Agnieszka Lemanska

Background: In England, people from marginalised groups are more likely to be diagnosed with, and treated for, late-stage breast cancer. Differences in routes to diagnosis, time to diagnosis and time to treatment may be contributing factors. Methods: Data from the Clinical Practice Research Datalink and the Cancer Registration Tumour and Treatment datasets were assessed for 86,564 adults diagnosed between 01 January 2009 and 31 December 2018. Associations between patient characteristics and route to diagnosis, time to diagnosis and time to treatment were examined using logistic regression and accelerated failure time models. Results: People of Asian (aOR: 0.87, CI 0.79, 0.97), Black (aOR: 0.71, CI 0.62, 0.82), or Mixed ethnicity (aOR: 0.67, CI 0.51, 0.88), those experiencing deprivation (aOR: 0.89, CI 0.85, 0.95), and those with severe mental illness (aOR: 0.87, CI 0.78, 0.98) were less likely to be diagnosed via screening. Conversely, these groups were more likely to be diagnosed via urgent suspected cancer referral and/or emergency presentation. Time to diagnosis was longer for people with a learning disability (aTR: 1.18, CI 1.06, 1.32), while time to treatment was longer for people with a learning disability (1.08, CI 1.03, 1.13), people with severe mental illness (aTR: 1.07, CI 1.04, 1.09) and people of Black (aTR: 1.10, CI 1.07, 1.13) or Other ethnicity (aTR: 1.06 CI 1.03, 1.10). Conclusions: This study provides insights into which patient groups experience inequalities in routes to diagnosis, time to diagnosis and time to treatment. The findings can be used to target strategies to reduce inequalities in stage at diagnosis and treatment.

Objectives: Pancreatic cancer is diagnosed in approximately 1% of individuals with new-onset diabetes, increasing to 3% among those aged ≥60 years with weight loss. UK clinical guidelines recommend abdominal imaging to rule out pancreatic cancer in this high-risk group. In June 2025, National Health Service (NHS) England launched a case-finding pilot to test approaches to improve primary care referrals for imaging in these patients and improve the quality of body weight and diabetes-related data recorded in electronic healthcare records (EHRs). This study reports referral and imaging rates among the eligible group and the availability of body weight and glycated haemoglobin (HbA1c) measurements in people with diabetes, providing baseline data prior to implementation of the NHS England pilot. Design: Retrospective cohort study. Setting: Primary care. The database of 8 million patients from 781 general practices from the Royal College of General Practitioners Research and Surveillance Centre. Participants: Adults diagnosed with diabetes between 2015 and 2021. Outcome measures: Proportions of eligible individuals who received a referral and imaging within 12 months before or after diabetes diagnosis and the number of body weight and HbA1c measurements recorded for individuals with diabetes. Results: Among 180 815 individuals diagnosed with diabetes, 92 210 (51.0%) were aged ≥60 years (median age 71, 46% women). Overall, 152 300 (84.2%) had at least one body weight and 161 631 (89.4%) had at least one HbA1c measurement recorded in EHRs. Among the 1411 patients with new-onset diabetes and weight loss, 372 (26.4%) had a referral, 141 (10.0%) imaging and 40 (2.8%) had pancreatic cancer recorded. Conclusions: This study demonstrated potential underutilisation of referral guidance and under-referral among the eligible population. The findings provide baseline data to support the launch of the NHS England pilot. Further research is needed to better understand current practice and support the implementation of cancer referral guidelines.

