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Venning B, Pearce A, De Abreu Lourenco R, Hall R, Bergin RJ, Lee A, Donohoe K, Emery J. Patient preferences for investigating cancer-related symptoms in Australian general practice: a discrete-choice experiment. Br J Gen Pract 2024; 74:e517-e526. [PMID: 38395444 PMCID: PMC11289936 DOI: 10.3399/bjgp.2023.0583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Striking the right balance between early cancer diagnosis and the risk of excessive testing for low-risk symptoms is of paramount importance. Patient-centred care must also consider patient preferences for testing. AIM To investigate the diagnostic testing preferences of the Australian public for symptoms associated with oesophagogastric (OG), bowel, or lung cancer. DESIGN AND SETTING One of three discrete-choice experiments (DCEs) related to either OG, bowel, or lung cancer were administered to a nationally representative sample of Australians aged ≥40 years. METHOD Each DCE comprised three scenarios with symptom positive predictive values (PPVs) for undiagnosed cancer ranging from 1% to 3%. The numerical risk was concealed from participants. DCE attributes encompassed the testing strategy, GP familiarity, test and result waiting times, travel duration, and test cost. Preferences were estimated using conditional and mixed logit models. RESULTS A total of 3013 individuals participated in one of three DCEs: OG (n = 1004), bowel (n = 1006), and lung (n = 1003). Preferences were chiefly driven by waiting time and test cost, followed by the test type. There was a preference for more invasive tests. When confronted with symptoms carrying an extremely low risk (symptom PPV of ≤1%), participants were more inclined to abstain from testing. CONCLUSION Access-related factors, particularly waiting times and testing costs, emerged as the most pivotal elements influencing preferences, underscoring the substantial impact of these systemic factors on patient choices regarding investigations.
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Affiliation(s)
- Brent Venning
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia, and Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Alison Pearce
- Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, Australia, and Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Haymarket, Australia
| | | | - Rebecca J Bergin
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia; Centre for Cancer Research, University of Melbourne, Melbourne, Australia; and Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Australia
| | - Alex Lee
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia, and Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Keith Donohoe
- Consumer Advisory Committee, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Jon Emery
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia, and Centre for Cancer Research, University of Melbourne, Melbourne, Australia
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Mallabar-Rimmer B, Merriel SWD, Webster AP, Jackson L, Wood AR, Barclay M, Tyrrell J, Ruth KS, Thirlwell C, Oram R, Weedon MN, Bailey SER, Green HD. Colorectal cancer risk stratification using a polygenic risk score in symptomatic primary care patients-a UK Biobank retrospective cohort study. Eur J Hum Genet 2024:10.1038/s41431-024-01654-3. [PMID: 39090236 DOI: 10.1038/s41431-024-01654-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 05/15/2024] [Accepted: 06/17/2024] [Indexed: 08/04/2024] Open
Abstract
Colorectal cancer (CRC) is a leading cause of cancer mortality worldwide. Accurate cancer risk assessment approaches could increase rates of early CRC diagnosis, improve health outcomes for patients and reduce pressure on diagnostic services. The faecal immunochemical test (FIT) for blood in stool is widely used in primary care to identify symptomatic patients with likely CRC. However, there is a 6-16% noncompliance rate with FIT in clinic and ~90% of patients over the symptomatic 10 µg/g test threshold do not have CRC. A polygenic risk score (PRS) quantifies an individual's genetic risk of a condition based on many common variants. Existing PRS for CRC have so far been used to stratify asymptomatic populations. We conducted a retrospective cohort study of 50,387 UK Biobank participants with a CRC symptom in their primary care record at age 40+. A PRS based on 201 variants, 5 genetic principal components and 22 other risk factors and markers for CRC were assessed for association with CRC diagnosis within 2 years of first symptom presentation using logistic regression. Associated variables were included in an integrated risk model and trained in 80% of the cohort to predict CRC diagnosis within 2 years. An integrated risk model combining PRS, age, sex, and patient-reported symptoms was predictive of CRC development in a testing cohort (receiver operating characteristic area under the curve, ROCAUC: 0.76, 95% confidence interval: 0.71-0.81). This model has the potential to improve early diagnosis of CRC, particularly in cases of patient noncompliance with FIT.
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Affiliation(s)
| | - Samuel W D Merriel
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Amy P Webster
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Leigh Jackson
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Andrew R Wood
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Matthew Barclay
- Department of Behavioural Science & Health, Institute of Epidemiology & Health Care, University College London, London, UK
| | - Jessica Tyrrell
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Katherine S Ruth
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | | | - Richard Oram
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Michael N Weedon
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Sarah E R Bailey
- Department of Health and Community Sciences, University of Exeter, Exeter, UK
| | - Harry D Green
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK.
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Venning B, Emery JD. Symptomatic cancer diagnosis in general practice: a critical perspective of current guidelines and risk assessment tools. Med J Aust 2024; 220:446-450. [PMID: 38679756 DOI: 10.5694/mja2.52287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 03/26/2024] [Indexed: 05/01/2024]
Affiliation(s)
- Brent Venning
- Centre for Cancer Research, University of Melbourne, Melbourne, VIC
| | - Jon D Emery
- Centre for Cancer Research, University of Melbourne, Melbourne, VIC
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Dennison RA, Thomas CV, Morris S, Usher-Smith JA. A discrete choice experiment to understand public preferences and priorities for risk-stratified bowel cancer screening programmes in the UK. Prev Med 2023; 177:107786. [PMID: 37984646 DOI: 10.1016/j.ypmed.2023.107786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE Public acceptability of bowel cancer screening programmes must be maintained, including if risk stratification is introduced. We aimed to describe and quantify preferences for different attributes of risk-stratified screening programmes amongst the UK population, focussing on who to invite for bowel screening. METHODS We conducted a discrete choice experiment (DCE) including the following attributes: risk factors used to estimate bowel cancer risk (age plus/minus sex, lifestyle factors and genetics); personalisation of risk feedback; risk stratification strategy plus resource implications; default screening in the case of no risk information; number of deaths prevented by screening; and number experiencing physical harm from screening. We used the results of conditional logit regression models to estimate the importance of each attribute, willingness to trade-off between the attributes, and preferences for different programmes using contemporary risk scores and models. RESULTS 1196 respondents completed the survey, generating 21,528 DCE observations. Deaths prevented was the most influential attribute on respondents' decision-making (contributing to 58.8% of the choice), followed by harms experienced (15.9%). For every three additional deaths prevented, respondents were willing to accept an additional screening harm per 100,000 people. Risk factors and risk stratification strategy contributed to just 11.1% and 3.6% of the choice, respectively. Although the influence on decision-making was small, respondents favoured more personalised feedback. CONCLUSIONS Bowel cancer screening programmes that improve cancer outcomes, particularly by preventing more deaths amongst those screened, are most preferred by the public. Optimising risk prediction models, developing public communication, and readying infrastructure should be prioritised for implementation.
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Affiliation(s)
- Rebecca A Dennison
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK.
| | - Chloe V Thomas
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - Stephen Morris
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
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Baird TA, Wright DR, Britto MT, Lipstein EA, Trout AT, Hayatghaibi SE. Patient Preferences in Diagnostic Imaging: A Scoping Review. THE PATIENT 2023; 16:579-591. [PMID: 37667148 DOI: 10.1007/s40271-023-00646-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND As new diagnostic imaging technologies are adopted, decisions surrounding diagnostic imaging become increasingly complex. As such, understanding patient preferences in imaging decision making is imperative. OBJECTIVES We aimed to review quantitative patient preference studies in imaging-related decision making, including characteristics of the literature and the quality of the evidence. METHODS The Pubmed, Embase, EconLit, and CINAHL databases were searched to identify studies involving diagnostic imaging and quantitative patient preference measures from January 2000 to June 2022. Study characteristics that were extracted included the preference elicitation method, disease focus, and sample size. We employed the PREFS (Purpose, Respondents, Explanation, Findings, Significance) checklist as our quality assessment tool. RESULTS A total of 54 articles were included. The following methods were used to elicit preferences: conjoint analysis/discrete choice experiment methods (n = 27), contingent valuation (n = 16), time trade-off (n = 4), best-worst scaling (n = 3), multicriteria decision analysis (n = 3), and a standard gamble approach (n = 1). Half of the studies were published after 2016 (52%, 28/54). The most common scenario (n = 39) for eliciting patient preferences was cancer screening. Computed tomography, the most frequently studied imaging modality, was included in 20 studies, and sample sizes ranged from 30 to 3469 participants (mean 552). The mean PREFS score was 3.5 (standard deviation 0.8) for the included studies. CONCLUSIONS This review highlights that a variety of quantitative preference methods are being used, as diagnostic imaging technologies continue to evolve. While the number of preference studies in diagnostic imaging has increased with time, most examine preventative care/screening, leaving a gap in knowledge regarding imaging for disease characterization and management.
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Affiliation(s)
- Trey A Baird
- University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Davene R Wright
- Division of Child Health Research and Policy, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Maria T Britto
- University of Cincinnati, College of Medicine, Cincinnati, OH, USA
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Adolescent Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Ellen A Lipstein
- University of Cincinnati, College of Medicine, Cincinnati, OH, USA
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Andrew T Trout
- University of Cincinnati, College of Medicine, Cincinnati, OH, USA
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Shireen E Hayatghaibi
- University of Cincinnati, College of Medicine, Cincinnati, OH, USA.
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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Bradley SH, Francetic I. Don't assume that cutting back on cancer diagnosis would improve other services. BMJ 2023; 382:1698. [PMID: 37491024 DOI: 10.1136/bmj.p1698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
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Dennison RA, Usher-Smith JA, John SD. The ethics of risk-stratified cancer screening. Eur J Cancer 2023; 187:1-6. [PMID: 37094523 DOI: 10.1016/j.ejca.2023.03.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/08/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023]
Abstract
Cancer screening programmes aim to save lives and reduce cancer burden through prevention or early detection of specific cancers. Risk stratification, where one or more elements of a screening programme are systematically tailored based on multiple individual-level risk factors, could improve the balance of screening benefits and harms and programme efficiency. In this article, we explore the resulting ethical issues and how they impact risk-stratified screening policymaking using Beauchamp and Childress's principles of medical ethics. First, in line with universal screening programme principles, we acknowledge that risk-stratified screening should be introduced only when the expected total benefits outweigh the harms, and where it has a favourable overall impact compared to alternative options. We then discuss how these are difficult to both value and quantify, and that risk models typically perform differently in sub-populations. Second, we consider whether screening is an individual right and whether it is fair to offer more or less intensive screening to some and not others based on personal characteristics. Third, we discuss the need to maintain respect for autonomy, including ensuring informed consent and considering the screening implications for those who cannot or choose not to participate in the risk assessment. In summary, from an ethical perspective, focusing on population-level effectiveness alone is insufficient when planning risk-stratified screening programmes and the range of ethical principles must be considered.
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Affiliation(s)
- Rebecca A Dennison
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK.
