Posts Tagged ‘Risk’

Close relative of a breast cancer survivor had more than a two-fold increased risk of ovarian cancer compared to women with no family history of breast cancer.

Reporter: Aviva Lev-Ari, PhD, RN

July 24, 2013

Family Cancer Ties Run Deep

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Reviewed by:

Joseph V. Madia, MD


Risks of different cancer types higher in first degree relatives of cancer survivors

(dailyRx News) If a woman’s mother, sister or daughter has had breast cancer, she has increased risks of developing the disease herself. But is this woman at greater risk of other types of cancer, too?

A recent study has found that a family history of cancer may increase the risk of close relatives developing the same type of cancer as well as different forms of the disease.

For example, this study showed that the close relative of a breast cancer survivor had more than a two-fold increased risk of ovarian cancer compared to women with no family history of breast cancer.

“Alert your healthcare providers about any family history of cancer.”

Eva Negri, MatSciD, head of the Laboratory of Epidemiologic Methods at the Mario Negri Institute for Pharmacological Research in Milan, Italy, was the corresponding author of the study.

The goal of this study was to look at the cancer histories of close relatives, particularly first-degree relatives (siblings, parents and children), of cancer survivors.

Dr. Negri and colleagues from Switzerland and France analyzed case-control studies (cancer cases versus healthy comparisons) on thirteen different types of cancer conducted between 1991 and 2009.

Cancer types included mouth and throat, nasal, larynx (voicebox), esophageal (tube between throat and stomach), stomach, colorectal, liver, pancreas, throat, breast, endometrial, ovary, prostate and kidney.

Data was collected on more than 12,000 cancer cases and more than 11,000 comparisons.

Along with information on family history of cancer, the researchers looked at age of diagnosis, body shape, lifestyle habits such as diet, smoking and alcohol use and personal history including reproductive history, use of birth control and hormonal therapies.

After accounting for all other factors, the researchers found the following:

  • Women with a family history of colorectal cancer had a 1.5-fold increased risk of developing breast cancer.
  • Female first-degree relatives of a breast cancer survivor had a 2.3-fold increased risk of ovarian cancer.
  • Male first-degree relatives of a bladder cancer survivor had a 3.4-fold increased risk of prostate cancer.
  • Close relatives of someone who had mouth (oral) or throat cancer had a four-fold increased risk of esophageal cancer.
  • People with a first-degree relative who had cancer of the larynx had a 3.3-fold increased risk of developing oral or throat cancer.
  • If cancer was diagnosed in an individual before the age of 60, the risk of close family members developing a different type of cancer was greater.

“Our results point to several potential cancer syndromes that appear among close relatives and that indicate the presence of genetic factors influencing multiple cancer sites,” the authors wrote.

Dr. Negri said in a prepared statement, “These findings may help researchers and clinicians to focus on the identification of additional genetic causes of selected cancers and on optimizing screening and diagnosis, particularly in people with a family history of cancer at a young age.”

This study was published July 24 in the Annals of Oncology.

This work was supported by the Italian Association for Cancer Research, the Italian Ministry of Education and the Swiss League Against Cancer.

No conflicts of interest were disclosed.



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Review Date:

July 25, 2013

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July 25, 2013



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Participatory Healthcare: A New Trend in Research?

 Author: Dr Anayo Unachukwu, MBBS, LLM


When the great innovation appears, it will almost certainly be in muddled, incomplete and confusing form….For any speculation which does not at first glance look crazy, there is no hope”

Freeman Dyson

Healthcare by its very nature is complex. It comprises of not just one single integrated system, but consists of a large number of interrelated systems.[1] Risk[2] is inherent in the system. As a result of its complexity, it is also prone to errors due to concatenation of multiple small failures.[3] Given the fore-goings, it is unsurprising that a patient care pathway can be complex as regards the nature of care delivered and in the number of organisations that contribute to the care.[4] In parallel to this is the mounting cost of healthcare, emergence of post approval hurdle-pricing reimbursement and health technology assessments-that are more stringent.

Risk in general lacks precision both in definition and the impact it presents. There appears to be an inverse relationship between the tolerance of risk in a given society and its level of affluence. However, most affluent society seeks change in the delivery of service. This is to make for faster, efficient and effective delivery of quality services taking advantage of new technologies. The paradox is that change is front-loaded with uncertainty and it is inherently risky. In the National Health Service-as in many public organisations in developed societies that are involved in healthcare-change is influenced by the public choice theory[5] and market theory principles.[6] The government is increasingly relying on effective partnership to deliver on broad outcome measures[7] which is the nature of Public Service Agreement (PSA). Of note, it recognises that good risk management is integral to delivery of successful partnership.[8] Collaboration, co-invention and partnership have now become the buzz words in the pharmaceutical industries as part of to optimise on their research and development efforts, reduce redundant capacity and adoption of Darwinian approach to portfolio management.

