T Waddell

S Gollins

W Soe

J Valle

J Allen

D Bentley

J Morris

A Lloyd

R Swindell

M B Taylor

Dr Mark P Saunders
email: mark.saunders@christie.nhs.uk

Phase II study of short-course capecitabine plus oxaliplatin (XELOX) followed by maintenance capecitabine in advanced colorectal cancer: XelQuali study

Keywords: metastatic colorectal cancer, capecitabine, oxaliplatin, stop-and-go strategy, quality of life

Phase II study of short-course capecitabine plus oxaliplatin (XELOX) followed by maintenance capecitabine in advanced colorectal cancer: XelQuali study

METHODS

Patients received intravenous oxaliplatin 130 mg/m 2 on d1 plus oral capecitabine 1000 mg/m 2 twice daily (bid) on d1-14 every 21 days for 4 cycles. Patients achieving stable disease (SD) or better then received capecitabine 1250 mg/m 2 bid on d1-14 every 21 days until disease progression. The primary endpoint was progression-free survival (PFS).

RESULTS

Overall 21/45 (47%) of patients responded to the initial XELOX chemotherapy whilst SD or better was documented in 76%. Median PFS was 6.7 (95% CI 5.7-9.6) months, and median overall survival (OS) was 20.5 (95% CI 13.1-28.1) months. In the 34 patients who then received capecitabine maintenance therapy, the median PFS was 8.1 (95% CI 6.2-11.8) months and median OS was 23.1 (95% CI 17.8-28.5) months. A marked reduction in the vast majority of all grades of adverse event occurred on switching from initial XELOX to maintenance capecitabine chemotherapy including grade 1-2 (77% vs. 47%) and grade 3 (7% vs. 3%) neuropathy, diarrhoea and lethargy.

INTRODUCTION

Over the past decade, several new cytotoxic and targeted agents have become available for the treatment of patients with colorectal cancer. However, the optimal duration and sequence of therapy remains to be determined. Previously, the UK Medical Research Council Colorectal Cancer Group compared an intermittent regimen of 5fluorouracil/leucovorin (5-FU/LV) (i.e. 12 weeks of therapy with retreatment on disease progression) with conventional continuous 5-FU/LV in patients with metastatic colorectal cancer [START_REF] Maughan | Comparison of intermittent and continuous palliative chemotherapy for advanced colorectal cancer: a multicentre randomised trial[END_REF]. This study showed conclusively that intermittent treatment was as effective as continuous treatment, but that patients receiving the intermittent regimen had a better quality of life (QoL).

Oxaliplatin can be combined with either 5-FU/LV [START_REF] Goldberg | A randomized controlled trial of fluorouracil plus leucovorin, irinotecan, and oxaliplatin combinations in patients with previously untreated metastatic colorectal cancer[END_REF][START_REF] Goldberg | Randomized controlled trial of reduced-dose bolus fluorouracil plus leucovorin and irinotecan or infused fluorouracil plus leucovorin and oxaliplatin in patients with previously untreated metastatic colorectal cancer: a North American Intergroup Trial[END_REF][START_REF] De Gramont | Leucovorin and fluorouracil with or without oxaliplatin as first-line treatment in advanced colorectal cancer[END_REF] or the oral fluoropyrimidine, capecitabine (Xeloda ® ) [START_REF] Cassidy | Randomized phase III study of capecitabine plus oxaliplatin compared with fluorouracil/folinic acid plus oxaliplatin as first-line therapy for metastatic colorectal cancer[END_REF][START_REF] Díaz-Rubio | Spanish Cooperative Group for the Treatment of Digestive Tumors Trial (2007) Phase III trial of capecitabine and oxaliplatin (XELOX) vs continuous infusion 5-fluorouracil plus oxaliplatin (FUOX) as first-line therapy in metastatic colorectal cancer: final report of the Spanish TTD group trial[END_REF][START_REF] Ducreux | Efficacy and safety findings from a randomized phase III study of capecitabine (X) + oxaliplatin (O) (XELOX) vs. infusional 5-FU/LV + O (FOLFOX-6) for metastatic colorectal cancer (MCRC)[END_REF], to give an effective first-line regimen for patients with metastatic colorectal cancer. However, oxaliplatin can cause sensory neuropathy, a cumulative, dose-related toxicity, which is generally observed after 4 to 6 months of therapy [START_REF] Goldberg | A randomized controlled trial of fluorouracil plus leucovorin, irinotecan, and oxaliplatin combinations in patients with previously untreated metastatic colorectal cancer[END_REF][START_REF] Goldberg | Randomized controlled trial of reduced-dose bolus fluorouracil plus leucovorin and irinotecan or infused fluorouracil plus leucovorin and oxaliplatin in patients with previously untreated metastatic colorectal cancer: a North American Intergroup Trial[END_REF][START_REF] Giacchetti | Phase III multicenter randomized trial of oxaliplatin added to chronomodulated fluorouracil-leucovorin as first-line treatment of metastatic colorectal cancer[END_REF]. The median time to response with oxaliplatin-based regimens, however, generally occurs earlier (2 to 5 months) [START_REF] De Gramont | Leucovorin and fluorouracil with or without oxaliplatin as first-line treatment in advanced colorectal cancer[END_REF][START_REF] Giacchetti | Phase III multicenter randomized trial of oxaliplatin added to chronomodulated fluorouracil-leucovorin as first-line treatment of metastatic colorectal cancer[END_REF]. It may therefore be possible to devise a regimen which achieves maximum treatment effect before cumulative neurotoxicity appears. Support for this concept has recently come from the OPTIMOX-1 and OPTIMOX-2 studies, which documented the efficacy of a "stop-and-go" strategy consisting of FOLFOX-7 for 12 weeks, followed by 5-FU/LV maintenance therapy for 24 weeks, and reintroduction of FOLFOX-7 thereafter, [START_REF] Tournigand | OPTIMOX1: a randomized study of FOLFOX4 or FOLFOX7 with oxaliplatin in a stop-and-Go fashion in advanced colorectal cancer: a GERCOR study[END_REF][START_REF] Maindrault-Goebel | OPTIMOX2, a large randomized phase II study of maintenance therapy or chemotherapy-free intervals (CFI) after FOLFOX in patients with metastatic colorectal cancer (MRC): a GERCOR study[END_REF]. The GISCAD study further demonstrated the feasibility and efficacy of an intermittent irinotecan-based regimen (i.e. FOLFIRI for 8 weeks alternating with an 8-week chemotherapy-free interval) [START_REF] Labianca | Italian Group for the Study of Digestive Tract Cancers (2006) Alternating versus continuous "FOLFIRI" in advanced colorectal cancer (ACC): A randomized "GISCAD[END_REF].

The XELoda QUALIty-of-life study was conducted to evaluate the efficacy, safety and QoL of a short course of oxaliplatin in combination with capecitabine (XELOX) followed by maintenance treatment with single-agent capecitabine in patients with previously untreated, inoperable metastatic colorectal cancer. The aim of this treatment strategy was to elicit an initial response with the XELOX regimen, and then maintain this response with a simpler, better-tolerated single-agent regimen which might also improve patient QoL. Both XELOX [START_REF] Cassidy | Randomized phase III study of capecitabine plus oxaliplatin compared with fluorouracil/folinic acid plus oxaliplatin as first-line therapy for metastatic colorectal cancer[END_REF][START_REF] Díaz-Rubio | Spanish Cooperative Group for the Treatment of Digestive Tumors Trial (2007) Phase III trial of capecitabine and oxaliplatin (XELOX) vs continuous infusion 5-fluorouracil plus oxaliplatin (FUOX) as first-line therapy in metastatic colorectal cancer: final report of the Spanish TTD group trial[END_REF][START_REF] Ducreux | Efficacy and safety findings from a randomized phase III study of capecitabine (X) + oxaliplatin (O) (XELOX) vs. infusional 5-FU/LV + O (FOLFOX-6) for metastatic colorectal cancer (MCRC)[END_REF] and capecitabine monotherapy [START_REF] Hoff | Comparison of oral capecitabine versus intravenous fluorouracil plus leucovorin as first-line treatment in 605 patients with metastatic colorectal cancer: results of a randomized phase III study[END_REF][START_REF] Van Cutsem | Xeloda Colorectal Cancer Study Group (2001) Oral capecitabine compared with intravenous fluorouracil plus leucovorin in patients with metastatic colorectal cancer: results of a large phase III study[END_REF] have established efficacy in the firstline treatment of metastatic colorectal cancer, but have not been investigated in this manner previously.

PATIENTS AND METHODS

Study design

This single-arm, open-label, phase II study was conducted at 2 centres in the United Kingdom. It was performed in accordance with the Declaration of Helsinki and Good Clinical Practice Guidelines. The protocol was reviewed and approved by the ethics committee at each participating site. Written informed consent was obtained from all patients prior to study participation.

Patient population

Ambulatory patients aged ≥18 years with non-resectable locally advanced or metastatic colorectal cancer were enrolled. Patients were required to have tumours which were measurable or evaluable according to Response Evaluation Criteria in Solid Tumors (RECIST) criteria [START_REF] Therasse | New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada[END_REF]. No previous chemotherapy for metastatic disease was permitted.

Adjuvant chemotherapy, if administered, must have been completed >4 months prior to trial entry and could include bolus 5-FU but not infusional 5-FU, oxaliplatin or irinotecan.

Patients were required to have a WHO performance status of 0-2, a life expectancy of >3 months and normal renal, hepatic, and haematological function.

Exclusion criteria included: concurrent uncontrolled medical illness; other previous or current malignant disease likely to interfere with study treatment; partial or complete bowel obstruction; chronic diarrhoea or inflammatory bowel disease; inability to comply with QoL assessments; regular/uncontrolled angina or cardiac arrhythmias; brain metastases; pregnant or lactating women; and peripheral neuropathy.

Treatment plan and salvage therapy

All patients received intravenous oxaliplatin 130 mg/m 2 as a 120-minute infusion on day 1 plus oral capecitabine 1000 mg/m 2 twice daily on days 1-14 every 21 days (XELOX) for 4 cycles (i.e. 12 weeks). Patients achieving at least stable disease in response to XELOX then received oral capecitabine 1250 mg/m 2 twice daily on days 1-14 every 21 days until disease progression at the discretion of the investigator.