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
| | - Stephen D John
- Department of History and Philosophy of Science, University of Cambridge, Cambridge CB2 3RH, UK
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Jones D, Ali OM, Honey S, Surr C, Scott S, De Wit N, Neal RD. Patients' views on the decision to investigate cancer symptoms in older adults: a qualitative interview study in primary care. Br J Gen Pract 2023:BJGP.2022.0622. [PMID: 37365009 PMCID: PMC10327112 DOI: 10.3399/bjgp.2022.0622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/13/2023] [Accepted: 04/04/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Cancer is predominantly a disease of older adults. To date there has been little research on the experiences of older adults or their views on the diagnostic pathway. AIM To gain an improved understanding of the views and experiences of older adults on all aspects of cancer investigation. DESIGN AND SETTING This was a qualitative study using semi-structured interviews with patients aged ≥70 years. Patients were recruited from primary care in West Yorkshire, UK. METHOD Data were analysed using a thematic framework analysis. RESULTS The themes identified in participants' accounts included the patients' process of decision making, the value of having a diagnosis, the patients' experience of cancer investigations, and the impact of the COVID-19 pandemic on the diagnostic pathway. Older adults in this study indicated a clear preference for having clarity on the cause of symptoms and the diagnosis, even in the face of unpleasant investigations. Patients suggested they wanted to be involved in the decision process. CONCLUSION Older adults who present to primary care with symptoms suggestive of cancer may accept diagnostic testing solely for the benefit of knowing the diagnosis. There was a clear patient preference that referrals and investigations for cancer symptoms should not be deferred or delayed based on age or subjective assessments of frailty. Shared decision making and being involved in the decision-making process are important to patients, regardless of age.
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Affiliation(s)
- Daniel Jones
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Omer M Ali
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Stephanie Honey
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Suzanne Scott
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Niek De Wit
- Julius Center for Health Sciences and Primary Care, and professor of general practice, University Medical Center, Utrecht, the Netherlands
| | - Richard D Neal
- Department of Health and Community Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
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Gathani T, Cutress R, Horgan K, Kirwan C, Stobart H, Kan SW, Reeves G, Sweetland S. Age and sex can predict cancer risk in people referred with breast symptoms. BMJ 2023; 381:e073269. [PMID: 37100445 PMCID: PMC10142097 DOI: 10.1136/bmj-2022-073269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Affiliation(s)
- Toral Gathani
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ramsey Cutress
- Cancer Sciences, University of Southampton and University Hospitals Southampton, Southampton, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kieran Horgan
- Department of Breast Surgery, St James's Hospital, Leeds, UK
| | - Cliona Kirwan
- Division of Cancer Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
- Nightingale Breast Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Sau Wan Kan
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Gillian Reeves
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sian Sweetland
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Dennison RA, Taylor LC, Morris S, Boscott RA, Harrison H, Moorthie SA, Rossi SH, Stewart GD, Usher-Smith JA. Public Preferences for Determining Eligibility for Screening in Risk-Stratified Cancer Screening Programs: A Discrete Choice Experiment. Med Decis Making 2023; 43:374-386. [PMID: 36786399 PMCID: PMC10021112 DOI: 10.1177/0272989x231155790] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND Risk stratification has been proposed to improve the efficiency of population-level cancer screening. We aimed to describe and quantify the relative importance of different attributes of potential screening programs among the public, focusing on stratifying eligibility. METHODS We conducted a discrete choice experiment in which respondents selected between 2 hypothetical screening programs in a series of 9 questions. We presented the risk factors used to determine eligibility (age, sex, or lifestyle or genetic risk scores) and anticipated outcomes based on eligibility criteria with different sensitivity and specificity levels. We performed conditional logit regression models and used the results to estimate preferences for different approaches. We also analyzed free-text comments on respondents' views on the programs. RESULTS A total of 1,172 respondents completed the survey. Sensitivity was the most important attribute (7 and 11 times more important than specificity and risk factors, respectively). Eligibility criteria based on age and sex or genetics were preferred over age alone and lifestyle risk scores. Phenotypic and polygenic risk prediction models would be more acceptable than screening everyone aged 55 to 70 y if they had high discrimination (area under the receiver-operating characteristic curve ≥0.75 and 0.80, respectively). LIMITATIONS Although our sample was representative with respect to age, sex, and ethnicity, it may not be representative of the UK population regarding other important characteristics. Also, some respondents may have not understood all the information provided to inform decision making. CONCLUSIONS The public prioritized lives saved from cancer over reductions in numbers screened or experiencing unnecessary follow-up. Incorporating personal-level risk factors into screening eligibility criteria is acceptable to the public if it increases sensitivity; therefore, maximizing sensitivity in model development and communication could increase uptake. HIGHLIGHTS The public prioritized lives saved when considering changing from age-based eligibility criteria to risk-stratified cancer screening over reductions in numbers of people being screened or experiencing unnecessary follow-up.The risk stratification strategy used to do this was the least important component, although age plus sex or genetics were relatively preferable to using age alone and lifestyle risk scores.Communication strategies that emphasize improvements in the numbers of cancers detected or not missed across the population are more likely to be salient than reductions in unnecessary investigations or follow-up among some groups.Future research should focus on developing implementation strategies that maximize gains in sensitivity within the context of resource constraints and how to present attributes relating to specificity to facilitate understanding and informed decision making.
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Affiliation(s)
- Rebecca A Dennison
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Lily C Taylor
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephen Morris
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Rachel A Boscott
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Hannah Harrison
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Sabrina H Rossi
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Jarimba R, Quaresma V, Pedroso Lima J, Eliseu M, Tavares da Silva E, Moreira P, Figueiredo A. Predicting bladder cancer risk in patients with hematuria. A single-centre retrospective study. Arch Ital Urol Androl 2023; 95:11026. [PMID: 36924379 DOI: 10.4081/aiua.2023.11026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 03/17/2023] Open
Abstract
INTRODUCTION The presence of blood in the urine should be promptly investigated to rule out urological malignancies, bladder cancer being the most frequent. Given its frequency among general population and the lack of unlimited health resources in an era of cost-effectiveness, it is important to prioritize patients with higher risk of malignancy. OBJECTIVES To identify predictive factors of bladder cancer among patients presenting with hematuria. PATIENTS AND METHODS We retrospectively reviewed 296 cases referred to our department for hematuria. We evaluated different demographic, clinical and ultrasound features to uncover possible associations with diagnosis of bladder cancer in those patients, to estimate the individual risk of being diagnosed with bladder cancer during the investigation of hematuria. RESULTS A total of 296 patients were studied for hematuria between January 1, 2017 and December 31, 2019, 23.6% of those having ultimately bladder cancer confirmed after transurethral resection. Older age, male gender (OR 2.727, p = 0.069), a history of smoking (OR 3.84, p < 0.05), recurrent hematuria (OR 3.396, p < 0.05) and positive ultrasound exam for bladder cancer (OR 30.423, p < 0.05) were identified as predictors of bladder cancer in patients with hematuria. CONCLUSIONS This study suggests that it is possible to reliably estimate the risk of bladder cancer in patients with hematuria, using clinical and imaging data to help defining who should be investigated first and in whom the investigation could be postponed.
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Affiliation(s)
- Roberto Jarimba
- Urology and Renal Transplantation Department, Centro Hospitalar e Universitário de Coimbra, Coimbra; Faculty of Medicine, University of Coimbra.
| | - Vasco Quaresma
- Urology and Renal Transplantation Department, Centro Hospitalar e Universitário de Coimbra, Coimbra.
| | - João Pedroso Lima
- Urology and Renal Transplantation Department, Centro Hospitalar e Universitário de Coimbra, Coimbra; Faculty of Medicine, University of Coimbra.
| | - Miguel Eliseu
- Urology and Renal Transplantation Department, Centro Hospitalar e Universitário de Coimbra, Coimbra; Faculty of Medicine, University of Coimbra.
| | - Edgar Tavares da Silva
- Urology and Renal Transplantation Department, Centro Hospitalar e Universitário de Coimbra, Coimbra; Faculty of Medicine, University of Coimbra.
| | - Pedro Moreira
- Urology and Renal Transplantation Department, Centro Hospitalar e Universitário de Coimbra, Coimbra.
| | - Arnaldo Figueiredo
- Urology and Renal Transplantation Department, Centro Hospitalar e Universitário de Coimbra, Coimbra; Faculty of Medicine, University of Coimbra.
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Smith L, Von Wagner C, Kaushal A, Rafiq M, Lyratzopoulos G, Renzi C. The Role of Type 2 Diabetes in Patient Symptom Attribution, Help-Seeking, and Attitudes to Investigations for Colorectal Cancer Symptoms: An Online Vignette Study. Cancers (Basel) 2023; 15:1668. [PMID: 36980553 PMCID: PMC10045970 DOI: 10.3390/cancers15061668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/05/2023] [Accepted: 03/06/2023] [Indexed: 03/12/2023] Open
Abstract
OBJECTIVES Type 2 diabetes is associated with a higher risk of colorectal cancer (CRC) and advanced-stage cancer diagnosis. To help diagnose cancer earlier, this study aimed at examining whether diabetes might influence patient symptom attribution, help-seeking, and willingness to undergo investigations for possible CRC symptoms. METHODS A total of 1307 adults (340 with and 967 without diabetes) completed an online vignette survey. Participants were presented with vignettes describing new-onset red-flag CRC symptoms (rectal bleeding or a change in bowel habits), with or without additional symptoms of diabetic neuropathy. Following the vignettes, participants were asked questions on symptom attribution, intended help-seeking, and attitudes to investigations. RESULTS Diabetes was associated with greater than two-fold higher odds of attributing changes in bowel habits to medications (OR = 2.48; 95% Cl 1.32-4.66) and of prioritising diabetes-related symptoms over the change in bowel habits during medical encounters. Cancer was rarely mentioned as a possible explanation for the change in bowel habits, especially among diabetic participants (10% among diabetics versus 16% in nondiabetics; OR = 0.55; 95% CI 0.36-0.85). Among patients with diabetes, those not attending annual check-ups were less likely to seek help for red-flag cancer symptoms (OR = 0.23; 95% Cl 0.10-0.50). CONCLUSIONS Awareness of possible cancer symptoms was low overall. Patients with diabetes could benefit from targeted awareness campaigns emphasising the importance of discussing new symptoms such as changes in bowel habits with their doctor. Specific attention is warranted for individuals not regularly attending healthcare despite their chronic morbidity.
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Affiliation(s)
- Lauren Smith
- Research Department of Behavioural Science and Health, University College London, London WC1E 6BT, UK; (L.S.)
| | - Christian Von Wagner
- Research Department of Behavioural Science and Health, University College London, London WC1E 6BT, UK; (L.S.)
| | - Aradhna Kaushal
- Research Department of Behavioural Science and Health, University College London, London WC1E 6BT, UK; (L.S.)
| | - Meena Rafiq
- Research Department of Behavioural Science and Health, University College London, London WC1E 6BT, UK; (L.S.)
- Centre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne 3052, Australia
| | - Georgios Lyratzopoulos
- Research Department of Behavioural Science and Health, University College London, London WC1E 6BT, UK; (L.S.)
| | - Cristina Renzi
- Research Department of Behavioural Science and Health, University College London, London WC1E 6BT, UK; (L.S.)
- Faculty of Medicine, University Vita-Salute San Raffaele, 20132 Milan, Italy
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Venning B, Bergin R, Pearce A, Lee A, Emery JD. Factors affecting patient decisions to undergo testing for cancer symptoms: an exploratory qualitative study in Australian general practice. BJGP Open 2023; 7:BJGPO.2022.0168. [PMID: 36750375 DOI: 10.3399/bjgpo.2022.0168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 11/21/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Patients presenting to their GP are often concerned their symptoms may be due to cancer. However, there is a lack of evidence on the factors that influence patient decisions to undergo investigation for suspected cancer in the general practice setting. AIM To identify the factors influencing patient decisions to undertake investigations for suspected cancer in general practice. DESIGN & SETTING An exploratory qualitative, semi-structured interview study of patients attending rural and metropolitan general practices in Victoria, Australia. METHOD A purposive sample of 15 general practice patients aged ≥40 years participated. Thematic analysis of transcripts drew on interpretative description methodology and shared decision-making (SDM) theory. RESULTS Cancer-related concerns such as 'cancer worry' prompt patients to seek investigations from their GP. Participants prefer that their symptoms are investigated regardless of cancer risk. The perceived 'best test' provides the most reassurance. Trust and SDM enhance dialogue between patients and GPs about diagnostic testing strategies. Deterrents to testing included out-of-pocket costs, waiting time, travel time, and competing work and family demands. CONCLUSION There may be a mismatch between efforts to rationalise investigation use and patient preferences for investigation. SDM that incorporates patient concerns, facilitators, and barriers to testing may ensure appropriate and timely investigation of cancer symptoms.
