I am a Lecturer in Cancer Care in the School of Health Sciences at the University of Surrey and oversee HSstats our statistical advice service for Health Science students and staff.
I have worked in Health Sciences research since 2003. Previously I worked as a Research Fellow for the EU funded eSMART project, an RCT using smartphone-based remote-monitoring to monitor chemotherapy-related toxicities for people with cancer across five European countries. I have worked in the independent research sector as a Senior Researcher at the National Centre for Social Research (2006-2011) and as a Research Associate at King's College London (2003-2006; 2011-2017).
My research interests include digital health services research, clinical trials and feasibility studies, statistical modelling and questionnaire design . I am particularly interested health-related anxiety, the use of predictive risk models in psychosocial oncology (the topic of my PhD at King's College London) and interventions aimed at supporting people live with and beyond cancer.
Objectives: Walking is an adaptable, inexpensive and accessible form of physical activity. However its impact on quality of life and symptom severity in people with advanced cancer is unknown. This study aimed to assess the feasibility and acceptability of a randomised controlled trial (RCT) of a community-based walking intervention to enhance quality of life (QoL) in people with recurrent/metastatic cancer.
Design: We used a mixed-methods design comprising a two-centre RCT and nested qualitative interviews. Participants: Patients with advanced breast, prostate, gynaecological or haematological cancers randomised 1:1 between intervention and usual care.
Intervention: The intervention comprised Macmillan?s ?Move More? information, a short motivational interview with a recommendation to walk for at least 30 minutes on alternate days and attend a volunteer-led group walk weekly.
Outcomes: we assessed feasibility and acceptability of the intervention and RCT by evaluating study processes (rates of recruitment, consent, retention, adherence and adverse events), and using end of study questionnaires and qualitative interviews. Patient reported outcome measures (PROMS) assessing quality of life (QoL), activity, fatigue, mood and self-efficacy were completed at baseline and 6, 12 and 24 weeks.
Results: We recruited 42 (38%) of eligible participants. Recruitment was lower than anticipated (goal n=60), the most commonly reported reason being unable to commit to walking groups (n=19). Randomisation procedures worked well with groups evenly matched for age, sex and activity. By week 24, there was a 45% attrition rate. Most PROMs whilst acceptable were not sensitive to change and did not capture key benefits.
Conclusions: The intervention was acceptable, well tolerated and the study design was judged acceptable and feasible. Results are encouraging and demonstrate that exercise was popular and conveyed benefit to participants. Consequently, an effectiveness RCT is warranted, with some modifications to the intervention to include greater tailoring and more appropriate PROMs selected.
Purpose: To identify potential candidate predictors of anxiety in women with early stage breast cancer (BC) after adjuvant treatments and evaluate methodological development of existing multivariable models to inform the future development of a predictive risk stratification model (PRSM).
Methods: Databases (MEDLINE, Web of Science, CINAHL, CENTRAL and PsycINFO) were searched from inception to November 2015. Eligible studies were prospective, recruited women with stage 0-3 BC, used a validated anxiety outcome e 3 months' post-treatment completion and used multivariable prediction models. Internationally accepted quality standards were used to assess predictive risk of bias and strength of evidence.
Results: Seven studies were identified, five were observational cohorts and two secondary analyses of RCTs. Variability of measurement and selective reporting precluded meta-analysis. Twenty-one candidate predictors were identified in total. Younger age and previous mental health problems were identified as risk factors in e 3 studies. Clinical variables (e.g. treatment, tumour grade) were not identified as predictors in any studies. No studies adhered to all quality standards.
Conclusions: Pre-existing vulnerability to mental health problems and younger age increased the risk of anxiety after completion of treatment for BC survivors, but there was no evidence that chemotherapy was a predictor. Multiple predictors were identified but many lacked reproducibility or were not measured across studies, and inadequate reporting did not allow full evaluation of the multivariable models. The use of quality standards in the development of PRSM within supportive cancer care would improve model quality and performance thereby allowing professionals to better target support for patients.
and common mental disorder, using the English Adult Psychiatric Morbidity Survey 2007.