If, in the opinion of the treating consultant, an alternative treatment modality was indicated at any stage, it could be offered to patients (e.g. hepatic resection, palliative radiotherapy, bypass surgery). It was anticipated that this would involve stopping trial treatment in most cases, but trial treatment could be continued after the other treatment if appropriate.

If the patient responded to trial treatment but stopped for reasons other than disease progression, they could be re-challenged with XELOX upon disease progression at the discretion of the investigator. When disease progression occurred on or after trial treatment, options for further chemotherapy or symptomatic treatment were considered according to local policy.

Assessments

Medical history; physical examination; WHO performance status; full blood count; and blood biochemistry were assessed within 4 weeks of the start and every 3 weeks of study treatment: Tumour assessments, using CT or MRI scans, were performed within 4 weeks prior to starting study treatment. They were repeated every 12 weeks thereafter until disease progression was documented. RECIST guidelines [START_REF] Therasse | New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada[END_REF] were used to define all responses.

Adverse events were evaluated using the National Cancer Institute Common Terminology Criteria for Adverse Events (version 3) every 3 weeks during treatment.

Quality of life

QoL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) questionnaire QLQ-C30 [START_REF] Aaronson | The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology[END_REF] together with the colorectal cancer-specific module QLQ-CR38 [START_REF] Sprangers | The construction and testing of the EORTC colorectal cancer-specific quality of life questionnaire module (QLQ-CR38). European Organization for Research and Treatment of Cancer Study Group on Quality of Life[END_REF]. QoL questionnaires were completed in the clinic at baseline (prior to study registration), 6 weeks, 12 weeks, 18 weeks, 24 weeks and then 12-weekly thereafter.

When the QoL assessment coincided with a treatment cycle, the questionnaire was to be completed before treatment was given. Patients were asked to complete all questionnaires (i.e. even if they refused on a previous occasion or did not complete study treatment) and without conferring with friends or relatives. A patient diary was also provided to record details of medication taken and any adverse events/comments.

Statistical analysis

Combination chemotherapy with oxaliplatin and either 5-FU or capecitabine would be expected to achieve a progression-free survival (PFS) of 7 to 9 months [START_REF] De Gramont | Leucovorin and fluorouracil with or without oxaliplatin as first-line treatment in advanced colorectal cancer[END_REF][START_REF] Giacchetti | Phase III multicenter randomized trial of oxaliplatin added to chronomodulated fluorouracil-leucovorin as first-line treatment of metastatic colorectal cancer[END_REF]. In the present study, the aim was to achieve a similar PFS even though oxaliplatin was stopped after 12 weeks of treatment. This statistical analysis was based on an extrapolation of Gehan's 2step model and was formulated after discussion with Dr R. Swindell (Head of Statistics, Christie Hospital). The primary efficacy endpoint was PFS, which was defined as the interval from the first day of treatment to first evidence of clinical / radiological progression or death. Secondary objectives were comparative assessments of toxicity and QoL between XELOX and singleagent capecitabine. Secondary endpoints were objective response rate, compliance, and overall survival, which was defined as the time from registration to death from any cause. Time to event data were analysed using the Kaplan-Meier method. Median values with 95% confidence intervals (CI) were presented.

10

RESULTS

Between 14 February 2005 and 20 February 2006, a total of 45 patients were enrolled in the study. Patients' baseline characteristics are shown in Table 1.

Treatment exposure

A study flow chart for all 45 patients is presented in Figure 1

Efficacy

Efficacy data were available for all 45 patients. Three patients received only 1 cycle of chemotherapy followed by clinical deterioration; one patient's disease was not measurable, whilst a further patient did not receive chemotherapy since their liver function deteriorated after screening. Since it was our intention to treat all patients that were entered into the study, all 45 patients were included in the analysis. A complete response was documented in 1 (2%) patient and partial responses in 20 (44%) patients, giving an overall response rate of 47%. A further 13 (29%) patients had stable disease giving a clinical benefit (i.e. stable disease or better) of 76%. Median PFS in the total evaluable patient population was 6.7 (95% CI 5.7-9.6) months, and overall survival was 20.5 (95% CI 13.1-28.1) months.

Kaplan-Meier curves for PFS and OS are shown in Figures 2 and3, respectively. In the 34 patients who received XELOX followed by capecitabine maintenance therapy, the median PFS was 8.1 (95% CI 6.2-11.8) months and median overall survival was 23.1 (95% CI 17.8-28.5) months. In the 14 patients in whom XELOX was reintroduced at disease progression, median PFS was 8.1 (95% CI 5.8-11.0) months and median overall survival was 23.1 (95% CI 17.8-28.5) months from the start of the trial; median overall survival was 11.6 (95% CI 8.7-16.3) months from restarting XELOX. Four (9%) of the 45 patients enrolled had tumour downsizing and were able to undergo liver resection; all of these patients were alive at last follow-up and 3 had no signs of disease recurrence or progression.

Quality of life

The following number of patients completed QoL forms at each study time-point: baseline (n=41); 6 weeks (n=27); 12 weeks (n=23); 18 weeks (n=12); 24 weeks (n=18); 36 weeks (n=11); and 48 weeks (n=10).

No differences in QoL were observed during treatment with XELOX (up to week 12) and single-agent capecitabine (after week 12). To illustrate this, scores for the overall health domain of the EORTC QLQ-C30 during the course of the study are shown in Figure 4.

Safety

Safety data were available for 44 patients who received initial therapy with XELOX, and for 34 patients who received follow-on capecitabine maintenance therapy. The most frequent adverse events reported in these patient cohorts are presented in Table 2. No grade 4 adverse events were documented during the trial.

During initial XELOX therapy, most adverse events were grade 1 or 2 in severity. The most frequent grade 3 clinical adverse events were: diarrhoea (16%); lethargy (12%); neuropathy (7%); anorexia (5%); nausea (2%); vomiting (2%); and hand-foot syndrome (2%). No grade 3 or 4 haematological adverse events were documented.

There was a marked reduction in the frequency of most grade 1-2 and grade 3 adverse events after switching to capecitabine maintenance therapy (Table 2). The only exceptions were abnormal liver function tests and hand-foot syndrome, which increased in frequency because of the higher capecitabine dose used during maintenance therapy. The only grade 3 adverse events which occurred during capecitabine maintenance therapy were hand-foot syndrome (9%) and neuropathy (3%). Neuropathy documented during capecitabine maintenance therapy is likely to have been residual toxicity after the use of oxaliplatin.

Treatment was discontinued because of adverse events during initial XELOX therapy in 4 patients (allergic-type reactions to oxaliplatin, n=3; grade 3 anorexia/lethargy, n=1); none of the patients who experienced an allergic-type reaction to oxaliplatin had pain on infusion. During capecitabine maintenance therapy, 2 patients discontinued treatment because of adverse events (hand-foot syndrome, n=1; renal impairment, n=1). No treatment-related deaths occurred.

DISCUSSION

Despite the recent introduction of several new cytotoxic and targeted agents with proven efficacy in the treatment of patients with metastatic colorectal cancer, many questions remain regarding their use. These include the optimal duration of first-line therapy and the management of treatment-related toxicity. The present study shows that a short course of XELOX followed by maintenance therapy with single-agent capecitabine produces a favourable rate of disease control and duration of survival in patients with metastatic colorectal cancer. These findings suggest that a short course of oxaliplatin-based chemotherapy elicits a tumour response, which can then be maintained by a simpler maintenance regimen. The validity of this "stop-and-go" strategy has also recently been demonstrated in the OPTIMOX-1 study which showed that FOLFOX-7 for 6 cycles followed by 5-FU/LV for 12 cycles followed by reintroduction of FOLFOX-7 had similar efficacy to continuous FOLFOX-4, but with a greatly reduced risk of grade 3/4 toxicity [START_REF] Tournigand | OPTIMOX1: a randomized study of FOLFOX4 or FOLFOX7 with oxaliplatin in a stop-and-Go fashion in advanced colorectal cancer: a GERCOR study[END_REF].

The good tolerability profile of the present treatment strategy was notable. Limiting the exposure to XELOX appeared to reduce the risk of severe adverse events; no grade 4 clinical adverse events or grade 3 or 4 haematological adverse events were documented in the present study. Grade 3 neuropathy also occurred infrequently (7% of patients), a rate that compares favourably with rates reported in previous large phase III studies of continuous XELOX (4%, 18%, 8%) [START_REF] Cassidy | Randomized phase III study of capecitabine plus oxaliplatin compared with fluorouracil/folinic acid plus oxaliplatin as first-line therapy for metastatic colorectal cancer[END_REF][START_REF] Díaz-Rubio | Spanish Cooperative Group for the Treatment of Digestive Tumors Trial (2007) Phase III trial of capecitabine and oxaliplatin (XELOX) vs continuous infusion 5-fluorouracil plus oxaliplatin (FUOX) as first-line therapy in metastatic colorectal cancer: final report of the Spanish TTD group trial[END_REF][START_REF] Ducreux | Efficacy and safety findings from a randomized phase III study of capecitabine (X) + oxaliplatin (O) (XELOX) vs. infusional 5-FU/LV + O (FOLFOX-6) for metastatic colorectal cancer (MCRC)[END_REF]. Switching to single-agent capecitabine was also accompanied by a marked reduction in the frequency of most adverse events (e.g. grade 3 lethargy 12% vs. 0%) and grade 3 diarrhoea 16% vs. 0%), confirming once again the tolerability benefits of this approach to therapy. Despite the improvement in tolerability evident after switching to single-agent capecitabine, no clinically meaningful QoL differences were detected between the XELOX and maintenance phases of therapy. This may have been because of residual toxicity (e.g. parasthesia, lethargy, diarrhoea) from initial XELOX therapy manifesting during the maintenance phase. Alternatively, a steady decline in the number of patients completing the QoL questionnaires may have influenced the outcome. This pattern of attrition, however, is common in the palliative setting and is similar to that reported in other studies of patients with metastatic colorectal cancer [START_REF] Cunningham | Randomised trial of irinotecan plus supportive care versus supportive care alone after fluorouracil failure for patients with metastatic colorectal cancer[END_REF][START_REF] Hobday | Efficacy and quality-oflife data are related in a phase II trial of oral chemotherapy in previously untreated patients with metastatic colorectal carcinoma[END_REF]. Although not captured by the EORTC questionnaires, several other relevant QoL and pharmacoeconomic benefits were evident with the regimen tested. These included the improved convenience of only 4 initial infusions of oxaliplatin to patients, medical staff and pharmacy personnel, and the reduced direct medical costs of this regimen (i.e. fewer oxaliplatin infusions, less pharmacy and chemotherapy suite time).