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Affiliation(s)
- Brent Venning
- Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Rebecca Bergin
- Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Australia
| | - Alison Pearce
- Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Alex Lee
- Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Jon D Emery
- Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
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Khasawneh F, Osborne T, Danaher P, Barnes D, Chapman CJ, Stephenson JA, Singh B. Faecal immunochemical testing reduces demand and improves yield of Leicester's 2-week pathway for change in bowel habit. Colorectal Dis 2022; 25:640-646. [PMID: 36478367 DOI: 10.1111/codi.16445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 10/09/2022] [Accepted: 10/10/2022] [Indexed: 12/30/2022]
Abstract
AIM We look at the effect of introducing the faecal immunochemical test (FIT) in the straight-to-test 2-week pathway for change in bowel habit (CIBH). METHOD The FIT in primary care triages 2-week wait (2WW) colorectal referrals for patients aged 60 years and above for straight-to-test CT colonography (CTC). We compare the impact of the FIT on numbers of 2WW CTCs, in the year before and after FIT, in both colorectal cancer (CRC) detection and cost-effectiveness at both 4 μg Hb/g faeces and 10 μg Hb/g faeces. RESULTS At a threshold of 4 μg Hb/g faeces, the positive predictive value of the FIT for diagnosis of CRC is 5.0% with a negative predictive value of 99.8% and a polyp detection rate of 25.5%. The introduction of the FIT resulted in a reduction in the number of CTCs performed through the CIBH pathway from a mean of 143.9 per month prior to the FIT to 66.8 CTCs per month once the FIT was well established. Given a FIT threshold of 10 μg Hb/g the number of CTCs would be predicted to fall by 70.4% to 42.6 CTCs per month resulting in higher CRC and polyp detection rate, and an estimated annual cost saving of £238 258 in our institution. CONCLUSION The FIT use in primary care improves the yield of 2WW referrals for CIBH alone and reduces the burden and cost of investigations to exclude CRC. Improvements may be possible by increasing the cut-off employed, without adversely affecting the risk of missing a cancer.
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Affiliation(s)
- Farah Khasawneh
- University Hospitals of Leicester NHS Trust, University of Leicester, Leicester, UK
| | | | - Paul Danaher
- GP Principal at Groby Road Medical Centre, Leicester, UK
| | - Daniel Barnes
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Caroline J Chapman
- Nottingham University Hospitals, NHS Trust, University of Nottingham, Nottingham, UK
| | | | - Baljit Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
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Applying a genetic risk score for prostate cancer to men with lower urinary tract symptoms in primary care to predict prostate cancer diagnosis: a cohort study in the UK Biobank. Br J Cancer 2022; 127:1534-1539. [PMID: 35978138 PMCID: PMC9553867 DOI: 10.1038/s41416-022-01918-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 07/01/2022] [Accepted: 07/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prostate cancer is highly heritable, with >250 common variants associated in genome-wide association studies. It commonly presents with non-specific lower urinary tract symptoms that are frequently associated with benign conditions. METHODS Cohort study using UK Biobank data linked to primary care records. Participants were men with a record showing a general practice consultation for a lower urinary tract symptom. The outcome measure was prostate cancer diagnosis within 2 years of consultation. The predictor was a genetic risk score of 269 genetic variants for prostate cancer. RESULTS A genetic risk score (GRS) is associated with prostate cancer in symptomatic men (OR per SD increase = 2.12 [1.86-2.41] P = 3.5e-30). An integrated risk model including age and GRS applied to symptomatic men predicted prostate cancer (AUC 0.768 [0.739-0.796]). Prostate cancer incidence was 8.1% (6.7-9.7) in the highest risk quintile. In the lowest quintile, prostate cancer incidence was <1%. CONCLUSIONS This study is the first to apply GRS in primary care to improve the triage of symptomatic patients. Men with the lowest genetic risk of developing prostate cancer could safely avoid invasive investigation, whilst those identified with the greatest risk could be fast-tracked for further investigation. These results show that a GRS has potential application to improve the diagnostic pathway of symptomatic patients in primary care.
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Dennison RA, Boscott RA, Thomas R, Griffin SJ, Harrison H, John SD, Moorthie SA, Morris S, Rossi SH, Stewart GD, Thomas CV, Usher‐Smith JA. A community jury study exploring the public acceptability of using risk stratification to determine eligibility for cancer screening. Health Expect 2022; 25:1789-1806. [PMID: 35526275 PMCID: PMC9327868 DOI: 10.1111/hex.13522] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Using risk stratification to determine eligibility for cancer screening is likely to improve the efficiency of screening programmes by targeting resources towards those most likely to benefit. We aimed to explore the implications of this approach from a societal perspective by understanding public views on the most acceptable stratification strategies. METHODS We conducted three online community juries with 9 or 10 participants in each. Participants were purposefully sampled by age (40-79 years), sex, ethnicity, social grade and English region. On the first day, participants were informed of the potential benefits and harms of cancer screening and the implications of different ways of introducing stratification using scenarios based on phenotypic and genetic risk scores. On the second day, participants deliberated to reach a verdict on the research question, 'Which approach(es) to inviting people to screening are acceptable, and under what circumstances?' Deliberations and feedback were recorded and analysed using thematic analysis. RESULTS Across the juries, the principle of risk stratification was generally considered to be an acceptable approach for determining eligibility for screening. Disregarding increasing capacity, the participants considered it to enable efficient resource allocation to high-risk individuals and could see how it might help to save lives. However, there were concerns regarding fair implementation, particularly how the risk assessment would be performed at scale and how people at low risk would be managed. Some favoured using the most accurate risk prediction model whereas others thought that certain risk factors should be prioritized (particularly factors considered as non-modifiable and relatively stable, such as genetics and family history). Transparently justifying the programme and public education about cancer risk emerged as important contributors to acceptability. CONCLUSION Using risk stratification to determine eligibility for cancer screening was acceptable to informed members of the public, particularly if it included risk factors they considered fair and when communicated transparently. PATIENT OR PUBLIC CONTRIBUTION Two patient and public involvement representatives were involved throughout this study. They were not involved in synthesizing the results but contributed to producing study materials, co-facilitated the community juries and commented on the interpretation of the findings and final report.
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Affiliation(s)
- Rebecca A. Dennison
- Primary Care Unit, Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | | | - Rae Thomas
- Institute for Evidence‐Based HealthcareBond UniversityGold CoastQueenslandAustralia
| | - Simon J. Griffin
- Primary Care Unit, Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | - Hannah Harrison
- Primary Care Unit, Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | - Stephen D. John
- Department of History and Philosophy of ScienceUniversity of CambridgeCambridgeUK
| | | | - Stephen Morris
- Primary Care Unit, Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | | | | | - Chloe V. Thomas
- School of Health and Related ResearchUniversity of SheffieldSheffieldUK
| | - Juliet A. Usher‐Smith
- Primary Care Unit, Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
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Rai BP, Luis Dominguez Escrig J, Vale L, Kuusk T, Capoun O, Soukup V, Bruins HM, Yuan Y, Violette PD, Santesso N, van Rhijn BWG, Hugh Mostafid A, Imran Omar M. Systematic Review of the Incidence of and Risk Factors for Urothelial Cancers and Renal Cell Carcinoma Among Patients with Haematuria. Eur Urol 2022; 82:182-192. [PMID: 35393159 DOI: 10.1016/j.eururo.2022.03.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 02/12/2022] [Accepted: 03/17/2022] [Indexed: 12/21/2022]
Abstract
CONTEXT The current impact of haematuria investigations on health care organisations is significant. There is currently no consensus on how to investigate patients with haematuria. OBJECTIVE To evaluate the incidence of bladder cancer, upper tract urothelial carcinoma (UTUC), and renal cell carcinoma (RCC) among patients undergoing investigation for haematuria and identify any risk factors for bladder cancer, UTUC, and RCC (BUR). EVIDENCE ACQUISITION Medline, Embase, and Cochrane controlled trials databases and ClinicalTrials.gov were searched for all relevant publications from January 1, 2000 to June 2021 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Prospective, retrospective, and cross-sectional studies with a minimum population of 50 patients with haematuria were considered for the review. EVIDENCE SYNTHESIS A total of 44 studies were included. The total number of participants was 229701. The pooled incidence rate for urothelial bladder cancer was 17% (95% confidence interval [CI] 14-20%) for visible haematuria (VH) and 3.3% (95% CI 2.45-4.3%) for nonvisible haematuria (NVH). The pooled incidence rate for RCC was 2% (95% CI 1-2%) for VH and 0.58% (95% CI 0.42-0.77%) for NVH. The pooled incidence rate for UTUC was 0.75% (95% CI 0.4-1.2%) for VH and 0.17% (95% CI 0.081-0.299%) for NVH. On sensitivity analysis, the proportions of males (risk ratio [RR] 1.14, 95% CI 1.10-1.17 for VH; 1.54, 95% CI 1.34-1.78 for NVH; p < 0.00001; moderate certainty evidence) and individuals with a smoking history (RR 1.41, 95% CI 1.24-1.61 for VH; 1.53, 95% CI 1.36-1.72 for NVH; p < 0.00001; moderate certainty evidence) appeared to be higher in BUR than in non-BUR groups. CONCLUSIONS Male gender and smoking history are risk factors for BUR cancer in haematuria, with bladder cancer being the commonest cancer. The incidence of RCC and UTUC in NVH is low. The review serves as a reference standard for future policy-making on investigation of haematuria by global organisations. PATIENT SUMMARY Our review shows that male gender and smoking history are risk factors for cancers of the bladder, kidney, and ureter. The review also provides information on the proportion of patients who have cancer when they have blood in their urine (haematuria) and will allow policy-makers to decide on the most appropriate method for investigating haematuria in patients.