The development of risk assessment and management is largely due to trends in the wider society, technological advances in health care, and the paradigm shift from paternalism to autonomy, consumerism, and clinical negligence litigation.[9] Further, in post-Vioxx world, the regulatory environment in the industry has become more challenging resulting in robust risk management and label restrictions. The political and economic trends and impacts on risk assessment and management are now more ubiquitous; and conflate and complicate the perception of risks.

Given this background, wholesale or partial significant changes in healthcare or a significant change in direction must be done circumspectly whilst factoring in inter alia: the complexity of the sector, risk management and resource reallocation among the various competing influences. According to Le Chatelier’s principle[10] which can be roughly stated as:

“Any change in status quo within a closed system will result in an opposing reaction in the responding system”.

At this stage in this discourse, it may be pertinent to look at the practical applications of change particularly with respect to research in healthcare as recently advocated by some healthcare leaders.

In December 2012, Lucien Engelen, director Raboud REshape and Innovation Centre at Raboud University Njimegen Medical Centre communicated his ‘Big Ideas 2013:The ideas include a launch of an initiative where patients together with their family and informal carers will come up with research-ideas and patients will also try to raise the money for chosen research ideas’. According to Mr Engelen, ‘This will start a new movement”.

Mr Engelen’s qualities as a visionary leader (his innovation centre is the second largest Academic Medical Centre in the Netherlands) and indeed enthusiasm are never in doubt. Neither is his honest intention to make healthcare truly participatory with patient at the very heart of service delivery. In principle participatory healthcare is laudable, given that patients come into such partnership/relationship better informed and able to negotiate better and take active part in management of their health.

However, it may be of some concern when ‘Big Ideas’ are bandied around with a complete disconnect between fundamental research and applied research. His idea of research needless to say is informed by the wisdom of the crowd and successes in other fields-art and culture, new technology etc. Healthcare is unique in more ways than one and attempts to extrapolate from other unrelated sector may have the unintended consequences that have far reaching implications.

Bold initiatives and innovation are laudable in all human efforts and endeavours, be it healthcare, other sectors, etc. The problem with the big ideas in research as advanced by Mr Englene is that it is emotive-and I dare say-has a whiff of personal imprimatur in his attempt to vivify research. Further, big ideas by its very nature, generally have at stake self beliefs, ego and personal ambitions, etc; “outcomes”[11] (as it is said torture data long enough it will confess to anything) become everything. The new game will be the end justifies the means and as a result ‘Lance Armstronging’[12] investigative studies will not be off the radar of the “researchers,” given that the vocal minority backing the effort will be banking on immediate positive outcomes. This cannot by any stretch of definition be called a scientific quest for truth. Call it by any other name-by all means-but not research. Research in healthcare is complex and is beset with vicissitudes of life. Serendipity is integral to any serious research effort and certainly it has changed lives. Part of the reasons why pharmaceutical industries have not had as many successes as previously-apart from the fact that previous research efforts have picked the low hanging fruits-is the ‘sanitised’ funding that leaves little room for serendipity. I am pleased to note that The Dean of the University where Mr Englene is based, Paul Smits, although he likes the idea-‘it brings science into the living room’-however cautioned that care ought to be exercised that the big ideas are not pursued at the expense of fundamental research.

We have to accept that certain endeavours are more difficult than others, no matter how much other disciplines may attempt to borrow from science or even language up what they do to imbricate scientific investigations. The output will be at best a pseudoscientific pretender. Einstein’s wise words are instructive: “Everything should be made as simple as possible, but not simpler”.


[1] Ellie Scrivens, Quality, Risk And Control in Health Care. Open University Press 2005. p. 8

[2] HM Treasure. The Orange Book Management of Risk-Principle and Concepts (October 2004).

[3] Ibid.

[4] Sheila Peskett, “The challenges of commissioning healthcare: a discussion paper,” Int J Health Plann Mgmt 2009; 24: 95-112.

[5] This take the view that publicly provided services are prone to be less efficient, less productive and less focused on their customers than privately provided services.

[6] Competition amongst providers will drive up quality, innovation and productivity whilst containing costs.

[7] This applies not only in the  health sector and other public sectors.

[8] HM TREASURY. Managing risks with delivery partners. Office of Government Commerce (OGC).