Perhaps not surprisingly, the degree of benefit experienced by patients from our treatment strategy increased with number of cycles completed. Obviously this could also reflect the biology of the disease in that those patients with a less aggressive cancer did better. Median PFS was 6.7 months in the total evaluable patient population, which increased to 8.1 months in patients who completed or partially completed both XELOX and capecitabine treatment phases. In the absence of a control group, it is of interest that these data, particularly those from the last patient cohort, compare favourably with recent phase III studies of continuous first-line XELOX in patients with metastatic colorectal cancer [START_REF] Cassidy | Randomized phase III study of capecitabine plus oxaliplatin compared with fluorouracil/folinic acid plus oxaliplatin as first-line therapy for metastatic colorectal cancer[END_REF][START_REF] Díaz-Rubio | Spanish Cooperative Group for the Treatment of Digestive Tumors Trial (2007) Phase III trial of capecitabine and oxaliplatin (XELOX) vs continuous infusion 5-fluorouracil plus oxaliplatin (FUOX) as first-line therapy in metastatic colorectal cancer: final report of the Spanish TTD group trial[END_REF][START_REF] Ducreux | Efficacy and safety findings from a randomized phase III study of capecitabine (X) + oxaliplatin (O) (XELOX) vs. infusional 5-FU/LV + O (FOLFOX-6) for metastatic colorectal cancer (MCRC)[END_REF].

In these studies, median PFS ranged from 7.3 to 8.9 months and median overall survival ranged from 18.1 to 19.9 months.

Although not a formal part of the study treatment plan, some of our patients (31%) went on to receive further XELOX on disease progression. The median PFS in this patient cohort was 8.1 months and median overall survival was 23.1 months, which is similar to the findings of the OPTIMOX-1 study which tested a similar 5-FU-based regimen (8.7 and 21.2 months, respectively) [START_REF] Tournigand | OPTIMOX1: a randomized study of FOLFOX4 or FOLFOX7 with oxaliplatin in a stop-and-Go fashion in advanced colorectal cancer: a GERCOR study[END_REF]. The feasibility of reintroducing oxaliplatin was questioned by the OPTIMOX-1 investigators as only 40% of patients completed this stage of study treatment. It is interesting to note, however, that a separate post hoc analysis of the OPTIMOX-1 data revealed that oxaliplatin reintroduction was a significant and independent predictor of improved overall survival [START_REF] De Gramont | Reintroduction of oxaliplatin is associated with improved survival in advanced colorectal cancer[END_REF]. The results of other ongoing studies (i.e. DREAM, CONCEPT, OASIS), which are investigating various stop-and-go treatment strategies with oxaliplatin-based regimens and targeted agents, will help to confirm the validity of this approach.

In conclusion, short-course XELOX followed by capecitabine maintenance therapy provides an effective treatment option for patients with previously untreated metastatic colorectal cancer. By limiting the number of oxaliplatin infusions, this approach minimises the risk of unwanted cumulative neurotoxicity, lethargy and diarrhoea plus is convenient to both patients and healthcare providers. It is also cheaper in terms of drug costs and administration, which is becoming even more of a pressing issue in all health economies.

  . Thirty-five patients received 4 cycles of XELOX, of whom 31 received capecitabine maintenance therapy. The remaining 10 patients received less than 4 cycles of XELOX, for the following reasons: disease-related death/deterioration during treatment (n=4); allergic-type reaction to oxaliplatin (n=3); grade 3 toxicity (n=1); did not meet inclusion criteria (n=1); or patient withdrawal after 1 cycle of chemotherapy (n=1). Three of these 10 patients went on to receive capecitabine maintenance therapy. XELOX was reintroduced at disease progression in 14 patients. Enrolled patients (n=45) received a median of 4 (range 0 to 4) cycles of XELOX and a median of 3 (range 0 to 16) cycles of capecitabine maintenance therapy. Patients who received any capecitabine maintenance therapy (n=34) received a median of 4 (range 1 to 16) cycles. Patients who had XELOX (n=14) reintroduced received a median of 4 (range 2 to 8) cycles of XELOX.

Figure 1 .Figure 2 .Figure 3 .Figure 4 .

 1234 Figure 1. Patient treatment schema

Figure 2

 2 Figure 2.

Table 1 .

 1 Baseline patient characteristics (n=45)

	Characteristic	No.	%
	Gender
	Male	28	62
	Female	17	38
	Age, years
	Median (range)	58 (38-79)
	WHO performance status
	0	20	44
	1-2	25	56
	Metastatic sites(s)
	Liver	35	78
	Lymph nodes	17	38
	Lung	16	36
	Adrenal	2	4
	Ovary	2	4
	Omentum	2	4
	Other	3	7

Table 2 .

 2 Most frequent adverse events (>20% of patients)

	Adverse event		Initial XELOX		Capecitabine maintenance
				(n=43)				(n=34)
		Grade 1-2	Grade 3	Grade 1-2	Grade 3
		No.	%	No.	%	No.	%	No.	%
	Clinical/laboratory events
	Neuropathy	33	77	3	7	16	47	1	3
	Lethargy	33	77	5	12	27	79	0	0
	Diarrhoea	21	49	7	16	13	38	0	0
	Nausea	27	63	1	2	11	32	0	0
	Hand-foot syndrome	15	35	1	2	17	50	3	9
	Vomiting	13	30	1	2	4	12	0	0
	Mucositis	12	28	0	0	3	9	0	0
	Infection	11	26	1	2	9	26	0	0
	Constipation	10	23	1	2	3	9	0	0
	Abnormal liver function tests	13	30	0	0	19	56	0	0
	Haematological events
	Anaemia	19	44	0	0	14	41	0	0
	Thrombocytopenia	14	33	0	0	9	26	0	0
	Neutropenia	12	28	0	0	5	15	0	0
	Leukopenia	10	23	0	0	6	18	0	0

Abbreviations: XELOX, capecitabine and oxaliplatin.

ACKNOWLEDGMENTS

Roche provided an educational grant for administration of the XelQuali trial.

DISCLOSURES


Anna Bazsó

Kris Ztina Sevcic

Ilonka Orbán

Gyula Poór

Zsolt Balogh

Emese Kiss

Overlapping juvenile idiopathic arhtritis and systemic lupus erythe matosusa case report

Keywords:

Hereby we report the case of a 12 year-old girl developing oligoarthritis and progressing into a polyarticular form. Rheumatoid factor was positive and juvenile idiopathic arthritis (JIA) was diagnosed. After a poor response to DMARDs, an anti-TNF agent (infliximab) was initiated, but to be discontinued due to an allergic reaction. The same complication was observed with the fully human derivative, adalimumab. At the age of 22, the patient presented septicemia with severe anemia and subsequent develop ment of leukopenia, myocarditis with heart failure, and ANA, aSm, aSS-A, aCL positivies, and nephrotic syndrome. These new clinical manifestations fullfilled the classification criteria for the diagnosis of systemic lupus erythematosus. Due to the poor the rapeutic responses for both diseases, alternative medical options has to be considered, such as targeted therapy with anti-CD20 or interlukin-6 receptor antagonist monoclonal antibodies. This patient may also be a candidate for autologous hemopoietic stem cell transplantation.

Introduction

Juvenile Idiopathic Arthritis (JIA) encompasses of a heterogeneous group of disorders with unknown etiology that usually starts before the age of 16 and persists for at least 6 weeks. It is characterized by the persistent swelling of one or more joints [START_REF] Özen | Juvenile Idiopathic Arthritis, Eular On-line Course on Rheumatic Diseases-module n14[END_REF]. This autoimmune disorder is a major cause of chronic disability in children. Although the onset and disease course may differ, all subtypes of JIA share the occurrence of chronic inflammation of the joints [START_REF] Russo | Clinical remission in patients with systemic juvenile idiopathic arthritis treated with anti-tumor necrosis factor agents[END_REF]. Arthritis affecting 4 or fewer joints during the first 6 months of the disease is denoted as pauci-articular by the European league Againts Rheumatism (EULAR) [START_REF] Brewer Ej | Current proposed revision of JRA Criteria. JRA Criteria Subcommittee of the Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Section of The Arthritis Founda tion[END_REF][START_REF]European League Against Rheumatism: EULAR Bulletin No. 4: Nomenclature and Classification of Arthritis in Children[END_REF] or oligo-articular by International League of Association for Rheumatology (ILAR) [START_REF] Peety | International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: Second Revision. Edmonton 2001[END_REF][START_REF] Cassidy | Oligoarthritis[END_REF]. The ILAR classification of JIA, oligo-arthritis is further characterized, as either persistent (no more than four joints are affected during the disease course), or extended (if, after the initial 6-month period, the total number of affected joints is more than four) oligo-articular forms. Polyarthritis affects primarily more than four joints during the first 6 months of the disease course and further subclassified as rheumatoid factor (RF)-negative, or, if RF is detected on two occasions at least 3 months apart, RF-positive [START_REF] Brewer Ej | Current proposed revision of JRA Criteria. JRA Criteria Subcommittee of the Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Section of The Arthritis Founda tion[END_REF][START_REF]European League Against Rheumatism: EULAR Bulletin No. 4: Nomenclature and Classification of Arthritis in Children[END_REF][START_REF] Peety | International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: Second Revision. Edmonton 2001[END_REF].