We examined whether carers are more exposed to other stressors additional to caring?such
as domestic violence and debt?and if so whether this explains their elevated rates of mental
disorder. We analysed differences between carers and non-carers in common mental
disorders (CMD), suicidal thoughts, suicidal attempts, recent stressors, social support, and
social participation. We used multivariate models to investigate whether differences between
carers and non-carers in identifiable stressors and supports explained the association
between caring and CMD, as measured by the revised Clinical Interview Schedule. The
prevalence of CMD (OR= 1.64 95% CI 1.37?1.97), suicidal thoughts in the last week (OR &
of whom experience reduced quality of life resulting from the physical and psychosocial
consequences of cancer and its treatment. While drug treatments are important at alleviating
some symptoms, there is increasing evidence of the benefits of exercise in enhancing
quality of life and health outcomes. Walking is an inexpensive and accessible form of
exercise. To our knowledge, no studies have investigated whether a walking intervention is
sufficient to enhance quality of life and alleviate symptoms in people with recurrent or
metastatic cancer across a range of tumor types. This paper describes the CanWalk study
protocol, which aims to assess the feasibility and acceptability of undertaking a randomized
controlled trial of a community-based walking program to enhance quality of life and well &
reliable diagnosis of common mental disorders such as anxiety and depression. The
questionnaire also covered aspects of housing conditions and financial strain related to
domestic fuel use, including presence of mould, cutting back on fuel usage, lack of central
heating and double-glazing, being cold at home, and fuel-related problem debt or utility
disconnection. This report presents the prevalence of different aspects of poor housing in the
English population and identifies which types of household are at greatest risk. It also
explores how poor housing conditions and fuel related debt relate to other indicators of
poverty, and goes on to examine associations with mental and physical health and disability.
Method. We derived a sample of 3425 working-age respondents from the Adult Psychiatric Morbidity Survey 2007. Occupations were classified by Standard Occupational Classification group, and CMD measured by the Revised Clinical Interview Schedule. Job characteristics were measured by questionnaire, and tested as explanatory factors in associations of occupation and CMD.
Results. After adjusting for age, gender, housing tenure and marital status, caring personal service occupations had the greatest risk of CMD compared with all occupations (odds ratio 1.73, 95% confidence interval 1.16?2.58). The prevalence of adverse psychosocial work characteristics did not follow the pattern of CMD by occupation. Work characteristics did not explain the increased risk of CMDs associated with working in personal service occupations. Contrary to our hypotheses, adding work characteristics individually to the association of occupation and CMD tended to increase rather than decrease the odds for CMD.
Conclusions. As has been found by others, psychosocial work characteristics were associated with CMD. However,
we found that in our English national dataset they could not explain the high rates of CMD in particular occupations. We suggest that selection into occupations may partly explain high CMD rates in certain occupations. Also, we did not measure emotional demands, and these may be important mediators of the relationship between occupation type and CMDs.
meetings (MDMs), and test criterion validity, inter-rater reliability/agreement and describe performance.
Design: Clinicians and experts in teamwork used a mixed-methods approach to develop and refine the tool. Study 1 observers rated pre-determined optimal/sub-optimal MDM film excerpts and Study 2 observers independently rated video-recordings of 10 MDMs.
Setting: Study 2 included 10 cancer MDMs in England.
Participants: Testing was undertaken by 13 health service staff and a clinical and non-clinical observer.
Main Outcome Measures: Tool development, validity, reliability/agreement and variability in MDT performance.
Results: Study 1: Observers were able to discriminate between optimal and sub-optimal MDM performance
(P d 0.05). Study 2: Inter-rater reliability was good for 3/10 domains. Percentage of absolute agreement was high (e80%) for 4/10 domains and percentage agreement within 1 point was high for 9/10 domains. Four MDTs performed well (scored 3+ in at least 8/10 domains), 5 MDTs performed
well in 6?7 domains and 1 MDT performed well in only 4 domains. Leadership and chairing of the meeting, the organization and administration of the meeting, and clinical decision-making processes all varied significantly between MDMs (P d 0.01).