Aim: Pancreatic enzyme replacement therapy (PERT) is essential for the management of pancreatic exocrine insufficiency. Since June 2023, the United Kingdom has been affected by a global shortage of PERT. We investigated the impact of this shortage on national prescribing trends for Creon, Nutrizym, Pancrex and Pangrol. Methods: We analysed primary and secondary care prescribing data in England from January 2019 to February 2026 and used linear regression with an interrupted time series approach to assess the impact of the shortage. Results: Creon 25 000 was the most prescribed PERT with an increasing trend. Following the onset of the shortage, prescribing in primary care increased to 12 192 (95% CI: 11 682–12 702) thousand capsules across 43 203 (41 549–44 856) prescriptions per month but remained below predicted levels ( p < 0.001). Secondary care prescribing was higher than predicted ( p < 0.001). Prescribing of Creon 10 000 also increased, with an excess of 912 (493–1330) thousand capsules and 2202 (1308–3097) prescriptions per month in primary care and 235 (192–279) thousand capsules in secondary care (approximately threefold higher than predicted, p < 0.001). Nutrizym more than doubled in primary care to 841 (743–940) and tripled in secondary care to 30 (24–35) thousand capsules per month ( p < 0.001). Pancrex doubled in primary care ( p = 0.001) but remained below predicted levels in secondary care ( p = 0.005). The number of capsules per prescription increased for Creon 10 000 by 15 (6–23; p = 0.002) but decreased for all other formulations ( p < 0.001). Conclusion: Although prescribing remained highest for Creon 25 000, the shortage was associated with a shift towards Creon 10 000 and an increase in alternative products, particularly Nutrizym.

Background: Pancreatic cancer has a very low survival rate due to late diagnosis. Symptoms are often non-specific, thereby complicating early detection in primary care. The Enriching New-onset Diabetes for Pancreatic Cancer (ENDPAC) algorithm uses weight change, glycaemic control, and age at diabetes onset to identify patients with new-onset diabetes (NOD) who are at increased risk of pancreatic cancer. It was developed in the US and has not been validated in the UK. Aim: To validate ENDPAC in a UK primary care population and assess its predictive utility. Design & setting: Retrospective cohort study using ORCHID, a national primary care sentinel network. Method: Adults aged ≥50 years with NOD, requisite glycated haemoglobin (HbA1c), and weight data were included. ENDPAC scores were calculated and model performance was evaluated via discrimination, calibration, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The Youden index identified optimal cut-offs. Sensitivity analyses were used to assess measurement timing, repeat HbA1c testing, and multiple values. Results: Among 70 050 individuals, 185 (0.26%) developed pancreatic cancer. These people were older, and had higher HbA1c and greater weight-loss levels at diagnosis than those who did not develop pancreatic cancer. ENDPAC achieved an area under the curve of 0.734. An optimal ENDPAC score cut-off of ≥3 classified 27.8% of individuals as high risk, with 62.6% sensitivity, 72.5% specificity, 0.6% PPV, and 99.9% NPV. Sensitivity analyses showed similar performance across measurement windows and handling of multiple values. Conclusion: ENDPAC shows moderate discrimination in UK primary care. Although it had a relatively low PPV, integration into routine systems as part of a sequential diagnostic pathway could provide scalable, low-cost, automated risk stratification, thereby identifying people with NOD who are at a higher risk of developing pancreatic cancer.

Objective To examine whether satisfaction with information provision and involvement in decision-making among people with breast cancer (BC) treated in English hospitals was associated with age and other patient characteristics. Design Retrospective population-based cohort study, conducted as part of the National Audit of Primary Breast Cancer and the National Audit of Metastatic Breast Cancer. Setting National Cancer Patient Experience Survey (CPES) responses linked to National Cancer Registration data for BC patients (stage 0–4) diagnosed between 2017 and 2021. Participants 40 018 patients diagnosed with BC who responded to CPES between 2017 and 2021. Primary and secondary outcome measures Responses to questions about overall experience of care, satisfaction with information provision, involvement in decision-making and clinical nurse specialist (CNS) contact were examined. The relationships between responses, personal, disease and clinical characteristics were analysed using multivariable Poisson regression. Results 90% of patients rated their overall care as ≥8 out of 10 (0=very poor; 10=very good), decreasing to 82% for those aged Conclusion Most patients reported high satisfaction with their BC care. Satisfaction was consistently lower among younger people and those with advanced disease; this finding might partly reflect more complex pathways but requires further exploration, ideally in partnership with patients to codesign solutions. Actionable remedial strategies are proposed.

