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Krogstad H, Loge JH, Grotmol KS, Kaasa S, Kiserud CE, Salvesen Ø, Hjermstad MJ. Symptoms in the general Norwegian adult population - prevalence and associated factors. BMC Public Health 2020; 20:988. [PMID: 32576168 PMCID: PMC7310321 DOI: 10.1186/s12889-020-09109-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 06/12/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Patients´ own perceptions and evaluations of symptoms, functioning and other health-related factors, i.e. Patient Reported Outcomes (PROs), are important elements for providing good patient care. Symptoms are subjective and best elicited by the patient orally or by using PRO measures (PROMs), be it on paper, or as electronic assessment tools. Reference values on frequently used PROMs facilitate the interpretation of scores for use in clinics and research settings, by comparing patient data with relevant samples from the general population. Study objectives were to (1) present reference values for the M.D. Anderson Symptom Inventory (MDASI) (2) examine the occurrence and intensity of symptoms assessed by the MDASI in a general Norwegian adult population sample, and (3) examine factors associated with higher symptom burden defined as the sum score of all symptoms, and factors associated with symptoms` interference on functions. METHODS In 2015, MDASI was sent by mail as part of a larger survey, to a representative sample of the general Norwegian adult population (N = 6165). Medical comorbidities were assessed by the Self-Administered Comorbidity Questionnaire. Depression was self-reported on the Patient Health Questionnaire 9 (PHQ-9). Linear multivariable regression analysis was used to examine for factors associated with MDASI sum score and factors associated with symptoms' interference on functions. RESULTS The response rate was 36%. More women (54%) than men (46%) responded. Mean age was 55 years (SD 14). The most frequent symptoms were fatigue (59.7%), drowsiness (56.2%) and pain (56.1%). Fatigue, pain and disturbed sleep had the highest mean scores. The presence of one or more comorbidities, increasing PHQ-9 score and lower level of education were associated with higher MDASI sum score (p < 0.001). The MDASI sum score and the PHQ-9 score were positively associated with all interference items (p < 0.001) except for walking (p = 0.22). CONCLUSION This study provides the first Norwegian reference values for MDASI. The presence of one or more comorbidities, higher level of depressive symptoms and lower level of education were significantly associated with higher MDASI sum score. These covariates must be controlled for when using the reference values.
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Affiliation(s)
- Hilde Krogstad
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, and St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway. .,Cancer Clinic, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Jon Håvard Loge
- Regional Advisory Unit in Palliative Care, Department of Oncology, Oslo University Hospital, Oslo, Norway.,European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kjersti S Grotmol
- Regional Advisory Unit in Palliative Care, Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Cecilie E Kiserud
- National advisory unit for late effects after cancer treatment, Oslo University Hospital, and University of Oslo, Oslo, Norway
| | - Øyvind Salvesen
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Marianne Jensen Hjermstad
- Regional Advisory Unit in Palliative Care, Department of Oncology, Oslo University Hospital, Oslo, Norway.,European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Hultstrand C, Coe AB, Lilja M, Hajdarevic S. GPs' perspectives of the patient encounter - in the context of standardized cancer patient pathways. Scand J Prim Health Care 2020; 38:238-247. [PMID: 32314634 PMCID: PMC8570742 DOI: 10.1080/02813432.2020.1753388] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective: We aim to explore how GPs assign meanings and act upon patients' symptoms in primary care encounters in the context of standardized cancer patient pathways (CPPs).Design, setting and subjects: Thirteen individual interviews were conducted with GPs, at primary healthcare centers (n = 4) in one county in northern Sweden. Interviews were analyzed using grounded theory method. The results were then linked to symbolic interactionism.Main outcome measures: GPs' perspectives about assigning meanings to patients' presented symptoms and perception about CPPs.Results: In the encounter, GPs engaged in two simultaneous interactions, one with patients' symptoms - and the other with CPPs. The core category Disentangling patients' care trajectory consists of three categories, interpreted as GPs' strategies developed to assign meaning to symptoms. These strategies are carried out not in a straightforward manner but rather in a conflicting way, illuminating the complexity of GPs' daily work.Conclusions: Interacting with patients is vital for assigning meaning to presented symptoms. However, nowadays GPs are not only required to interact with patients, they are also required to interact with CPPs. These standardized routines might create pressure and demands on GPs, especially for those experiencing a lack of information about CPPs. Beside of carrying out the challenging patient/person-centered dialogues and interpreting presented symptoms, GPs also need to link the interpreted symptoms to CPPs. Therefore, it is essential that GPs are given opportunities at their workplaces to continuously be informed and be supported in order to practice CPPs and thereby optimize trajectories for patients undergoing cancer diagnostics.Key points Current awareness: • GPs deliberation about patients' trajectories is a complex process, often dealing with vague symptoms. How CPPs influence this process within the encounter has not been studied. Main statements: • GPs in our study were involved in two simultaneous interactions, one with patients' symptoms in the encounter - and the other with CPPs within the healthcare organization. • Symbolic interactionism helped capture how GPs deliberated about conflicting and paradoxical aspects of the encounter, in terms of balancing two contradictory ways of action that GPs face when providing patient/person-centered care and linking to CPPs. • Based on our results, primary care needs support from healthcare organizations to build capacity about CPPs and how to use them.
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Affiliation(s)
- Cecilia Hultstrand
- Department of Nursing, Umeå University, Umeå, Sweden;
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden;
- CONTACT Cecilia Hultstrand Department of Nursing, Umeå University, Umeå, SE-901 87, Sweden
| | | | - Mikael Lilja
- Department of Public Health and Clinical Medicine, Unit of Research, Education, and Development, Östersund Hospital, Umeå University, Umeå, Sweden
| | - Senada Hajdarevic
- Department of Nursing, Umeå University, Umeå, Sweden;
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden;
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Burton JK, Yates LC, Whyte L, Fitzsimons E, Stott DJ. New horizons in iron deficiency anaemia in older adults. Age Ageing 2020; 49:309-318. [PMID: 32103233 DOI: 10.1093/ageing/afz199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/17/2019] [Accepted: 01/02/2020] [Indexed: 12/24/2022] Open
Abstract
Iron deficiency anaemia (IDA) is common in older adults and associated with a range of adverse outcomes. Differentiating iron deficiency from other causes of anaemia is important to ensure appropriate investigations and treatment. It is possible to make the diagnosis reliably using simple blood tests. Clinical evaluation and assessment are required to help determine the underlying cause and to initiate appropriate investigations. IDA in men and post-menopausal females is most commonly due to occult gastrointestinal blood loss until proven otherwise, although there is a spectrum of underlying causative pathologies. Investigation decisions should take account of the wishes of the patient and their competing comorbidities, individualising the approach. Management involves supplementation using oral or intravenous (IV) iron then consideration of treatment of the underlying cause of deficiency. Future research areas are outlined including the role of Hepcidin and serum soluble transferrin receptor measurement, quantitative faecal immunochemical testing, alternative dosing regimens and the potential role of IV iron preparations.
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Affiliation(s)
- Jennifer Kirsty Burton
- Academic Section of Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Luke C Yates
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Lindsay Whyte
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Edward Fitzsimons
- Department of Haematology, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - David J Stott
- Academic Section of Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Nicholson BD, Hamilton W, Koshiaris C, Oke JL, Hobbs FDR, Aveyard P. The association between unexpected weight loss and cancer diagnosis in primary care: a matched cohort analysis of 65,000 presentations. Br J Cancer 2020; 122:1848-1856. [PMID: 32291391 PMCID: PMC7283307 DOI: 10.1038/s41416-020-0829-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 01/27/2020] [Accepted: 02/19/2020] [Indexed: 02/06/2023] Open
Abstract
Background We aimed to understand the time period of cancer diagnosis and the cancer types detected in primary care patients with unexpected weight loss (UWL) to inform cancer guidelines. Methods This retrospective matched cohort study used cancer registry linked electronic health records from the UK’s Clinical Practice Research Datalink from between 2000 and 2014. Univariable and multivariable time-to-event analyses examined the association between UWL, and all cancers combined, cancer site and stage. Results In all, 63,973 patients had UWL recorded, of whom 1375 (2.2%) were diagnosed with cancer within 2 years (days-to-diagnosis: mean 181; median 80). Men with UWL (HR 3.28 (2.88–3.73)) and women (1.87 (1.68–2.08)) were more likely than comparators to be diagnosed with cancer within 3 months. The association was greatest in men aged ≥50 years and women ≥70 years. The commonest cancers were pancreas, cancer of unknown primary, gastro-oesophageal, lymphoma, hepatobiliary, lung, bowel and renal-tract. The majority were late-stage, but there was some evidence of association with stage II and stage III cancers. In the 3–24 months after presenting with UWL, cancer diagnosis was less likely than in comparators. Conclusion UWL recorded in primary care is associated with a broad range of cancer sites of early and late-stage.
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Affiliation(s)
- Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK.
| | | | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Jason L Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
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Cooper JA, Ryan R, Parsons N, Stinton C, Marshall T, Taylor-Phillips S. The use of electronic healthcare records for colorectal cancer screening referral decisions and risk prediction model development. BMC Gastroenterol 2020; 20:78. [PMID: 32213167 PMCID: PMC7093989 DOI: 10.1186/s12876-020-01206-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 02/24/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The database used for the NHS Bowel Cancer Screening Programme (BCSP) derives participant information from primary care records. Combining predictors with FOBTs has shown to improve referral decisions and accuracy. The richer data available from GP databases could be used to complement screening referral decisions by identifying those at greatest risk of colorectal cancer. We determined the availability of data for key predictors and whether this information could be used to inform more accurate screening referral decisions. METHODS An English BCSP cohort was derived using the electronic notifications received from the BCSP database to GP records. The cohort covered a period between 13th May 2009 to 17th January 2017. Completeness of variables and univariable associations were assessed. Risk prediction models were developed using Cox regression and multivariable fractional polynomials with backwards elimination. Optimism adjusted performance metrics were reported. The sensitivity and specificity of a combined approach using the negative FOBT model plus FOBT positive patients was determined using a probability equivalent to a 3% PPV NICE guidelines level. RESULTS 292,059 participants aged 60-74 were derived for the BCSP screening cohort. A model including the screening test result had a C-statistic of 0.860, c-slope of 0.997, and R2 of 0.597. A model developed for negative screening results only had a C-statistic of 0.597, c-slope of 0.940, and R2 of 0.062. Risk predictors included in the models included; age, sex, alcohol consumption, IBS diagnosis, family history of gastrointestinal cancer, smoking status, previous negatives and whether a GP had ordered a blood test. For the combined screening approach, sensitivity increased slightly from 53.90% (FOBT only) to 58.82% but at the expense of an increased referral rate. CONCLUSIONS This research has identified several potential predictors for CRC in a BCSP population. A risk prediction model developed for BCSP FOBT negative patients was not clinically useful due to a low sensitivity and increased referral rate. The predictors identified in this study should be investigated in a refined algorithm combining the quantitative FIT result. Combining data from multiple sources enables fuller patient profiles using the primary care and screening database interface.
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Affiliation(s)
- Jennifer Anne Cooper
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
| | - Ronan Ryan
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Nick Parsons
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Chris Stinton
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Tom Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Sian Taylor-Phillips
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
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Akanuwe JNA, Black S, Owen S, Siriwardena AN. Communicating cancer risk in the primary care consultation when using a cancer risk assessment tool: Qualitative study with service users and practitioners. Health Expect 2020; 23:509-518. [PMID: 31967704 PMCID: PMC7104630 DOI: 10.1111/hex.13016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 11/26/2019] [Accepted: 12/05/2019] [Indexed: 12/15/2022] Open
Abstract
Background Cancer risk assessment tools are designed to help detect cancer risk in symptomatic individuals presenting to primary care. An early detection of cancer risk could mean early referral for investigations, diagnosis and treatment, helping to address late diagnosis of cancer. It is not clear how best cancer risk may be communicated to patients when using a cancer risk assessment tool to assess their risk of developing cancer. Objective We aimed to explore the perspectives of service users and primary care practitioners on communicating cancer risk information to patients, when using QCancer, a cancer risk assessment tool. Design A qualitative study involving the use of individual interviews and focus groups. Setting and participants Conducted in primary care settings in Lincolnshire with a convenience sample of 36 participants (19 service users who were members of the public) and 17 primary care practitioners (general practitioners and practice nurses). Results Participants suggested ways to improve communication of cancer risk information: personalizing risk information; involving patients in use of the tool; sharing risk information openly; and providing sufficient time when using the tool during consultations. Conclusion Communication of cancer risk information is complex and difficult. We identified strategies for improving communication with patients involving cancer risk estimations in primary care consultations.