Conclusions: MDT-MOT demonstrated good criterion validity. Agreement between clinical and nonclinical
observers (within one point on the scale) was high but this was inconsistent with reliability coefficients and warrants further investigation. If further validated MDT-MOT might provide a useful mechanism for the routine assessment of MDMs by the local workforce to drive improvements in MDT performance.
We construct validated the instrument to evaluate assessor learning curves and the feasibility and interrater reliability of MTB-MODe for assessing the decision making process using video recorded multidisciplinary tumor board meetings.
Materials and Methods
Multidisciplinary tumor boards are becoming standard practice for managing cancer internationally but no standards have been agreed on to assess the efficacy of such teams. The MTB-MODe tool assesses the process of multidisciplinary tumor board decision making by standardized observation (1 to 5 anchored scales) of the quality of information presented at the multidisciplinary tumor board as well as board member contributions to the case review. We assessed 683 multidisciplinary tumor board case discussions using MTB-MODe in a multiphase study, including 332 cases (9 urology boards) by 1 urologist in vivo and 224 cases (6 urology boards) by 2 urologists in vivo. The instrument was refined and subsequently used to rate 127 video recorded case discussions (5 tumor types) by a total of 8 multidisciplinary tumor boards.
Good interrater reliability was achieved in vivo and at the video recorded multidisciplinary tumor board meetings (ICC e0.70). MTB-MODe scores were higher in cases that resulted in a decision than in cases in which no decision was made (mean ± SD 2.54 ± 0.47 vs 2.02 ± 0.65, p d0.001).
A standardized method to assess the quality of multidisciplinary tumor board discussions can enhance the quality of cancer care and the ability of the boards to self-evaluate performance, thus, promoting good practice. Video recordings offer a feasible, reliable method of assessing how multidisciplinary tumor boards work.
Cancer multidisciplinary teams (MDTs) are well established worldwide and are an expensive resource yet no standardised tools exist to measure performance. We aimed to develop and test an MDT self-assessment tool underpinned by literature review and consensus from over 2000 UK MDT members about the ?characteristics of an effective MDT.?
Questionnaire items relating to all characteristics of MDTs (particularly Leadership and Chairing; Teamworking and Culture; Patient-centred care; Clinical decision-making process; and Organisation and administration during meetings) were developed by an expert panel. Acceptability, feasibility and psychometric properties were tested by online completion of the questionnaire by 23 MDTs from 4 UK NHS Trusts followed by interviews with 74 team members including members from all teams and nonresponders. 10 of the MDTs also completed questionnaires that directly translated each characteristic to an item (for the five domains above) to test content validity.
A total of 47 items were created, each rated for agreement on a 5-point scale. A total of 329 (52 %) of 637 team members completed the questionnaire, including representation from medical, nursing and clerical MDT members. Responses correlated well with domain-specific questionnaires (r > 0.67, p = 0.01), most domain-scales had acceptable internal consistency (Cronbach alpha > 0.60), and good item discrimination (majority of items r Conclusions
Self-assessment of team performance using this tool may support MDT development.
in individuals who were employed, unemployed and receiving various UK benefits. It also investigated associations between duration of unemployment, gender and CMD. Study design An analysis of 5090 working-age participants from the Adult Psychiatric Morbidity
Survey 2007, a stratified probability sample survey conducted among adults aged 16 years
and over living in private households in England. Methods CMD was assessed using the
Clinical Interview Schedule (Revised). Information was gathered on sociodemographics,
employment, income, benefits and debt. Data were analysed using logistic regression &
Multidisciplinary team (MDT) working is well established as the foundation for providing cancer services in the UK and elsewhere. A core activity is the weekly meeting (or case conference/tumor boards) where the treatment recommendations for individual patients are agreed. Evidence suggests that the quality of team working varies across cancer teams, and this may impact negatively on the decision-making process, and ultimately patient care. Feedback on performance by expert observers may improve performance, but can be resource-intensive to implement. This proof of concept study sought to: develop a structured observational assessment tool for use by peers (managers or clinicians from the local workforce) and explore its usability; assess the feasibility of the principle of observational assessment by peers; and explore the views of MDT members and observers about the utility of feedback from observational assessment.