Introduction: Gonadotropin-releasing hormone (GnRH) agonists are the most commonly used form of androgen deprivation therapy (ADT) for advanced prostate cancer, often prescribed with radiotherapy or chemotherapy. This study examined national trends in the prescribing of injectable GnRH agonists in England from 2015 to 2024, by formulation type and demographic factors (age, ethnicity, and deprivation). We hypothesised that the use of longer-acting formulations has been increasing over time, specifically during the COVID-19 pandemic when access to face-to-face appointments was limited, and that variation over time and by demographics could inform future service delivery. Methods: With the approval of NHS England, we conducted a cohort study using the OpenSAFELY-TPP database of 24 million adults. Monthly prescription counts and rates (per 100,000 men with prostate cancer) were visualised over time. Generalised linear models were used to estimate the impact of the COVID-19 pandemic. Results: The cohort included 390,265 men with prostate cancer (mean age 69.8 years, SD 13.5). Overall, 1,535,725 prescriptions were issued to 208,010 participants (53%). Monthly prescription counts increased by 40%, from 11,787 in 2015 to 16,697 in 2024, while rates declined from 8453 to 7721. During 2020–2021, prescribing of 1- and 3-monthly formulations decreased, whereas 6-monthly formulations increased from 437 per month (245 per 100,000 men) in 2019 to 755 (349 per 100,000 men) in 2024, an excess of 29%. Conclusions: Before the pandemic, 6-monthly formulations were rarely prescribed. Their uptake during the pandemic suggested a shift towards longer-acting formulations, reducing treatment burden. Declining GnRH rates may reflect earlier diagnosis and evolving treatment guidelines. Divergence between prescription counts and rates, and variation by demographic factors, reflected challenges faced by healthcare systems.

Objectives: Primary care electronic health records provide a rich source of information for inequalities research. However, the reliability and validity of the research derived from these records depend on the completeness and resolution of the codelists (ie, collections of medical terms/codes) used to identify populations of interest. The aim of this project was to develop comprehensive codelists for identifying people from ethnic minority groups, people with learning disabilities (LDs), people with severe mental illness (SMI) and people who are transgender. Design: We followed a three-stage process to define and extract relevant codelists. First, groups of interest were defined a priori. Next, relevant clinical codes, relating to the groups, were identified by searching Clinical Practice Research Datalink (CPRD) publications, codelist repositories and the CPRD Code Browser. Relevant codelists were extracted and merged according to group, and duplicates were removed. Finally, the remaining codes were reviewed by two general practitioners (GPs). Setting: The curated codelists were compared using a representative sample in the UK. The frequencies of individuals identified using the curated codelists were assessed and compared with widely used alternative codelists. Participants: Comprehensiveness was assessed in a representative CPRD population of 10 966 759 people. Results: After removal of duplicates and GP review, codelists were finalised with 325 unique codes for ethnicity, 558 for LD, 499 for SMI and 38 for transgender. Compared with comparator codelists, an additional 48 017 (76.6%), 52 953 (68.9%) and 508 (36.9%) people with LD, SMI or transgender code were identified. The proportions identified for ethnicity, meanwhile, were consistent with expectations for the UK (eg, 6.50% Asian, 2.66% black and 1.44% mixed). Conclusions: The curated codelists are more sensitive than those widely used in practice and research. Discrepancies between national estimates and primary care records suggest potential record/retention issues. Resolving these requires further investigation and could lead to improved data quality for research.

