An investigation of cancer survival inequalities associated with individual-level socio-economic status, area-level deprivation, and contextual effects, in a cancer patient cohort in England and Wales

Background People living in more deprived areas of high-income countries have lower cancer survival than those in less deprived areas. However, associations between individual-level socio-economic circumstances and cancer survival are relatively poorly understood. Moreover, few studies have addressed contextual effects, where associations between individual-level socio-economic status and cancer survival vary depending on area-based deprivation. Methods Using 9276 individual-level observations from a longitudinal study in England and Wales, we examined the association with cancer survival of area-level deprivation and individual-level occupation, education, and income, for colorectal, prostate and breast cancer patients aged 20–99 at diagnosis. With flexible parametric excess hazard models, we estimated excess mortality across individual-level and area-level socio-economic variables and investigated contextual effects. Results For colorectal cancers, we found evidence of an association between education and cancer survival in men with Excess Hazard Ratio (EHR) = 0.80, 95% Confidence Interval (CI) = 0.60;1.08 comparing “degree-level qualification and higher” to “no qualification” and EHR = 0.74 [0.56;0.97] comparing “apprenticeships and vocational qualification” to “no qualification”, adjusted on occupation and income; and between occupation and cancer survival for women with EHR = 0.77 [0.54;1.10] comparing “managerial/professional occupations” to “manual/technical,” and EHR = 0.81 [0.63;1.06] comparing “intermediate” to “manual/technical”, adjusted on education and income. For breast cancer in women, we found evidence of an association with income (EHR = 0.52 [0.29;0.95] for the highest income quintile compared to the lowest, adjusted on education and occupation), while for prostate cancer, all three individual-level socio-economic variables were associated to some extent with cancer survival. We found contextual effects of area-level deprivation on survival inequalities between occupation types for breast and prostate cancers, suggesting wider individual-level inequalities in more deprived areas compared to least deprived areas. Individual-level income inequalities for breast cancer were more evident than an area-level differential, suggesting that area-level deprivation might not be the most effective measure of inequality for this cancer. For colorectal cancer in both sexes, we found evidence suggesting area- and individual-level inequalities, but no evidence of contextual effects. Conclusions Findings highlight that both individual and contextual effects contribute to inequalities in cancer outcomes. These insights provide potential avenues for more effective policy and practice.

Drug utilisation in neonatal units in England and Wales: a national cohort study

Purpose To describe drug utilisation patterns in neonatal units. Methods Retrospective observational cohort study using data held in the National Neonatal Research Database (NNRD) for neonatal units in England and Wales including infants born at 23 to 44 weeks’ gestational age (GA) from 01 January 2010 to 31 December 2017. Results The cohort included 17,501 (3%) extremely preterm infants; 40,607 (7%) very preterm infants; 193,536 (31%) moderate-to-late preterm infants; and 371,606 (59%) term infants. The number of unique drugs received by an infant (median (IQR)) increased with decreasing GA: 17 (11–24) in extremely preterm, 7 (5–11) in very preterm, 3 (0–4) in moderate-to-late preterm, and 3 (0–3) in term infants. The two most frequently prescribed drugs were benzylpenicillin and gentamicin in all GA groups, and caffeine in extremely preterm. Other frequently used drugs among preterm infants were electrolytes, diuretics and anti-reflux medications. Among infants <32 weeks’ GA, the largest increase in use was for surfactant (given on the neonatal unit), caffeine and probiotics, while domperidone and ranitidine had the largest decline. Conclusion Antibiotics, for all GAs and caffeine, among preterm infants, are the most frequently used drugs in neonatal medicine. Preterm infants are exposed to a high burden of drugs, particularly antibiotics. Changing patterns in use reflect the emergence of evidence in some areas but several non-evidence-based drugs continue to be used widely. Improvements are needed to ensure rational drug use on neonatal units. Registration ClinicalTrials.gov (NCT03773289). Date of registration 21 Dec 2018.

Margaret Clitherow

In the life of Margaret Clitherow (b. 1552/3–d. 1586), international Counter-Reformation piety met English national and provincial politics and led to the creation of a Catholic martyr. She was born Margaret Middleton in predominantly Protestant York and in 1571 married a widowed butcher and father of two, John Clitherow. By the end of 1574 she had given him at least two more children but had also embraced Catholicism, refusing to attend prescribed Protestant services. This recusancy resulted in three prison terms, each of six months or more, in 1577–1578, 1580–1581, and 1583–1584. She was particularly inspired by the heroism of missionary priests from the English seminaries in Continental Europe and made a point of sheltering them at the family home in York’s Shambles. One such was John Mush, who returned from Rome to England in 1583 and became her spiritual director from c. 1584. The 1585 Act against Jesuits and seminary priests made it a capital felony to harbor such clerics: the sentence could be death. On 10 March 1586 the Clitherows’ house was searched, evidence of Catholic worship was found and Margaret arrested. Her trial followed four days later, though it was for her refusal to enter a plea that she was sentenced to death peine forte et dure, being crushed to death. Her stepfather was then serving as York’s lord mayor, so it was a high-profile case in a close-knit community. Every effort was made to prevent the law taking its course, but Margaret would not be dissuaded from the path of martyrdom. The sentence was executed on 25 March, crushed to death under a door loaded with weights. Mush was among those who buried her body; he then wrote a life of the martyr. That Life is integral to all subsequent developments: popular Catholic devotion to the “Pearl of York,” her inclusion among the lives of the martyred priests, the opening of a formal process in 1874, beatification by Pius XI in 1929, and canonization—as one of the Forty Martyrs of England and Wales—by Paul VI in 1970. Apart from the pious and the scholarly, there are few obvious divisions within the literature on Margaret Clitherow: Reference Works and an Overview derive from John Mush’s Life. Other Lives either parallel Mush or follow in his wake, though there are many other sources for wider studies of Recusancy in Yorkshire. For the martyr’s Trial and Death one must rely on Mush and his sources. His failure to locate the place of her burial has had diverse consequences, as conveyed in the final section of the present article, Burial and Legacy.