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Affiliation(s)
- Bhavan P Rai
- Department of Urology, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
| | | | - Luís Vale
- Department of Urology, Centro Hospital Universitário S. João, Porto, University of Porto, Porto, Portugal
| | - Teele Kuusk
- Department of Urology, Darent Valley Hospital, Dartford and Gravesham NHS Trust, Dartford, UK
| | - Otakar Capoun
- Department of Urology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Viktor Soukup
- Department of Urology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Harman M Bruins
- Department of Urology, Zuyderland Medical Center, Sittard-Geleen-Heerlen, The Netherlands
| | - Yuhong Yuan
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, ON, Canada
| | - Philippe D Violette
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Surgery, Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Nancy Santesso
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote Cochrane Canada Centre, McMaster University, Hamilton, ON, Canada
| | - Bas W G van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - A Hugh Mostafid
- Department of Urology, Royal Surrey County Hospital, Guildford, UK
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Bradley SH, Bhartia BS, Kennedy MP, Frank LK, Watson J. Investigating suspected lung cancer. BMJ 2022; 378:e068384. [PMID: 35831012 DOI: 10.1136/bmj-2021-068384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Smith CF, Kristensen BM, Andersen RS, Ziebland S, Nicholson BD. Building the case for the use of gut feelings in cancer referrals: perspectives of patients referred to a non-specific symptoms pathway. Br J Gen Pract 2022; 72:e43-e50. [PMID: 34844921 PMCID: PMC8714524 DOI: 10.3399/bjgp.2021.0275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/02/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Gut feelings may be useful when dealing with uncertainty, which is ubiquitous in primary care. Both patients and GPs experience this uncertainty but patients' views on gut feelings in the consultation have not been explored. AIM To explore patients' perceptions of gut feelings in decision making, and to compare these perceptions with those of GPs. DESIGN AND SETTING Qualitative interviews with 21 patients in Oxfordshire, UK. METHOD Patients whose referral to a cancer pathway was based on their GP's gut feeling were invited to participate. Semi-structured interviews were conducted from November 2019 to January 2020, face to face or over the telephone. Data were analysed with a thematic analysis and mind-mapping approach. RESULTS Some patients described experiencing gut feelings about their own health but often their willingness to share this with their GP was dependent on an established doctor-patient relationship. Patients expressed similar perspectives on the use of gut feelings in consultations to those reported by GPs. Patients saw GPs' gut feelings as grounded in their experience and generalist expertise, and part of a process of evidence gathering. Patients suggested that GPs were justified in using gut feelings because of their role in arranging access to investigations, the difficult 'grey area' of presentations, and the time- and resource-limited nature of primary care. When GPs communicated that they had a gut feeling, some saw this as an indication that they were being taken seriously. CONCLUSION Patients accepted that GPs use gut feelings to guide decision making. Future research on this topic should include more diverse samples and address the areas of concern shared by patients and GPs.
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Affiliation(s)
| | | | - Rikke Sand Andersen
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Factors affecting the decision to investigate older adults with potential cancer symptoms: a systematic review. Br J Gen Pract 2021; 72:e1-e10. [PMID: 34782315 PMCID: PMC8597772 DOI: 10.3399/bjgp.2021.0257] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/27/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Older age and frailty increase the risk of morbidity and mortality from cancer surgery and intolerance of chemotherapy and radiotherapy. The effect of old age on diagnostic intervals is unknown; however, older adults need a balanced approach to the diagnosis and management of cancer symptoms, considering the benefits of early diagnosis, patient preferences, and the likely prognosis of a cancer. AIM To examine the association between older age and diagnostic processes for cancer, and the specific factors that affect diagnosis. DESIGN AND SETTING A systematic literature review. METHOD Electronic databases were searched for studies of patients aged >65 years presenting with cancer symptoms to primary care considering diagnostic decisions. Studies were analysed using thematic synthesis and according to the Synthesis Without Meta-analysis guidelines. RESULTS Data from 54 studies with 230 729 participants were included. The majority of studies suggested an association between increasing age and prolonged diagnostic interval or deferral of a decision to investigate cancer symptoms. Thematic synthesis highlighted three important factors that resulted in uncertainty in decisions involving older adults: presence of frailty, comorbidities, and cognitive impairment. Data suggested patients wished to be involved in decision making, but the presence of cognitive impairment and the need for additional time within a consultation were significant barriers. CONCLUSION This systematic review has highlighted uncertainty in the management of older adults with cancer symptoms. Patients and their family wished to be involved in these decisions. Given the uncertainty regarding optimum management of this group of patients, a shared decision-making approach is important.
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21
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Colorectal Cancer Screening: Have We Addressed Concerns and Needs of the Target Population? GASTROINTESTINAL DISORDERS 2021. [DOI: 10.3390/gidisord3040018] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Despite the recognized benefits of colorectal cancer (CRC) screening, uptake is still suboptimal in many countries. In addressing this issue, one important element that has not received sufficient attention is population preference. Our review provides a comprehensive summary of the up-to-date evidence relative to this topic. Four OVID databases were searched: Ovid MEDLINE® ALL, Biological Abstracts, CAB Abstracts, and Global Health. Among the 742 articles generated, 154 full texts were selected for a more thorough evaluation based on predefined inclusion criteria. Finally, 83 studies were included in our review. The general population preferred either colonoscopy as the most accurate test, or fecal occult blood test (FOBT) as the least invasive for CRC screening. The emerging blood test (SEPT9) and capsule colonoscopy (nanopill), with the potential to overcome the pitfalls of the available techniques, were also favored. Gender, age, race, screening experience, education and beliefs, the perceived risk of CRC, insurance, and health status influence one’s test preference. To improve uptake, CRC screening programs should consider offering test alternatives and tailoring the content and delivery of screening information to the public’s preferences. Other logistical measures in terms of the types of bowel preparation, gender of endoscopist, stool collection device, and reward for participants can also be useful.
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Cancer detection via primary care urgent referral and association with practice characteristics: a retrospective cross-sectional study in England from 2009/2010 to 2018/2019. Br J Gen Pract 2021; 71:e826-e835. [PMID: 34544690 PMCID: PMC8463132 DOI: 10.3399/bjgp.2020.1030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 05/17/2021] [Indexed: 11/17/2022] Open
Abstract
Background There is substantial variation in the use of urgent suspected cancer referral (2-week wait [2WW]) between practices. Aim To examine the change in use of 2WW referrals in England over 10 years (2009/2010 to 2018/2019) and the practice and population factors associated with cancer detection. Design and setting Retrospective cross-sectional study of English general practices and their 2WW referral and Cancer Waiting Times database detection data (all cancers other than non-melanoma skin cancers) from 2009/2010 to 2018/2019. Method A retrospective study conducted using descriptive statistics of changes over 10 years in 2WW referral data. Yearly linear regression models were used to determine the association between cancer detection rates and quintiles of practice and population characteristics. Predicted cancer detection rates were calculated, as well as the difference between lowest to highest quintiles. Results Over the 10 years studied there were 14.89 million 2WW referrals (2.24 million in 2018/2019), and 2.68 million new cancer diagnoses, of which 1.26 million were detected following 2WW. The detection rate increased from 41% to 52% over the time period. In 2018/2019 an additional 66 172 cancers were detected via 2WW compared with 2009/2010. Higher cancer detection via 2WW referrals was associated with larger practices and those with younger GPs. From 2016/2017 onwards more deprived practice populations were associated with decreased cancer detection. Conclusion From 2009/2010 to 2018/2019 2WW referrals increased on average by 10% year on year. The most consistent association with higher cancer detection was found for larger practices and those with younger GPs, though these differences became attenuated over time. The more recent association between increased practice deprivation and lower cancer detection is a cause for concern. The COVID-19 pandemic has led to significant impacts on 2WW referral activity and the impact on patient outcomes will need to be studied.
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Interpreting negative test results when assessing cancer risk in general practice. Br J Gen Pract 2021; 71:298-299. [PMID: 34319881 PMCID: PMC8249029 DOI: 10.3399/bjgp21x716189] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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Madaan A, Kuusk T, Hamdoon M, Elliott A, Pearce D, Madaan S. Nurse‐led one stop hematuria clinic: Outcomes from 2,714 patients. BJUI COMPASS 2021; 2:385-394. [PMID: 35474702 PMCID: PMC8988527 DOI: 10.1002/bco2.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/08/2021] [Accepted: 05/26/2021] [Indexed: 12/14/2022] Open
Abstract
Objectives Objective of this study is to report the results of nurse led hematuria clinic service outcome of 2,714 patients. Subjects and methods We conducted a retrospective, single center review of 2714 patients with visible and nonvisible hematuria managed by a well‐trained nurse specialist in a rapid access clinic (RAC) between 2014 and 2020. All patients received a full review, flexible cystoscopy performed by a nurse, and ultrasound of urinary tracts. After investigations, patients were reassured and discharged or referred for rigid cystoscopy, TURBT, and CT urography. Results In total, 2714 patients attended the RAC between October 2014 and March 2020. Of these, 1684 (62%) were males and 1030 (38%) females. The median age of patients was 68.3 (IQR 58‐79). Of the 1030 females, 500 (48.5%) presented with nonvisible hematuria (NVH), and 530 (51.5%) presented with visible hematuria (VH). The median age was 66 (IQR 56‐76). The number of females diagnosed with any form of malignancy was 72 (7% of all females). Of the 1684 males, 288 (17.1%) presented with NVH, and 1396 (82.9%) presented with VH. The median age was 72 (IQR 59‐81). The number of males diagnosed with some form of malignancy was 258 (15.3% of all males). Overall, 1926 patients presented with VH and 788 patients presented with NVH. After investigations, 290 patients (15.1%) with VH and 40 (5.1%) patients with NVH had some form of malignancy. The highest number of malignancies found in VH was bladder cancer (n = 222, 11.5%), followed by prostate (n = 28, 1%), renal (n = 23, 0.8%), UT urothelial (n = 17, 0.6%), gynaecological (n = 7, 0.3%), and gastrointestinal (n = 5, 0.2%) cancer. The highest number of pathologies found in NVH was infection (n = 44, 5.6%). Cancer detection rate for symptomatic NVH was more than double that of asymptomatic NVH, 6.5% versus 3.1%, respectively. Conclusion Overall, 15.1% with VH and 5.1% with NVH present with malignancy. Nurse‐led rapid access hematuria clinic and flexible cystoscopy investigation by trained nurse is safe and feasible.
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Affiliation(s)
- Anika Madaan
- Faculty of Medicine Imperial College London London UK
| | - Teele Kuusk
- Department of Urology and Nephrology Dartford and Gravesham NHS Trust Dartford UK
| | - Musaab Hamdoon
- Department of Urology and Nephrology Royal Liverpool University Hospital Liverpool UK
| | - Angela Elliott
- Department of Urology and Nephrology Dartford and Gravesham NHS Trust Dartford UK
| | - Dianne Pearce
- Department of Urology and Nephrology Dartford and Gravesham NHS Trust Dartford UK
| | - Sanjeev Madaan
- Department of Urology and Nephrology Dartford and Gravesham NHS Trust Dartford UK
- Department of Urology and Nephrology Canterbury Christ Church University Canterbury UK
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Could Ovarian Cancer Prediction Models Improve the Triage of Symptomatic Women in Primary Care? A Modelling Study Using Routinely Collected Data. Cancers (Basel) 2021; 13:cancers13122886. [PMID: 34207611 PMCID: PMC8228892 DOI: 10.3390/cancers13122886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/04/2021] [Accepted: 06/06/2021] [Indexed: 12/03/2022] Open
Abstract
Simple Summary Earlier detection of ovarian cancer has the potential to improve patient outcomes, including survival. However, determining which women presenting in primary care to refer for specialist assessment and investigation is a clinical dilemma. In this study, we used routinely collected English primary care data from 29,962 women with symptoms of possible ovarian cancer who were tested for the ovarian cancer biomarker CA125. We developed diagnostic prediction models to estimate the probability of the disease. A relatively simple model, consisting of age and CA125 level, performed well for the identification of ovarian cancer. Including additional risk factors within the model did not materially improve model performance. Following further validation, this model could be used to help triage symptomatic women in primary care based on their risk of undiagnosed ovarian cancer, identifying those at high risk for urgent specialist investigation and those at lower (but still elevated) risk for non-urgent investigation or monitoring. Abstract CA125 is widely used as an initial investigation in women presenting with symptoms of possible ovarian cancer. We sought to develop CA125-based diagnostic prediction models and to explore potential implications of implementing model-based thresholds for further investigation in primary care. This retrospective cohort study used routinely collected primary care and cancer registry data from symptomatic, CA125-tested women in England (2011–2014). A total of 29,962 women were included, of whom 279 were diagnosed with ovarian cancer. Logistic regression was used to develop two models to estimate ovarian cancer probability: Model 1 consisted of age and CA125 level; Model 2 incorporated further risk factors. Model discrimination (AUC) was evaluated using 10-fold cross-validation. The sensitivity and specificity of various model risk thresholds (≥1% to ≥3%) were compared with that of the current CA125 cut-off (≥35 U/mL). Model 1 exhibited excellent discrimination (AUC: 0.94) on cross-validation. The inclusion of additional variables (Model 2) did not improve performance. At a risk threshold of ≥1%, Model 1 exhibited greater sensitivity (86.4% vs. 78.5%) but lower specificity (89.1% vs. 94.5%) than CA125 (≥35 U/mL). Applying the ≥1% model threshold to the cohort in place of the current CA125 cut-off, 1 in every 74 additional women identified had ovarian cancer. Following external validation, Model 1 could be used as part of a ‘risk-based triage’ system in which women at high risk of undiagnosed ovarian cancer are selected for urgent specialist investigation, while women at ‘low risk but not no risk’ are offered non-urgent investigation or interval CA125 re-testing. Such an approach has the potential to expedite ovarian cancer diagnosis, but further research is needed to evaluate the clinical impact and health–economic implications.