For tool development, the content was informed by national clinical consensus recommendations for best practice in cancer MDTs and developed in collaboration with an expert steering group. It consisted of ten subdomains of team working observable in MDT meetings that were rated on a 10-point scale (very poor to very good). For observational assessment, a total of 19 peer observers used the tool (assessing performance in 20 cancer teams from four hospitals). For evaluation, telephone interviews with 64 team members and all peer observers were analyzed thematically.
The tool was easy to use and areas for refinement were identified. Peer observers were identified and most indicated that undertaking observation was feasible. MDT members generally reported that observational assessment and feedback was useful, with the potential to facilitate improvements in team working.
This study suggests that observation and feedback by peers may provide a feasible and acceptable approach to enhance MDT performance. Further tool refinement and validation is required.
Purpose of review
As rising numbers of people are living with the long-term impact of cancer, digital health is playing an increasingly important role in the monitoring and support of survivors and their caregivers. This article reviews current evidence, practice and developments, and identifies emerging issues and opportunities.
Digital health innovations, primarily using internet or smartphone-enabled applications, have been successfully developed, particularly in the areas of symptom management, decision-making, survivorship and follow-up care and palliative care. The research is characterized by much developmental activity, and evidence is accruing for efficacy and effectiveness. Opportunities afforded by digital health include timelier and patient-centred evidence-based care, offering improved clinical outcomes and independence. Barriers to implementation include lack of patient and professional engagement, perceived burden, depersonalization and missed care.
There is much enthusiasm for the role of digital health in monitoring and providing support to cancer survivors, but further research is needed to establish clinical efficacy and understand the mechanisms for successful implementation in practice. The role of wearables, the internet of things and big data analytics is yet to be fully explored in supportive cancer care and may present new opportunities to enhance care and survivor experience.
The benefits of physical activity for cancer survivors are increasingly recognised and smartphone applications are available to assist them to become more physically active. Cancer clinicians, however, lack confidence about which physical activity apps to recommend as evidence on their quality and content is limited. Therefore, we reviewed freely available commercial physical activity/fitness apps to systematically assess their behavioural change content and quality of their design.
Systematic searches of the app stores for Apple and Android operating systems were conducted and apps were screened to identify free apps appropriate for cancer survivors. Quality was assessed using the Mobile App Rating Scale (MARS) and behavioural content was evaluated using the Behavioural Change Techniques Taxonomy (BCTT).
Of 341 apps identified, 67 were judged appropriate for cancer survivors and 46% combined aerobic and strength/stretching content. The overall number of behavioural change techniques (BCT) included was 3.96 (SD = 2.09), with the most frequent being ?feedback on behaviour? and ?goal setting behaviour?. The mean scores for objective and subjective quality were 4.11 (SD = 0.59) and 3.07 (SD = 0.91) respectively (range 0 to 5). Finally, a modest positive correlation was found between the number of BCT and the quality of engagement, awareness and knowledge as assessed by the MARS.
Only a fifth of retrieved physical activity apps contained potentially suitable content for people affected by cancer. Overall, most apps we reviewed appeared to perform well in terms of their objective quality, but less well at promoting knowledge and awareness or help seeking related to physical activity.
Implications for Cancer Survivors
Many physical activity apps are available but the combined use of MARS and BCTT suggests that not all of them are suitable to the needs is a promising and feasible approach for assessing the applicability, usability and content of physical activity of apps employed by cancer survivors and this study is a first step toward developing a guide.