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Reducing Asbestos related Lung Cancer on Wirral

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Asbestos Exposure, Asbestos Removal, lung cancer

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                                        PROTOCOL - third draft

          Reducing Asbestos-related Lung Cancer on Wirral

          Background

          Combined exposure to toxic agents and tobacco smoke in the environment, particularly
          in workplaces, amplifies the severity of adverse effects beyond what could be expected
          from smoking or the toxic hazard alone (WHO factsheet No. 158, 1998). Asbestos has
          a range of harmful effects, mainly on respiratory health, including asbestosis (lung and
          pleural fibrosis), lung cancer, pleural mesothelioma, cancer in other parts of the body,
          and obstructive airways disease in smokers. Smokers who have been exposed to




                                                                                         M
          asbestos have a 10-40 times greater risk of developing these diseases compared to a
          non-smoking asbestos worker, and a 90-fold greater risk compared to a non-smoker not




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          occupationally exposed to asbestos (WHO factsheet No.158, 1998).




                                                                               .C
          What is the size of the problem locally?




                                                                     PE
          The population of Wirral may be expected to have had a relatively high historic



                                                                    A
          exposure to asbestos, due to its shipbuilding industry, but we would expect this to be
          unevenly distributed across Wirral. Current data for lung cancer mortality shows that
                                                            -T
          three wards on the Mersey side of the peninsula experience the highest death rates.
          These are also the most economically deprived wards. Therefore we have designated
                                                           N
          the high mortality area as a putative “high exposure” area , and selected one practice
                                                      .C

          from there, and designated the west Wirral low lung cancer mortality wards as a
          putative “low exposure” area.
                                                W



          Precise figures on the population likely to be exposed are not available, but estimates
                                           W




          can be derived based on relevant information which is to hand. Liverpool Occupational
          Health Project (LOHP) conducted interviews with full occupational history with
                                   tW




          patients waiting to see their GP (for unrelated conditions) in selected practices in
          Liverpool over a number of years. From April to October 1992 they surveyed 2601
                             ne




          people specifically about previous asbestos exposure; about one in eight men reported
          asbestos exposure at some time in their working life, of whom a third were still smoking
          (LOHP -
                         y




          Annual Report).
                   lth




          As mesothelioma is so closely related to asbestos exposure, mesothelioma can be taken
              ea




          as an index of past exposure to asbestos in the population. From a study of cohorts of
          men born from the end of the 19th century onwards, it appears that men born in the
          H




          1940s are worst affected by the “asbestos epidemic” - and asbestos-related mortality can
          be expected to continue to rise until sometime between 2010 and 2020. Analysis of
          occupation on death certificates shows that building workers, especially plumbers and
          gas fitters, carpenters and electricians are numerically the largest high-risk group (Peto
          et al, 1995).

          Wirral’s shipbuilding industry would be a major source of exposure for those working
          up to the mid-1970s when tighter control came into force.



          third draft Protocol - Reducing Asbestos related lung cancer on Wirral
          17/04/01                                                                              1
What can be done to reduce lung cancer?

A review of surveillance and intervention studies on respiratory cancers in asbestos-
exposed workers has recently been published (Merler et al, 1997). Studies were either
national or regional surveillance programmes (4), programmes based in factories or
industrial sectors (8) or chemoprevention (beta-carotene and retinol) studies (3). The
studies had different aims and outcomes.

A cross-sectional cohort study in Telemark, Norway, where 21,319 men were followed
up over 8 years, found that those (asbestos exposed men) who abstained from tobacco
for greater than 12 years reduced their lung cancer risk by two thirds (Waage et al,




                                                                                M
1993).