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Affiliation(s)
- Joseph N A Akanuwe
- Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - Sharon Black
- Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - Sara Owen
- Waterford Institute of Technology, Waterford, Ireland
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Evaluation of a national lung cancer symptom awareness campaign in Wales. Br J Cancer 2019; 122:491-497. [PMID: 31839675 PMCID: PMC7029011 DOI: 10.1038/s41416-019-0676-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 11/06/2019] [Accepted: 11/19/2019] [Indexed: 01/21/2023] Open
Abstract
Background Lung cancer is the leading cause of cancer mortality in Wales. We conducted a before- and after- study to evaluate the impact of a four-week mass-media campaign on awareness, presentation behaviour and lung cancer outcomes. Methods Population-representative samples were surveyed for cough symptom recall/recognition and worry about wasting doctors’ time pre-campaign (June 2016; n = 1001) and post-campaign (September 2016; n = 1013). GP cough symptom visits, urgent suspected cancer (USC) referrals, GP-ordered radiology, new lung cancer diagnoses and stage at diagnosis were compared using routine data during the campaign (July–August 2016) and corresponding control (July–August 2015) periods. Results Increased cough symptom recall (p < 0.001), recognition (p < 0.001) and decreased worry (p < 0.001) were observed. GP visits for cough increased by 29% in the target 50+ age-group during the campaign (p < 0.001) and GP-ordered chest X-rays increased by 23% (p < 0.001). There was no statistically significant change in USC referrals (p = 0.82), new (p = 0.70) or early stage (p = 0.27) diagnoses, or in routes to diagnosis. Conclusions Symptom awareness, presentation and GP-ordered chest X-rays increased during the campaign but did not translate into increased USC referrals or clinical outcomes changes. Short campaign duration and follow-up, and the small number of new lung cancer cases observed may have hampered detection effects.
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McDonald L, Carroll R, Harish A, Tanna N, Mehmud F, Alikhan R, Ramagopalan SV. Suspected cancer symptoms and blood test results in primary care before a diagnosis of lung cancer: a case-control study. Future Oncol 2019; 15:3755-3762. [PMID: 31668096 DOI: 10.2217/fon-2019-0442] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Aim: To compare symptoms and blood test results prior to cancer diagnosis in individuals who developed lung cancer and those who did not. Patients & methods: Nested case-control study, lung cancer patients were matched to up four controls with no record of cancer. Differences in symptoms and blood test results were investigated in the 2-year period prior to diagnosis. Results: 26,379 lung cancer patients were matched to 92,125 controls. Elevated C-reactive protein (CRP) was independently predictive of lung cancer at every 2-month interval 12 months prior to diagnosis. Elevated CRP in conjunction with at least one symptom was associated with greater than fourfold higher odds of lung cancer. Conclusion: CRP may be a prediagnostic marker for lung cancer, and when present with other symptoms could facilitate the investigation of high-risk individuals.
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Affiliation(s)
- Laura McDonald
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, United Kingdom
| | - Robert Carroll
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, United Kingdom
| | | | - Nikhil Tanna
- Bristol-Myers Squibb, Uxbridge, UB8 1DH, United Kingdom
| | - Faisal Mehmud
- Bristol-Myers Squibb, Uxbridge, UB8 1DH, United Kingdom
| | - Raza Alikhan
- University Hospital of Wales, Cardiff & Vale University Health Board, CF14 4XW, United Kingdom
| | - Sreeram V Ramagopalan
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, United Kingdom
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Affiliation(s)
- Jessica Watson
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
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van Erp NF, Helsper CW, Olyhoek SM, Janssen RRT, Winsveen A, Peeters PHM, de Wit NJ. Potential for Reducing Time to Referral for Colorectal Cancer Patients in Primary Care. Ann Fam Med 2019; 17:419-427. [PMID: 31501203 PMCID: PMC7032917 DOI: 10.1370/afm.2446] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 03/29/2019] [Accepted: 04/11/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE An optimal diagnostic process in primary care is pivotal for reducing cancer-related disease burden. This study aims to explore reasons for long times to referral for Dutch colorectal cancer (CRC) patients in primary care. METHODS A retrospective cohort study of anonymized free-text primary care records from the Julius General Practitioners' Network database, linked to the Netherlands Cancer Registry. Patients with a confirmed CRC diagnosis from 2007 through 2011 that symptomatically presented in primary care were included. Median time and interquartile ranges from presentation in primary care to referral were calculated for multiple patient and presentation characteristics. Associations of these characteristics with long time to referral (75th percentile was ≥59 days) were examined with log-binomial regression analyses. Routes to referral of patients with the longest times to referral were explored using thematic free-text analyses (90th percentile at ≥219 days). RESULTS Among the 309 people with CRC, patients who were female, did not have a registered family history, had a history of malignancy, lacked alarm symptoms at presentation, or had hemorrhoids at physical examination were at risk for longer time to referral in univariable analyses (longer median durations and/or univariable association with the 75th percentile). Only presentation without alarm symptoms showed a statistically significant association with long duration (75th percentile) in multivariable analysis (relative risk = 1.7; 95% CI, 1.1-2.6). Thematic exploration of the diagnostic routes to referral of patients with the longest durations (90th percentile) showed 2 dominating themes: "alternative working diagnosis" and "suboptimal diagnostic strategies," and included the sub-themes "omitting to reconsider an initial diagnosis" and "lacking follow-up." CONCLUSIONS Long time to referral for CRC in primary care is mainly related to low cancer suspicion. There is potential for reducing the longest times to referral for patients with CRC in primary care, with earlier reconsideration of the initial hypothesis and implementation of strict follow-up consultations.
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Affiliation(s)
- Nicole F van Erp
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Charles W Helsper
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Saskia M Olyhoek
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ramon R T Janssen
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Amber Winsveen
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Petra H M Peeters
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Niek J de Wit
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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Larsen MB, Njor SH, Jensen TM, Ingeholm P, Andersen B. Potential for prevention: a cohort study of colonoscopies and removal of adenomas in a FIT-based colorectal cancer screening programme. Scand J Gastroenterol 2019; 54:1008-1014. [PMID: 31397598 DOI: 10.1080/00365521.2019.1647282] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction: Evidence suggests that colorectal cancer (CRC) screening using guaiac faecal occult blood tests (gFOBT) reduces the CRC burden by facilitating timely removal of adenomas. Yet, the faecal immunochemical test (FIT) is being implemented in many countries. The aim of this study was to analyse the risk of having adenomas detected when invited for FIT-based screening as compared to those not yet invited. Material and Methods: The study was designed as a register-based retrospective cohort study. The potential for prevention was estimated as number of individuals who had no adenomas, non-advanced adenomas, and advanced adenomas detected per 1000 invited/not yet invited individuals and the relative risk (RR) of each of the three outcomes. Results: A total of 1,359,340 individuals were included, 29.6% of whom had been invited and 70.4% had not yet been invited to participate in CRC screening. Compared with the not yet invited population, the invited group had a RR of no adenomas of 2.28 (2.22-2.34) and a RR of advanced adenomas of 7.41 (6.93-7.91). The RR of colonoscopy was 2.93 (2.87-2.99) for the invited population compared with the not yet invited population. Conclusion: The RR of having a colonoscopy was three times higher among those invited compared to those not yet invited for CRC screening and twice as often those who had been invited compared to those not yet invited had no adenomas detected. Still, the risk of advanced adenomas was more than seven times higher among the invited population, indicating that the screening programme holds great potential for reducing the CRC burden. Abbreviations: CI: Confidence interval; CRC: Colorectal cancer; FIT: Faecal immunochemical test; ICD: International Classification of Disease; RR: Relative risk.
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Affiliation(s)
- Mette Bach Larsen
- Department of Public Health Programmes, Randers Regional Hospital, Central Denmark Region , Randers , Denmark
| | - Sisse Helle Njor
- Department of Public Health Programmes, Randers Regional Hospital, Central Denmark Region , Randers , Denmark
| | | | - Peter Ingeholm
- Department of Pathology, Herlev Hospital, Capital Region of Denmark , Herlev , Denmark
| | - Berit Andersen
- Department of Public Health Programmes, Randers Regional Hospital, Central Denmark Region , Randers , Denmark
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Use of multiple inflammatory marker tests in primary care: using Clinical Practice Research Datalink to evaluate accuracy. Br J Gen Pract 2019; 69:e462-e469. [PMID: 31208975 PMCID: PMC6582449 DOI: 10.3399/bjgp19x704309] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 04/11/2019] [Indexed: 01/21/2023] Open
Abstract
Background Research comparing C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and plasma viscosity (PV) in primary care is lacking. Clinicians often test multiple inflammatory markers, leading to concerns about overuse. Aim To compare the diagnostic accuracies of CRP, ESR, and PV, and to evaluate whether measuring two inflammatory markers increases accuracy. Design and setting Prospective cohort study in UK primary care using the Clinical Practice Research Datalink. Method The authors compared diagnostic test performance of inflammatory markers, singly and paired, for relevant disease, defined as any infections, autoimmune conditions, or cancers. For each of the three tests (CRP, ESR, and PV), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under receiver operator curve (AUC) were calculated. Results Participants comprised 136 961 patients with inflammatory marker testing in 2014; 83 761 (61.2%) had a single inflammatory marker at the index date, and 53 200 (38.8%) had multiple inflammatory markers. For ‘any relevant disease’, small differences were seen between the three tests; AUC ranged from 0.659 to 0.682. CRP had the highest overall AUC, largely because of marginally superior performance in infection (AUC CRP 0.617, versus ESR 0.589, P<0.001). Adding a second test gave limited improvement in the AUC for relevant disease (CRP 0.682, versus CRP plus ESR 0.688, P<0.001); this is of debatable clinical significance. The NPV for any single inflammatory marker was 94% compared with 94.1% for multiple negative tests. Conclusion Testing multiple inflammatory markers simultaneously does not increase ability to rule out disease and should generally be avoided. CRP has marginally superior diagnostic accuracy for infections, and is equivalent for autoimmune conditions and cancers, so should generally be the first-line test.
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Stenman E, Palmér K, Rydén S, Sävblom C, Svensson I, Rose C, Ji J, Nilbert M, Sundquist J. Diagnostic spectrum and time intervals in Sweden's first diagnostic center for patients with nonspecific symptoms of cancer. Acta Oncol 2019; 58:296-305. [PMID: 30632871 DOI: 10.1080/0284186x.2018.1537506] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Fast-track referral is an increasingly used method for diagnostic evaluation of patients suspected of having cancer. This approach is challenging and not used as often for patients with only nonspecific symptoms. In order to expedite the diagnostics for these patients, we established Sweden's first Diagnostic Center (DC) focusing on outcomes related to diagnoses and diagnostic time intervals. MATERIAL AND METHODS The study was designed as a prospective cohort study. Patients aged ≥18 years who presented in primary care with nonspecific symptoms of a serious disease were eligible for referral to the DC after having completed an initial investigation. Acceptable diagnostic time intervals were defined to be a maximum of 15 days in primary care and 22 days at the DC. Diagnostic outcome, length of diagnostic time intervals and patient satisfaction were evaluated. RESULTS A total of 290 patients were included in the study. Cancer was diagnosed in 22.1%, other diseases in 64.1%, and no diagnosis was identified in 13.8% of these patients. Patients diagnosed with cancer were older, had shorter patient interval (time from first symptom to help-seeking), shorter DC-interval (time from referral decision in primary care to diagnosis) and showed a greater number of symptoms compared to patients with no diagnosis. The median primary care interval was 21 days and the median DC interval was 11 days. Few symptoms, no diagnosis, female sex, longer patient interval, and incomplete investigations were associated with prolonged diagnostic time intervals. Patient satisfaction was high; 86% of patients reported a positive degree of satisfaction with the diagnostic procedures. CONCLUSIONS We demonstrated that the DC concept is feasible with a diagnosis reached in 86.2% of the patients in addition to favorable diagnostic time intervals at the DC and a high degree of patient satisfaction.
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Affiliation(s)
- Emelie Stenman
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Karolina Palmér
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Stefan Rydén
- Regional Cancer Centre South, Region Skåne, Lund, Sweden
| | | | - Inga Svensson
- Central Hospital of Kristianstad, Region Skåne, Kristianstad, Sweden
| | - Carsten Rose
- CREATE Health, Faculty of Engineering LTH, Lund University, Lund, Sweden
| | - Jianguang Ji
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Mef Nilbert
- Institute of Clinical Sciences, Division of Oncology and Pathology, Lund University, Lund, Sweden
- Clinical Research Centre Copenhagen University Hospital, Hvidovre, Denmark
- Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Jan Sundquist
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
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Rasmussen S, Haastrup PF, Balasubramaniam K, Elnegaard S, Christensen RD, Storsveen MM, Søndergaard J, Jarbøl DE. Predictive values of colorectal cancer alarm symptoms in the general population: a nationwide cohort study. Br J Cancer 2019; 120:595-600. [PMID: 30792531 PMCID: PMC6461905 DOI: 10.1038/s41416-019-0385-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 01/07/2019] [Accepted: 01/10/2019] [Indexed: 12/11/2022] Open
Abstract
Background Alarm symptoms are used in many cancer referral guidelines. The objectives were to determine the 1-year predictive values (PVs) of colorectal cancer (CRC) alarm symptoms in the general population and to describe the proportion of alarm symptoms reported prior to diagnosis. Methods A nationwide prospective cohort of 69,060 individuals ≥40 years randomly selected from the Danish population was invited to complete a survey regarding symptoms and healthcare-seeking in 2012. Information on CRC diagnoses in a 12-month follow-up came from the Danish Cancer Registry. PVs and positive and negative likelihood ratios were calculated. Results A total of 37,455 individuals participated (response rate 54.2%). Sixty-four individuals were diagnosed with CRC. The single symptom with the highest positive PVs (PPV) and LR+ was rectal bleeding. PPVs were generally higher among individuals aged ≥75 years and highest among those reporting at least one specific alarm symptom that led to a GP contact. Conclusion In general, the PPVs of CRC alarm symptoms are low and the NPVs high, especially in the youngest age groups. The LR + show a relative association with specific symptoms like rectal bleeding. Future campaigns on early diagnosis of CRC should focus on healthcare-seeking when experiencing rectal bleeding and target older people with the highest incidence.