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Diagnostic performance of a faecal immunochemical test for patients with low-risk symptoms of colorectal cancer in primary care: an evaluation in the South West of England. Br J Cancer 2021; 124:1231-1236. [PMID: 33462361 PMCID: PMC8007716 DOI: 10.1038/s41416-020-01221-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/20/2020] [Accepted: 12/02/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The faecal immunochemical test (FIT) was introduced to triage patients with low-risk symptoms of possible colorectal cancer in English primary care in 2017, underpinned by little primary care evidence. METHODS All healthcare providers in the South West of England (population 4 million) participated in this evaluation. 3890 patients aged ≥50 years presenting in primary care with low-risk symptoms of colorectal cancer had a FIT from 01/06/2018 to 31/12/2018. A threshold of 10 μg Hb/g faeces defined a positive test. RESULTS Six hundred and eighteen (15.9%) patients tested positive; 458 (74.1%) had an urgent referral to specialist lower gastrointestinal (GI) services within three months. Forty-three were diagnosed with colorectal cancer within 12 months. 3272 tested negative; 324 (9.9%) had an urgent referral within three months. Eight were diagnosed with colorectal cancer within 12 months. Positive predictive value was 7.0% (95% CI 5.1-9.3%). Negative predictive value was 99.8% (CI 99.5-99.9%). Sensitivity was 84.3% (CI 71.4-93.0%), specificity 85.0% (CI 83.8-86.1%). The area under the ROC curve was 0.92 (CI 0.86-0.96). A threshold of 37 μg Hb/g faeces would identify patients with an individual 3% risk of cancer. CONCLUSIONS FIT performs exceptionally well to triage patients with low-risk symptoms of colorectal cancer in primary care; a higher threshold may be appropriate in the wake of the COVID-19 crisis.
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Cancer Prevalence and Risk Stratification in Adults Presenting With Hematuria: A Population-Based Cohort Study. Mayo Clin Proc Innov Qual Outcomes 2021; 5:308-319. [PMID: 33997630 PMCID: PMC8105499 DOI: 10.1016/j.mayocpiqo.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective To calculate the prevalence of renal cell carcinoma (RCC), upper urinary tract urothelial carcinoma (UT-UC), and lower urinary tract urothelial carcinoma (LT-UC) in patients with gross asymptomatic microhematuria (AMH) and symptomatic microhematuria (SMH). Patients and Methods This study was a population-based retrospective descriptive study. The study was approved by both the Mayo Clinic Institutional Review Board and the Olmsted Medical Center Institutional Review Board, and the population used was Olmsted County residents. A total of 4453 patients who presented with an initial episode of hematuria from January 1, 2000, through December 30, 2010, were included. Of the 4453 patients (median age, 58 years; interquartile range, 44.6-73.3 years), 1487 (33.4%) had gross hematuria, 2305 (51.8%) had AMH, and 661 (14.8%) had SMH. Results In the 1487 patients with gross hematuria, the prevalence of RCC, UT-UC, and LT-UC was 1.3%, 0.8%, and 9.0%, respectively. In the 2305 patients with AMH, the prevalence of RCC, UT-UC, and LT-UC was 0.2%, 0.3%, and 1.6%, respectively. In the 661 patients with SMH, the prevalence of RCC, UT-UC, and LT-UC was 0.6%, 0.2%, and 0.3%, respectively. Age was the most relevant risk factor for any hematuria type. Conclusion This unique cohort study reported that the prevalence of RCC or UC in patients with AMH and SMH was low, especially in the young cohort, and a large number of intense work-ups, such as cystoscopy and computed tomography urography, currently conducted could be omitted if stratified by hematuria type and age.
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Key Words
- AMH, asymptomatic microhematuria
- AUA, American Urological Association
- CT, computed tomography
- GH, gross hematuria
- LT-UC, lower urinary tract urothelial carcinoma
- OR, odds ratio
- RBC, red blood cell
- RCC, renal cell carcinoma
- REP, Rochester Epidemiology Project
- SMH, symptomatic microhematuria
- UC, urothelial carcinoma
- UT-UC, upper urinary tract urothelial carcinoma
- UTI, urinary tract infection
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Rogers SN, Dailey Y, Langton S. Re: re: Two-week rule: suspected head and neck cancer referrals from a general medical practice perspective. Br J Oral Maxillofac Surg 2020; 59:612-613. [PMID: 33865646 DOI: 10.1016/j.bjoms.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 12/01/2020] [Indexed: 11/26/2022]
Affiliation(s)
- S N Rogers
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, L39 4QP; Liverpool Head and Neck Centre, Liverpool University Hospital Aintree, Liverpool, UK.
| | - Y Dailey
- 1829 Building, Countess of Chester Health Park, Chester, CH2 1HU, UK.
| | - S Langton
- 2 Ravensdale Road, Bolton, Greater Manchester, BL1 5DN.
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Funston G, Hardy V, Abel G, Crosbie EJ, Emery J, Hamilton W, Walter FM. Identifying Ovarian Cancer in Symptomatic Women: A Systematic Review of Clinical Tools. Cancers (Basel) 2020; 12:cancers12123686. [PMID: 33302525 PMCID: PMC7764009 DOI: 10.3390/cancers12123686] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/02/2020] [Accepted: 12/04/2020] [Indexed: 12/23/2022] Open
Abstract
Simple Summary Most women with ovarian cancer are diagnosed after they develop symptoms—identifying symptomatic women earlier has the potential to improve outcomes. Tools, ranging from simple symptom checklists to diagnostic prediction models that incorporate tests and risk factors, have been developed to help identify women at increased risk of undiagnosed ovarian cancer. In this review, we systematically identified studies evaluating these tools and then compared the reported diagnostic performance of tools. All included studies had some quality concerns and most tools had only been evaluated in a single study. However, four tools were evaluated in multiple studies and showed moderate diagnostic performance, with relatively little difference in performance between tools. While encouraging, further large and well-conducted studies are needed to ensure these tools are acceptable to patients and clinicians, are cost-effective and facilitate the early diagnosis of ovarian cancer. Abstract In the absence of effective ovarian cancer screening programs, most women are diagnosed following the onset of symptoms. Symptom-based tools, including symptom checklists and risk prediction models, have been developed to aid detection. The aim of this systematic review was to identify and compare the diagnostic performance of these tools. We searched MEDLINE, EMBASE and Cochrane CENTRAL, without language restriction, for relevant studies published between 1 January 2000 and 3 March 2020. We identified 1625 unique records and included 16 studies, evaluating 21 distinct tools in a range of settings. Fourteen tools included only symptoms; seven also included risk factors or blood tests. Four tools were externally validated—the Goff Symptom Index (sensitivity: 56.9–83.3%; specificity: 48.3–98.9%), a modified Goff Symptom Index (sensitivity: 71.6%; specificity: 88.5%), the Society of Gynaecologic Oncologists consensus criteria (sensitivity: 65.3–71.5%; specificity: 82.9–93.9%) and the QCancer Ovarian model (10% risk threshold—sensitivity: 64.1%; specificity: 90.1%). Study heterogeneity precluded meta-analysis. Given the moderate accuracy of several tools on external validation, they could be of use in helping to select women for ovarian cancer investigations. However, further research is needed to assess the impact of these tools on the timely detection of ovarian cancer and on patient survival.
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Affiliation(s)
- Garth Funston
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK; (V.H.); (J.E.); (F.M.W.)
- Correspondence:
| | - Victoria Hardy
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK; (V.H.); (J.E.); (F.M.W.)
| | - Gary Abel
- University of Exeter Medical School, University of Exeter, Exeter EX1 1TX, UK; (G.A.); (W.H.)
| | - Emma J. Crosbie
- Gynaecological Oncology Research Group, Division of Cancer Sciences, University of Manchester, Manchester M13 9WL, UK;
- Department of Obstetrics and Gynaecology, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester M13 9WL, UK
| | - Jon Emery
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK; (V.H.); (J.E.); (F.M.W.)
- Centre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, VIC 3000, Australia
| | - Willie Hamilton
- University of Exeter Medical School, University of Exeter, Exeter EX1 1TX, UK; (G.A.); (W.H.)
| | - Fiona M. Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK; (V.H.); (J.E.); (F.M.W.)
- Centre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, VIC 3000, Australia
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Harris M, Brekke M, Dinant GJ, Esteva M, Hoffman R, Marzo-Castillejo M, Murchie P, Neves AL, Smyrnakis E, Vedsted P, Aubin-Auger I, Azuri J, Buczkowski K, Buono N, Foreva G, Babić SG, Jacob E, Koskela T, Petek D, Šter MP, Puia A, Sawicka-Powierza J, Streit S, Thulesius H, Weltermann B, Taylor G. Primary care practitioners' diagnostic action when the patient may have cancer: an exploratory vignette study in 20 European countries. BMJ Open 2020; 10:e035678. [PMID: 33130560 PMCID: PMC7783622 DOI: 10.1136/bmjopen-2019-035678] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Cancer survival rates vary widely between European countries, with differences in timeliness of diagnosis thought to be one key reason. There is little evidence on the way in which different healthcare systems influence primary care practitioners' (PCPs) referral decisions in patients who could have cancer.This study aimed to explore PCPs' diagnostic actions (whether or not they perform a key diagnostic test and/or refer to a specialist) in patients with symptoms that could be due to cancer and how they vary across European countries. DESIGN A primary care survey. PCPs were given vignettes describing patients with symptoms that could indicate cancer and asked how they would manage these patients. The likelihood of taking immediate diagnostic action (a diagnostic test and/or referral) in the different participating countries was analysed. Comparisons between the likelihood of taking immediate diagnostic action and physician characteristics were calculated. SETTING Centres in 20 European countries with widely varying cancer survival rates. PARTICIPANTS A total of 2086 PCPs answered the survey question, with a median of 72 PCPs per country. RESULTS PCPs' likelihood of immediate diagnostic action at the first consultation varied from 50% to 82% between countries. PCPs who were more experienced were more likely to take immediate diagnostic action than their peers. CONCLUSION When given vignettes of patients with a low but significant possibility of cancer, more than half of PCPs across Europe would take diagnostic action, most often by ordering diagnostic tests. However, there are substantial between-country variations.