                                                                            O
To date I have found no study based in a primary care setting, i.e. getting practice staff




                                                                       .C
to ask “screening” questions to establish previous exposure to asbestos, in order to
target this high risk group with a smoking cessation intervention. Further literature




                                                             PE
search is underway. An Aberdeen based study is underway to look at the effect of
computer generated letters from practice-held information on smoking (Lennox,



                                                            A
National Research Register), but this will be limited by the lack of both occupational
and smoking data in most general practices.
                                                   -T
Newell and Vogel (1988) presented a helpful summary of personal risk factors in cancer
                                                  N
over a decade ago:
                                             .C

(1) individuals at risk are often unaware of their risk
(2) physicians may not know those factors associated with the highest cancer risk
                                       W


(3) methods to reduce risk have been under-applied because of lack of knowledge, lack
of funds, or lack of motivation among both patients and physicians.
                                  W




These points are still very relevant in the UK in the year 2000.
                         tW




The challenge is to come up with an intervention which is simple, which primary care
staff will have the resources to deal with, and yet will reach the very high risk group
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(men born in the 1940s) in time to help them reduce their personal cancer risk . The
present study is seen as providing necessary background for the planning of a more
definitive study or programme for which major R&D funding will be sought.
               y
         lth




The present study (Phase 1) combines elements of both research and audit - the findings
which are generalisable and help inform a more definitive strategy and further study can
    ea




be considered research. The findings which will be fed back into patients’ records at the
practice, and hopefully assist future patient management can be considered audit. As it
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is difficult to separate the two, the study is being treated as a whole, and submitted for
ethical consideration in its entirety.

Phase 2 will entail an intervention being developed targeting those current smokers who
have been exposed to asbestos and express a desire to quit smoking. This will involve
working closely with the practice nurses in the 2 practices, and doing qualitative
research (observation and patient interviews).
This will be researched separately by Chris Harwood, as part of a Masters degree, and
the protocol once refined will be submitted for ethical review.


third draft Protocol - Reducing Asbestos related lung cancer on Wirral
17/04/01                                                                                2
Aim: To reduce the risk of lung cancer (and other related morbidity) in people who
have been exposed to asbestos and are still smoking tobacco.

Objectives:

1.      To establish the prevalence of current smoking and previous asbestos exposure
in two practice populations, one is a supposed high-exposure area (Tranmere) and one
in a low exposure area (Heswall).

2.     To test the validity of the questionnaire developed.

3.      To assess the impact of the survey, and perhaps heightened awareness of the




                                                                               M
issues, on patients and staff at the practices.




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                                                                     .C
Methods




                                                            PE
Prevalence study




                                                           A
We are working collaboratively with two general practices, one in a supposed high-
exposure area (Tranmere) and one in a low exposure area (Heswall). They have adult
populations of 4396 and 3636 respectively.
                                                  -T
                                                 N
In order to determine prevalence of both smoking and asbestos exposure, we will survey
                                            .C

all adults (aged 18 and over) in the two practices. No existing tool was quite fit to
purpose, so a new one has had to be devised (See Appendix 1). It has been designed to
                                      W


be as brief and simple to complete as possible, with smoking questions on one side, and
occupational history on the reverse.
                                 W




Piloting the questionnaire and cover letter
                         tW




A pilot study will be conducted on approximately 30 people, who are waiting to be seen
                   ne




at a similar practice in Tranmere (Dr Oates’) - to test for understandability,
acceptability, readability of the questionnaire and cover letter. One or two of the
researchers will be present in the waiting room, and ask patients to look at questionnaire
               y




and cover letter and comment on how acceptable and understandable they find them.
          lth




Minor modifications to wording and layout will then be made if necessary.
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Sending out the questionnaire
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A letter-headed cover letter from the patient’s own practice will accompany the
(amended) questionnaire. This will bear a printed signature from one of the GPs. (See
Appendix 2)

All questionnaires will be numbered with the patients’ existing NHS number. This is
necessary to allow linking back to patients own records so that they can be amended
with the up-to-date smoking and occupational data. A master record of patient
identifying details (name, address, date of birth, NHS number) will be downloaded from
practice computer systems (using Miquest) to an Excel spreadsheet, to be held in Wirral
Health Authority.

third draft Protocol - Reducing Asbestos related lung cancer on Wirral
17/04/01                                                                              3
It is our intention to prepare all the letters and questionnaires for mailing, and then mail
out all 8032 in one batch. This is to make the logging period for response shorter, and
to concentrate any extra activity generated by the study into as short a period as possible
for the benefit of practice staff.