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Affiliation(s)
- Sanne Rasmussen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000, Odense C, Denmark.
| | - Peter Fentz Haastrup
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000, Odense C, Denmark
| | - Kirubakaran Balasubramaniam
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000, Odense C, Denmark
| | - Sandra Elnegaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000, Odense C, Denmark
| | - René dePont Christensen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000, Odense C, Denmark
| | - Maria Munch Storsveen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000, Odense C, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000, Odense C, Denmark
| | - Dorte Ejg Jarbøl
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000, Odense C, Denmark
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Abstract
Significant advances in the management of both early and advanced stage lung cancer have not yet led to the scale of improved outcomes which have been achieved in other cancers over the last 40 years. Diagnosis of lung cancer at the earliest stage of disease is strongly associated with improved survival. Therefore, although recent advances in oncology may herald breakthroughs in effective treatment, achieving early diagnosis will remain crucial to obtaining optimal outcomes. This is challenging, as most lung cancer symptoms are non-specific or are common respiratory symptoms which usually represent benign disease. Identification of patients at risk of lung cancer who require further investigation is an important responsibility for general practitioners (GPs). Diagnosis has historically relied upon plain chest X-ray (CXR), organised in response to symptoms. The sensitivity of this modality, however, compares unfavourably with that of computed tomography (CT). In some jurisdictions screening high-risk individuals with low dose CT (LDCT) is now recommended. However uptake remains low and the eligibility for screening programmes is restricted. Therefore, even if screening is widely adopted, most patients will continue to be diagnosed after presenting with symptoms. Achieving early diagnosis requires GPs to maintain an appropriate level of suspicion and readiness to investigate in high-risk patients or those with non-resolving symptoms. This article discusses the early detection of lung cancer from a primary care perspective. We outline risk factors and epidemiology, the role of screening and offer guidance on the recognition of symptomatic presentation and the investigation and referral of suspected lung cancer.
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Sullivan SA, Hamilton W, Tilling K, Redaniel T, Moran P, Lewis G. Association of Primary Care Consultation Patterns With Early Signs and Symptoms of Psychosis. JAMA Netw Open 2018; 1:e185174. [PMID: 30646393 PMCID: PMC6324409 DOI: 10.1001/jamanetworkopen.2018.5174] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
IMPORTANCE Primary care is an important part of the care pathway for patients with psychosis; therefore, primary care physicians need to be able to accurately identify those at clinical high risk of psychosis. The difficulty of this task is increased because clinical high-risk symptoms are frequently nonspecific to psychosis. OBJECTIVE To determine whether the consultation patterns for a prespecified set of symptoms can be used to identify primary care patients who later developed a psychotic illness. DESIGN, SETTING, AND PARTICIPANTS This nested case-control study used primary care consultation data collected from 530 primary care practices in 13 UK regions from January 1, 2000, through September 30, 2009. Participants included 11 690 adults with a diagnosis of psychosis and 81 793 control participants who did not have a diagnosis of psychosis individually matched by age group, sex, and primary care practice. Data were analyzed from July 1, 2015, through June 2, 2017. EXPOSURES Prespecified symptoms selected from literature included attention-deficit/hyperactivity disorder-like symptoms, bizarre behavior, blunted affect, problems associated with cannabis, depressive symptoms, role functioning problems, social isolation, symptoms of mania, obsessive-compulsive disorder-like symptoms, disordered personal hygiene, sleep disturbance, problems associated with cigarette smoking, and suicidal behavior (including self-harm). MAIN OUTCOMES AND MEASURES Case (diagnosis of psychosis) or control (no diagnosis of psychosis) status. Conditional logistic regression was used to investigate the association between symptoms and case-control status in the 5 years before diagnosis. Positive predictive values (PPVs) were calculated using the Bayes theorem for symptoms stratified by age group and sex. Repeated-measures Poisson regression was used to investigate symptom consultation rate. RESULTS Of the total sample of 93 483 participants, 57.4% were female and 40.0% were older than 60 years (mean [SD] age, 51.34 [21.75] years). Twelve symptoms were associated with a later psychotic diagnosis (all prespecified symptoms except disordered personal hygiene). The strongest association was with suicidal behavior (odds ratio [OR], 19.06; 95% CI, 16.55-21.95). Positive predictive values were heterogeneous across age and sex. The highest PPVs were for suicidal behavior (33.0% in men 24 years or younger [95% CI, 24.2%-43.2%] and 19.6% in women aged 25-34 years [95% CI, 13.7%-27.2%]). Pairs of symptoms were associated with an increase in PPV. Consultation rates were higher in cases and increased 3 months before diagnosis. CONCLUSIONS AND RELEVANCE Most of the preselected nonspecific symptoms were associated with a later psychotic diagnosis, particularly among young men consulting for suicidal behavior, especially if consulting with increasing frequency. These symptoms should alert physicians to patients who may benefit from a further assessment of psychotic symptoms.
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Affiliation(s)
- Sarah A. Sullivan
- Centre for Academic Primary Care, University of Bristol, Bristol, United Kingdom
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West, University Hospitals Bristol National Health Service Foundation Trust, University of Bristol, Bristol, United Kingdom
| | - William Hamilton
- Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Kate Tilling
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West, University Hospitals Bristol National Health Service Foundation Trust, University of Bristol, Bristol, United Kingdom
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Theresa Redaniel
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West, University Hospitals Bristol National Health Service Foundation Trust, University of Bristol, Bristol, United Kingdom
| | - Paul Moran
- Centre for Academic Mental Health, University of Bristol, Bristol, United Kingdom
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, United Kingdom
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Nielsen N, Vedsted P, Jensen H. Risk of cancer and repeated urgent referral after negative investigation for cancer. Fam Pract 2018; 35:582-588. [PMID: 29420706 DOI: 10.1093/fampra/cmx138] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Many countries have implemented cancer patient pathways (CPPs) for organ-specific cancers. However, due to high symptom diversity, it can be difficult for the General Practitioner (GP) to decide on the appropriate CPP. OBJECTIVE The aim of this study was to estimate the proportion of patients who were referred to a second CPP, were diagnosed with cancer or died within 6 months after receiving a negative result from clinical investigation through an initial CPP. METHODS We conducted a historical cohort study using routinely collected data with 6 months of follow-up. Data were collected from Danish registries. RESULTS We included 109998 study subjects: 0.6% received a cancer diagnosis, 2.3% died and 6.1% were referred to a second CPP within 6 months. A total of 48.9% of the re-referrals after a first CPP in the gastrointestinal (GI) area were also referred to a second CPP in the GI area. Re-referral to a second CPP corresponded to a positive predictive value (PPV) of 4.4% to be diagnosed with cancer. CONCLUSION A total of 6% of patients who received a negative result after investigation in an organ-specific CPP were re-referred within 6 months to a new organ-specific CPP; many of these were in the same anatomical area as the first CPP. The PPV of 4.4% to be diagnosed with cancer indicates that some cancers may be missed in the diagnostic investigation through the first CPP. This calls for reconsideration of how CPPs may best support the primary cancer diagnosis.
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Affiliation(s)
- Ninna Nielsen
- Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark.,Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Henry Jensen
- Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark.,Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Aarhus, Denmark
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Solvang M, Elnegaard S, Jarbøl DE. Urological symptoms among 23,240 men in the general danish population - concerns about symptoms, their persistence and influence on primary care contacts. Scand J Prim Health Care 2018; 36:227-236. [PMID: 30043660 PMCID: PMC6381536 DOI: 10.1080/02813432.2018.1487377] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To analyse possible associations between men's likelihood of contacting a general practitioner (GP) for urological symptoms and the persistence of the symptoms, the influence on daily activities and the level of concern about the symptoms. DESIGN Web-based nationwide cross-sectional questionnaire study. SETTING The general population in Denmark. SUBJECTS 48,910 randomly selected men aged 20+ years. MAIN OUTCOME MEASURES Urological symptom prevalence and odds ratios for GP contact with urological symptoms in regard to concern for the symptom, influence on daily activities and the persistence of the symptom. RESULTS Some 23,240 men responded to the questionnaire, yielding a response rate of 49.8%. The prevalence of at least one urological symptom was 59.9%. Among men experiencing at least one urological symptom almost one-fourth reported contact to general practice regarding the symptom. Approximately half of the symptoms reported to be extremely concerning were discussed with a GP. CONCLUSION Increased symptom concern, influence on daily activities and long-term persistence increased the likelihood of contacting a GP with urological symptoms. This research points out that guidelines for PSA testing might be challenged by the high prevalence of urological symptoms. Key points The decision process of whether to contact the general practitioner (GP) is influenced by different factors, but contradictory results has been found in triggers and barriers for help-seeking with urological symptoms. • Increased symptom concern, influence on daily activities and long-term persistence consistently increased the likelihood of contacting a general practitioner with urological symptoms in men. • Only 50% of the symptoms reported to be extremely concerning were however discussed with the GP. • Guidelines for PSA testing might be challenged by the high prevalence of urological symptoms.
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Affiliation(s)
| | - Sandra Elnegaard
- Research Unit of General Practice, University of Southern Denmar
| | - Dorte Ejg Jarbøl
- Research Unit of General Practice, University of Southern Denmar
- CONTACT Dorte Ejg Jarbøl J.B. Winsløws Vej 9A, 5000Odense C, Denmark
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Jarbøl DE, Rasmussen S, Svendsen RP, Balasubramaniam K, Haastrup PF, Petersen MS, Fallah M, Elnegaard S. Barriers to contacting general practice with alarm symptoms of colorectal cancer: a population-based study. Fam Pract 2018; 35:399-405. [PMID: 29240888 DOI: 10.1093/fampra/cmx117] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A prerequisite for general practitioners (GPs) being able to refer patients with cancer alarm symptoms for further investigations is that individuals present to the GP. Knowledge of barriers to help-seeking is, however, sparse. Objectives. The aim of this study was to analyse associations between the experience of recent-onset alarm symptom of colorectal cancer and four different barriers towards GP contact. METHODS A nationwide web-based cohort survey was conducted in 100000 individuals aged 20 years or above, randomly selected from the Danish Civil Registration System. Items regarding experience of four predefined alarm symptoms of colorectal cancer (rectal bleeding, abdominal pain, change in stool texture and change in stool frequency), decisions about contact to GPs and barriers towards GP contact were included. RESULTS A total of 37455 respondents over 40 years (51.8%) completed the questionnaire. The proportion of individuals with no contact to the GP varied between 69.8% and 79.8% for rectal bleeding and change in stool frequency, respectively. The most widely reported barriers were being worried about wasting the doctor's time and being too busy to make time to visit the doctor. Men with rectal bleeding significantly more often reported being worried about what the doctor might find. The proportion of individuals who reported barriers was, in general, higher among the youngest age group. CONCLUSION Barriers to contacting the GP were frequent when experiencing alarm symptoms of colorectal cancer. Reporting the different barriers was significantly associated with gender and age.