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Affiliation(s)
- Michael Harris
- Department for Health, University of Bath, Bath, Somerset, UK
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Mette Brekke
- Department of General Practice and General Practice Research Unit, University of Oslo, Oslo, Norway
| | - Geert-Jan Dinant
- Department of General Practice, Maastricht University, Maastricht, The Netherlands
| | - Magdalena Esteva
- Balearic Islands Health Research Institute (IdISBa), Palma de Mallorca, Illes Balears, Spain
| | - Robert Hoffman
- Department of Family Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Peter Murchie
- Division of Applied Health Science, University of Aberdeen, Aberdeen, UK
| | - Ana Luísa Neves
- Centre for Health Policy, Imperial College London, London, UK
- Centre for Health Technology and Services Research, Department of Community Medicine, Information and Health Decision Sciences, University of Porto, Porto, Portugal
| | - Emmanouil Smyrnakis
- Laboratory of Primary Health Care, General Practice and Health Services Research, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Peter Vedsted
- Research Unit for General Practice, University of Aarhus, Aarhus, Denmark
| | - Isabelle Aubin-Auger
- Department of General Practice, Université Paris Diderot, Paris, Île-de-France, France
| | - Joseph Azuri
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Krzysztof Buczkowski
- Department of Family Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Nicola Buono
- Department of Family Medicine, National Society of Medical Education in General Practice (SNaMID), Prata Sannita, Italy
| | | | | | - Eva Jacob
- Primary Health Centre, Centro de Saúde Sarria, Sarria, Lugo, Spain
| | - Tuomas Koskela
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Davorina Petek
- Department of Family Medicine, Univerza v Ljubljani, Ljubljana, Slovenia
| | - Marija Petek Šter
- Department of Family Medicine, Univerza v Ljubljani, Ljubljana, Slovenia
| | - Aida Puia
- Family Medicine Department, Iuliu Hagieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | | | - Sven Streit
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Hans Thulesius
- Department of Research and Development, Lund University, Malmö, Sweden
| | - Birgitta Weltermann
- Institut für Hausarztmedizin, University of Bonn, Bonn, Nordrhein-Westfalen, Germany
| | - Gordon Taylor
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
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Affiliation(s)
- I T H Au-Yong
- Department of Radiology, Nottingham University Hospitals, Nottingham, UK
| | - W Hamilton
- University of Exeter Medical School, St Luke's Campus, Exeter EX1 2LU, UK
| | - J Rawlinson
- British Thoracic Oncology Group (advocate steering committee member), NCRI Lung subGroup (consumer), and European Lung Foundation LC Patient advisory group, Sandwell, UK
| | - D R Baldwin
- Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK
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Funston G, Hamilton W, Abel G, Crosbie EJ, Rous B, Walter FM. The diagnostic performance of CA125 for the detection of ovarian and non-ovarian cancer in primary care: A population-based cohort study. PLoS Med 2020; 17:e1003295. [PMID: 33112854 PMCID: PMC7592785 DOI: 10.1371/journal.pmed.1003295] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 09/11/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The serum biomarker cancer antigen 125 (CA125) is widely used as an investigation for possible ovarian cancer in symptomatic women presenting to primary care. However, its diagnostic performance in this setting is unknown. We evaluated the performance of CA125 in primary care for the detection of ovarian and non-ovarian cancers. METHODS AND FINDINGS We studied women in the United Kingdom Clinical Practice Research Datalink with a CA125 test performed between 1 May 2011-31 December 2014. Ovarian and non-ovarian cancers diagnosed in the year following CA125 testing were identified from the cancer registry. Women were categorized by age: <50 years and ≥50 years. Conventional measures of test diagnostic accuracy, including sensitivity, specificity, and positive predictive value, were calculated for the standard CA125 cut-off (≥35 U/ml). The probability of a woman having cancer at each CA125 level between 1-1,000 U/ml was estimated using logistic regression. Cancer probability was also estimated on the basis of CA125 level and age in years using logistic regression. We identified CA125 levels equating to a 3% estimated cancer probability: the "risk threshold" at which the UK National Institute for Health and Care Excellence advocates urgent specialist cancer investigation. A total of 50,780 women underwent CA125 testing; 456 (0.9%) were diagnosed with ovarian cancer and 1,321 (2.6%) with non-ovarian cancer. Of women with a CA125 level ≥35 U/ml, 3.4% aged <50 years and 15.2% aged ≥50 years had ovarian cancer. Of women with a CA125 level ≥35 U/ml who were aged ≥50 years and who did not have ovarian cancer, 20.4% were diagnosed with a non-ovarian cancer. A CA125 value of 53 U/ml equated to a 3% probability of ovarian cancer overall. This varied by age, with a value of 104 U/ml in 40-year-old women and 32 U/ml in 70-year-old women equating to a 3% probability. The main limitations of our study were that we were unable to determine why CA125 tests were performed and that our findings are based solely on UK primary care data, so caution is need in extrapolating them to other healthcare settings. CONCLUSIONS CA125 is a useful test for ovarian cancer detection in primary care, particularly in women ≥50 years old. Clinicians should also consider non-ovarian cancers in women with high CA125 levels, especially if ovarian cancer has been excluded, in order to prevent diagnostic delay. Our results enable clinicians and patients to determine the estimated probability of ovarian cancer and all cancers at any CA125 level and age, which can be used to guide individual decisions on the need for further investigation or referral.
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Affiliation(s)
- Garth Funston
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | | | - Gary Abel
- University of Exeter, Exeter, United Kingdom
| | - Emma J. Crosbie
- Gynaecological Oncology Research Group, Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Obstetrics and Gynaecology, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Brian Rous
- National Cancer Registration and Analysis Service, Public Health England, Cambridge, United Kingdom
| | - Fiona M. Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
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Kaushal A, Waller J, von Wagner C, Kummer S, Whitaker K, Puri A, Lyratzopoulos G, Renzi C. The role of chronic conditions in influencing symptom attribution and anticipated help-seeking for potential lung cancer symptoms: a vignette-based study. BJGP Open 2020; 4:bjgpopen20X101086. [PMID: 32816742 PMCID: PMC7606154 DOI: 10.3399/bjgpopen20x101086] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 02/07/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Very little is known about the influence of chronic conditions on symptom attribution and help-seeking for potential cancer symptoms. AIM To determine if symptom attribution and anticipated help-seeking for potential lung cancer symptoms is influenced by pre-existing respiratory conditions (often referred to as comorbidity), such as asthma or chronic obstructive pulmonary disease (COPD). DESIGN & SETTING A total of 2143 adults (1081 with and 1062 without a respiratory condition) took part in an online vignette survey. METHOD The vignette described potential lung cancer symptoms (persistent cough and breathlessness) after which questions were asked on symptom attribution and anticipated help-seeking. RESULTS Attribution of symptoms to cancer was similar in participants with and without respiratory conditions (21.5% and 22.1%, respectively). Participants with respiratory conditions, compared with those without, were more likely to attribute the new or changing cough and breathlessness to asthma or COPD (adjusted odds ratio [OR] = 3.64, 95% confidence interval [CI] = 3.02 to 4.39). Overall, 56.5% of participants reported intention to seek help from a GP within 3 weeks if experiencing the potential lung cancer symptoms. Having a respiratory condition increased the odds of prompt help-seeking (OR = 1.25, 95% CI = 1.04 to 1.49). Regular healthcare appointments were associated with higher odds of anticipated help-seeking. CONCLUSION Only one in five participants identified persistent cough and breathlessness as potential cancer symptoms, and half said they would promptly seek help from a GP, indicating scope for promoting help-seeking for new or changing symptoms. Chronic respiratory conditions did not appear to interfere with anticipated help-seeking, which might be explained by regular appointments to manage chronic conditions.
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Affiliation(s)
- Aradhna Kaushal
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Jo Waller
- Research Department of Behavioural Science and Health, University College London, London, UK
- School of Cancer & Pharmaceutical Sciences, King's College London, London, UK
| | - Christian von Wagner
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Sonja Kummer
- Research Department of Behavioural Science and Health, University College London, London, UK
| | | | - Aishwarya Puri
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Georgios Lyratzopoulos
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Cristina Renzi
- Research Department of Behavioural Science and Health, University College London, London, UK
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Investigating cancer symptoms in older people: what are the issues and where is the evidence? Br J Gen Pract 2020; 70:321-322. [PMID: 32586799 DOI: 10.3399/bjgp20x710789] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Non-visible haematuria for the Detection of Bladder, Upper Tract, and Kidney Cancer: An Updated Systematic Review and Meta-analysis. Eur Urol 2020; 77:583-598. [DOI: 10.1016/j.eururo.2019.10.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 10/18/2019] [Indexed: 12/12/2022]
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Public preferences for using quantitative faecal immunochemical test versus colonoscopy as diagnostic test for colorectal cancer: evidence from an online survey. BJGP Open 2020; 4:bjgpopen20X101007. [PMID: 32019773 PMCID: PMC7330201 DOI: 10.3399/bjgpopen20x101007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND There has been interest in using the non-invasive, home-based quantitative faecal immunochemical test (FIT) to rule out colorectal cancer (CRC) in high-risk symptomatic patients. AIM To elicit public preferences for FIT versus colonoscopy (CC) and its delivery in primary care. DESIGN & SETTING A cross-sectional online survey in England. METHOD A total of 1057 adults (without CRC symptoms and diagnosis) aged 40-59 years were invited from an English online survey panel. Responders were asked to imagine they had been experiencing CRC symptoms that would qualify them for a diagnostic test. Participants were presented with choices between CC and FIT in ascending order of number of CRCs missed by FIT (from 1-10%). It was measured at what number of missed CRCs responders preferred CC over FIT. RESULTS While 150 participants did not want either of the tests when both missed 1% CRCs, the majority (n = 741, 70.0%) preferred FIT to CC at that level of accuracy. However, this preference reduced to 427 (40.4%) when FIT missed one additional cancer. Women were more likely to tolerate missing CRC when using FIT. Having lower numeracy and perceiving a higher level of risk meant participants were less likely to tolerate a false negative test. Most of those who chose FIT preferred to return it by mail (62.2%), to be informed about normal test results by letter (42.1%), and about abnormal test results face to face (32.5%). CONCLUSION While the majority of participants preferred FIT over CC when both tests had the same sensitivity, tolerance for missed CRCs was low.
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John JB, Coscione A, Acher P, Speakman M. Non-visible haematuria: would discontinuing urgent investigation have a visible impact? Br J Hosp Med (Lond) 2020; 81:1-7. [PMID: 32339006 DOI: 10.12968/hmed.2020.0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
National guidance in the UK continues to recommend urgent referral of selected patients with non-visible haematuria for urological assessment. The positive predictive value of non-visible haematuria for urological cancer is low, so it is uncertain whether this is an effective and equitable use of healthcare resources. This article considers rationales for and against continuing this practice, and outlines alternative investigative strategies for patients presenting with non-visible haematuria based on current knowledge and modern technology.