Reminders

An extensive body of research shows that using reminders increases response rate
significantly from this type of community survey. Those patients who have not
responded within 3 weeks will be sent a reminder postcard through the post, asking
them to please return the questionnaire within the next 2 weeks, or to ring for a




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replacement to be sent out to them if the questionnaire has been discarded.




                                                                             O
Logging impact on services




                                                                        .C
Practice staff at the two practices will be briefed about the study, so that they will be




                                                             PE
aware should any patients contact them. Contacts should be directed to:
        (a) at Victoria Park practice, to Sue Gethin, practice nurse



                                                            A
        (b) at Silverdale practice, to Sister Margaret Clarke, practice nurse
who can answer patients’ questions, advise them about the specific options open to them
with regard to smoking cessation.
                                                    -T
                                                   N
Briefing for practice staff will be at two levels. All staff (including receptionists) will
                                             .C

be informed that a study is underway, and its basic purpose. As many sessions as
necessary will be arranged to catch all staff. They will be advised to refer any specific
                                        W


patient queries to the named contact, and to log any contacts from patients regarding
these issues over the subsequent four weeks on a specific log sheet for all enquiries to
                                  W




reception staff.
                         tW




More in-depth briefing - supplemented by reference literature and how to get further
expert advice, and where to refer patients for specialist advice has been drafted. This
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will be sent for review to a chest physican with a specialist interest in occupational
disease, a solicitor who deals with asbestos claims, and a local support group who are
aware of benefits for victims of asbestos. This briefing will be aimed at the GPs and
               y




practice nurses, and will take the form of a lunchtime presentation, supplemented with a
         lth




document summarising the main points and providing contact details for further
information.
    ea




The two practice nurses will keep log sheets of patient contact pertaining to the study,
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and receptionists also asked to log any patient queries. All GPs in the two practices will
also be asked to log any patient queries and outcomes stemming from the letter and
questionnaire over the next four weeks.

Data input

Returned questionnaires will be processed by Health Authority staff. Date of response
will be recorded, and patient responses entered on the Excel spreadsheet set up for this
purpose, in the appropriate patient specific fields. Although it was intended to
download to practice computer systems, it seems that the GP systems involved cannot

third draft Protocol - Reducing Asbestos related lung cancer on Wirral
17/04/01                                                                                 4
receive this type of input. If this is the case, we will liaise with staff from the Medical
Audit Advisory Group, and the two practices about how they could input the individual
data for practice records.

Testing the validity of the questionnaire

As the questionnaire is a new instrument, we do not know how effective it is at picking
up asbestos exposure in a community sample. There is no definitive “gold standard”
against which to assess the instrument, but we intend to use the experience of the
Liverpool Occupational Health Partnership to slightly amend the basic interview they
evolved over seven years of interviewing patients waiting in surgery waiting rooms.
We plan to conduct these similar semi-structured, face-to-face interviews with a




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randomly selected sub sample of approximately 100 patients who returned
questionnaires, and agreed to be contacted again (question No. 8 of our questionnaire).




                                                                            O
The interview schedule and separate information sheet and consent form for this sub-




                                                                       .C
sample will be submitted as a protocol amendment once refined.