Polyarthritis accounts for approximately 30% of patients with JIA. Children with RFpositive polyarticular JIA have late onset in childhood or aldolescence. These patients often develop of symmetric small and large joint involvement that resembles adult RA, with rheumatoid nodules, early onset of erosive synovitis, and chronic disease course persisting well into adulthood [START_REF] Cassidy | Polyarthritis[END_REF][START_REF] Agrawal | Immune complexes contain immunglobulin A rheumatoid factor in serum and synovial fluid of patients with polyarticular juvenile rheumatoid arthritis[END_REF]. Systemic manifestations in children with polyarthritis include low-grade fever, anorexia, growth failure and weight loss [START_REF] Uziel | Seasonal onset of systemic-onset juvenile rheumatoid arthritis[END_REF]. Fatigue may be a prominent symptom. Slight-to-moderate hepato-splenomegaly or lymph node enlargement may be present, but these are less prominent compared to children with systemic JIA [START_REF] Bowyer | Pediatric rheumatology clinic populations in the United States: results of a 3 year survey. Pediatric Rheumatology Database Research Group[END_REF].

Biological agents have been designed to target particular immunologically active molecules, which play role in the pathogenesis of disease. Until now, the tumor necrosis factor alpha (TNF-α) blockers, etanercept and adalimumab are approved for the treatment of active poly-articular JIA and these drugs have dramatically improved disease outcome as well as quality of life [START_REF] Pain | Challenges in the management of juvenile idiopathic arthritis with etanercept[END_REF][START_REF] Katsicas | Use of adalimumab in patients with juvenile idiopathic arthritis refractory to etanercept and/or infliximab[END_REF]. Systemic Lupus Erythematosus (SLE) is a multifactorial syste mic autoimmune disease characterized by heterogenous clinical manifestations; e.g. skin symptoms, polyarthritis, serositis, neuropsychiatric symptoms, kidney disease, hematological abnormalities and the presence of different antinuclear and other autoantibodies. Despite the survival and treatment options of SLE have improved markedly, its morbidity and treatment-related adverse effects are still considerable [START_REF] Ruperto | Paediatric Rheumatology International Trials Organization (PRINTO)[END_REF]. Although the exact causes of lupus are unknown, some trigger factorssuch as the use of anti-TNF inhibitorshave already been confirmed in the pathomechanism, which could trigger the appearance of other antibodies against double stranded DNA (a-dsDNA) as well as anti-cardiolipin antibodies (aCL) [START_REF] Kanakoudi-Tsakalidou | The significance of persistent newly developed autoantibodies in JIA patients under long-term anti-TNF treatment[END_REF]. This case report focuses on the overlap syndromes that may occur not only in adults but in childhood. Clinical features, inadequate therapeutic responses make us to demonstrate that careful monitoring is important and besides various biological treatments, other therapeutic options might be essential. However, it is also important to provide the optimal treatmentmodality for such patients that is beneficial for both diseases

Case report

We report a case of a Caucasian girl, who was first admitted to our hospital in 1997 (at the age of 12) with oligo-articular onset of JIA. The immune serology was positive for RF and ANA, while a-dsDNA was negative, as well as HLA-B27. It was not possible to measure anti-citrullinated peptid antibody (aCCP) at that time. In 2007, the patient developed an E. coli septicaemia with severe anemia and toxic cardiomyopathy resulting in heart failure. Within the following 8 weeks, leukopenia and different autoantibodies, namely ANA, antibodies against Smith antigen (aSm) and Sjögren syndrome A antigen (aSS-A) as well as anti-cardiolipin (aCL), appeared.

Nephrotic syndrome developed and kidney biopsy proved an ISN/RPS type II lupus nephritis. The patient fulfilled the diagnostic criteria of SLE, established by the American Collage of Rheumatology and modified in 1997 [START_REF] Hochberg | Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus[END_REF]. Together with appropriate antibiotic therapy, corticosteroids and later azathioprine were administered, which resulted in partial remission. Lupus nephritis relapsed one year later with nephrotic syndrome, microscopic hematuria, high anti-dsDNA concentration accompanied with hypocomplementemia. The patient refused kidney re-biopsy, but the histopathological progression was feasible.

Therefore, six cycles of intravenous pulse cyclophosphamide were given and resulted in a partial remission again as indicated by the fall of proteinuria from 10 g to 1 g per day.

However, after a few months with corticosteroid and azathioprine maintenance therapy, the disease relapsed again. At the same time we observed the deterioration of joint inflammation with a progressively increasing number of bone erosions and joint space narrowing, typically consistent with JIA. RF was normal while aCCP level was significantly high. The progression of both diseases requires new therapeutic decision.

Discussion

The coexistence of two or more autoimmune diseases in the same patient occurs with variable frequency, but relatively rarely [START_REF] Woo | Overlap Syndromes[END_REF]. Some genetic studies have identified various loci associated with increased risk for both RA and SLE, along with candidate genes associated with predisposition to autoimmune diseases in general [START_REF] Gregersen | Genetics of autoimmune diseases-disorders of autoimmune homeostasis[END_REF], supporting the hypothesis of "shared autoimmunity". These results suggest a common and specific genetic background. However, if the classification criteria of the systemic diseases are not fulfilled initially, the early symptoms refer to the coexisting diseases [START_REF] Icen | Systemic Lupus Erythematosus Features in Rheumatoid Arthritis and Their Effect on Overall Mortality[END_REF][START_REF] Amezcua-Guerra | Overlap between systemic lupus erythematosus and rheumatoid arthritis: is it real or just an illusion?[END_REF]. Synovitis and arthritis are typical features of almost all inflammatory rheumatic disorders, but the localization and the extent of the inflamed joints and erosions could help in the differential diagnosis. Erosive arthritis in SLE is unusual and only a minority of patients develop deforming a non-erosive, RF-negative process, denoted as "Jaccoud's arthropathy" [START_REF] Ostendorf | Jaccoud's arthropathy in systemic lupus erythematosus: differentiation of deforming and erosive patterns by magnetic resonance imaging[END_REF].

The RF and aCCP levels correlate directly with the disease activity in RA, but not in SLE.

Although CRP is also a marker of disease activity in systemic JIA and RA, it may also act as an active pathogenic agent for an erosive arthritis pattern among SLE patients [START_REF] Szer | Arthritis in Children and Aldolescents; Juvenile Idiopathic Arthritis[END_REF].

It is likely that genetic polymorphisms play an important role, particularly in RF-positive polyarthritis [START_REF] Cassidy | Polyarthritis[END_REF]. The onset of polyarthritis in a pre-adolescent or adolescent girl should suggest the possible diagnosis of SLE. The arthritis may mimic that of JIA. Its clinical manifestations are extremely variable and its natural history is unpredictable [START_REF] Cassidy | Systemic Lupus Erythematosus[END_REF]. Without serological markers with the clinical hallmarks of SLE the exact diagnosis may be difficult.

There are further unusual and critical points in this case, namely the arthritis appeared first as an oligoarticular type and then progressed into a polyarticular form, together with severe kidney, heart and hematological involvements. Pericarditis or pleuritis are infrequent in JIA [START_REF] Dikensoy | Bronchiolitis obliterans in a case of juvenile rheumatoid arthritis presented with pneumomediastinum[END_REF][START_REF] Dikensoy | Bronchiolitis obliterans in a case of juvenile rheumatoid arthritis presented with pneumomediastinum[END_REF][START_REF] Ozer | Mitral and aortic insufficiency in polyarticular juvenile rheumatoid arthritis[END_REF]; and cardiac valve disease and glomerulonephritis are uncommon complications in RF-positive polyarthritis [START_REF] Uziel | Lymphocytic interstitial pneumonitis preceding polyarticular juvenile rheumatoid arthritis[END_REF][START_REF] Nossent | Disease activity and damage accrual during the early disease course in a multinational inception cohort of patients with systemic lupus erythematosus[END_REF][START_REF] Rohayem | Pulmonary fibrosis and other clinical manifestation of small vessel vasculitis in a family with serpositive juvenile rheumatoid arthritis[END_REF]. The rapid progression and variable organ manifestations may confirm the hypothesis of the complete dysregulation of the immune system. The third cause could be the side effect of the anti-TNF therapy; the biological therapy might induce the appearance of autoantibodies and lupus symptoms in this case [START_REF] Kanakoudi-Tsakalidou | The significance of persistent newly developed autoantibodies in JIA patients under long-term anti-TNF treatment[END_REF][START_REF] Aringer | The role of tumor necrosis factor-alpha in systemic lupus erythematosus[END_REF][START_REF] Aringer | Effects of short-term infliximab therapy on autoantibodies in systemic lupus erythematosus[END_REF]. However, the patient was treated with TNF-blockers only for a short period of time because of the allergic reaction, so the cumulative doses of the two anti-TNF therapies were unlikely to be able to induce anti-dsDNA, or other lupusrelated antibodies, such as anti-ENA, anti-histone or anti-nucleosome antibodies and the clinically relevant lupus-like symptoms [START_REF] Aringer | The role of tumor necrosis factor-alpha in systemic lupus erythematosus[END_REF][START_REF] Aringer | Effects of short-term infliximab therapy on autoantibodies in systemic lupus erythematosus[END_REF]. Previously it has been described that anti-TNF therapy could be a potentially effective and useful therapeutic option for SLE patients [START_REF] Aringer | The role of tumor necrosis factor-alpha in systemic lupus erythematosus[END_REF]. Altough, TNF blockade was clinically effective, the majority of SLE patients treated with infliximab showed a transient increase in autoantibodies to nuclear antigens and phospholipids, without any association with disease flares. Increased availability of apoptotic antigens after TNF blockade may lead to autoantibody formation induced by this treatment regime [START_REF] Aringer | The role of tumor necrosis factor-alpha in systemic lupus erythematosus[END_REF][START_REF] Aringer | Effects of short-term infliximab therapy on autoantibodies in systemic lupus erythematosus[END_REF]. An open-label data suggest that TNF blockade suppresses inflammatory manifestations of SLE, and long-term benefit was seen in patients with lupus nephritis [START_REF] Aringer | The role of tumor necrosis factor-alpha in systemic lupus erythematosus[END_REF].