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Affiliation(s)
- Joseph B John
- Department of Urology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Alberto Coscione
- Department of Urology, Southend University Hospital NHS Foundation Trust, Southend-on-Sea, UK
| | - Peter Acher
- Department of Urology, Southend University Hospital NHS Foundation Trust, Southend-on-Sea, UK
| | - Mark Speakman
- Department of Urology, Taunton and Somerset NHS Foundation Trust, Taunton, UK
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Tsai KP, Hudnall MT, Weiner AB, Keeter MK, Meeks JJ. Willingness to Participate in Home Screening for Urologic Cancers in the General Population: An Online Survey of Over 1400 Adults. Urology 2020; 136:35-40. [DOI: 10.1016/j.urology.2019.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/10/2019] [Accepted: 11/19/2019] [Indexed: 12/24/2022]
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Watson J, Salisbury C, Banks J, Whiting P, Hamilton W. Predictive value of inflammatory markers for cancer diagnosis in primary care: a prospective cohort study using electronic health records. Br J Cancer 2019; 120:1045-1051. [PMID: 31015558 PMCID: PMC6738065 DOI: 10.1038/s41416-019-0458-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 04/04/2019] [Accepted: 04/04/2019] [Indexed: 12/14/2022] Open
Abstract
Background Early identification of cancer in primary care is important and challenging. This study examined the diagnostic utility of inflammatory markers (C-reactive protein, erythrocyte sedimentation rate and plasma viscosity) for cancer diagnosis in primary care. Methods Cohort study of 160,000 patients with inflammatory marker testing in 2014, plus 40,000 untested matched controls, using Clinical Practice Research Datalink (CPRD), with Cancer Registry linkage. Primary outcome was one-year cancer incidence. Results Primary care patients with a raised inflammatory marker have a one-year cancer incidence of 3.53% (95% CI 3.37–3.70), compared to 1.50% (1.43–1.58) in those with normal inflammatory markers, and 0.97% (0.87–1.07) in untested controls. Cancer risk is greater with higher inflammatory marker levels, with older age and in men; risk rises further when a repeat test is abnormal but falls if it normalises. Men over 50 and women over 60 with raised inflammatory markers have a cancer risk which exceeds the 3% NICE threshold for urgent investigation. Sensitivities for cancer were 46.1% for CRP, 43.6% ESR and 49.7% for PV. Conclusion Cancer should be considered in patients with raised inflammatory markers. However, inflammatory markers have a poor sensitivity for cancer and are therefore not useful as ‘rule-out’ test.
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Affiliation(s)
- Jessica Watson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK. .,NIHR CLAHRC West, Bristol, UK.
| | - Chris Salisbury
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,NIHR CLAHRC West, Bristol, UK
| | - Jonathan Banks
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,NIHR CLAHRC West, Bristol, UK
| | - Penny Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,NIHR CLAHRC West, Bristol, UK
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Exploring public attitudes towards the new Faster Diagnosis Standard for cancer: a focus group study with the UK public. Br J Gen Pract 2019; 69:e413-e421. [PMID: 30858334 PMCID: PMC6532807 DOI: 10.3399/bjgp19x702677] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 11/21/2018] [Indexed: 11/10/2022] Open
Abstract
Background The Faster Diagnosis Standard (FDS) is to be introduced in England in 2020. This standard is a new policy in which patients should have cancer ruled out or diagnosed within 28 days of referral. Aim To explore public attitudes towards the FDS within the context of their recent referral experiences. Design and setting Four 90-minute focus groups (two in Guildford, two in Bradford). Method Participants aged >50 years without a current cancer diagnosis (N = 29), who had completed certain diagnostic tests, for example, ultrasound, and received results within the last 6 months were recruited. Age, education, and sex were evenly distributed across groups through purposive sampling. Results The largest cause of concern was the waiting process for obtaining test results. Most had experienced swift referral, and it was difficult for participants to understand how the new standard could impact upon time progressing through the system. Responsibility for meeting the standard was also a concern: participants did not see their own behaviours as a form of involvement. The GP’s role was conceptualised by patients as communicating about their referral, establishing patients’ preferences for information, and continued involvement at each stage of the referral process. The standard legitimised chasing for test results, but 28 days was considered too long. Conclusion Patients should be asked what they would like to know about their referral. GPs should be more transparent about the referral process and the potential for a lack of clarity around next steps.
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A little ‘suspect’? Br J Gen Pract 2019; 69:85. [DOI: 10.3399/bjgp19x701105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Prabhu V, Rosenkrantz AB, Otazo R, Sodickson DK, Kang SK. Population net benefit of prostate MRI with high spatiotemporal resolution contrast-enhanced imaging: A decision curve analysis. J Magn Reson Imaging 2019; 49:1400-1408. [DOI: 10.1002/jmri.26318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/10/2018] [Accepted: 08/13/2018] [Indexed: 12/29/2022] Open
Affiliation(s)
- Vinay Prabhu
- Department of Radiology; NYU School of Medicine; New York New York USA
| | | | - Ricardo Otazo
- Department of Medical Physics; Memorial Sloan Kettering Cancer Center; New York USA
| | | | - Stella K. Kang
- Department of Radiology; NYU School of Medicine; New York New York USA
- Department of Population Health; NYU School of Medicine; New York New York USA
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Pilot Teledermatology Service for Assessing Solitary Skin Lesions in a Tertiary London Dermatology Center. J Healthc Qual 2019; 41:e1-e6. [DOI: 10.1097/jhq.0000000000000142] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Atkin W, Cross AJ, Kralj-Hans I, MacRae E, Piggott C, Pearson S, Wooldrage K, Brown J, Lucas F, Prendergast A, Marchevsky N, Patel B, Pack K, Howe R, Skrobanski H, Kerrison R, Swart N, Snowball J, Duffy SW, Morris S, von Wagner C, Halloran S. Faecal immunochemical tests versus colonoscopy for post-polypectomy surveillance: an accuracy, acceptability and economic study. Health Technol Assess 2019; 23:1-84. [PMID: 30618357 PMCID: PMC6340104 DOI: 10.3310/hta23010] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In the UK, patients with one or two adenomas, of which at least one is ≥ 10 mm in size, or three or four small adenomas, are deemed to be at intermediate risk of colorectal cancer (CRC) and referred for surveillance colonoscopy 3 years post polypectomy. However, colonoscopy is costly, can cause discomfort and carries a small risk of complications. OBJECTIVES To determine whether or not annual faecal immunochemical tests (FITs) are effective, acceptable and cost saving compared with colonoscopy surveillance for detecting CRC and advanced adenomas (AAs). DESIGN Diagnostic accuracy study with health psychology assessment and economic evaluation. SETTING Participants were recruited from 30 January 2012 to 30 December 2013 within the Bowel Cancer Screening Programme in England. PARTICIPANTS Men and women, aged 60-72 years, deemed to be at intermediate risk of CRC following adenoma removal after a positive guaiac faecal occult blood test were invited to participate. Invitees who consented and returned an analysable FIT were included. INTERVENTION We offered participants quantitative FITs at 1, 2 and 3 years post polypectomy. Participants testing positive with any FIT were referred for colonoscopy and not offered further FITs. Participants testing negative were offered colonoscopy at 3 years post polypectomy. Acceptibility of FIT was assessed using discussion groups, questionnaires and interviews. MAIN OUTCOME MEASURES The primary outcome was 3-year sensitivity of an annual FIT versus colonoscopy at 3 years for detecting advanced colorectal neoplasia (ACN) (CRC and/or AA). Secondary outcomes included participants' surveillance preferences, and the incremental costs and cost-effectiveness of FIT versus colonoscopy surveillance. RESULTS Of 8008 invitees, 5946 (74.3%) consented and returned a round 1 FIT. FIT uptake in rounds 2 and 3 was 97.2% and 96.9%, respectively. With a threshold of 40 µg of haemoglobin (Hb)/g faeces (hereafter referred to as µg/g), positivity was 5.8% in round 1, declining to 4.1% in round 3. Over three rounds, 69.2% (18/26) of participants with CRC, 34.3% (152/443) with AAs and 35.6% (165/463) with ACN tested positive at 40 µg/g. Sensitivity for CRC and AAs increased, whereas specificity decreased, with lower thresholds and multiple rounds. At 40 µg/g, sensitivity and specificity of the first FIT for CRC were 30.8% and 93.9%, respectively. The programme sensitivity and specificity of three rounds at 10 µg/g were 84.6% and 70.8%, respectively. Participants' preferred surveillance strategy was 3-yearly colonoscopy plus annual FITs (57.9%), followed by annual FITs with colonoscopy in positive cases (31.5%). FIT with colonoscopy in positive cases was cheaper than 3-yearly colonoscopy (£2,633,382), varying from £485,236 (40 µg/g) to £956,602 (10 µg/g). Over 3 years, FIT surveillance could miss 291 AAs and eight CRCs using a threshold of 40 µg/g, or 189 AAs and four CRCs using a threshold of 10 µg/g. CONCLUSIONS Annual low-threshold FIT with colonoscopy in positive cases achieved high sensitivity for CRC and would be cost saving compared with 3-yearly colonoscopy. However, at higher thresholds, this strategy could miss 15-30% of CRCs and 40-70% of AAs. Most participants preferred annual FITs plus 3-yearly colonoscopy. Further research is needed to define a clear role for FITs in surveillance. FUTURE WORK Evaluate the impact of ACN missed by FITs on quality-adjusted life-years. TRIAL REGISTRATION Current Controlled Trials ISRCTN18040196. FUNDING National Institute for Health Research (NIHR) Health Technology Assessment programme, NIHR Imperial Biomedical Research Centre and the Bobby Moore Fund for Cancer Research UK. MAST Group Ltd provided FIT kits.
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Affiliation(s)
- Wendy Atkin
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Amanda J Cross
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ines Kralj-Hans
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Eilidh MacRae
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Carolyn Piggott
- Bowel Cancer Screening Programme Southern Hub, Guildford, UK
| | - Sheena Pearson
- Bowel Cancer Screening Programme Southern Hub, Guildford, UK
| | - Kate Wooldrage
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jeremy Brown
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Fiona Lucas
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Aaron Prendergast
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Natalie Marchevsky
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Bhavita Patel
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kevin Pack
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Rosemary Howe
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Hanna Skrobanski
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Robert Kerrison
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Nicholas Swart
- Department of Applied Health Research, University College London, London, UK
| | - Julia Snowball
- Bowel Cancer Screening Programme Southern Hub, Guildford, UK
| | - Stephen W Duffy
- Centre for Cancer Prevention, Wolfson Institute of Preventative Medicine, Queen Mary University, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Christian von Wagner
- Research Department of Behavioural Science and Health, University College London, London, UK
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Ankus E, Price SJ, Ukoumunne OC, Hamilton W, Bailey SER. Cancer incidence in patients with a high normal platelet count: a cohort study using primary care data. Fam Pract 2018; 35:671-675. [PMID: 29659802 DOI: 10.1093/fampra/cmy018] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND A platelet count >400 × 109/l (i.e. thrombocytosis) is a recently discovered risk marker of cancer. The risk of undiagnosed cancer in patients with thrombocytosis is 11.6% for men and 6.2% for women, well above the 3% risk threshold set by National Institute for Health and Care Excellence (NICE) for cancer investigation. Patients with a platelet count at the upper end of the normal range (325-400 × 109/l) could be at increased risk of undiagnosed malignancy. OBJECTIVE To quantify the risk of an undiagnosed cancer in patients with a platelet count at the upper end of the normal range. METHODS A primary care-based cohort study using Clinical Practice Research Datalink (CPRD) data from 2000 to 2013. The study sample comprised 2704 individuals stratified by platelet count: 325-349 × 109/l; 350-374 × 109/l; 375-399 × 109/l. Incident cancer diagnoses in the year following that platelet count were obtained from patient records. RESULTS Cancer incidence rose with increasing platelet count: 2.6% [95% confidence interval (CI) 1.9 to 3.6] in subjects with a count of 325-349 × 109/l, 3.7% (95% CI 2.5 to 5.3) in subjects with a count of 350-374 × 109/l and 5.1% (95% CI 3.4 to 7.5) in those with a count of 375-399 × 109/l. Colorectal cancer was most commonly diagnosed in all three groups. Cancer incidence was consistently higher in males than in females. CONCLUSION These results suggest that clinicians should consider cancer in patients with a platelet count >375 × 109/l, review reasons for testing and any additional reported symptoms. Until these results are replicated on a larger scale, recommendations for clinical action cannot be made.