                                                             PE
                                                            A
Analysis

Patient data
                                                   -T
                                                  N
Results will be analysed to provide:
                                             .C

(a) response rate
(b) prevalence of current smoking:
                                       W


        (i) smoking exposure (how long X how many)
        (ii) % wishing to give up
                                  W




        (iii) % of those wishing to give up who have had previous attempts to
quit
                         tW




        (iv) addiction levels?
(c) prevalence of asbestos exposure
                    ne




        (i) patient reported exposure
        (ii) occupational history suggestive of exposure (?graded)
               y




The frequencies above will also be displayed broken down by gender, age group and
           lth




practice.
    ea




Cross-tabulations will be calculated to identify various sub-groups - especially those
who want to quit and have been exposed to asbestos (i.e. our high-risk group).
H




Service data

The logs of enquiries related to or stemming from the letter and questionnaire from the
named practice contact, GPs and receptionists will be collated.
SUPPORT data for the relevant period for the two practices (perhaps also

Audit data

We could compare the data from the survey with existing practice data on smoking.

third draft Protocol - Reducing Asbestos related lung cancer on Wirral
17/04/01                                                                                5
Costs

Most of the costs of undertaking this study are being met by existing staff of Wirral
Health Authority, Wirral Medical Audit Advisory Group and the two practices. The
consumable costs are being met through the Health Authority’s clinical audit budget.

Additional R&D costs (as opposed to extra service costs) to practices may be
reimbursable through the R&D in primary care network funds (i.e. spending time at
steering group meetings, but not counseling patients who may be caused anxiety by the
questionnaire).
Practices to estimate how much additional practice nurse time will be spent on project,




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and submit to the network.




                                                                           O
Consumables




                                                                    .C
Post-paid return envelopes (8500 - may need to get a print run of 10,000)




                                                          PE
Practice letter-headed paper - Tranmere practice 5000 @ £x per thousand
                                     Heswall practice 4000 @ £x per thousand



                                                         A
Large envelopes for survey 8500
Copying the questionnaire (1 sheet A4, double-sided, coloured paper) 8500
Reminder post cards to be printed.
                                                 -T
                                                N
Time scale
                                           .C

July 2000     Final draft protocol submitted to Ethics Committee
                                      W


              Pilot questionnaire and cover letter in Dr Oates’ surgery.
              Briefing circulated for expert opinion.
                                W




August 2000 Ordering stationery, printing of letters, questionnaires
                        tW




            Compiling initial database, and using this to print address labels
            Briefing sessions (as many as necessary to catch all staff)
                   ne




            Recruit/second assistant.
            Training in SPSS arranged.
               y




Sept 2000     Questionnaires dispatched
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              Responses logged
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Oct 2000      Services continue logging relevant contacts
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              Data input.
              Finalise validity interview structure and submit to LREC.

Oct- Feb    Data input completed, data cleaned, and analysis performed.
       2001 Prevalence report drafted.
            Data transfer to practice systems completed.

Jan - Mar 2001        Conduct validity interviews.

May 2001      Planning of the study of the impact of the high risk message
              Final report of this study circulated.

third draft Protocol - Reducing Asbestos related lung cancer on Wirral
17/04/01                                                                            6
References

Merler E, Buiatti E, Vainio H, 1997 Surveillance and intervention studies on
respiratory cancers in asbestos-exposed workers, Scand J Work Environ Health; 23:83-
92

Newell GR & Vogel VG, 1988 Personal Risk Factors. What Do They Mean?, Cancer
62:1695-1701

Peto J, Hodgson JT, Matthews FE, Jones JR, 1995 Continuing increase in mesothelioma
mortality in Britain, The Lancet Vol 345:535-539




                                                                          M
Waage HP, Vatten LJ, Opedal E, Hilt B, 1993 Smoking Intervention in Subjects at Risk
of Asbestos-Related Lung Cancer, American Journal of Industrial Medicine 31:705-712




                                                                      O
                                                                 .C
WHO factsheet No.158, 1998 - http://www.who.int/inf-fs/en/fact158.html




                                                        PE
                                                       A
                                               -T
                                              N
                                         .C
                                    W
                               W
                       tW
                  ne
              y
        lth
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third draft Protocol - Reducing Asbestos related lung cancer on Wirral
17/04/01                                                                         7
Appendix 1
                                                       Practice ID No.____________
Draft questions for the prevalence study in two practices