Edmund Campion

Edmund Campion (b. 1540–d. 1581) was born in London and educated there and at Oxford, as a member of the newly founded St John’s College, a pillar of Mary Tudor’s Catholic revival. By the time he graduated Mary had been succeeded by Elizabeth I and Catholicism by an episcopally led form of Protestantism. Campion remained in Oxford, as tutor, lecturer, and orator, and was ordained as a deacon of the Church of England in 1569, but retained strong Catholic sympathies. In 1570 Elizabeth was excommunicated by Pius V and Campion retreated to Ireland. The following year he made his way to Douai in the Spanish Netherlands, where he recanted his Protestantism, and, in 1573, proceeded to Rome, where he entered the Society of Jesus. His Jesuit novitiate was undertaken in Brno, after which he taught in Prague. In 1579 he was chosen to undertake a mission to England, supporting those of his fellow countrymen who had remained loyal to Rome and endeavoring to convert those who had not. Together with Robert Persons (or Parsons [b. 1546–d. 1610]) and Ralph Emerson, Campion left Rome in April 1580. Arriving in England, he issued a challenge to debate doctrinal matters with leading Protestants. This was his so-called Brag. It was followed by the lengthier Rationes decem. All the while, he ministered in secret to the Catholic minority, until he was arrested at Lyford Grange, Berkshire, on 17 July 1581. During his imprisonment in the Tower of London he was granted his wish to debate with Protestant divines, but the four events were rigged against him. In November he was tried and found guilty of treasonable conspiracy against the queen, and on 1 December hanged at Tyburn with two other priests, Ralph Sherwin and Alexander Briant. He was beatified by Leo XIII in 1886 and canonized (as one of the Forty Martyrs of England and Wales) by Paul VI in 1970. As this article confirms, Campion’s story is related in numerous Reference Works, expanded and/or placed in context in Overviews and examined in detail in Journals and Collections of Papers. For present purposes, his career is divided chronologically: up to 1570 under London and Oxford, 1570–1571 under History of Ireland, and the self-explanatory Mission to England, 1580–1581, which is subdivided into Primary Sources and Analysis. His afterlife is addressed under Legacy, first for the period 1581–1618, and then From Hagiography to Biography.

Rape Stereotype Acceptance in the General Population of England and Wales

The #MeToo movement has facilitated a growing awareness in the UK of rape stereotypes but there has been little research on how accurately rape is perceived in this region, especially regarding demographics such as ethnicity and age. This study recruited 1,000 participants, representative of the UK population, to complete an online survey prompting beliefs about rape perpetrators, rape victims, rape allegations, male rape, and motives for and consequences of rape. After carrying out frequency analyses on agree-incorrect and disagree-incorrect statements, we found that, generally, accuracy was high, although there were higher levels of stereotype acceptance for perpetrator related stereotypes. Further analysis found that in terms of demographic differences, Black and Asian participants and men were significantly more likely to accept stereotypes than other demographic groups. Implications for policy and practice are discussed, including potential for jury education, and educational media campaigns aimed at the demographics most likely to accept stereotypes.

The Attorney-General, politics and logistics – a fork in the road?

The appointment of recent Attorney-Generals for England and Wales has occasioned much comment about their experience. This paper considers whether, following the transmogrification of the Lord Chancellorship over a decade ago, the backgrounds and activities of recent leaders of the Attorney-General's Office suggest the time is now right for similar changes to the Law Officers’ roles. In doing so, it presents a range of original data on aspects of the role and on characteristics of Attorney-Generals, which suggests that unless self-restraint is exercised (by the Prime Minister and the post-holders) we may ineluctably be on the path to reform.

Classical deterrence theory revisited: An empirical analysis of Police Force Areas in England and Wales

The severity, certainty and celerity (swiftness) of punishment are theorised to influence offending through deterrence. Yet celerity is rarely included in empirical studies of criminal activity and the three deterrence factors have never been analysed in one empirical model. We address this gap with an analysis using unique panel data of recorded theft, burglary and violence against the person for 41 Police Force Areas in England and Wales using variables that capture these three theorised factors of deterrence. We find that the three factors affect crime in different ways. Increased detection by the police (certainty) is associated with reduced theft and burglary but not violence. We find that variation in the celerity of sanction has a significant impact on theft offences but not on burglary or violence offences. Increased average prison sentences (severity) reduce burglary only. We account for these results in terms of data challenges and the likely different motivations underlying violent and acquisitive crime.