Anti-TNF therapies are promising new strategies in the treatment not only in adult RA but in JIA, as well (23,[START_REF] Williams | Anti-TNF-induced lupus[END_REF][START_REF] Lovell | Pediatric Rheumatology Collaborative Study Group. Long-term efficiacy and Safety of Etanercept in Children with Polyarticular Course Juvenile Rheumatoid Arthritis[END_REF][START_REF] Kanakoudi-Tsakalidou | The significance of persistent newly developed autoantibodies in JIA patients under long-term anti-TNF treatment[END_REF][START_REF] Gregersen | Genetics of autoimmune diseases-disorders of autoimmune homeostasis[END_REF]. Despite good clinical efficacy and tolerance, the possible occurrence of drug-induced autoimmune disorders remains a matter of concern. Induction of ANA and anti-DNA antibodies is observed in some patients treated with TNF-α inhibitors (anti-TNF-α monoclonal antibodies or soluble TNF-α receptor) possibly leading to the initation of lupus [START_REF] Debandt | Anti-TNF-alpha-induced systemic lupus syndrome[END_REF][START_REF] Pain | Challenges in the management of juvenile idiopathic arthritis with etanercept[END_REF].

The use of protein-based anti-TNF-α therapies such as antibodies and soluble TNF-α receptors is commonly associated with the induction of autoantibodies, whereas anti-TNFinduced lupus (ATIL) is rare. ATIL can occur with any of the available TNF-inhibitors, but the frequency and clinical characteristics of ATIL vary between different drugs [START_REF] Lovell | Pediatric Rheumatology Collaborative Study Group. Long-term efficiacy and Safety of Etanercept in Children with Polyarticular Course Juvenile Rheumatoid Arthritis[END_REF].

Conclusion

Overlap syndromes may occur not only in adulthood but in children, as well [START_REF] Hochberg | Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus[END_REF]. There are a few publications about JIA + SLE associations overviewing the consequences of this particular overlap [START_REF] Unsal | Lupus arthropathy: a case series of patients with rhupus[END_REF][START_REF] Fernández | Lupus arthropathy: a case series of patients with rhupus[END_REF][START_REF] Ragsdale | The clinical progression of apparent juvenile rheumatoid arthritis to systemic lupus erythematosus[END_REF]. The thorough follow-up and monitoring of laboratory parameters and organ functions is of utmost importance in order to diagnose the early detection of serious manifestations and potential progression or overlapping of the diseases. The other critical point of this case is to consider the poor response to standard DMARDs modifying agents, as well as to anti-TNF therapy, and as such, to switch between biological agents with different mechanisms of action. Further therapeutical goal could be B-cell depletion teherefore. So, rituximab could be an eligible and available chance to achieve remission. Another possibility to control the common inflammatory pathway of JIA and SLE is blocking interleukin-6 (IL-6) with the soluble IL-6 receptor tocilizumab.

We belive that the better understanding of the common pathogenic pathways in JIA and SLE overlap could lead to the development of optimal therapeutic modalities and improved quality of life these patients.

  Between 1997 and 2003, sulfasalazine, methotrexate, leflunomide, cyclosporin A, corticosteroids and non-steroidal anti-inflammatory drugs (NSAID) were administreted without any long-standing therapeutic effect. Increasing the number of the joints involved, the disease progressed into an erosive polyarticular form. Because of the permanent and severe disease activity, the patient was eligible to be involved into a randomized doubleblind controlled intra-patient dose escalation phase II trial of infliximab in 2003. The treatment had to be discontinued due to an allergic reaction occurring within 3 months of initiating the therapy. Between 2003 and 2006, various disease-modifying anti-rheumatic drugs (DMARDs), local and systemic corticosteroids were used with poor efficacy. Side effects, such as leukopenia, peptic ulcer and hair loss were also present. The patient became positive for anti-citrullinated peptide antibody (ACPA) in 2004. In 2006, adalimumab was started and withdrawn soon, due to allergic reactions occurring again. From 2006 to 2007, the patient was treated with methotrexate and leflunomide, however, during this period, various infections appeared, requiring different courses of antibiotic therapy.

  Acknowledgement: The authors are greatly thankful to Marco Gattorno MD, PhD (2 nd Division of Pediatrics, EULAR Centre of Excellence in Rheumatology, Genova, Italy), Péter Fülöp, MD, PhD (1 st Dept. of Internal Medicine, University of Debrecen Medical and Health Science Center, Debrecen, Hungary), Péter Szodoray MD, PhD (Institute of Immunology, Rikshospitalet,University of Oslo) for their kind remarks and recommendations.

Table of

 of

	abbreviations.
	JIA	Juvenile Idiopathic Arthritis
	RA	Rheumatoid Arthritis
	EULAR	European League Against Rheumatism
	ILAR	International League Against Rheumatism
	RF	Rheumatoid Factor
	SLE	Systemic Lupus Erythematosus
	ANA	antinuclear antibody
	a-dsDNA	antibody against double stranded
	a-CL	anti-cardiolipin antibodies
	aCCP	anti-citrullinated peptid antibody
	NSAID	non-steroidal anti-inflammatory drugs
	DMARDs	disease-modifying anti-rheumatic drugs
	ACPA	anti-citrullinated peptide antibody
	aSM	Smith antigen
	aSS-A	Sjögren syndrome A antigen
	ISN/RPS	International Society of Nephrologist/ Renal
		Pathology Society
	ENA	Anti-extractable-nuclear-antibody
	TNF-α	Tumor-necrosis factor alfa
	E.coli	Escherichia coli
	anti-TNF	Anti-tumor-necrosis factor
	ATIL	anti-TNF-induced lupus


Gráinne O'keeffe

The Irish in Multicultural London : The Fight for Recognition as the Other

Keywords: cultural background, ethnicity, local authorities, minority, multicultural, white

The Irish in England in the post-World War II period were not recognised in official discourse as an immigrant population or an ethnic minority group. This meant that the Irish were left out of policy initiatives and financing aimed at England's recognised minorities. Taking advantage of the politicisation of ethnicity in multicultural London during the 1980s, this article shows how the Irish voluntary sector began to mobilise around the concept of ethnicity. This sector revendicated the existence and the recognition of an Irish ethnic identity in English society. Through the lobbying for the inclusion of an Irish 'ethnic' box under the 'Ethnic Group' question in the 2001 national census we will see how the Irish voluntary sector in London instrumentalised the concept of ethnicity in order to encourage the maximum amount of people to claim an Irish ethnic identity.

Introduction

Throughout the 19 th century and much of the 20 th century, Irish emigrants were constructed as the outcasts of British society -outcasts from British capitalism as the poorest of the poor, from mainstream British politics as separatist nationalists and republicans, from the 'Anglo-Saxon' race as 'Celts', and as Catholics from the dominant forms of British Protestantism 1 . The Irish were outsiders in terms of class, nationality, race and religion and were a visible Other of British society at this time.

This was a position the Irish were to hold until the arrival of the New Commonwealth immigrants in the post-World War II period. The introduction of immigration controls in Britain in 1962, which excluded the Irish, played an important role in the disappearance of their difference in official discourse on immigration and their incorporation into mainstream British white society. The fact that the Irish were excluded from these immigration controls directly contributed to their subsequent 'invisibility' as a migrant group and later as an ethnic 1 Roger Swift "The historiography of the Irish in nineteenth-century Britain", in Patrick O'Sullivan (ed) The Irish in the New Communities, The Irish World Wide, volume 2, Leicester: Leicester University Press, 1992, p.72. minority in British society. Having been constructed as the Other for so long, the Irish were now constructed as the 'same' as the British.

This article is divided into two parts. Firstly, I will look at how British society evolved and discourses on immigration changed in the post-World War II period when Britain was faced with the arrival and settlement of large immigrant groups from the New Commonwealth. Secondly, I will examine how the Irish no longer considered as an immigrant group in official discourse and consequently finding themselves left out of policy initiatives aimed at improving the life of Britain's immigrants fought for recognition of their own unique ethnic identity and their distinct minority status in English society. I will concentrate my analysis on London, the epicentre of change during the 1980s, and on the rapid development of the Irish voluntary sector there which positioned itself as the porte-parole of the Irish community. I will look at how this sector took advantage of the politicisation of ethnicity in multicultural Britain instrumentalising this concept to its own advantage to claim and gain recognition of the existence of a distinct Irish ethnic identity. This led to the inclusion of an Irish ethnic category in the British national census in 2001, the Irish were the first white minority group to be included under this category marking formal recognition of Irish Otherness in British society.

Here to stay

In the post-World War II period Great Britain was faced with a large influx of not only Irish immigrants but also New Commonwealth immigrants who wanted to participate in the post-war reconstruction boom. West Indians, for example, who as a result of the McCarren-Walter Immigration Act of 1952 were no longer eligible to settle in the USA, were beginning to settle in England 2 . However, the development which caused the most alarm bells to ring in the Home Office and the Commonwealth Relations Office in the late 1950s was a very sudden and 'alarming' increase in the number of immigrants arriving from Pakistan and India. By 1959 some 20,000 were entering the country each year. In 1960, the number rose to 58,100 3 .

2 Alan Sked and Chris Cook, Post-War Britain : A Political History, London : Penguin Books, 1993, p. 178. 3 Idem.

The British government decided to discuss the possibility of introducing immigration controls to reduce this influx, the racial disturbances which took place in Nottingham and Notting Hill in London in 1958 doing nothing to appease the government's concerns. Many officials and ministers believed that 'coloured' immigration in substantial numbers was likely to lead to a range of serious social and economic problems. The government reacted in 1962 by introducing the Commonwealth Immigration Bill which became law that July. The Labour Opposition and the Liberal Party condemned the Bill as it effectively introduced a 'colour bar'. This point of view is easy to defend when we consider that the Irish, principally a white immigrant group, were excluded from this restrictive immigration legislation. The numbers of Irish immigrants arriving in Britain from 1956 to 1959 considerably exceeded the number from the Indian Sub-continent, the Caribbean and Africa combined by some 89,000 people4 . On average there were about 60,000 Irish emigrants entering Britain each year5 . In addition, the Irish, no longer members of the Commonwealth, were not even British subjects and had less of a right to enter Britain than the New Commonwealth immigrants.

However, no-one in government wished to exclude the ample supply of white labour from Ireland considered to assimilate better into British society. According to the working party on immigration at this time, Irish labour added 'fit young men and women to the population'6 . Whether from the Caribbean or South Asia, the New Commonwealth immigrants were perceived to be 'different' from the native population: people of different racial, different cultural and different linguistic stock7 . Consequently, during this period, immigration became associated in the public mind with being non-white immigration, and an 'immigrant' in popular discourse came to mean a non-white person -usually an Afro-Caribbean or Asian.