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Affiliation(s)
- Dorte E Jarbøl
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Sanne Rasmussen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Rikke P Svendsen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Kirubakaran Balasubramaniam
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Peter F Haastrup
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | | | | | - Sandra Elnegaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Decision support for diagnosis should become routine in 21st century primary care. Br J Gen Pract 2018; 67:494-495. [PMID: 29074677 DOI: 10.3399/bjgp17x693185] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Nieroda ME, Lophatananon A, McMillan B, Chen LC, Hughes J, Daniels R, Clark J, Rogers S, Muir KR. Online Decision Support Tool for Personalized Cancer Symptom Checking in the Community (REACT): Acceptability, Feasibility, and Usability Study. JMIR Cancer 2018; 4:e10073. [PMID: 29973334 PMCID: PMC6053613 DOI: 10.2196/10073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/30/2018] [Accepted: 05/08/2018] [Indexed: 01/11/2023] Open
Abstract
Background Improving cancer survival in the UK, despite recent significant gains, remains a huge challenge. This can be attributed to, at least in part, patient and diagnostic delays, when patients are unaware they are suffering from a cancerous symptom and therefore do not visit a general practitioner promptly and/or when general practitioners fail to investigate the symptom or refer promptly. To raise awareness of symptoms that may potentially be indicative of underlying cancer among members of the public a symptom-based risk assessment model (developed for medical practitioner use and currently only used by some UK general practitioners) was utilized to develop a risk assessment tool to be offered to the public in community settings. Such a tool could help individuals recognize a symptom, which may potentially indicate cancer, faster and reduce the time taken to visit to their general practitioner. In this paper we report results about the design and development of the REACT (Risk Estimation for Additional Cancer Testing) website, a tool to be used in a community setting allowing users to complete an online questionnaire and obtain personalized cancer symptom-based risk estimation. Objective The objectives of this study are to evaluate (1) the acceptability of REACT among the public and health care practitioners, (2) the usability of the REACT website, (3) the presentation of personalized cancer risk on the website, and (4) potential approaches to adopt REACT into community health care services in the UK. Methods Our research consisted of multiple stages involving members of the public (n=39) and health care practitioners (n=20) in the UK. Data were collected between June 2017 and January 2018. User views were collected by (1) the “think-aloud” approach when participants using the website were asked to talk about their perceptions and feelings in relation to the website, and (2) self-reporting of website experiences through open-ended questionnaires. Data collection and data analysis continued simultaneously, allowing for website iterations between different points of data collection. Results The results demonstrate the need for such a tool. Participants suggest the best way to offer REACT is through a guided approach, with a health care practitioner (eg, pharmacist or National Health Service Health Check nurse) present during the process of risk evaluation. User feedback, which was generally consistent across members of public and health care practitioners, has been used to inform the development of the website. The most important aspects were: simplicity, ability to evaluate multiple cancers, content emphasizing an inviting community “feel,” use (when possible) of layperson language in the symptom screening questionnaire, and a robust and positive approach to cancer communication relying on visual risk representation both with affected individuals and the entire population at risk. Conclusions This study illustrates the benefits of involving public and stakeholders in developing and implementing a simple cancer symptom check tool within community. It also offers insights and design suggestions for user-friendly interfaces of similar health care Web-based services, especially those involving personalized risk estimation.
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Affiliation(s)
- Marzena Ewa Nieroda
- Division of Management Sciences and Marketing, Alliance Manchester Business School, The University of Manchester, Manchester, United Kingdom
| | - Artitaya Lophatananon
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Brian McMillan
- Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Li-Chia Chen
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - John Hughes
- IT Services, University of Manchester, Manchester, United Kingdom
| | - Rona Daniels
- REACT project, University of Manchester, Manchester, United Kingdom
| | - James Clark
- Greater Manchester Cancer Vanguard Innovation, Manchester, United Kingdom
| | - Simon Rogers
- Bodey Medical Centre, Manchester, United Kingdom
| | - Kenneth Ross Muir
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
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Larsen MB, Njor S, Ingeholm P, Andersen B. Effectiveness of Colorectal Cancer Screening in Detecting Earlier-Stage Disease-A Nationwide Cohort Study in Denmark. Gastroenterology 2018; 155:99-106. [PMID: 29626451 DOI: 10.1053/j.gastro.2018.03.062] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 03/15/2018] [Accepted: 03/28/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Most studies of the effectiveness of screening for colorectal cancer (CRC) using the fecal occult blood test tested the guaiac fecal occult blood test. However, the fecal immunochemical test (FIT) is now commonly used in screening. We aimed to evaluate the effectiveness of FIT-based screening for CRC on the number of incident CRC diagnoses and stage at diagnosis for individuals in Denmark who were invited for screening vs not yet invited. METHODS We collected data for this register-based retrospective cohort study during the first 16 months of the prevalence round of a FIT-based CRC screening program (March 1, 2014 through June 30, 2015). A total of 402,826 residents of Denmark (50-72 years old) were randomly invited to undergo CRC screening within the study period, and 956,514 were invited thereafter. We obtained information on CRC diagnosis, date, and stage at diagnosis from the Danish Colorectal Cancer Group database. Cancer incidence per 100,000 invited/not yet invited individuals was calculated, along with the relative risk (RR) of CRC among invited compared with not yet invited individuals. RESULTS CRC incidence during the study period was 339.4/100,000 invited individuals and 169.6/100,000 not yet invited individuals. CRC incidence increased with age among invited and not yet invited individuals. For invited women compared with not yet invited women, the RR of being diagnosed with stage I CRC was 3.39 (95% CI, 2.61-4.39), with stage II CRC was 2.16 (95% CI, 1.71-2.72), with stage III CRC was 1.37 (95% CI, 1.08-1.75), and with stage IV CRC was 0.92 (95% CI, 0.68-1.23). For invited men compared with not yet invited men, the RR of being diagnosed with stage I CRC was 3.71 (95% CI, 2.97-4.64); with stage II CRC was 2.26 (95% CI, 1.84-2.77), with stage III CRC was 1.88 (95% CI, 1.53-2.30), and with stage IV CRC was 1.20 (95% CI, 0.95-1.52). CONCLUSIONS In analyzing data from a register-based cohort study in Denmark, we found that inviting individuals to undergo FIT-based CRC screening led to detection of almost 2-fold more cases of CRC than not inviting participants. The significant increase of CRC incidence among those invited for screening indicates a need for awareness of treatment capacity in countries introducing FIT-based CRC screening.
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Affiliation(s)
- Mette Bach Larsen
- Department of Public Health Programmes, Randers Regional Hospital, Central Denmark Region, Randers NØ, Denmark.
| | - Sisse Njor
- Department of Public Health Programmes, Randers Regional Hospital, Central Denmark Region, Randers NØ, Denmark
| | - Peter Ingeholm
- Department of Pathology, Herlev Hospital, Capital Region of Denmark, Herlev, Denmark
| | - Berit Andersen
- Department of Public Health Programmes, Randers Regional Hospital, Central Denmark Region, Randers NØ, Denmark
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Mashlab S, Large P, Laing W, Ng O, D’Auria M, Thurston D, Thomson S, Acheson AG, Humes DJ, Banerjea A. Anaemia as a risk stratification tool for symptomatic patients referred via the two-week wait pathway for colorectal cancer. Ann R Coll Surg Engl 2018; 100:350-356. [PMID: 29543046 PMCID: PMC5956597 DOI: 10.1308/rcsann.2018.0030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2017] [Indexed: 01/12/2023] Open
Abstract
Introduction Anaemia is associated with cancer. In 2014 a new form was introduced in our department requesting a haemoglobin (Hb) result on every two-week wait referral for suspected colorectal cancer (CRC). The aim of this study was to review the impact of this intervention. In particular, the significance of any evidence of anaemia (without additional indices) was investigated. Methods A review was conducted of 1,500 consecutive suspected CRC referrals recorded prospectively over a 10-month period. Data on demographics, referral Hb, referral criteria and outcomes were analysed. Anaemia was defined according to World Health Organization criteria (Hb <120g/l for women, Hb <130g/l for men). Results Overall, 1,015 patients were eligible for inclusion in the study. Over a third (38.2%) were documented as anaemic on referral. These patients were three times more likely to be diagnosed with CRC than non-anaemic patients (odds ratio [OR]: 3.22, 95% confidence interval [CI]: 1.87-5.57). Using a more stringent threshold (Hb <100g/l for women and <110g/l for men), they were four times more likely to have CRC (OR: 4.27, 95% CI: 2.35-7.75). Almost a quarter (23.7%) were actually anaemic at the time of referral but not referred with anaemia. In this subgroup, there was a 2.8-fold increase in risk of CRC diagnosis compared with non-anaemic patients (adjusted OR: 2.77, 95% CI: 1.55-4.95). Conclusions Nearly a quarter of patients not referred with iron deficiency anaemia had evidence of anaemia and this was still associated with a higher rate of CRC detection. A full blood count alone might help to risk stratify symptoms such as change in bowel habit in patients on urgent pathways and identify those cases most likely to benefit from invasive investigation.
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Affiliation(s)
- S Mashlab
- Nottingham University Hospitals NHS Trust, UK
| | - P Large
- Nottingham University Hospitals NHS Trust, UK
| | - W Laing
- Nottingham University Hospitals NHS Trust, UK
| | - O Ng
- Nottingham University Hospitals NHS Trust, UK
| | - M D’Auria
- Nottingham University Hospitals NHS Trust, UK
| | - D Thurston
- Nottingham University Hospitals NHS Trust, UK
| | - S Thomson
- Nottingham University Hospitals NHS Trust, UK
| | - AG Acheson
- Nottingham University Hospitals NHS Trust, UK
| | - DJ Humes
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - A Banerjea
- Nottingham University Hospitals NHS Trust, UK
| | - On behalf of the Nottingham Colorectal Service
- Non-author contributors: J Abercrombie, S Asgari, B Bharathan, R Briggs, H Edis, C Maxwell-Armstrong, K Mohiuddin, M Robinson, J Scholefield, K Thomas, K Walter, J Williams
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Abdominal symptoms and cancer in the abdomen: prospective cohort study in European primary care. Br J Gen Pract 2018; 68:e301-e310. [PMID: 29632003 DOI: 10.3399/bjgp18x695777] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 11/20/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Different abdominal symptoms may signal cancer, but their role is unclear. AIM To examine associations between abdominal symptoms and subsequent cancer diagnosed in the abdominal region. DESIGN AND SETTING Prospective cohort study comprising 493 GPs from surgeries in Norway, Denmark, Sweden, Scotland, Belgium, and the Netherlands. METHOD Over a 10-day period, the GPs recorded consecutive consultations and noted: patients who presented with abdominal symptoms pre-specified on the registration form; additional data on non-specific symptoms; and features of the consultation. Eight months later, data on all cancer diagnoses among all study patients in the participating general practices were requested from the GPs. RESULTS Consultations with 61 802 patients were recorded and abdominal symptoms were documented in 6264 (10.1%) patients. Malignancy, both abdominal and non-abdominal, was subsequently diagnosed in 511 patients (0.8%). Among patients with a new cancer in the abdomen (n = 251), 175 (69.7%) were diagnosed within 180 days after consultation. In a multivariate model, the highest sex- and age-adjusted hazard ratio (HR) was for the single symptom of rectal bleeding (HR 19.1, 95% confidence interval = 8.7 to 41.7). Positive predictive values of >3% were found for macroscopic haematuria, rectal bleeding, and involuntary weight loss, with variations according to age and sex. The three symptoms relating to irregular bleeding had particularly high specificity in terms of colorectal, uterine, and bladder cancer. CONCLUSIONS A patient with undiagnosed cancer may present with symptoms or no symptoms. Irregular bleeding must always be explained. Abdominal pain occurs with all types of abdominal cancer and several symptoms may signal colorectal cancer. The findings are important as they influence how GPs think and act, and how they can contribute to an earlier diagnosis of cancer.
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Rubin G, Walter F, Emery J, de Wit N. Reimagining the diagnostic pathway for gastrointestinal cancer. Nat Rev Gastroenterol Hepatol 2018; 15:181-188. [PMID: 29410534 DOI: 10.1038/nrgastro.2018.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A crisis is looming for the diagnosis of gastrointestinal cancers, one grounded only partly in the steady increase in their overall incidence. Public demand for diagnostic tests to be undertaken early and at lower levels of risk is reflected in early diagnosis being a widely held policy objective for reasons of both clinical outcome and patient experience. In the UK, urgent referrals for suspected lower gastrointestinal cancer have increased by 78% in the past 6 years, with parallel increases in endoscopy and imaging activity. Such growth in demand is unsustainable with current models of care. If gastrointestinal cancer diagnosis is to be affordable, the roles of professionals and their interactions with each other will need to be reframed while retaining public confidence in the process. In this Perspective, we consider how the relationship between medical specialists and generalists could be redefined to make better use of the skills of each while delivering optimal clinical outcomes and a good patient experience.