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Affiliation(s)
- Emily Ankus
- University of South Florida, Tampa, Florida, USA
| | | | - Obioha C Ukoumunne
- National Institute for Health Research (NIHR) CLAHRC South West Peninsula, University of Exeter Medical School, Exeter, UK
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Ungar N, Schmidt L, Gabrian M, Haussmann A, Tsiouris A, Sieverding M, Steindorf K, Wiskemann J. Which self-management strategies do health care professionals recommend to their cancer patients? An experimental investigation of patient age and treatment phase. J Behav Med 2018; 42:342-352. [PMID: 30353398 DOI: 10.1007/s10865-018-9980-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 10/13/2018] [Indexed: 10/28/2022]
Abstract
This vignette based study aimed to examine recommendations of health care professionals (HCPs) in promoting self-management strategies to cancer patients. Nine-hundred-forty-two physicians and nurses were asked to (1) indicate if they would recommend self-management strategies to a vignette cancer patient, and (2) to specify those in an open format. Vignettes included a manipulation of patient age (60 vs. 75 years) and treatment phase (currently treated versus treatment completed). Six categories emerged through coding a total of 2303 recommendations: physical activity (71.8%), nutrition (64.3%), psychological support (36.7%), medical support (29.2%), conscious living (17.2%) and naturopathy (12.3%). While psychological support was particularly recommended during treatment, physical activity was more frequently recommended after completion of treatment. Results suggest that HCPs recommend a variety of self-management strategies besides standard medical treatment. Patient's treatment phase and age seem to partly influence recommendation behavior, potentially indicating insecurities regarding acute treatment situations and age-related stereotypes.
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Affiliation(s)
- Nadine Ungar
- Institute of Psychology, Heidelberg University, Hauptstr. 47-51, 69117, Heidelberg, Germany.
| | - Laura Schmidt
- Institute of Psychology, Heidelberg University, Hauptstr. 47-51, 69117, Heidelberg, Germany
| | - Martina Gabrian
- Institute of Psychology, Heidelberg University, Hauptstr. 47-51, 69117, Heidelberg, Germany
| | - Alexander Haussmann
- Division of Physical Activity, Prevention and Cancer, National Center for Tumor Diseases (NCT) Heidelberg and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Angeliki Tsiouris
- Division of Medical Oncology, National Center for Tumor Diseases (NCT) Heidelberg and University Hospital Heidelberg, Heidelberg, Germany
| | - Monika Sieverding
- Institute of Psychology, Heidelberg University, Hauptstr. 47-51, 69117, Heidelberg, Germany
| | - Karen Steindorf
- Division of Physical Activity, Prevention and Cancer, National Center for Tumor Diseases (NCT) Heidelberg and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Joachim Wiskemann
- Division of Medical Oncology, National Center for Tumor Diseases (NCT) Heidelberg and University Hospital Heidelberg, Heidelberg, Germany
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Sanghavi K, Moses I, Moses D, Gordon A, Chyr L, Bodurtha J. Family health history and genetic services-the East Baltimore community stakeholder interview project. J Community Genet 2018; 10:219-227. [PMID: 30171451 DOI: 10.1007/s12687-018-0379-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 08/23/2018] [Indexed: 12/30/2022] Open
Abstract
Discussion of family health history (FH) has the potential to be a communication tool within families and with health providers to stimulate health promotion related to many chronic conditions, including those with genetic implications for prevention, screening, diagnosis, treatment. Diverse communities with disparities in health outcomes may require different approaches to engage individuals and families in the evolving areas of genetic risk communication, assessment, and services. This work was a partnership of a local urban agency and academic genetics professionals to increase understanding of community concerns and preferences related to FH and genetic awareness. Thirty community stakeholders in the East Baltimore area participated in structured interviews conducted by community members. We identified key themes on family health history FH, risk assessment, and genetic services. Forty-three percent (18/27) of community stakeholders thought families in East Baltimore did not discuss family health history FH with doctors. Stakeholders recognized the benefits and challenges of potential actions based on genetic risk assessment and the multiple competing priorities of families. FH awareness with community engagement and genetics education were the major needs identified by the participants. Research undertaken in active collaboration with community partners can provide enhanced consumer perspectives on the importance of family health history and its potential connections to health promotion and prevention activities.
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Affiliation(s)
- Kunal Sanghavi
- The Jackson Laboratory for Genomic Medicine, Farmington, CT, USA.
| | - Ivy Moses
- Johns Hopkins Hospital, Baltimore, MD, USA
- Jesus' Stop Restoration, Inc., Baltimore, MD, USA
| | - DuWade Moses
- Jesus' Stop Restoration, Inc., Baltimore, MD, USA
| | - Adelaide Gordon
- Chapel Hill School of Nursing, University of North Carolina, Chapel Hill, NC, USA
| | - Linda Chyr
- Maryland Department of Health, Office of Health Services, Maryland Medicaid, Baltimore, MD, USA
| | - Joann Bodurtha
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Prout HC, Barham A, Bongard E, Tudor-Edwards R, Griffiths G, Hamilton W, Harrop E, Hood K, Hurt CN, Nelson R, Porter C, Roberts K, Rogers T, Thomas-Jones E, Tod A, Yeo ST, Neal RD, Nelson A. Patient understanding and acceptability of an early lung cancer diagnosis trial: a qualitative study. Trials 2018; 19:419. [PMID: 30075741 PMCID: PMC6090834 DOI: 10.1186/s13063-018-2803-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 07/10/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The ELCID (Early Lung Cancer Investigation and Diagnosis) trial was a feasibility randomised controlled trial examining the effect on lung cancer diagnosis of lowering the threshold for referral for urgent chest x-ray for smokers and recent ex-smokers, aged over 60 years with new chest symptoms. The qualitative component aimed to explore the feasibility of individually randomising patients to an urgent chest x-ray or not and to investigate any barriers to patient recruitment and participation. We integrated this within the feasibility trial to inform the design of any future definitive trial, particularly in view of the lack of research exploring symptomatic patients' experiences of participating in diagnostic trials for possible/suspected lung cancer. Although previous studies contributed valuable information concerning screening for lung cancer and patient participation in trials, this paper is the first to explore issues relating to this specific patient group. METHODS Qualitative interviews were conducted with 21 patients, comprising 9 who had been randomised to receive an immediate chest x-ray, 10 who were randomised to receive the standard treatment according to the National Institute for Health and Care Excellence guidelines, and 2 who chose not to participate in the trial. Interviews were analysed using a framework approach. RESULTS The findings of this analysis showed that altruism, personal benefit and the reassurance of not having lung cancer were important factors in patient participation. However, patients largely believed that being in the intervention arm was more beneficial, highlighting a lack of understanding of clinical equipoise. Disincentives to participation in the trial included the stigmatisation of patients who smoked (given the inclusion criteria). Although the majority of patients reported that they were happy with the trial design, there was evidence of poor understanding. Last, for several patients, placing trust in health professionals was preferred to understanding the trial processes. CONCLUSIONS The integration of a qualitative study focusing on participant experience as a secondary outcome of a feasibility trial enabled exploration of patient response to participation and recruitment. The study demonstrated that although it is feasible to recruit patients to the ELCID trial, more work needs to be done to ensure an understanding of study principles and also of smoking stigmatisation. TRIAL REGISTRATION ClinicalTrials.gov, NCT01344005 . Registered on 27 April 2011.
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Affiliation(s)
- Hayley C. Prout
- Marie Curie Palliative Care Research Centre, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Emily Bongard
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | | | - Emily Harrop
- Marie Curie Palliative Care Research Centre, School of Medicine, Cardiff University, Cardiff, UK
| | - Kerry Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Chris N. Hurt
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Rosie Nelson
- Marie Curie Palliative Care Research Centre, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Kirsty Roberts
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Trevor Rogers
- Doncaster Royal Infirmary, Doncaster and Bassetlaw NHS Foundation Trust, Doncaster, UK
| | | | - Angela Tod
- School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Seow Tien Yeo
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Richard D. Neal
- Academic Unit of Primary Care, Leeds Institute of Health Sciences, Worsley Building (Room 10.35), Clarendon Way, Leeds, LS2 9NL UK
| | - Annmarie Nelson
- Marie Curie Palliative Care Research Centre, School of Medicine, Cardiff University, Cardiff, UK
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Tan WS, Feber A, Sarpong R, Khetrapal P, Rodney S, Jalil R, Mostafid H, Cresswell J, Hicks J, Rane A, Henderson A, Watson D, Cherian J, Williams N, Brew-Graves C, Kelly JD. Who Should Be Investigated for Haematuria? Results of a Contemporary Prospective Observational Study of 3556 Patients. Eur Urol 2018; 74:10-14. [DOI: 10.1016/j.eururo.2018.03.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 03/07/2018] [Indexed: 11/26/2022]
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Funston G, O'Flynn H, Ryan NAJ, Hamilton W, Crosbie EJ. Recognizing Gynecological Cancer in Primary Care: Risk Factors, Red Flags, and Referrals. Adv Ther 2018; 35:577-589. [PMID: 29516408 PMCID: PMC5910472 DOI: 10.1007/s12325-018-0683-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Indexed: 12/11/2022]
Abstract
Early diagnosis of symptomatic gynecological cancer is likely to improve patient outcomes, including survival. The primary care practitioner has a key role to play in this-they must recognize the symptoms and signs of gynecological cancer and make prompt evidence-based decisions regarding further investigation and referral. However, this is often difficult as many of the symptoms of gynecological cancers are nonspecific and are more likely to be caused by benign rather than malignant disease. As primary care is generally the first point of patient contact, those working in this setting usually encounter cancer patients at an earlier, and possibly less symptomatic, stage than practitioners in secondary care. Despite these challenges, research has improved our understanding of the symptoms patients present to primary care with, and a range of tests and referral pathways now exist in the UK and other countries to aid early diagnosis. Primary care practitioners can also play a key role in gynecological cancer prevention. A significant proportion of gynecological cancer is preventable either through lifestyle changes such as weight loss, or, for cervical cancer, vaccination and/or engagement with screening programs. Primary care provides an excellent opportunity to discuss cancer risk with patients and to promote risk reduction strategies and lifestyle change. In this article, the first in a series discussing cancer detection in primary care, we concentrate on gynecological cancer and focus on the three most common forms that a primary care practitioner is likely to encounter: ovarian, endometrial, and cervical cancer. We outline key risk factors, briefly discuss prevention and screening strategies, and offer practical guidance on the recognition of symptoms and signs and the investigation and referral of women with suspected cancer. While this article is written from a UK primary care perspective, much of what is discussed will be of relevance to those working in other healthcare systems.
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Affiliation(s)
- Garth Funston
- Centre for Primary Care, University of Manchester, Manchester, UK.
| | - Helena O'Flynn
- Centre for Primary Care, University of Manchester, Manchester, UK
| | - Neil A J Ryan
- Gynaecological Oncology Group, University of Manchester, Manchester, UK
| | | | - Emma J Crosbie
- Gynaecological Oncology Group, University of Manchester, Manchester, UK
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