1. Do you currently smoke at least one cigarette, cigar or pipe a day?

         No, I have never been a smoker
         No, I do not smoke now, I gave up in ________
                                                                (write year)
                                   (please go to question 6, overleaf)




                                                                         M
         Yes, I smoke cigarettes (please go to question 2)
         Yes, I smoke cigars




                                                                         O
         Yes, I smoke a pipe




                                                                 .C
2. How long have you smoked in total? _______________




                                                        PE
                                                    (write in years)




                                                       A
3. How many cigarettes a day do you usually smoke? ______
                                               -T
                                              N
4. Do you want to give up smoking?
                                         .C

         No
                                    W


         Yes
                               W




5. Have you tried to quit smoking before?
                       tW




         No
         Yes
               - if yes, how many times _____________
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               - and what was the longest time you managed to stay off the
cigarettes (or cigars or pipe)?
               y




                                     ________________________
        lth




                                     (please write days, months or years)
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                                 Please turn over ↓
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third draft Protocol - Reducing Asbestos related lung cancer on Wirral
17/04/01                                                                       8
6. To your knowledge, have you ever worked with asbestos, or been exposed to the
dust or fibres from asbestos?

          No
          Yes


7. Have you ever worked in the following industries?

If so please show roughly how long by ticking all the appropriate boxes in the grid
below:




                                                                          M
                                                                      O
Industry / trade                Less than 1 year     1 -10 years      10 years +




                                                                   .C
metal plate or shipbuilding
vehicle manufacture




                                                        PE
plumbing/ gas fitting
carpentry



                                                       A
electrics or electrical plant
upholstery
construction work
                                               -T
                                              N
boiler operation
                                         .C

chemical engineering
docks
                                    W


machine and tool operation
                                W
                          tW




and finally,

8. Would you be prepared to be contacted again to ask more in-depth questions
                    ne




about your work history?

          No
                y




          Yes
         lth




(Your participation in any research is entirely voluntary and will in no way affect
    ea




the care you receive).
H




  Thank you very much. Now place your completed questionnaire in the post-paid
                            return envelope and post it.
                  (to be printed on coloured paper, double sided)




third draft Protocol - Reducing Asbestos related lung cancer on Wirral
17/04/01                                                                           9
Appendix 2

Cover letter

(to be printed on appropriate practice letter-headed paper)

Dear Patient,

This practice is trying to reduce cancer in our patients. You are probably aware that
smoking is the biggest risk factor for lung cancer and many other health problems.
Workplace exposure to certain harmful chemicals can also increase the risk of cancer
caused by smoking.




                                                                                M
The good news is that this risk can be reduced by quitting smoking. Help is at hand




                                                                            O
both in the practice, and at the new specialist smoking cessation service “SUPPORT”.




                                                                      .C
To help us update our information on occupation and smoking, would you please fill in




                                                               PE
the enclosed questionnaire, and return it to us in the pre-paid envelope.




                                                              A
The information you provide will be used to help the Health Authority plan campaigns
to reduce cancer on the Wirral. All information which is collected about you will be
                                                   -T
kept strictly confidential, and that which leaves the practice will have your name and
address removed so that you cannot be recognised from it. The survey results will be
                                                  N
published in a report available from Wirral Health Authority from May 2001. Your
                                            .C

own data will be summarised in your medical records.
                                       W


If you want to discuss any of the issues raised by this questionnaire, the practice nurse
_____________________ would be happy to speak to you ...... contact details?)
                                  W




If you do not wish to be contacted about this matter again, please return the blank
                         tW




questionnaire in the post-paid envelope enclosed. This will in no way affect the care
you receive from the practice.
                    ne




Yours sincerely
                y
         lth




Dr Murray Freeman (for the Victoria Park Practice) - confirmed
    ea




? Dr Tom Hennessey (for the Silverdale Practice - to be confirmed with practice
doctors)
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third draft Protocol - Reducing Asbestos related lung cancer on Wirral
17/04/01                                                                              10

								
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