[9] Department of Health Making Amends: A Consultation Paper Setting out proposals for Reforming the Approach to Clinical Negligence in the NHS (2003); the cost of compensating patients jumped 400 per cent in the course of the 1970s and 750 per cent in the 1990s.

[10] This principle is native to chemistry and  in its original form states that in a closed system-a chemical system-if it experiences a change in concentration, temperature, volume or pressure, the new equilibrium is achieved to counteract the imposed change.

[11] Who is measuring; always bear in mind Hawthorn’s effect

[12] One is not talking about being dishonest to achieve a success, but going to an inordinate extraordinary length to see that success is ensured without counting the cost in the long term.

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Author: Dr Anayo Unachukwu, MBBS, LLM


Modern society is built on the twin pillars of Judaeo-Christian jurisprudence and Graeco-Roman civilisation. The jurisprudence has provided us with the moral[1], ethical and legal system that has sustained the civilisation. The civilisation prides itself with the legacy it bequeathed modern society-science. Revolution in science has often been preceded by revolution in measurement. The scientific endeavours have led to delineating, characterising, validating and reliably predicting and identifying the origin of concepts, phenomena, etc encountered by mankind and seeking remedies for these with some degree of certainty and accuracy. The prodigious advances in science and technology within the ethico-legal framework that stemmed from it have brought with it advantages in medical science and related fields. These pervade our every day environment; and we are all witnesses to the consequences of its innovation and creativity. Given the new found confidence in these fields, there have been attempts by medical and behavioural scientists to stretch its research frontiers further in providing succinct explanation to often complex human behaviour and interaction within social spheres. The science behind these quests usually has aural of purity-value free and bereft of ideology. However as Rose puts it: “It may well be that it is only in the periods of social and intellectual crisis that we can glimpse the interconnections between science and social system.[2]

One of the preoccupations of prehistoric man has been attempts at classification and categorisation; this heuristic pursuit-through generalisation-is a way of navigating the complex environment he finds himself. Attempts at generalisation by extrapolating from medical model to account for mental disorders[3] have not altogether been helpful. This could be due to lack of clarity in understanding the aetiological underpinnings; stigma and labeling intrinsic to the sufferers and skepticisms that surround the practice of psychiatry.

The mentally disordered offender raises questions which have troubled theologians, moral philosophers and lawyers throughout the Christian era.[4] It is not only these professions that grapple with this group of offenders; as Eastman puts it psychopaths[5] are the moral and scientific junctional case between the mad and the bad, both in terms of treatment and of punishment.[6]

Psychopathy[7] as a construct throws up more questions than answers-origin, remedial attempts[8] and heuristic generalisation as regards prognostic inferences. There is larger debate on whether psychopathy and personality disorder[9] are primarily legal or diagnostic categories, or neither.[10] Given that psychopathy straddles interpersonal and social domain in everyday human endeavours which impacts on both clinical and legal settings; one would have thought that a complete delineation and categorisation would have been understood by relevant practitioners[11] involved, but this appears not to be the case. Some researchers both clinical and non clinical strongly disagree on the nosological certainty of psychopathy and its inclusion in the medical classificatory system.

However, all agrees that the disorder generates a lot of controversy; and the emotive[12] issue that it provokes-social, psychological, economic and legal-reverberates further afield way beyond the field of clinical sciences.

From social policy perspective, other characteristics of psychopathy notwithstanding, criminal and violent behaviours are the main hallmarks of the disorder.[13] Psychopaths are high risk offenders with many criminogenic needs (i.e., personal characteristics correlated with recidivism).[14] In fact, recent research efforts have shown that there is a relationship between psychopathy and both general and violent crimes.[15] The criminogenic derivative that stem from the disorder had a legal ringing endorsement.[16]

In contrast to the relationship between psychopathy and rate of recidivism; Gibbens et al[17] eight-year comparative follow-up study on criminal psychopaths (diagnosed as ‘severe cases’) and criminal non psychopaths as regards their reconviction rates showed insignificant differences in the reconviction rate for both groups. The conclusion from this study was broadly similar to a two year follow-up study by Walker et al[18] which compared the rates of reconviction amongst psychopaths and non psychopaths who were diagnosed with severe mental illness, schizophrenia and those diagnosed as subnormal (learning disability); the rate of recidivism for both groups were not statistically significant.