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Affiliation(s)
- Greg Rubin
- Institute of Health and Society, Newcastle University, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK
| | - Fiona Walter
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Jon Emery
- Centre for Cancer Research and Department of General Practice, University of Melbourne, Victoria Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3010, Australia
| | - Niek de Wit
- Julius Center for Health Sciences and Primary Care University Medical Center, Utrecht, Netherlands
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Osses DF, Alberts AR, Bausch GCF, Roobol MJ. Multivariable risk-based patient selection for prostate biopsy in a primary health care setting: referral rate and biopsy results from a urology outpatient clinic. Transl Androl Urol 2018; 7:27-33. [PMID: 29594017 PMCID: PMC5861274 DOI: 10.21037/tau.2017.12.11] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background According to their guidelines, Dutch general practitioners (GPs) refer men with prostate-specific antigen (PSA) level ≥3.0 ng/mL to the urologist for risk-based patient selection for prostate biopsy using the Rotterdam Prostate Cancer Risk Calculator (RPCRC). Use of the RPCRC in primary care could optimize the diagnostic pathway even further by reducing unnecessary referrals. To investigate this, we calculated the risk and assessed the rate of men referred to the urologist with PSA level ≥3.0 ng/mL by implementing the RPCRC in a primary health care setting. Methods In January 2014, an exploratory study was initiated in collaboration with the primary health care facility of the GP laboratory in Rotterdam. GPs were given the possibility to refer men with a suspicion of prostate cancer (PCa) or a screening wish to this primary care facility (STAR-SHL) where further assessment was performed by specially trained personnel. Risk-based advice on referral to the urologist was given to the GP on the basis of the RPCRC results. If requested, advice on the treatment of lower urinary tract symptoms (LUTS) was provided. All men signed informed consent. Results Between January 2014 and September 2017, a total of 243 men, median age 64 [interquartile range (IQR), 57-70] years were referred for a consultation at the primary care facility. Of the 108 men with PSA level ≥3.0 ng/mL and a referral related to PCa, GPs were advised to refer 58 men to the urologist (54%). Of the men with available follow-up (FU) data [n=187, median FU, 16 (IQR, 9-25) months] 54 men were considered high-risk (i.e., had an elevated risk of PCa as calculated by the RPCRC). Of these men, 51 (94%) were actually referred to secondary care by their GP, and so far 38 men underwent biopsy. PCa was detected in 30 men [47% had Gleason score (GS) ≥3+4 PCa], translating to an overall positive predictive value (PPV) of 79%. Within the available FU time, 2 out of 38 (5%) men with PSA level ≥3.0 ng/mL which were considered low-risk have been diagnosed with GS 3+3 PCa. Conclusions Risk-stratification with the RPCRC in a primary health care setting could prevent almost half of referrals of men with PSA level ≥3.0 ng/mL to the urologist. In more than three-quarters of men referred for prostate biopsy, the suspicion of PCa was confirmed and almost half of men had clinically significant PCa (GS ≥3+4 PCa). These data show a huge potential for multivariable risk-stratification in primary care.
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Affiliation(s)
- Daniël F Osses
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Arnout R Alberts
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gonny C F Bausch
- STAR-SHL Medical Diagnostic Center, GP laboratory, Rotterdam, The Netherlands
| | - Monique J Roobol
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Nicholson BD, Oke J, Friedemann Smith C, Phillips JA, Lee J, Abel L, Kelly S, Gould I, Mackay T, Kaveney Z, Anthony S, Hayles S, Lasserson D, Gleeson F. The Suspected CANcer (SCAN) pathway: protocol for evaluating a new standard of care for patients with non-specific symptoms of cancer. BMJ Open 2018; 8:e018168. [PMID: 29358427 PMCID: PMC5780707 DOI: 10.1136/bmjopen-2017-018168] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Cancer survival in England lags behind most European countries, due partly to lower rates of early stage diagnosis. We report the protocol for the evaluation of a multidisciplinary diagnostic centre-based pathway for the investigation of 'low-risk but not no-risk' cancer symptoms called the Suspected CANcer (SCAN) pathway. SCAN is a new standard of care being implemented in Oxfordshire; one of a number of pathways implemented during the second wave of the Accelerate, Coordinate, Evaluate (ACE) programme, an initiative which aims to improve England's cancer survival rates through establishing effective routes to early diagnosis. METHODS AND ANALYSIS To evaluate SCAN, we are collating a prospective database of patients referred onto the pathway by their general practitioner (GP). Patients aged over 40 years, with non-specific symptoms such as weight loss or fatigue, who do not meet urgent cancer referral criteria or for whom symptom causation remains unclear after investigation via other existing pathways, can be referred to SCAN. SCAN provides rapid CT scanning, laboratory testing and clinic review within 2 weeks. We will follow all patients in the primary and secondary care record for at least 2 years. The data will be used to understand the diagnostic yield of the SCAN pathway in the short term (28 days) and the long term (2 years). Routinely collected primary and secondary care data from patients not referred to SCAN but with similar symptoms will also be used to evaluate SCAN. We will map the routes to diagnosis for patients referred to SCAN to assess cost-effectiveness. Acceptability will be evaluated using patient and GP surveys. ETHICS AND DISSEMINATION The Oxford Joint Research Office Study Classification Group has judged this to be a service evaluation and so outside of research governance. The results of this project will be disseminated by peer-reviewed publication and presentation at conferences.
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Affiliation(s)
- Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jason Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | - Jennifer Lee
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lucy Abel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sadie Kelly
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Isabella Gould
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Toni Mackay
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Zoe Kaveney
- Delivery and Localities Directorate, Oxfordshire Clinical Commissioning Group, Oxford, UK
| | - Suzie Anthony
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Shelley Hayles
- Delivery and Localities Directorate, Oxfordshire Clinical Commissioning Group, Oxford, UK
| | - Daniel Lasserson
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Fergus Gleeson
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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78
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Nicholson BD, Aveyard P, Hobbs FDR, Smith M, Fuller A, Perera R, Hamilton W, Stevens S, Bankhead CR. Weight loss as a predictor of cancer and serious disease in primary care: an ISAC-approved CPRD protocol for a retrospective cohort study using routinely collected primary care data from the UK. Diagn Progn Res 2018; 2:1. [PMID: 31093551 PMCID: PMC6460783 DOI: 10.1186/s41512-017-0019-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 11/16/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Unexpected weight loss is a symptom of serious disease in primary care, for example between 1 in 200 and 1 in 30 patients with unexpected weight loss go on to develop cancer. However, it remains unclear how and when general practitioners (GPs) should investigate unexpected weight loss. Without clarification, GPs may wait too long before referring (choosing to watch and wait and potentially missing a diagnosis) or not long enough (overburdening hospital services and exposing patients to the risks of investigation). The overall aim of this study is to provide the evidence necessary to allow GPs to more effectively manage patients with unexpected weight loss. METHODS A retrospective cohort analysis of UK Clinical Practice Research Datalink (CPRD) data to: (1) describe how often in UK primary care the symptom of reported weight loss is coded, when weight is measured, and how GPs respond to a patient attending with unexpected weight loss; (2) identify the predictive value of recorded weight loss for cancer and serious disease in primary care, using cumulative incidence plots to compare outcomes between subgroups and Cox regression to explore and adjust for covariates. Preliminary work in CPRD estimates that weight loss as a symptom is recorded for approximately 148,000 eligible patients > 18 years and is distributed evenly across decades of age, providing adequate statistical power and precision in relation to cancer overall and common cancers individually. Further stratification by cancer stage will be attempted but may not be possible as not all practices within CPRD are eligible for cancer registry linkage, and staging information is often incomplete. The feasibility of using multiple imputation to address missing covariate values will be explored. DISCUSSION This will be the largest reported retrospective cohort of primary care patients with weight measurements and unexpected weight loss codes used to understand the association between weight measurement, unexpected weight loss, and serious disease including cancer. Our findings will directly inform international guidelines for the management of unexpected weight loss in primary care populations.
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Affiliation(s)
- B. D. Nicholson
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG UK
| | - P. Aveyard
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG UK
| | - F. D. R. Hobbs
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG UK
| | - M. Smith
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG UK
| | - A. Fuller
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG UK
| | - R. Perera
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG UK
| | - W. Hamilton
- 0000 0004 1936 8024grid.8391.3University of Exeter, Medical School, St Luke’s Campus, Exeter, EX1 2LU UK
| | - S. Stevens
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG UK
| | - C. R. Bankhead
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG UK
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The researchers' role in knowledge translation: a realist evaluation of the development and implementation of diagnostic pathways for cancer in two United Kingdom localities. Health Res Policy Syst 2017; 15:103. [PMID: 29237463 PMCID: PMC5729249 DOI: 10.1186/s12961-017-0267-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 11/21/2017] [Indexed: 02/03/2023] Open
Abstract
Background In examining an initiative to develop and implement new cancer diagnostic pathways in two English localities, this paper evaluates ‘what works’ and examines the role of researchers in facilitating knowledge translation amongst teams of local clinicians and policy-makers. Methods Using realist evaluation with a mixed methods case study approach, we conducted documentary analysis of meeting minutes and pathway iterations to map pathway development. We interviewed 14 participants to identify the contexts, mechanisms and outcomes (CMOs) that led to successful pathway development and implementation. Interviews were analysed thematically and four CMO configurations were developed. Results One site produced three fully implemented pathways, while the other produced two that were partly implemented. In explaining the differences, we found that a respected, independent, well-connected leader modelling partnership working and who facilitates a local, stable group that agree about the legitimacy of the data and project (context) can empower local teams to become sufficiently autonomous (mechanism) to develop and implement research-based pathways (outcome). Although both teams designed relevant, research-based cancer pathways, in the site where the pathways were successfully implemented the research team merely assisted, while, in the other, the research team drove the initiative. Conclusion Based on our study findings, local stakeholders can apply local and research knowledge to develop and implement research-based pathways. However, success will depend on how academics empower local teams to create autonomy. Crucially, after re-packaging and translating research for local circumstances, identifying fertile environments with the right elements for implementation and developing collaborative relationships with local leaders, academics must step back. Electronic supplementary material The online version of this article (doi:10.1186/s12961-017-0267-8) contains supplementary material, which is available to authorized users.
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Possible missed opportunities for diagnosing colorectal cancer in Dutch primary care: a multimethods approach. Br J Gen Pract 2017; 68:e54-e62. [PMID: 29203683 DOI: 10.3399/bjgp17x693905] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 10/11/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Early detection of colorectal cancer (CRC) is important to achieve better survival. Discriminating symptoms suggestive of CRC from benign conditions is a challenge for GPs because most known 'alarm symptoms' have low predictive values. AIM To further understand the diagnostic process of CRC in general practice in terms of healthcare use and by analysing factors related to diagnostic intervals. DESIGN AND SETTING A multimethod approach comprising a historical, prospective registry study and qualitative content analysis. METHOD Healthcare use in the year before referral for colonoscopy was compared between patients diagnosed with CRC and an age-, sex,- and GP-matched control population. Qualitative content analysis was performed on free texts in electronic patient records from a purposive sample of patients with CRC. RESULTS Patients with CRC (n = 287) had 41% (25-59%) more face-to-face contacts and 21% (7-37%) more medication prescriptions than controls (n = 828). Forty-six per cent of patients with CRC had two or more contacts for digestive reasons, compared with 12.2% of controls, more often for symptoms than diagnoses. From qualitative analysis two themes emerged: 'possible missed diagnostic opportunities' and 'improvements in diagnostic process unlikely'. Possible missed diagnostic opportunities were related to patients waiting before presenting symptoms, doctors attributing symptoms to comorbid conditions or medication use, or doctors sticking to an initial diagnosis. CONCLUSION Fewer missed diagnostic opportunities might occur if GPs are aware of pitfalls in diagnosing CRC: the assumption that symptoms are caused by comorbid conditions or medication, or relating complaints to pre-existing medical conditions. GPs also need to be aware that repeated digestive complaints warrant rethinking an earlier diagnosis.
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81
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Næser E, Møller H, Fredberg U, Frystyk J, Vedsted P. Routine blood tests and probability of cancer in patients referred with non-specific serious symptoms: a cohort study. BMC Cancer 2017; 17:817. [PMID: 29202799 PMCID: PMC5715646 DOI: 10.1186/s12885-017-3845-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 11/24/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Danish cancer patients have lower survival rates than patients in many other western countries. Half of the patients present with non-alarm symptoms and thus have a long diagnostic pathway. Consequently, an urgent referral pathway for patients with non-specific serious symptoms was implemented throughout Denmark in 2011-2012. As part of the diagnostic workup, a panel of blood tests are performed for all patients referred by their general practitioner (GP) to the urgent referral pathway. In this study, we analysed the probability of being diagnosed with cancer in GP-referred patients with abnormal blood test results. METHOD We performed a cohort study that included all patients aged 18 years or older referred by their GP to Silkeborg Regional Hospital for analysis of a panel of blood tests. All patients were followed for 3 months for a cancer diagnosis in the Danish Cancer Registry. The likelihood ratio and post-test probability of subsequently finding cancer were calculated in relation to abnormal blood test results. RESULTS Among the 1499 patients included in the study, 12.2% were subsequently diagnosed with cancer. The probability of cancer increased with the number of abnormal blood tests. Patients with specific combinations of two abnormal blood tests had a 23-62% probability of cancer. Only a few single abnormal blood tests were linked with a high post-test probability of cancer, and most abnormalities were not specific to cancer. CONCLUSIONS A number of specific abnormal blood tests and combinations of abnormal blood tests markedly increased the probability of cancer being diagnosed. Still, abnormal blood test results should be interpreted cautiously as most are non-specific to cancer. Thus, results from the blood test panel may strengthen the suspicion of cancer, but blood tests cannot be used as a stand-alone tool to rule out cancer.