Until the 1958 anti-Black race-riots, it had been thought that perhaps the New Commonwealth immigrants would eventually assimilate into British society but these race-riots soon put an end to any hopes of a rapprochement between the host society and the immigrant populations8 . It was then hoped they would integrate until it was realised that the melting pot didn't actually melt. Finally, British society moved towards multiculturalism in the 1970s with the recognition of the existence of small unmeltable minorities with their own essentially different communities. As a result, Race Relations Acts9 were introduced meant as positive measures to assist the integration of those immigrants already settled in Britain and to combat discrimination and racism10 .

In a speech concerning the Race Relations Bill of 1976, Winston Churchill praised the way that British people had reacted faced with these very 'alien' populations. He said: 'Would the Home Secretary at the same time pay tribute to the wonderful way in which the British people have accepted for the greater part, the very substantial influx of alien culture and alien race into their midst without open conflict or prejudice'11 . These 'alien' immigrant populations, considered to be of a different culture and race, along with their British-born children, became known in official discourse as Britain's 'ethnic groups'. An 'ethnic group' retained the meaning of minority status and foreign origins but most importantly 'ethnic groups' in Britain, were NOT white 12 . By ignoring internal differences in Britain and the long term presence of Irish immigrants, the British state constructed the issues of ethnic minorities as relating only to post-war black immigrants and Irish immigrants found themselves in an ambivalent position in relation to discourses and policies 13 . It became commonplace in research, policy and media representations to categorise all the minorities with a common label, 'black', and to depict the new British population in terms of a black-white divide14 .The Irish therefore found themselves excluded from debates concerning Britain's ethnic groups. However, this exclusion did not protect them from encountering similar kinds of problems to the recognised ethnic minorities.

The issue of race and immigration became increasingly politicised during the 1980s in Britain and became a familiar feature of local politics at this time. As Barnor Hesse puts it the period was, 'characterised by local political projects of anti-racism, high-profile black and Asian community struggles, prominent ethnic identifications and popular valorisations of cultural diversity' 15 . Local authorities played a central role in the politicisation of the debates 16 . Of course, responses varied from one local authority to another but the key to change in the practices of local authorities, as the Irish were soon to realise, lay in the pressure coming from both within and outside the institutions of local politics and policy making.

Black community groups, political leaders and the black voluntary sector had begun to place political pressure on local authorities and to lobby them for recognition of their particular needs. This movement in effect created a new black identity or a new black political identity and the Irish began to see the effectiveness of their organisation and lobbying.

The battle to be heard

The Irish then began to mobilise for the recognition of an Irish ethnic identity following the example of the black minority groups. In London, Irish voluntary sector organisations rapidly developed at this time in order to represent the needs of the disadvantaged sector of this community (see Annex 1). The Irish were largely absent from policy initiatives aimed at minority groups at the local level as they were not considered to be an ethnic minority. Consequently, they were also absent from all monitoring procedures concerning ethnic minority groups. This in turn meant that there were no statistics available from the local authorities to support the arguments of the Irish voluntary sector that a certain section of the Irish population was suffering from discrimination and disadvantage.

The Irish voluntary sector therefore decided to take advantage of the new multicultural discourse in British society during the 1980s and had as one of its principle demands, which it aimed primarily at the local authorities in London, the recognition of the Irish as a minority group with its own unique ethnic identity. The Irish voluntary sector in London wanted to prove that 'Non-white' and 'ethnic' were not synonymous. It was hoped that official 15 Barnor Hesse,op. cit.,p. 4. 16 Section 71 of the 1976 Race Relations Act placed a particular onus on local authorities to eliminate unlawful discrimination and promote equality of opportunity between persons of different racial groups in John Solomos, Race and Racism in Britain, England: Palgrave Macmillan, 2003, p. 102. recognition of an Irish ethnic identity would then mean the inclusion of an Irish category in ethnic monitoring systems and access to financial aid for their particular needs. Proving the existence of an Irish ethnic identity became a central element in the lobbying of Irish voluntary organisations. In the relations between the Irish voluntary sector and local government in London, a cultivated politics of identity 17 began to change the terms of the political discourse as the Irish began, like the other minorities, to express public declarations of their ethnic identity.

They were principally effective at the local level and much lobbying was carried out in several London local authorities during this period. Their main demand was recognitionrecognition of the Irish experience in Britain, recognition of Irish cultural difference, recognition of an Irish ethnic identity. A number of local authorities, traditional enclaves for Irish immigration, reacted in favour of Irish demands, employing Irish Liaison Officers, organising conferences to discuss Irish issues, consulting with the local Irish community and recognising the Irish as having a distinct ethnic identity.

The Irish voluntary sector lobbied tirelessly throughout the 1980s for Irish consciousness to be raised in London and wanted Irish people to take pride in their roots. The Irish were encouraged by the voluntary sector to express their solidarity and to organise as Irish people in mutual self-help and collective empowerment. In short, the voluntary sector hoped a new Irish political identity or a new Irish ethnic identity would be created and recognised. The Irish voluntary sector in London became essentially an interest group keen to represent a unified Irish community and to have access to the same advantages as the recognised minority groups. This is all the more true when the campaign for inclusion of an 'Irish' box under the 'Ethnic Group' category of the British national census is taken into consideration.

The first question on ethnicity was introduced into the national census in 1991 and an Irish category was not included which meant that important national statistics were not available on the Irish ethnic group. Despite having made much progress regarding recognition of Irish ethnicity in several London boroughs throughout the 1980s, and their inclusion in some ethnic monitoring practices at the local borough level, the Irish were still largely considered as not different enough to merit their inclusion under the 'Ethnic Group' category in the national census.

Throughout the 1990s, lobbying was carried out by the Irish voluntary sector, led by the Federation of Irish Societies (FIS)18 , to ensure the inclusion of the Irish ethnic group in the 2001 census. FIS demonstrated through research reports written about the Irish that sections of this population were facing discrimination and disadvantage in English society and that the inclusion of an Irish category under the 'Ethnic Group' question in the national census would prove very useful to have a clearer picture of the Irish situation. This lobbying was to prove effective and the Office for National Statistics (ONS), following pressure from the Commission for Racial Equality (CRE), decided that the Irish would be included with all the other ethnic groups in the following census in 2001. The Irish then became the first white minority group to be included under the ethnic group question of the national census.

Nevertheless, FIS feared that this category might not be taken up in sufficient numbers and it decided to launch a campaign to explain what the question on ethnicity meant and to encourage the maximum amount of people to tick the 'Irish' box. A considerable number of people of Irish cultural background, which included not only professional Irish-born but also 2 nd and 3 rd generation, had little or no contact with the organised Irish community. In addition, the elision between ethnicity and skin colour in English society meant publicising the Irish census campaign was going to be essential.

Meetings were organised with the member organisations of the Federation to explain to them the importance of encouraging people to tick the Irish box, a media campaign was launched on local radio stations, on the Irish television channel 'Tara TV', in the main Irish newspaper in Britain the 'Irish Post' and leaflets were printed encouraging people to tick the Irish ethnic box.

But just how did FIS explain what it meant to have an Irish ethnic identity? During the census campaign, on posters distributed throughout Great Britain, the following slogan could be read, 'Feel Irish? Be Irish! Census 2001'. Therefore, according to this slogan, if you felt Irish that was good enough to be Irish, you could tick the Irish ethnic box.

In an interview given to the Irish Post newspaper, the then head of FIS, Sean Hutton, declared that you didn't need an Irish passport to tick the Irish ethnic group box therefore stating that Irish ethnicity had nothing to do with nationality or citizenship 19 . He said: 'We think it should be made clear that a person does not need to hold an Irish passport or be an Irish citizen in order to mark the Irish category …… While we hope that all Irish citizens in England, Scotland and Wales will register themselves as Irish in the census, we hope also that the many hundreds of thousands of people who are not Irish citizens but have Irish links will do so as well' 20 .

The term 'Irish links' is fairly ambiguous and leaves a lot of scope for differing interpretations. Do 'links' mean a real common descent? Or as Weber suggests, perhaps it does not matter if a real objective blood relation exists? Simply the 'belief' that you belong to a group, that you have more similarities with this group than another, is enough to allow ethnic membership?

In its handout on the 2001 census FIS explained in more detail, but with just as wide an interpretation of ethnicity, how to judge if you belong to the Irish ethnic group. It stated: 'Those who consider themselves Irish (whether Irish-born or of Irish cultural background) should tick the 'Irish' box in section (a) of the Ethnic Group Question. [..] Some people completing sections (c), (d), (e) of the Ethnic Group Question -those of Asian, Black, Chinese or Other ethnic group -may wish to acknowledge an Irish cultural background because, for example, of birth and/or education in Ireland. People who wish to acknowledge an Irish cultural background in this way should tick the 'Any other …' box in the appropriate section and describe their cultural background in the write-in box below (e.g. 'Irish, Indian', 'Irish, African', 'Irish, Chinese'). The above advice is given on the basis that (a) Ethnic information is collected in the Census on the basis of your own understanding of your identity or cultural background [..]' 21 .

It is clear from these instructions that a very loose interpretation of Irish ethnicity was encouraged by FIS when we take into account that simply having studied in Ireland could give someone the right to claim Irish ethnicity! It was up to the person to decide which identity they possessed or which cultural background they wanted to choose. We can see through its campaign for the 2001 census FIS did its utmost to bring together the maximum 19 Irish Post, 3 April 2001. 20 Idem. 21 Sean Hutton, Census 2001 Strategy: Review andProposals, London : FIS, 2000, p.6. amount of people under the Irish ethnic umbrella. Nevertheless, the response to the question on Irish ethnicity was not taken up in large numbers disappointing those who had lobbied for so long. However, labels created for administrative purposes may not reflect the reality of people's lives and as Frederik Barth has pointed out, cultural identities are in a constant state of flux which means that any attempt to represent them all in statistical or administrative categories is problematic or even absurd 22 .

Conclusion

Possessing an ethnic identity in post-war Britain meant being from a non-white minority group. The black/white dichotomy, the 'them/us' division, was one to remain prevalent in much of the post-war period. This automatically excluded the Irish as a predominantly white minority from discourses and policies concerning Britain's ethnic minorities. The multicultural climate in Britain played an important part in encouraging people to define themselves in terms of difference and gave them confidence to openly assert their individual identity. Black and Asian activists rallied round and took up the concept of ethnicity to define their difference.