Without making an extraordinary reading of the follow-up studies, Cooke et al[19] had argued that criminal behaviour should not play a central role in the diagnosis of psychopathy; instead such behaviour is best viewed as a secondary feature; or sequel of the disorder. This view is consistent with Cleckley’s original classical description of psychopathy where criminal behaviour was not intrinsic to the disorder; the motivation of the behaviour when it is present is usually obscure.[20] Criminality and psychopathy are not the same construct; the core features of the disorder-glib charm, callousness, arrogance, shallow affect, deceitfulness, and lack of empathy do not necessarily involve or imply criminal behaviour.[21] Why then is there such a great emphasis in diagnosis of this disorder? The answer partly lies in the society we live. There appears to be an inverse relationship between the tolerance of risk[22] in a given society and its level of affluence. There is a political imperative driven by popular lay press for a ‘risk free’ society; such an unrealistic expectation has led to the bourgeoning of research in risk instruments for assessment and management of risks. The trend in the wider society, technological advances and rise in consumerism has all further fueled this gusto-risk intolerance. Risk assessment as a concept is not a legal issue per se as competence to stand trial or criminal responsibility; however, it forms important part of different decision making in law. As Fennell puts it, there is a role redefinition whereby risk management has assumed increasing centrality in the role of psychiatrists and other mental health professionals, and philosophies of risk management now permeate decision-making in both the psychiatric system and penal system.[23] It is a given that psychopaths are involved in violent crimes and they recidivate for both violent and non violent crime compared to non psychopath; hence violence risk is an “indirect” legal issue often relevant to ultimate decisions but rarely defining the ultimate issue specifically.[24] Therapeutic jurisprudence[25] partly relies on risk assessment and management in deciding on disposal options available when dealing with mentally disordered offenders. As Leacock and Sparks remarked; Risk…is a fashionable idea—one whose moment would appears to have arrived.[26] Risk is now so integral to every day discourse given the high profile homicides; most notable was the killing of Jonathan Zito (in England) by a stranger, Christopher Clunis, who suffered from schizophrenia. As a result, the risk management/public protection agenda is now prominent-in England and Wales-and since 1992, health authorities have a duty to carry out an independent inquiry in any case of homicide or suicide by a mentally disordered person in their care.[27]



Mentally disordered offenders-like the poor-will always be in our midst. Labelling and stigmatising this group as a whole may be unhelpful at best and amounts to discrimination. Managing risk out every day discourse is naivete to the extreme, given that in any society a trade-off has to be made as far as risk goes. Criminality as a construct should not be synonymous with psychopathy, given that not all psychopaths offend and not all criminals are psychopaths.

[1] Psychopathy which under the Mental Health Act 1983 is classified as a mental disorder is seen by some philosophers, lawyers, clinicians and the society at large as essentially a moral disorder. See Maibon, H.L. The Mad, the Bad, and the Psychopath. Neuroethics (2008) 1:167-184. DOI 10.1007/s12152-008-9013-9.

[2] Rose, S., Rose, H. (1971). The myth of the neutrality of science. In Watson Fuller (ed). The SOCIAL IMPACT OF MODERN BIOLOGY.Routledge & Keegan Paul. London. p.233

[3] The adoption of this term was recommended in the Report of the Royal Commission on the law relating to Mental Illness and Mental deficiency 1954-1957 (Cmnd 169 (1957)) Pt 3 paras 146-198. The Commission recommended its use as a general term covering all forms of mental ill-health or disability. S (1) of the amended Mental Health Act 2007 gives a broader description of mental disorder-any disorder of the mind; ‘mentally disordered’ shall be construed accordingly.

[4] Walker, N. (1968) Crime and Insanity in England. vol. I. Edinburgh University Press. p. 6

[5] Psychopathy is a personality disorder defined by a cluster of interpersonal, affective, and lifestyle characteristics that results in serious, negative consequences for society.

[6] Eastman, N (2002). The Ethics of Clinical Risk Assessment and Management:Developing Law and the Role of Mental Health Professionals. In Gray, N,  Lain, J,  Noaks, L. (Eds.). Criminal Justice, Mental Health and the Politics of Risk.(pp. 49-66). Cavendish Publishing Limited.

[7] The adverb psychopathic means literally ‘psychically damaged’ and was introduced in the 19th century Germany to cover all forms of psychopathology. From the outset it should be distinguished from psychopathic disorder which is a legal concept. Authors disagree on its definition; sometimes the usage is in vernacular, and this paints a derogatory picture. See Gunn, J. and Robertson G. (1976b) Psychopathic Personality: a conceptual problem. Psychological Medicine, 6, 63-4 (386).