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Affiliation(s)
- Esben Næser
- Department of Public Health, Research Unit for General Practice, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark. .,Department of Public Health, Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark. .,Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 1-3, 8600, Silkeborg, Denmark.
| | - Henrik Møller
- Department of Public Health, Research Unit for General Practice, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.,Department of Public Health, Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.,Cancer Epidemiology and Population Health, Kings College London, Great Maze Pond, London, SE1 9RT, UK
| | - Ulrich Fredberg
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 1-3, 8600, Silkeborg, Denmark
| | - Jan Frystyk
- Department of Clinical Medicine, Medical Research Laboratory, Aarhus University, Nørrebrogade 44, 8000, Aarhus C, Denmark
| | - Peter Vedsted
- Department of Public Health, Research Unit for General Practice, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.,Department of Public Health, Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.,Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 1-3, 8600, Silkeborg, Denmark
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82
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Burton C, Iversen L, Bhattacharya S, Ayansina D, Saraswat L, Sleeman D. Pointers to earlier diagnosis of endometriosis: a nested case-control study using primary care electronic health records. Br J Gen Pract 2017; 67:e816-e823. [PMID: 29109114 PMCID: PMC5697551 DOI: 10.3399/bjgp17x693497] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 08/11/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Endometriosis is a condition with relatively non-specific symptoms, and in some cases a long time elapses from first-symptom presentation to diagnosis. AIM To develop and test new composite pointers to a diagnosis of endometriosis in primary care electronic records. DESIGN AND SETTING This is a nested case-control study of 366 cases using the Practice Team Information database of anonymised primary care electronic health records from Scotland. Data were analysed from 366 cases of endometriosis between 1994 and 2010, and two sets of age and GP practice matched controls: (a) 1453 randomly selected females and (b) 610 females whose records contained codes indicating consultation for gynaecological symptoms. METHOD Composite pointers comprised patterns of symptoms, prescribing, or investigations, in combination or over time. Conditional logistic regression was used to examine the presence of both new and established pointers during the 3 years before diagnosis of endometriosis and to identify time of appearance. RESULTS A number of composite pointers that were strongly predictive of endometriosis were observed. These included pain and menstrual symptoms occurring within the same year (odds ratio [OR] 6.5, 95% confidence interval [CI] = 3.9 to 10.6), and lower gastrointestinal symptoms occurring within 90 days of gynaecological pain (OR 6.1, 95% CI = 3.6 to 10.6). Although the association of infertility with endometriosis was only detectable in the year before diagnosis, several pain-related features were associated with endometriosis several years earlier. CONCLUSION Useful composite pointers to a diagnosis of endometriosis in GP records were identified. Some of these were present several years before the diagnosis and may be valuable targets for diagnostic support systems.
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Affiliation(s)
- Christopher Burton
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield; Institute of Applied Health Sciences, University of Aberdeen, Aberdeen
| | | | | | | | | | - Derek Sleeman
- Computing Sciences, Natural and Computing Sciences, University of Aberdeen, Aberdeen
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83
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Birks J, Bankhead C, Holt TA, Fuller A, Patnick J. Evaluation of a prediction model for colorectal cancer: retrospective analysis of 2.5 million patient records. Cancer Med 2017; 6:2453-2460. [PMID: 28941187 PMCID: PMC5633543 DOI: 10.1002/cam4.1183] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/26/2017] [Accepted: 08/12/2017] [Indexed: 12/14/2022] Open
Abstract
Earlier detection of colorectal cancer greatly improves prognosis, largely through surgical excision of neoplastic polyps. These include benign adenomas which can transform over time to malignant adenocarcinomas. This progression may be associated with changes in full blood count indices. An existing risk algorithm derived in Israel stratifies individuals according to colorectal cancer risk using full blood count data, but has not been validated in the UK. We undertook a retrospective analysis using the Clinical Practice Research Datalink. Patients aged over 40 with full blood count data were risk‐stratified and followed up for a diagnosis of colorectal cancer over a range of time intervals. The primary outcome was the area under the receiver operating characteristic curve for the 18–24‐month interval. We also undertook a case–control analysis (matching for age, sex, and year of risk score), and a cohort study of patients undergoing full blood count testing during 2012, to estimate predictive values. We included 2,550,119 patients. The area under the curve for the 18–24‐month interval was 0.776 [95% confidence interval (CI): 0.771, 0.781]. Performance improves as the time interval reduces. The area under the curve for the age‐matched case–control analysis was 0.583 [0.574, 0.591]. For the population risk‐scored in 2012, the positive predictive value at 99.5% specificity was 8.8% with negative predictive value 99.6%. The algorithm offers an additional means of identifying risk of colorectal cancer, and could support other approaches to early detection, including screening and active case finding.
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Affiliation(s)
- Jacqueline Birks
- Oxford Biomedical Research Centre, Oxford University, Botnar Research Institute, Windmill Rd, Oxford, OX7 3LD, United Kingdom
| | - Clare Bankhead
- Nuffield Department of Primary Care Health Sciences, Oxford University, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, United Kingdom
| | - Tim A Holt
- Nuffield Department of Primary Care Health Sciences, Oxford University, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, United Kingdom
| | - Alice Fuller
- Nuffield Department of Primary Care Health Sciences, Oxford University, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, United Kingdom
| | - Julietta Patnick
- Cancer Epidemiology Unit, Nuffield Department of Population Health, Oxford University, Richard Doll Building, Old Road Campus, Oxford, OX3 7LF, United Kingdom
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84
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Emery JD, Gray V, Walter FM, Cheetham S, Croager EJ, Slevin T, Saunders C, Threlfall T, Auret K, Nowak AK, Geelhoed E, Bulsara M, Holman CDJ. The Improving Rural Cancer Outcomes Trial: a cluster-randomised controlled trial of a complex intervention to reduce time to diagnosis in rural cancer patients in Western Australia. Br J Cancer 2017; 117:1459-1469. [PMID: 28926528 PMCID: PMC5680459 DOI: 10.1038/bjc.2017.310] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/19/2017] [Accepted: 08/14/2017] [Indexed: 11/28/2022] Open
Abstract
Background: Rural Australians have poorer survival for most common cancers, due partially to later diagnosis. Internationally, several initiatives to improve cancer outcomes have focused on earlier presentation to healthcare and timely diagnosis. We aimed to measure the effect of community-based symptom awareness and general practice-based educational interventions on the time to diagnosis in rural patients presenting with breast, prostate, colorectal or lung cancer in Western Australia. Methods: 2 × 2 factorial cluster randomised controlled trial. Community Intervention: cancer symptom awareness campaign tailored for rural Australians. GP intervention: resource card with symptom risk assessment charts and local cancer referral pathways implemented through multiple academic detailing visits. Trial Area A received the community symptom awareness and Trial Area B acted as the community campaign control region. Within both Trial Areas general practices were randomised to the GP intervention or control. Primary outcome: total diagnostic interval (TDI). Results: 1358 people with incident breast, prostate, colorectal or lung cancer were recruited. There were no significant differences in the median or ln mean TDI at either intervention level (community intervention vs control: median TDI 107.5 vs 92 days; ln mean difference 0.08 95% CI −0.06–0.23 P=0.27; GP intervention vs control: median TDI 97 vs 96.5 days; ln mean difference 0.004 95% CI −0.18–0.19 P=0.99). There were no significant differences in the TDI when analysed by factorial design, tumour group or sub-intervals of the TDI. Conclusions: This is the largest trial to test the effect of community campaign or GP interventions on timeliness of cancer diagnosis. We found no effect of either intervention. This may reflect limited dose of the interventions, or the limited duration of follow-up. Alternatively, these interventions do not have a measurable effect on time to cancer diagnosis.
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Affiliation(s)
- Jon D Emery
- Department of General Practice and The Centre for Cancer Research, The University of Melbourne, Melbourne, VIC, Australia.,School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, WA, Australia.,The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK
| | - Victoria Gray
- School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, WA, Australia.,School of Population Health, The University of Western Australia, Crawley, WA, Australia.,Education and Research Division, Cancer Council Western Australia, Subiaco, WA, Australia
| | - Fiona M Walter
- School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, WA, Australia.,The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK.,General Practice and Primary Health Care Academic Centre, Melbourne Medical School, The University of Melbourne, Melbourne, VIC, Australia
| | - Shelley Cheetham
- School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, WA, Australia.,School of Nursing, Midwifery and Paramedicine, Curtin University, Bentley, WA, Australia
| | - Emma J Croager
- Education & Research Division, Cancer Council Western Australia; School of Psychology and Speech Pathology, Curtin University, Bentley, WA, Australia
| | - Terry Slevin
- Education & Research Division, Cancer Council Western Australia; School of Psychology and Speech Pathology, Curtin University, Bentley, WA, Australia
| | - Christobel Saunders
- School of Surgery, The University of Western Australia, Crawley, WA, Australia
| | - Timothy Threlfall
- Western Australia Cancer Registry, The Department of Health of Western Australia, Perth, WA, Australia
| | - Kirsten Auret
- Rural Clinical School of Western Australia, The University of Western Australia, Albany, WA, Australia
| | - Anna K Nowak
- School of Medicine, The University of Western Australia, Crawley, WA, Australia.,Department of Medical Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Elizabeth Geelhoed
- School of Population Health, The University of Western Australia, Crawley, WA, Australia
| | - Max Bulsara
- Institute for Health Research, University of Notre Dame, Freemantle, WA, Australia
| | - C D'Arcy J Holman
- School of Population Health, The University of Western Australia, Crawley, WA, Australia
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85
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Burton CD, McLernon DJ, Lee AJ, Murchie P. Distinguishing variation in referral accuracy from referral threshold: analysis of a national dataset of referrals for suspected cancer. BMJ Open 2017; 7:e016439. [PMID: 28827254 PMCID: PMC5629656 DOI: 10.1136/bmjopen-2017-016439] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To distinguish between variation in referral threshold and variation in accurate selection of patients for referral in fast-track referrals for possible cancer. To examine factors associated with threshold and accuracy and model the effects of changing thresholds. DESIGN Analysis of national data on cancer referrals from general practices in England over a 5-year period. We developed a new method to estimate specificity of referral to complement existing sensitivity. We used bivariate meta-analysis to produce summary measures and described practices in relation to these. SETTING 5479 general practitioner (GP) practices with data relating to more than 50 cancer cases diagnosed over the 5 years. OUTCOMES Number of practices whose 95% confidence regions for sensitivity and specificity indicated that they were outliers in terms of either referral threshold or decision accuracy. RESULTS 2019 practices (36.8%) were outliers in relation to referral threshold compared with 1205 practices (22%) in relation to decision accuracy. Practice age profile, cancer incidence and deprivation showed a modest association with decision accuracy but not with thresholds. If all practices shared the referral behaviour of those in the highest quintile of age-standardised referral rate, there would be a 3.3% increase in cancers detected through fast-track pathways at the cost of a 36.9% increase in urgent referrals. CONCLUSION This new method permits variation in referral to be described more precisely and quality improvement activities to be targeted. Changing referral thresholds without increasing accuracy will result in modest effects on detection rates and a large increase in demand on diagnostic services.
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Affiliation(s)
| | - David J McLernon
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Amanda J Lee
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Peter Murchie
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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86
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Næser E, Fredberg U, Møller H, Vedsted P. Clinical characteristics and risk of serious disease in patients referred to a diagnostic centre: A cohort study. Cancer Epidemiol 2017; 50:158-165. [PMID: 28781173 DOI: 10.1016/j.canep.2017.07.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 07/26/2017] [Accepted: 07/27/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Little is known about the clinical characteristics of patients referred to a diagnostic centre through the Danish urgent referral pathway for non-specific serious symptoms. We aimed at estimating the distribution of serious disease and the diagnostic value of clinical characteristics for the diagnosis of cancer and serious non-malignant disease in these patients. METHOD A cohort study of 938 patients referred by their GP to the diagnostic centre at Silkeborg Regional Hospital. All patients were followed up for three months in national registries. The likelihood ratio (LR) of cancer or serious non-malignant disease were calculated in relation to clinical characteristics. RESULTS A total of 327 (34.9%) patients were diagnosed with new serious disease within three months: 118 patients (12.6%) with malignant disease and 209 patients (22.3%) with non-malignant disease. Most patients presented general symptoms. The highest LR of cancer was found for abdominal mass, high lactate dehydrogenase or abnormal findings in the diagnostic imaging. The highest LR of non-malignant disease was found for swollen joints or abnormal auscultation of lung or chest. CONCLUSIONS Patients referred by their GP to the diagnostic centre have high risk of serious disease. A multidisciplinary diagnostic approach is needed to embrace the diagnostic spectrum.
