1. Risk of malignancy in patients with mental health problems Julia Hippisley-Cox Yana Vinogradova Carol Coupland Chris Parker SAPC, Keele July 2006

2. Aims of presentation OverallOverall –Present analysis of study examining risk of cancer in patients with mental health problems

3. Acknowledgements Co-author –Julia Hippisley-Cox –Carol Coupland –Chris Parker QRESEARCH team –Mike Pringle –Mike Heaps –Gavin Langford –David Stables –EMIS and EMIS practices

4. Funding body Funded by Disability Rights Commission Part of programme of work looking at health inequalities & outcomes for patients with serious mental health problems Schizophrenia Manic depression

5. Background No consistency in literature about cancer incidence in patients with mental health problemsNo consistency in literature about cancer incidence in patients with mental health problems –Protective effect of schizophrenia –Increased cancer incidence and mortality Fundamental differences in methodologyFundamental differences in methodology –Cohorts are often restricted to hospital patients –No control for confounding factors

6. Study design & setting Nested case control studyNested case control study Study period Jan 1995-July 2005Study period Jan 1995-July 2005 Separate sets of matched cases and controls for each cancerSeparate sets of matched cases and controls for each cancer –Breast –Colorectal –Gastroesophageal –Prostate –Respiratory

7. Cases & controls CASES 1 st ever record of cancer during 10 year study period1 st ever record of cancer during 10 year study periodCONTROLS 5 controls matched by5 controls matched by –Age –Sex –Practice –Calendar year

8. Study population: QRESEARCH database Currently largest database in the UKCurrently largest database in the UK 537 UK practices537 UK practices > 6 practices in every Strategic Health Authority (administrative area)> 6 practices in every Strategic Health Authority (administrative area) > 9 million patients including those who died, left and still registered> 9 million patients including those who died, left and still registered > 30 million person years of observation> 30 million person years of observation

9. Data source: QRESEARCH database Patient level consolidated databasePatient level consolidated database Anonymised dataAnonymised data Longitudinal data for 15+ yearsLongitudinal data for 15+ years Derived from GP clinical recordsDerived from GP clinical records Validated against external and internal measuresValidated against external and internal measures Industry independentIndustry independent

10. Statistical analysis Conditional logistic regressionConditional logistic regression Odds ratios + 95% CIOdds ratios + 95% CI Unadjusted & adjustedUnadjusted & adjusted

11. Sample: 47,924 incident cases of cancer 1995/2005 Breast 11,275 cases 49 S 47 MD 53,621 controls 164 S 173 MD Colorectal 8,356 cases 40 S 19 MD 40,010 controls 101 S 90 MD Gastro- oesophageal 3,854 cases 14 S 9 MD 18,477 controls 53 S 41 MD Prostate 10,190 cases 13 S 16 MD 48,748 controls 116 S 93 MD Respiratory 7,506 cases 23 S 35 MD 35,981 controls 148 S 103 MD

13. Confounding factors Townsend score quintiles Body mass index Less than 25 kg/m2 25 to 29.9 kg/m2 30 kg/m2 or more BMI not recorded Smoking status Non-smoker Smoker not recordedMedications NSAIDs Statins Cox2 inhibitors Aspirin Hormone replaced therapy Contraceptive pill Antipsychotic drugs Antidepressants

16. Methodological strengths Large sample size and representative populationLarge sample size and representative population Data electronically collected –unlikely misclassification biasData electronically collected –unlikely misclassification bias Data collected before the diagnosis - no recall biasData collected before the diagnosis - no recall bias Excluded diagnoses of mental health problems 12 months prior to cancer diagnosis – no information biasExcluded diagnoses of mental health problems 12 months prior to cancer diagnosis – no information bias

17. Risk of cancer compared to general population CancersSchizophrenia Manic depression Breast + 42%* + 26% Colorectal + 90%** + 1% Gastroesaphageal + 9% 0% Prostate - 41% - 16% Respiratory - 46%* + 18% * p < 0.05 ** p < 0.01

18. Conclusions Risk of certain cancers differ among people with schizophrenia compared with general populationRisk of certain cancers differ among people with schizophrenia compared with general population Patients with manic depression have similar cancer risk compared with general populationPatients with manic depression have similar cancer risk compared with general population