The Irish voluntary sector saw an opening and an opportunity for resource mobilisation not previously available and became willing to emphasise an Irish ethnic identity as a strategy for group improvement 23 . The importance of ethnicity for the Irish voluntary sector was conditional on the resources that the Irish could have access to based on their formation as an ethnic group. The Irish voluntary sector hoped that the right to use the ethnic 'label' would ensure access to financial aid for disadvantaged sectors of the Irish community.

Certainly, the Irish voluntary sector exploited the situation but could not have done so if there had not been a situation to exploit.

The disappointing take-up of the Irish ethnicity category in the 2001 census raises many questions-how effective was the Irish voluntary sector's camapign? Was the ethnic 'label' 'Irish' too restrictive for more complex, hybrid identities? Or do the Irish simply not recognise or want to recognise themselves in this 'label'? The next campaign leading up to the 22 Frederik Barth cited in Michel Wieviorka, 'Is multiculturalism the solution ? ', Ethnic and Racial Studies, vol. 21, no.5, septembre 1998, p. 903. 23 John Rex and David Mason (ed), Theories of Race and Ethnic Relations, Cambridge: Cambridge University Press, 1986, p.29 future census in 2011 and the type of category included under the question on ethnic background for the Irish may go some way towards answering these questions.

Annex 1 Irish Voluntary Group Year Established

Irish in Britain Representation Group (IRBG) …………………..

  ………………………………….. (1985) Brent Irish Mental Health Group ………………………………... (1985) An Teach Housing Association ………………………………….. (1986) Haringey Irish Community Care ………………………………… (1987) Safestart Foundation ……………………………………………... (1989)

125,593 immigrants from the Indian Sub-continent, the Caribbean and Africa and 214,984 immigrants from Ireland, a difference of 89,391 in Ian R. G.Spencer, British Immigration Policy Since 1939 : The Making ofMulti-Racial Britain, London : Routledge, 1997, p. 91.

Enda Delaney, Demography, State and Society, Liverpool : Liverpool University Press, 2000, p. 210.

Zig Layton-Henry, The Politics ofImmigration, Oxford: Blackwell Publishers, 1992, p. 33.

Ralph Grillo, Pluralism and the Politics of Difference, Oxford: Clarendon Press, 1998, p. 171.

Barnor Hesse, 'Un/settled Multiculturalisms' -Diasporas, Entanglements, Transruptions, London: Zed Books, 2000, p. 4.

Race Relations Acts 1965, 1968 and 1976. The 1976 Race Relations Act made it unlawful to discriminate on the grounds of colour, 'race', ethnic or national origins in employment, housing and the provision of commercial and other services.

Race Relations Act 1976, London : TSO, p.7.

 op. cit., p. 36.

Steve Fenton, Ethnicity, England: Polity Press, 2003, p. 39.

M.Hickman and B. Walter, 'Deconstructing Whiteness: Irish Women in Britain', Feminist Review, 50, 1995, pp. 5-19.

T.Modood, '"Black", Racial Equality and Asian identity', New Community, 14,

The Federation of Irish Societies is an umbrella organisation which regroups some 100 Irish voluntary organisations throughout Great Britain.


Grainne O'keeffe

For reference purposes, article appeared in : Irish Studies in Europe "Ireland

INTRODUCTION

The Irish in Great Britain in the post World War II period have received limited recognition in regard to monitoring, research and policymaking at both central and local government level compared to other ethnic minorities. This article proposes to examine whether an Irish dimension is included or excluded at local government level in monitoring procedures and policy initiatives and the factors affecting this. This will be done through an analysis of the preliminary results of interviews carried out in a selection of London boroughs.

Firstly, this article will trace how the Irish migrant generation went from a largely "invisible" minority in post World War II Britain to a certain level of assertiveness, finally becoming recognised in the 2001 British census under the "Ethnic Minority" category. It has been argued that the invisibility of the Irish has been one of the key reasons why an Irish dimension in monitoring and policy has been largely absent (Hickman,Walter 7). Both this invisibility and exclusion from the "Ethnic Minority" category of the census, when it was introduced in 1991, effectively meant that the Irish were excluded from many policy initiatives aimed at minorities in Britain. While thousands of Irish migrants have successfully integrated into British professional and cultural life, research has consistently shown that sectors of the Irish community are over-represented against indicators of disadvantage.

Secondly, the results of the Commission for Racial Equality (CRE) report will be analysed. The authors, Professors Mary Hickman and Bronwen Walter, sent out questionnaires to local authorities to find out to what extent an Irish dimension was included in monitoring in the early 1990s (Discrimination and the Irish Community in Britain 63). During the 1980s, and more especially the 1990s, the Irish became much more visible but it was only in 1997 that this important piece of research was published. This report showed there was indeed a need for monitoring of the Irish in order to combat the difficulty that some of this population was experiencing and brought the Irish issue of discrimination and disadvantage into the national arena. A brief analysis of these results will be given to show where the Irish were situated at local government level at this time with a special emphasis on the London area where a third of the Irish population in Britain lives.

Thirdly, the preliminary results of interviews that were carried out with officials in a selection of London boroughs will be discussed 1 . The aim was to determine developments since the publication of the CRE report in relation to monitoring for the Irish community and to find out what the driving force behind this monitoring at local government level was. The specific reasons for inclusion or exclusion of an Irish category at this level were not detailed in the CRE report. The results of these interviews also aimed at determining the influence of, firstly, the recent inclusion of "Irish" under the "Ethnic Minority" category in the 2001 census and secondly, the Race Relations Amendment Act 20002 .

METHODOLOGY

Interviews in a selection of London boroughs, eight in total, were carried out over a two-month period (see Table 1). These interviews were with members of Equality and Diversity Units and, where this unit was not in operation, with the Chief Executive and Director of Administration. These boroughs hold 28.5% of the Irish 1 Each respondent signed a consent form but in order to respect privacy the names of the interviewees in each borough will not be cited.

population in London according to 2001 census results (Table KS06 -Ethnic Group).

A cross-section of boroughs with both large and small Irish populations and boroughs that had not included an Irish dimension in their monitoring systems at the time of the CRE report were chosen. In addition, some of the boroughs had an Irish voluntary organisation present and some did not. This cross-section was selected to increase the reliability of the information produced. The interviews were structured and the questions were prepared with the help of a member of the Office for the Deputy Prime Minister, the central government department that is responsible for policy concerning local authorities in Britain.

FROM EXCLUSION TO INCLUSION?

When the Irish government withdrew from the Commonwealth and declared a Republic in 1949, Irish citizens were still to be treated with the same rights as British citizens under the Ireland Act 1949 (Lee 300). This gave them a special status in Britain even though the country was no longer a member of the Commonwealth and meant that the Irish could still continue to supply labour on the British market.

The British government introduced legislation, the 1962 Commonwealth Immigration Bill, to control the influx of immigrants from Commonwealth countries who came to Britain, like the Irish, to participate in the post-war reconstruction boom (Hickman 55). The government excluded the Irish on the ground that it was impossible to police the border between Northern Ireland and the Republic (Hickman,Deconstructing/Reconstructing Race,299). In addition, the Irish were needed to meet the demand for unskilled labour and were preferable to Commonwealth immigrants as it was thought they would integrate much easier, sharing the same skin colour and language (Hickman 55).

Since the Immigration Act 1971, Ireland has been part of the Common Travel Area and Irish citizens have not been subject to control and under the British Nationality Act 1981 nationals of the Republic of Ireland have "settled status" without restrictions on length of stay (HMSO 13). The Irish were not to be treated "any differently than British citizens" and could travel to and from Britain without hindrance, this is very significant because the exclusion of the Irish from controls on entry, and Ireland's special status with the United Kingdom, directly contributed to the subsequent invisibility of the Irish in British society (Hickman,Reconstructing/Deconstructing Race,289).

They were constructed as the "same" as the British and they were excluded from the restrictive immigration legislation which came to determine which groups were defined as "ethnic" and, therefore, different from the mainstream population. The non-inclusion of the Irish here also meant that an Irish dimension was subsequently ignored in debates surrounding harmonious race relations (Hickman,Reconstructing/Deconstructing Race,289). However, it must not be forgotten also that the discourse of immigration in British society became increasingly racialised from the riots of 1958 through to the 1960s.

When discrimination and racism against immigrants became officially recognised, legislation was introduced to combat this. The 1976 Race Relations Act defines discrimination on racial grounds as being on grounds of "colour, race, nationality or ethnic and national origins" (Central Office of Information 6). The definition of a racial group to include ethnic or national origins obviously includes the Irish. Nevertheless, even though the legal framework was present to include the Irish, they were not automatically recognised in official discourse as a distinct ethnic minority group subject to racism and discrimination like the "visible" minorities. Yet, they remained silent and kept a low profile. The "Troubles" in Northern Ireland and the association in British mindsets between Irish and terrorist may also have prevented them from openly asserting their rights (Hickman,Walter 127).

The 1980s was a period of change in British society for immigrants when "ethnic minority group" largely replaced the term "migrant". This term included both the migrant generation and the second and subsequent generations. Change began to occur also at this time for the Irish, especially in London. The Greater London Council (GLC) recognised the problems that the Irish community could encounter. This recognition was in no small part due to, the then Deputy Leader of the GLC, John

McDonnell's campaigning on behalf of the Irish. It published a policy report on the Irish community in the early 1980s. This was significant as the GLC acknowledged the importance for more funding for Irish community needs. It concluded that the Irish community was disadvantaged in many areas such as housing, employment and mental health (GLC 6-8).

The GLC was abolished in 1986, under the Thatcher government, before significant progress could be made but this period marks the point of departure for a more open articulation of an Irish identity in British society. Following its abolition, the onus was then on the local authorities to include an Irish dimension in ethnic monitoring procedures. The CRE's statutory "Race Relations Code of Practice" (1984) for the elimination of racial discrimination and the promotion of equality of opportunity in employment called for the use of monitoring recording the ethnic origin of individuals (Hickman, Walter 63). However, because of the overwhelming association of ethnicity and blackness in Britain, the Irish were not automatically included in ethnic monitoring procedures.