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Affiliation(s)
- Esben Næser
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark; Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark; Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 1-3, 8600 Silkeborg, Denmark.
| | - Ulrich Fredberg
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 1-3, 8600 Silkeborg, Denmark
| | - Henrik Møller
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark; Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark; Cancer Epidemiology and Population Health, King's College London, Great Maze Pond, London SE1 9RT, United Kingdom
| | - Peter Vedsted
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark; Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark; Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 1-3, 8600 Silkeborg, Denmark
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87
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Larsen MB, Mikkelsen EM, Rasmussen M, Friis-Hansen L, Ovesen AU, Rahr HB, Andersen B. Sociodemographic characteristics of nonparticipants in the Danish colorectal cancer screening program: a nationwide cross-sectional study. Clin Epidemiol 2017; 9:345-354. [PMID: 28721099 PMCID: PMC5500541 DOI: 10.2147/clep.s139168] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Fecal occult blood tests are recommended for colorectal cancer (CRC) screening in Europe. Recently, the fecal immunochemical test (FIT) has come into use. Sociodemographic differences between participants and nonparticipants may be less pronounced when using FIT as there are no preceding dietary restrictions and only one specimen is required. The aim of this study was to examine the associations between sociodemographic characteristics and nonparticipation for both genders, with special emphasis on those who actively unsubscribe from the program. METHODS The study was a national, register-based, cross-sectional study among men and women randomized to be invited to participate in the prevalence round of the Danish CRC screening program between March 1 and December 31, 2014. Prevalence ratios (PRs) were used to quantify the association between sociodemographic characteristics and nonparticipation (including active nonparticipation). PRs were assessed using Poisson regression with robust error variance. RESULTS The likelihood of being a nonparticipant was highest in the younger part of the population; however, for women, the association across age groups was U-shaped. Female immigrants were more likely to be nonparticipants. Living alone, being on social welfare, and having lower income were factors that were associated with nonparticipation among both men and women. For both men and women, there was a U-shaped association between education and nonparticipation. For both men and women, the likelihood of active nonparticipation rose with age; it was lowest among non-western immigrants and highest among social welfare recipients. CONCLUSION Social inequality in screening uptake was evident among both men and women in the Danish CRC screening program, even though the program is free of charge and the screening kit is based on FIT and mailed directly to the individuals. Interventions are needed to bridge this gap if CRC screening is to avoid aggravating existing inequalities in CRC-related morbidity and mortality.
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Affiliation(s)
- Mette Bach Larsen
- Department of Public Health Programmes, Randers Regional Hospital, Central Denmark Region, Randers NO
| | - Ellen M Mikkelsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Central Denmark Region, Aarhus N
| | - Morten Rasmussen
- Digestive Disease Center K, Bispebjerg Hospital, The Capital Region of Denmark, Copenhagen NV
| | - Lennart Friis-Hansen
- Department of Clinical Biochemistry, Nordsjællands Hospital, The Capital Region of Denmark, Hillerød
| | - Anders U Ovesen
- Department of Surgical Gastroenterology, Aalborg University Hospital, North Denmark Region, Aalborg
| | - Hans Bjarke Rahr
- Department of Surgery, Vejle Hospital, Region of Southern Denmark, Vejle, Denmark
| | - Berit Andersen
- Department of Public Health Programmes, Randers Regional Hospital, Central Denmark Region, Randers NO
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88
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Thompson MR, O'Leary DP, Flashman K, Asiimwe A, Ellis BG, Senapati A. Clinical assessment to determine the risk of bowel cancer using Symptoms, Age, Mass and Iron deficiency anaemia (SAMI). Br J Surg 2017. [PMID: 28634990 DOI: 10.1002/bjs.10573] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The aim of this study was to identify characteristics with independent predictive value for bowel cancer for use in the clinical assessment of patients attending colorectal outpatient clinics. METHODS This was a 22-year (1986-2007) retrospective cohort analysis of data collected prospectively from patients who attended colorectal surgical outpatient clinics in Portsmouth. The data set was split randomly into two groups of patients to generate and validate a predictive model. Multivariable logistic regression was used to create and validate a system to predict outcome. Receiver operating characteristic (ROC) curves and Hosmer-Lemeshow test were used to evaluate the model's predictive capability. The likelihood of bowel cancer was expressed as the odds ratio (OR). RESULTS Data from 29 005 patients were analysed. Discrimination of the model for bowel cancer was high in the development (C-statistic 0·87, 95 per cent c.i. 0·85 to 0·88) and validation (C-statistic 0·86, 0·84 to 0·87) groups. The most important co-variables in the final model were: age (OR 3·17-27·10), rectal (OR 31·48) or abdominal (OR 1·83-8·45) mass, iron deficiency anaemia (IDA) (OR 4·42-8·38), rectal bleeding and change in bowel habit in combination (OR 5·37), change in bowel habit without rectal bleeding, with or without abdominal pain (OR 2·12-2·52), and rectal bleeding with no perianal symptoms and without change in bowel habit (OR 2·91). Some 91·5 per cent of bowel cancers presented with these characteristics, 40·4 per cent with a mass and/or IDA. In patients with at least one of these characteristics the overall risk of having cancer was 10·0 (range 6·5-50·4) per cent, compared with 1·1 (0·3-2·3) per cent in patients without them. CONCLUSION A clinical assessment that systematically identifies or excludes four symptom-age combinations, a mass and IDA (SAMI) stratifies patients as having a low and higher risk of having bowel cancer. This could improve patient selection for referral and investigation.
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Affiliation(s)
- M R Thompson
- Department of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - D P O'Leary
- Department of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - K Flashman
- Department of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | | | - B G Ellis
- Swan Surgery General Practice, Petersfield, UK
| | - A Senapati
- Department of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
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89
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Larsen MB, Gabel P, Andersen B. Effectiveness of self-administered decision aids for people invited to participate in colorectal cancer screening: a systematic review protocol. ACTA ACUST UNITED AC 2017. [DOI: 10.11124/jbisrir-2016-002966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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90
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Sheringham J, Sequeira R, Myles J, Hamilton W, McDonnell J, Offman J, Duffy S, Raine R. Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes. BMJ Qual Saf 2017; 26:449-459. [PMID: 27651515 DOI: 10.1136/bmjqs-2016-005679] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/24/2016] [Accepted: 08/18/2016] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Lung cancer survival is low and comparatively poor in the UK. Patients with symptoms suggestive of lung cancer commonly consult primary care, but it is unclear how general practitioners (GPs) distinguish which patients require further investigation. This study examined how patients' clinical and sociodemographic characteristics influence GPs' decisions to initiate lung cancer investigations. METHODS A factorial experiment was conducted among a national sample of 227 English GPs using vignettes presented as simulated consultations. A multimedia-interactive website simulated key features of consultations using actors ('patients'). GP participants made management decisions online for six 'patients', whose sociodemographic characteristics systematically varied across three levels of cancer risk. In low-risk vignettes, investigation (ie, chest X-ray ordered, computerised tomography scan or respiratory consultant referral) was not indicated; in medium-risk vignettes, investigation could be appropriate; in high-risk vignettes, investigation was definitely indicated. Each 'patient' had two lung cancer-related symptoms: one volunteered and another elicited if GPs asked. Variations in investigation likelihood were examined using multilevel logistic regression. RESULTS GPs decided to investigate lung cancer in 74% (1000/1348) of vignettes. Investigation likelihood did not increase with cancer risk. Investigations were more likely when GPs requested information on symptoms that 'patients' had but did not volunteer (adjusted OR (AOR)=3.18; 95% CI 2.27 to 4.70). However, GPs omitted to seek this information in 42% (570/1348) of cases. GPs were less likely to investigate older than younger 'patients' (AOR=0.52; 95% CI 0.39 to 0.7) and black 'patients' than white (AOR=0.68; 95% CI 0.48 to 0.95). CONCLUSIONS GPs were not more likely to investigate 'patients' with high-risk than low-risk cancer symptoms. Furthermore, they did not investigate everyone with the same symptoms equally. Insufficient data gathering could be responsible for missed opportunities in diagnosis.
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Affiliation(s)
| | | | - Jonathan Myles
- Queen Mary University of London, Centre for Cancer Prevention, London, UK
| | - William Hamilton
- University of Exeter, Peninsula College of Medicine and Dentistry, Exeter, UK
| | - Joe McDonnell
- Department of Public Health, London Borough of Waltham Forest, London, UK
| | - Judith Offman
- Queen Mary University of London, Centre for Cancer Prevention, London, UK
| | - Stephen Duffy
- Queen Mary University of London, Centre for Cancer Prevention, London, UK
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91
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Round T. Primary care and cancer: Facing the challenge of early diagnosis and survivorship. Eur J Cancer Care (Engl) 2017; 26. [PMID: 28513052 DOI: 10.1111/ecc.12703] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2017] [Indexed: 11/29/2022]
Abstract
With ageing populations and an increasing lifetime risk of cancer, primary care will continue to play an increasingly important role in early diagnosis and cancer survivorship, especially with the lowering of risk thresholds for referral and diagnostic investigations. However, primary care in many countries is in crisis with increasing workloads for primary care physicians. Potential solutions to these challenges will be outlined including development of multidisciplinary teams, diagnostic decision support, increasing access to diagnostics and cost-effective referral pathways.
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Affiliation(s)
- Thomas Round
- Primary Care and Public Health Sciences, King's College London, London, UK
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92
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Wagland R, Brindle L, James E, Moore M, Esqueda AI, Corner J. Facilitating early diagnosis of lung cancer amongst primary care patients: The views of GPs. Eur J Cancer Care (Engl) 2017; 26. [PMID: 28497588 PMCID: PMC5949863 DOI: 10.1111/ecc.12704] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2017] [Indexed: 12/21/2022]
Abstract
Early diagnosis of lung cancer (LC) is a policy priority. However, symptoms are vague, associated with other morbidities, and frequently unrecognised by both patients and general practitioners (GPs). This qualitative study, part of a larger mixed methods study, explored GP views regarding the potential for early diagnosis of LC within primary care. Five focus group discussions (FGDs) were conducted with GPs (n = 16) at primary care practices (n = 5) across four counties in south England. FGDs were audio‐recorded, transcribed verbatim and analysed using a framework approach. Four broad themes emerged: patients’ reporting of symptoms; GP response to symptoms; investigating LC, and; potential initiatives for early diagnosis. GPs reported they often required high levels of suspicion to refer patients on to specialist respiratory consultations, and concerns of ‘system overload’ were prevalent. Greater access to more sensitive diagnostic investigations such as computed tomography, was argued for by some, particularly for symptomatic patients with negative chest X‐rays. GPs challenged current approaches to promoting earlier diagnosis through national symptom awareness campaigns, arguing instead that interventions targeted at high‐risk individuals might be more effective without burdening services already under pressure. Further work is needed to identify primary care patients who might most benefit from such targeted interventions.
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Affiliation(s)
- R Wagland
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - L Brindle
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - E James
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - M Moore
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - A I Esqueda
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - J Corner
- Executive Office, The Nottingham University, University Park, Nottingham, UK
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93
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Comorbid conditions delay diagnosis of colorectal cancer: a cohort study using electronic primary care records. Br J Cancer 2017; 116:1536-1543. [PMID: 28494470 PMCID: PMC5518856 DOI: 10.1038/bjc.2017.127] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 04/11/2017] [Accepted: 04/12/2017] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Pre-existing non-cancer conditions may complicate and delay colorectal cancer diagnosis. METHOD Incident cases (aged ⩾40 years, 2007-2009) with colorectal cancer were identified in the Clinical Practice Research Datalink, UK. Diagnostic interval was defined as time from first symptomatic presentation of colorectal cancer to diagnosis. Comorbid conditions were classified as 'competing demands' (unrelated to colorectal cancer) or 'alternative explanations' (sharing symptoms with colorectal cancer). The association between diagnostic interval (log-transformed) and age, gender, consultation rate and number of comorbid conditions was investigated using linear regressions, reported using geometric means. RESULTS Out of the 4512 patients included, 72.9% had ⩾1 competing demand and 31.3% had ⩾1 alternative explanation. In the regression model, the numbers of both types of comorbid conditions were independently associated with longer diagnostic interval: a single competing demand delayed diagnosis by 10 days, and four or more by 32 days; and a single alternative explanation by 9 days. For individual conditions, the longest delay was observed for inflammatory bowel disease (26 days; 95% CI 14-39). CONCLUSIONS The burden and nature of comorbidity is associated with delayed diagnosis in colorectal cancer, particularly in patients aged ⩾80 years. Effective clinical strategies are needed for shortening diagnostic interval in patients with comorbidity.
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94
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Walker S, Hamilton W. Risk of cervical cancer in symptomatic women aged ≥40 in primary care: A case-control study using electronic records. Eur J Cancer Care (Engl) 2017; 26. [PMID: 28474381 DOI: 10.1111/ecc.12706] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2017] [Indexed: 11/28/2022]
Abstract
There are approximately 3,000 new UK diagnoses of cervical cancer annually, with many women presenting symptomatically. We aimed to identify and quantify features of cervical cancer in primary care in a case-control study in the UK. Putative features of cervical cancer were identified, and odd ratios and positive predictive values (PPVs) were calculated. About 1,006 women aged ≥40 years diagnosed with cervical cancer and 4,992 age-, sex- and practice-matched controls were selected from the Clinical Practice Research Datalink. Median age at diagnosis was 61 years (interquartile range 51-75). Seven symptoms and two abnormal investigations were associated with cervical cancer: post-menopausal bleeding, odds ratio 43 (95% confidence interval 25, 75); vaginal discharge or vaginitis 8.8 (5.2, 15), intermenstrual bleeding 4.7 (1.6, 14); haematuria 4.6 (2.1, 10); irregular menstruation 3.8 (1.6, 9.0); urinary tract infection 1.9 (1.3, 2.8); abdominal pain 1.8 (1.4, 2.5); high white cell count 5.1 (2.9, 8.8) and low haemoglobin 2.6 (1.8, 3.8): all p < .005. The PPV of cervical cancer in women aged ≥55 with post-menopausal bleeding was 4.6% (2.5, 8.3). Other than for post-menopausal bleeding no symptom is high risk. Some symptoms, particularly haematuria, may be helpful. The primary care clinician must consider the unlikely diagnosis when the likely diagnosis does not settle with treatment.