[8] Cleckley, H. (1941). The mask of insanity. St. Louis, MO: Mosby. The present day conceptualisation of psychopathy is credited to the systematic writings and observation of Cleckley. He expressed concerns about the progressive nature of the disorder, social malady it posed to the society and therapeutic nihilism associated with it.

[9] The defining characteristic of personality disorder more than any symptom is the incomprehensibility and inaccessibility that the sufferer provokes in other people. It is classified as a mental disorder by both two international classificatory systems- World Health Organisation. (1992) International Classification of Disease and Related Health Problems: ICD-10. Geneva: WHO; and American Psychiatric Association. (1994) Diagnostic and Statistical Manual of Mental Disorders. DSM-IV. WashingtonDC: Mental Health Service.

[10] Ogloff, J.R.P., & Lyon, D.R. (1998). Legal issues associated with the concept of psychopathy. In D.J. Cooke, A.E. Forth, & R. D. Hare (Eds) Psychopathy: theory, research, and implications for society (pp. 401-422). Dordrecht, The Netherlands: Kluwer.

[11] Unfortunately among various practitioners not just legal practitioners, but most clinicians the conceptual cousins of psychopathy-sociopathy, dissocial personality and antisocial personality have been mistaken for psychopathy. See Gacono, C.B., Nieberding, R., Owen, A., Rubel, J., & Bodholdt, R. (2000). Treating juvenile and adult offenders with conduct disorder, antisocial and psychopathic personalities. In J. Ashford, B. Sales, & W.Reid (Eds.), Treating clients with special needs. WashingtonDC: American Psychological Association.

[12] Hare, R.D. (1996a). Psychopathy: A construct whose time has come. Criminal Justice Behavior. 23, 25-54.

[13] Patrick, C.J. (2006). Handbook of Psychopathy The Guilford Press. p.555

[14] Zinger, I., & Forth, A.E. (1998). Psychopathy and Canadian criminal proceedings: The potential for human right abuses. Canadian Journal of Criminology, 40, 237-276.

[15] Salekin, R.T., Rogers, R., & Sewell, K. W. (1996). A review and meta-analysis of the Psychopathy Checklist and Psychopathy checklist-Revised. Clinical Psychology: Science and Practice, 3, 203-215

[16] Carraher v HM Advocate 1946 JC 108 at 117, per Lord Normand: it is to my mind descriptive rather of a typical criminal than a person…regarded as being possessed of diminished responsibility.

[17] Gibbens, T.C.N., Pond, D.A. and Stafford-Clark, ‘A Follow-up Study of Criminal Psychopaths’ in (1959) 105, Journal of Mental Science, 108 ff.

[18] Walker, N., McCabe, S. (1973) Crime and Insanity in England. Vol. II. p.212. Edinburgh University Press.

[19] Cooke, D. J., Michie, C., Hart, S. D., et al (2004) Reconstructing psychopathy: Clarifying the significance of antisocial and socially deviant behavior in the diagnosis of psychopathic personality disorder. Journal of Personality Disorders, 18, 337-357.

[20] Cleckley,H. (1988) The Mask of Sanity (5th edn). Mosby. p.279

[21] Hare, R.D. (1998). Psychopathy, affect, and behaviour. In D.J. Cooke, A.E.Forth, & R.D. (Eds.), Psychopathy, theory, research, and implication for society (pp104-137). Dordrecht, the Netherlands: Kluwer.

[22] Risk is defined as the uncertainty of outcome whether opportunity or negative threat, of actions and event

[23] P, Fennell (2002) .The Ethics of Clinical Risk Assessment and Management:Developing Law and the Role of Mental Health Professionals. In Gray, N,  Lain, J,  Noaks, L. (Eds.). Criminal Justice, Mental Health and the Politics of Risk.(pp. 49-66). Cavendish Publishing Limited.

[24] Roesch, R., & McLachlan, K. (2007). Clinical Forensic Psychology and Law. Ashgate Publishing Ltd.

[25] Wexler, D., & Winck, B. (Eds.) (1996). Law in a therapeutic key. Durham, NC: Carolina Academic Press. At p. 32 describe it as a concept that addresses the issue of how knowledge, theories and insight of the mental health disciplines can help shape the development of law.

[26] R.D. Mackay (2002). Criminal Justice, Mental Health and the Politics of Risk. Crim. L.R. 2002, Sep, 765-767.

[27] Fennell, P (2010). HISTORY AND CONTEXT OF MENTAL HEALTH LAW AND POLICY. In Gostin, L., Bartlett, P., McHale, J., Mackay, R. (eds). PRINCIPLE OF MENTAL HEALTH POLICY AND LAW. Oxford University Press. p.53.


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