THE RESULTS OF THE CRE REPORT

The authors of the CRE report carried out a postal survey in 1994 contacting 514 local authorities in England, Wales and Scotland to determine whether ethnic monitoring took place and whether an Irish dimension was included or not (Hickman,Walter 64). Sixteen out of the 33 London boroughs carried out some form of ethnic monitoring which included an Irish category at this time (Hickman,Walter,64). For most of the authorities recognition came in the late 1980s and 1990s. But even when a local authority adopted the Irish monitoring category, it was often extended to only a few of the possible areas of employment and services (Hickman,Walter 64).

Only two London boroughs at that time, Brent and Southwark, claimed to monitor in all seven areas which were surveyed -personnel, housing, education, social services, environmental services, leisure and council tax benefit (Hickman,Walter 64).

Nevertheless, it was also discovered that most authorities appeared to make no further use of the statistics they had gathered. One official even asked: "WHY is IRISH to be monitored as a separate group within WHITE?" (Hickman,Walter 67). This evidence shows that even when an Irish dimension was included in monitoring, it was not largely translated into policy initiatives and there was incomprehension on the part of officials as to why the Irish needed to be monitored separately in the first place.

Monitoring of the Irish community is needed as Irish-born people are statistically more likely to be socially disadvantaged, experience high levels of physical and mental health problems and long-term disability and are also over represented as users of psychiatric services (London Civic Forum 5-6). Research

shows that Irish men are the only group whose life expectancy worsens on emigration to England (Greenslade 40). The 2001 census shows that 34% of the Irish population in Britain is over 60, 25.6% have a limiting long term illness and just over 21% live in accommodation rented from the council or other social rented (Table T13-Ethnicity).

What is an even more surprising figure is that over 37% are cited as having no qualifications or qualifications unknown (Table T13 -Ethnicity). The Irish figure highly also among homeless people and as recently as November 2003 an offer for employment was advertised at "The Passage", a centre for the homeless based in London, for an Irish Person's Coordinator.

During interviews carried put with members of the Irish voluntary sector in London, it could be established that the level of Irish people's needs was still high even though the Irish population had gone down since the 1991 census by over 60,000 people (Owen 4). The Brent Irish Advisory Service (BIAS) sees about 2,500 people each year and the London Irish Centre about 2,000 both from the Irish migrant population and second and third generation Irish (Interviews O'Callaghan and Kivlehan). There is a particular problem with older Irish people who find themselves in difficulty after not having made adequate provision for their retirement. They become isolated and some finish up living in bad accommodation. Members of these organisations have also noted that a lot of younger people are coming to them, some with no accommodation and not enough money to get started, and others with drug and alcohol related problems. Therefore, there is still need amongst a certain section of the Irish in London.

INTERVIEW RESULTS

Finally, the evolution of the situation since the publication of the CRE report and the inclusion, after much lobbying by certain sectors of the Irish community, especially the Federation of Irish Societies, for the incorporation of the Irish under the "Ethnic Minority" category will be analysed. It was argued at the time that the Irish should be included under this category because there was a section experiencing disadvantage and there was a requirement for a more accurate picture of the extent of Irish need. It was also hoped that this would encourage more extensive monitoring at local government level.

According to the 2001 census, the Irish in London form just over three per cent of the ethnic minority population (Table KS06 -Ethnic Group). This places them in fifth position after the Indians, Africans, Caribbean and the Other White category (Table KS06-Ethnic Group). The London borough, which has the largest Irish population, nearly seven per cent, is Brent, followed by Islington, Hammersmith and Fulham, Ealing, Camden and Harrow all having a representation of over four per cent Irish in their borough (See Table 1).

The boroughs with some of the most active Irish voluntary sector are Camden where the London Irish Centre and the Federation of Irish Societies are based, Brent, where the BIAS works from and Islington where the Action Group for Irish Youth (AGIY) and various housing associations are located, one of the principle ones being Innisfree Housing Association.

Fourteen boroughs were contacted and ten replies received and eight officials agreed to be interviewed. One borough said it could not provide information even though the Irish represent over four per cent of the population and another did not reply when a sample of the questions to be discussed were sent. Therefore, interviews were carried out in eight London boroughs and each person received a copy of the questions before each interview (See Table 1).

When asked the size of the Irish population in their borough, every respondent got this information from the census. One respondent said the National Survey preceded everything else (Interview Haringey). All respondents monitored according to the census categories and some, but not all, even went further than this and monitored to reflect the make-up of the local community, for example, including categories such as Turkish, Somali, Kosovo.

When asked if a specific Irish category was included in ethnic monitoring systems the answers were varying. Five of the boroughs (Camden, Brent, Islington, Haringey and Southwark) had included the Irish in their monitoring systems for many years although monitoring was uneven between departments. The other three (Wandsworth, Havering and Barnet) did not monitor the Irish at the time of the CRE report and had only recently included an Irish category.

A further question asked was what concrete changes or policy initiatives this data had initiated in those boroughs which had been monitoring the Irish in the past. It was difficult for the respondents to give specific answers. One official said the question was being asked at the moment concerning what to do with data and they were carrying out impact assessments (Interview Southwark). However, this borough had introduced a programme for travellers as a result of monitoring and a proportion of these travellers would be of Irish origin. It was also mentioned during interviews that funding had been given to the Irish voluntary sector. It could be argued that this has the tendency to show lack of commitment in dealing with Irish need and handing over responsibility to the voluntary sector. Apart from the traveller community none of the respondents could name any concrete changes that had come about in the last few years for the Irish in their borough. There seemed to be more concern over the arrival of refugees and asylum seekers.

Each respondent was given five choices concerning the influence on the inclusion of an Irish category in monitoring procedures: recent inclusion of "Irish" under the "Ethnic Minority" category in the census, Irish voluntary sector lobbying, central government policy, the CRE report on the Irish or other influences. The answers here varied. In the boroughs where the Irish had been included for some time answers ranged from: because we have a large Irish community, the influence of the community, Irish voluntary sector lobbying, people of Irish descent driving things forward, Irish councillors or councillors of Irish descent. For those boroughs, which had never monitored the Irish in the past, and had now included this category, the clear impetus was recognition in the 2001 census under the "Ethnic Minority" category.

With regard to the CRE report and its influence on gaining recognition for the Irish. Out of the three boroughs that had not been monitoring the Irish in the past, one respondent had heard about the launch ceremony for the report but had not attended.

Another had not read the report and the third had read the report but it had had no influence on monitoring procedures, even though, at that time the CRE had encouraged an Irish dimension to be included. The other respondents had all read or heard of the report. One respondent noted that an important aspect of this report was that it sent out a positive message showing the commitment of the CRE towards the Irish but it does not seem to have initiated any concrete changes with regard to policymaking (Interview Southwark).

The influence of the Race Relations Amendment Act was another area covered.

Under this Act all public authorities must produce a Race Equality Scheme and revise it every three years. Most of the respondents said that the Race Equality Scheme meant no more or no less for the Irish than for other minorities. However, this Act does place a legal duty on local authorities to take racial equality into account in policymaking, service delivery and employment practices. In one borough the Irish were specifically mentioned in the Race Equality Scheme (Interview Southwark).

CONCLUSION

To conclude, the Irish in Britain remained largely invisible in post World War II British society and were excluded from much of the research and policymaking at local government level in the past. The policy document published by the GLC in the 1980s brought Irish issues to the fore in London even though it was abolished before much progress could be made.

However, it took until the end of the 1990s to get a major piece of research out into the public arena. This publication showed that indeed Irish discrimination and disadvantage did exist for sections of the Irish community in Britain. It highlighted the lack of comprehension by officials as to why an Irish dimension should be included in monitoring practices. At the time 48% of London boroughs monitored the Irish but the results were, for the most part, not translated into policy initiatives. The campaign for inclusion of an "Irish" heading under the "Ethnic Minority" category of the 2001 census was considered essential in getting recognition for the Irish on a national level and also to generate a clearer picture of the Irish community in Britain.

From the preliminary results of the interviews, it can be concluded that the inclusion of the Irish under this category means that authorities that use the census "Ethnic Minority" category headings, which was all of the sample, now include the Irish in their monitoring procedures. This will mean that more data will be generated on the Irish in the future.

Local authorities now also have a statutory duty to promote racial equality under the Race Relations Amendment Act. However, even though more comprehensive data will be available in the future at borough level, unless a strong Irish voluntary sector or a vocal Irish community are present to put Irish issues on the local agenda, the risk is that the data will not be used to create policy initiatives for the Irish.

Therefore, it can be concluded that the Irish are present in data monitoring systems and, in the boroughs where they were included before the 2001 census, it has been largely due to voluntary sector lobbying and a strong community presence. The inclusion of the Irish in the census with other ethnic minorities has been the major influence on the boroughs which were slow to include them in the past. However, since the CRE publication there has been little evidence of concrete initiatives aimed at the Irish community at local authority level in the London area which goes in keeping with the results of the CRE report. Much work remains to be done if monitoring procedures are to be translated into policy initiatives for the Irish community in the future3 .

Table 1 Population of "White Irish" in London boroughs

 1

	Inner London:	Population:	%:
	Camden	9,149	4.62
	City of London	241	3.35
	Hackney	6,117	3.01
	Hammersmith and Fulham	7,983	4.83
	Haringey	9,302	4.29
	Islington	10,057	5.72
	Kensington and Chelsea	5,183	3.26
	Lambeth	8,689	3.26
	Lewisham	6,990	2.80
	Newham	3,231	1.32
	Southwark	7,674	3.13

The Race Relations Amendment Act 2000 was the government's response to the recommendations made in the Stephen Lawrence inquiry report. It amends and strengthens the 1976 Race Relations Act, so, for the first time ever, councils are prohibited from unlawfully discriminating in any of their functions. This places a general duty on councils to promote racial equality and, now, all local authorities must publicly demonstrate their awareness and commitment to race equality regardless of the size or the make-up of their workforce or local community.

I would like to express my gratitude and thanks to Piaras MacEinri, Director of the Irish Centre for Migration Studies (ICMS), University College Cork, for his comments on an earlier version of this paper.