the costs of travel for treatment.
Estimates of serious health-related suffering indicated the need for palliative care. In 2020, approximately 120 million days were spent with serious health-related suffering per year for people who died of their cancer. A further 520 million days were estimated for patients living with the disease.
Dr Carlos Barrios director of the the Oncology Research Center at Hospital São Lucas, Brazil, said: ‘Even in countries with well-developed healthcare systems, patients with breast cancer experience inadequate support and care. In countries lacking affordable health care facilities, patients experience these costs more commonly and intensely, too often leading to catastrophic spending and impoverishment.’
The Lancet Breast Cancer Commission advocates the development of new tools to estimate the hidden costs of breast cancer and better communication between healthcare workers and patients to improve the quality of life for patients and guide policymakers to invest in breast cancer prevention and interventions that relieve suffering, such as early detection, cost-effective therapy, optimal management and financial protection.
The researchers estimate that up to a quarter of breast cancer in high-income countries could be prevented by modifying risk factors for breast cancer. This involves education and awareness-raising efforts, as well as ‘bold policy changes’ that reduce the number of people exposed to these risk factors, such as alcohol consumption and being overweight.
In addition, systematic approaches that identify those at increased risk of the disease are essential to enable equitable access to personalised prevention strategies, including cheap and effective medications that can avert breast cancer for many women and early detection programmes.
Professor Benjamin Anderson, professor of surgery and global health medicine at the University of Washington, concluded: ‘Access to evidence-based prevention and care that isn’t dependent on where an individual lives or their ability to pay would reap wide-ranging benefits for patients, families and healthcare systems striving to achieve universal health coverage.’
A version of this article was originally published by our sister publication Nursing in Practice.
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