Background: Pancreatic cancer is the twelfth most common cancer worldwide, but high mortality rates make it the sixth leading cause of cancer deaths. Diagnosis is frequently too late for curative intervention. Risk assessment tools incorporating diagnostic prediction models may assist early pancreatic cancer detection by primary care clinicians. Aim and Methods: This mixed methods systematic review aims to identify risk assessment tools which can be used for the detection of pancreatic cancer and have been investigated in primary care. It also seeks to synthesise the qualitative and quantitative evidence relating to the patient and clinician perspectives and experiences with these tools. Results: Ten studies were included with five risk assessment tools identified: ‘QCancer’, ‘eRATs’ (electronic risk assessment tools), ‘CaDet’, ‘Future Health Today’ and ‘C the Signs’. No tools were found for pancreatic cancer alone. Thematic synthesis of stakeholder perspectives resulted in three themes: impact on clinical decision-making, impact on patient consultations and implementation barriers and facilitators. Overall, experiences and impacts were positive, especially if used by less experienced clinicians. Conclusion: There is little evidence for the inclusion of many developed pancreatic cancer diagnostic prediction models in risk assessment tools in primary care, and limited research into stakeholder perceptions, especially patient perceptions. This review can inform future tool development, and further research should be undertaken assessing these tools’ clinical validity to encourage uptake in clinical practice. Study Registration: This study was registered prospectively as PROSPERO CRD42024488160.

The COVID-19 pandemic and national lockdowns have had profound impacts on population mental health in Scotland. In this study, we examine the impact on the relationship between the number of patients receiving in-patient care for mental health related diagnoses and the number of patients on waiting lists for treatment. The relationship between waiting lists and in-patient treatment changed during the COVID-19 pandemic, and this may be contributing to additional pressures on hospitals and mental health services in Scotland.

Background: Traditionally, intramuscular vitamin B ₁₂ injections were considered by patients and clinicians the most effective treatment option for B ₁₂ deficiency. The improving understanding of the condition paired with the restricted National Health Service (NHS) resources, resulted in a shift from injections towards tablets. The COVID-19 pandemic accelerated this change, while healthcare services were adapted to reduce COVID-19 transmission. This included new guidelines on vitamin B ₁₂ prescribing where injections were substituted by tablets. Objective: We investigated changes between 2015 and 2024 in prescribing B ₁₂ injections and tablets including the effect of the COVID-19 pandemic. Design, population and setting: This was an observational study of general practice in England covering 100% of the population. Methods: We used prescribing data published by the NHS Business Service Authority. Monthly prescription counts and rates per 100 000 patients were visualised in longitudinal plots from 1 January 2015 to 30 September 2024. We stratified the analysis by regions in England. Changes in yearly counts and rates were summarised using descriptive statistics. Linear regression and data from before the COVID-19 pandemic were used to model trends from 2020 to 2024 as if the pandemic had not occurred. The predicted values and their 95% CI were used to assess the effect of the pandemic. Results: The number of prescriptions for B ₁₂ formulations doubled in the last 10 years from 2.5 million to 5 million per year. The prescriptions for tablets increased from half a million in 2015 to 2 million in 2024. While the prescriptions for injections increased from 2 million to 3 million. In 2020, there was a sharp drop in prescriptions for injections and a simultaneous rapid increase in prescriptions for tablets coinciding with the onset of the pandemic. There were 806 031 (27%) less than expected prescriptions for injections (2 171 924 observed vs 2 977 956 predicted, 95% CI 2 905 348 to 3 050 565) and 299 834 (27%) more prescriptions for tablets (1 415 315 observed vs 1 115 481 predicted, 95% CI 1 094 350 to 1 136 612). After the 2020 drop, by 2024, injections returned to the prepandemic levels of 3 million prescriptions per year and tablets doubled from 1 million in 2019 to 2 million prescriptions in 2024. Conclusions: In this study, we document important changes to vitamin B ₁₂ prescribing in England over the last 10 years. Before the pandemic, injections were the medication of choice for B ₁₂ deficiency but there had been an ongoing debate about the benefits and cost of injections over tablets. The pandemic accelerated the switch from injections to tablets. However, these changes in the pandemic were driven by the availability of resources and not necessarily clinical evidence or patient preference. To establish best practices, more evidence is needed comparing the safety and effectiveness of injections and tablets specific to the condition being treated.