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Affiliation(s)
- S Walker
- University of Exeter Medical School, Exeter, UK
| | - W Hamilton
- University of Exeter Medical School, Exeter, UK
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95
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Clinical features of bowel disease in patients aged <50 years in primary care: a large case-control study. Br J Gen Pract 2017; 67:e336-e344. [PMID: 28347985 PMCID: PMC5409433 DOI: 10.3399/bjgp17x690425] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 11/29/2016] [Indexed: 01/19/2023] Open
Abstract
Background Incidences of colorectal cancer (CRC) and inflammatory bowel disease (IBD) are increasing in those aged <50 years. Aim To identify and quantify clinical features in primary care of CRC/IBD in those aged <50 years. This study considered the two conditions together and aimed to determine which younger patients, presenting in primary care with symptoms, would benefit from investigation for potentially serious colorectal disease. Design and setting Matched case-control study using primary care records from the Clinical Practice Research Datalink, UK. Method Incident cases (aged <50 years) of CRC (n = 1661) and IBD (n = 9578) diagnosed between 2000 and 2013 were each matched with up to three controls (n = 3979 CRC; n = 22 947 IBD). Odds ratios (OR) and positive predictive values (PPV) were estimated for features of CRC/IBD in the year before diagnosis. Results Ten features were independently associated with CRC/IBD (all P<0.001): rectal bleeding, change in bowel habit, diarrhoea, raised inflammatory markers, thrombocytosis, abdominal pain, low mean cell volume (MCV), low haemoglobin, raised white cell count, and raised hepatic enzymes. PPVs were >3% for rectal bleeding with diarrhoea, thrombocytosis, low MCV, low haemoglobin or raised inflammatory markers; for change in bowel habit with low MCV, thrombocytosis or low haemoglobin; and for diarrhoea with thrombocytosis. Conclusion This study quantified the risk of serious bowel disease in symptomatic patients aged <50 years in primary care. Rectal bleeding and change in bowel habit are strongly predictive of CRC/IBD when combined with abnormal haematology. The present findings help prioritise patients for colonoscopy where the diagnosis is not immediately apparent.
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96
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Toftegaard BS, Bro F, Falborg AZ, Vedsted P. Impact of a continuing medical education meeting on the use and timing of urgent cancer referrals among general practitioners - a before-after study. BMC FAMILY PRACTICE 2017; 18:44. [PMID: 28327100 PMCID: PMC5361715 DOI: 10.1186/s12875-017-0607-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 03/01/2017] [Indexed: 11/29/2022]
Abstract
Background Detection of cancer in general practice is challenging because symptoms are diverse. Even so-called alarm symptoms have low positive predictive values of cancer. Nevertheless, appropriate referral is crucial. As 85% of cancer patients initiate their cancer diagnostic pathway in general practice, a Continuing Medical Education meeting (CME-M) in early cancer diagnosis was launched in Denmark in 2012. We aimed to investigate the effect of the CME-M on the primary care interval, patient contacts with general practice and use of urgent cancer referrals. Methods A before-after study was conducted in the Central Denmark Region included 396 general practices, which were assigned to one of eight geographical clusters. Practices were invited to participate in the CME-M with three-week intervals between clusters. Based on register data, we calculated urgent referral rates and patient contacts with general practice before referral. Information about primary care intervals was collected by requesting general practitioners to complete a one-page form for each urgent referral during an 8-month period around the time of the CME-Ms. CME-M practices were compared with non-participating reference practices by analysing before-after differences. Results Forty percent of all practices participated in the CME-M. There was a statistically significant reduction in the number of total contacts with general practice from urgently referred patients in the month preceding the referral and an increase in the proportion of patients who waited 14 days or more in general practice from the reported date of symptom presentation to the referral date from before to after the CME-M in the CME-M group compared to the reference group. Conclusions We found a reduced number of total patient contacts with general practice within the month preceding an urgent referral and an increase in the reported primary care intervals of urgently referred patients in the CME-M group. The trend towards higher urgent referral rates and longer primary care intervals may suggest raised awareness of unspecific cancer symptoms, which could cause the GP to register an earlier date of first symptom presentation. The standardised CME-M may contribute to optimising the timing and the use of urgent cancer referral. Trial registration NCT02069470 on ClinicalTrials.gov. Retrospectively registered, 1/29/2014 Electronic supplementary material The online version of this article (doi:10.1186/s12875-017-0607-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Berit Skjødeberg Toftegaard
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, Aarhus, DK-8000, Denmark. .,Research Centre for Cancer Diagnosis in Primary Care (CaP), Department of Public Health, Aarhus University, Bartholins Allé 2, Aarhus, DK-8000, Denmark. .,Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, Aarhus, DK-8000, Denmark.
| | - Flemming Bro
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, Aarhus, DK-8000, Denmark.,Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, Aarhus, DK-8000, Denmark
| | - Alina Zalounina Falborg
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, Aarhus, DK-8000, Denmark.,Research Centre for Cancer Diagnosis in Primary Care (CaP), Department of Public Health, Aarhus University, Bartholins Allé 2, Aarhus, DK-8000, Denmark.,Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, Aarhus, DK-8000, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, Aarhus, DK-8000, Denmark.,Research Centre for Cancer Diagnosis in Primary Care (CaP), Department of Public Health, Aarhus University, Bartholins Allé 2, Aarhus, DK-8000, Denmark.,Department of Clinical Medicine, University Clinic for Innovative Health Care Delivery, Silkeborg Hospital, Aarhus University, Aarhus, DK-8000, Denmark
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Harris M, Frey P, Esteva M, Gašparović Babić S, Marzo-Castillejo M, Petek D, Petek Ster M, Thulesius H. How the probability of presentation to a primary care clinician correlates with cancer survival rates: a European survey using vignettes. Scand J Prim Health Care 2017; 35:27-34. [PMID: 28277044 PMCID: PMC5361416 DOI: 10.1080/02813432.2017.1288692] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE European cancer survival rates vary widely. System factors, including whether or not primary care physicians (PCPs) are gatekeepers, may account for some of these differences. This study explores where patients who may have cancer are likely to present for medical care in different European countries, and how probability of presentation to a primary care clinician correlates with cancer survival rates. DESIGN Seventy-eight PCPs in a range of European countries assessed four vignettes representing patients who might have cancer, and consensus groups agreed how likely those patients were to present to different clinicians in their own countries. These data were compared with national cancer survival rates. SETTING A total of 14 countries. SUBJECTS Consensus groups of PCPs. MAIN OUTCOME MEASURES Probability of initial presentation to a PCP for four clinical vignettes. RESULTS There was no significant correlation between overall national 1-year relative cancer survival rates and the probability of initial presentation to a PCP (r = -0.16, 95% CI -0.39 to 0.08). Within that there was large variation depending on the type of cancer, with a significantly poorer lung cancer survival in countries where patients were more likely to initially consult a PCP (lung r = -0.57, 95% CI -0.83 to -0.12; ovary: r = -0.13, 95% CI -0.57 to 0.38; breast r = 0.14, 95% CI -0.36 to 0.58; bowel: r = 0.20, 95% CI -0.31 to 0.62). CONCLUSIONS There were wide variations in the degree of gatekeeping between countries, with no simple binary model as to whether or not a country has a "PCP-as-gatekeeper" system. While there was case-by-case variation, there was no overall evidence of a link between a higher probability of initial consultation with a PCP and poorer cancer survival. KEY POINTS European cancer survival rates vary widely, and health system factors may account for some of these differences. The data from 14 European countries show a wide variation in the probability of initial presentation to a PCP. The degree to which PCPs act as gatekeepers varies considerably from country to country. There is no overall evidence of a link between a higher probability of initial presentation to a PCP and poorer cancer survival.
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Affiliation(s)
- Michael Harris
- Department for Health, University of Bath, Bath, United Kingdom
- CONTACT Michael Harris Gore Cottage, Old Gore Lane, Emborough, Radstock, BA3 4SJ, UK
| | - Peter Frey
- Berner Institut für Hausarztmedizin, Universität Bern, Bern, Switzerland
| | - Magdalena Esteva
- Majorca Primary Health Care Department & Instituto de Investigación sanitaria Illes Balears (idISBA), Palma Mallorca, Spain
| | - Svjetlana Gašparović Babić
- Department for Health Education and Health Promotion, Teaching Institute of Public Health of Primorsko-Goranska County, University of Rijeka, Rijeka, Croatia
| | - Mercè Marzo-Castillejo
- Unitat de Suport a la Recerca, IDIAP Jordi Gol, Direcció d'Atenció Primària Costa de Ponent, Institut Català de la Salut, Cornellà de Llobregat, 08940, Spain
| | - Davorina Petek
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Marija Petek Ster
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Hans Thulesius
- Department of Clinical Sciences, Lund University, Lund, Sweden
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Clinical features of metastatic cancer in primary care: a case-control study using medical records. Br J Gen Pract 2017. [PMID: 26212847 DOI: 10.3399/bjgp15x686077] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND How metastatic cancer initially presents is largely unknown. AIM To identify clinical features of metastatic cancer in primary care. DESIGN AND SETTING Case-control study in 11 general practices in Devon, UK. METHOD Cases of patients who had died with metastatic breast, colorectal, or prostate cancer were selected. In addition, two control groups were formed of patients with the same primary cancer but without metastases ('cancer controls') and patients without cancer ('healthy controls'), matched for age, sex, and practice. All symptoms, signs, and laboratory test abnormalities in the year before metastasis were identified. The primary analysis used conditional logistic regression. RESULTS In total, 162 cases, 152 cancer controls, and 145 healthy controls were studied. Common symptoms associated with cancer were: vomiting, 40 (25%) cases and 13 (9%) cancer controls (multivariable odds ratio [OR] 3.5, 95% confidence interval [CI] = 1.3 to 9.4, P = 0.011); low back pain, 38 (24%) cases and 17 (11%) cancer controls (OR 2.5, 95% CI = 1.1 to 5.6, P = 0.032); loss of appetite, 32 (20%) cases and nine (6%) cancer controls (OR 4.0, 95% CI = 1.2 to 13.2, P = 0.021); and shoulder pain, 27 (17%) cases and eight (5%) cancer controls (OR 5.3, 95% CI = 1.6 to 18, P = 0.007). Groin pain was uncommon, but strongly associated (16 [10%] cases and one [1%] cancer control [OR 10, 95% CI = 1.2 to 82, P = 0.032]), as was pleural disease (nine [6%] cases and one [1%] cancer control [OR 10, 95% CI = 1.1 to 92, P = 0.038]). CONCLUSION These features of disseminated cancer have been reported before in studies from secondary care, but the scarcity of specific symptoms (such as local pain) and the fairly common occurrence of non-specific symptoms (vomiting and loss of appetite) is important and may explain delays in the diagnosis of metastases.
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de Wit NJ, Devroey D. Diagnostiek. ONCOLOGIE 2017. [DOI: 10.1007/978-90-368-0961-0_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Much time, effort and investment goes into the diagnosis of symptomatic cancer, with the expectation that this approach brings clinical benefits. This investment of resources has been particularly noticeable in the UK, which has, for several years, appeared near the bottom of international league tables for cancer survival in economically developed countries. In this Review, we examine expedited diagnosis of cancer from four perspectives. The first relates to the potential for clinical benefits of expedited diagnosis of symptomatic cancer. Limited evidence from clinical trials is available, but the considerable observational evidence suggests benefits can be obtained from this approach. The second perspective considers how expedited diagnosis can be achieved. We concentrate on data from the UK, where extensive awareness campaigns have been conducted, and initiatives in the primary-care setting, including clinical decision support, have all occurred during a period of considerable national policy change. The third section considers the most appropriate patients for cancer investigations, and the possible community settings for identification of such patients; UK national guidance for selection of patients for investigation is discussed. Finally, the health economics of expedited diagnosis are reviewed, although few studies provide definitive evidence on this topic.
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Affiliation(s)
- Willie Hamilton
- University of Exeter, College House, St Luke's Campus, Exeter EX2 4TE, UK
| | - Fiona M Walter
- Department of Public Health &Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Greg Rubin
- School of Medicine, Pharmacy and Health, Wolfson Building, Queen's Campus, University of Durham, Stockton-on-Tees TS17 6BH, UK
| | - Richard D Neal
- North Wales Centre for Primary Care Research, Bangor University, Gwenfro Unit 5, Wrexham Technology Park, Wrexham LL13 7YP, UK
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