The expanding role of primary care in cancer control

The Association of Established Primary Care with Postoperative Outcomes Among Medicare Patients with Digestive Tract Cancer

BACKGROUND

Primary care (PC) is essential to overall wellness and management of comorbidities. In turn, patients without adequate access to PC may face healthcare disparities. We sought to characterize the impact of established PC on postoperative outcomes among patients undergoing a surgical procedure for a digestive tract cancer.

METHODS

Medicare beneficiaries with a diagnosis of hepatobiliary, pancreas, and colorectal cancer between 2005 and 2019 were identified within the Surveillance, Epidemiology, and End Results program and Medicare-linked database. Individuals who did versus did not have PC encounters within 1-year before surgery were identified. A postoperative textbook outcome (TO) was defined as the absence of complications, no prolonged hospital stay, no readmission within 90 days, and no mortality.

RESULTS

Among 63,177 patients, 50,974 (80.7%) had at least one established PC visit before surgery. Patients with established PC were more likely to achieve TO (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.09-1.19) with lower odds for complications (OR, 0.85; 95% CI, 0.72-0.89), extended hospital stay (OR, 0.86; 95% CI, 0.81-0.94), 90-day readmission (OR, 0.94; 95% CI, 0.90-0.99), and 90-day mortality (OR, 0.87; 95% CI, 0.79-0.96). In addition, patients with established PC had a 4.1% decrease in index costs and a 5.2% decrease in 1-year costs. Notably, patients who had one to five visits with their PC in the year before surgery had improved odds of TO (OR, 1.21; 95% CI, 1.16-1.27), whereas individuals with more than 10 visits had lower odds of a postoperative TO (OR, 0.91; 95% CI, 0.84-0.98).

CONCLUSION

Most Medicare beneficiaries with digestive tract cancer had established PC within the year before their surgery. Established PC was associated with a higher probability of achieving ideal outcomes and lower costs. In contrast, patients with more than 10 PC appointments, which was likely a surrogate of overall comorbidity burden, experienced no improvement in postoperative outcomes.

Perceptions and attitudes about the contribution of the environment to childhood cancer: a pilot study in a medical guild and undergraduate students

BACKGROUND

Identifying and recognizing environmental risk factors for childhood cancer is crucial to prevent it. Medical guild are the first contact to monitor children's health. Therefore, courses about the contribution of chemical toxins in the environment and health outcomes such as cancer should be included in their professional training. This study aimed to evaluate the perceptions and attitudes of a medical guild and undergraduate students in health sciences about the contribution of the environment to childhood cancer.

METHODS

A pilot study was conducted, an online survey including thirteen questions was shared among medical guild members and undergraduate students in health sciences. Frequencies, percentages, and chi-square homogeneity tests were calculated to compare groups.

RESULTS

Genetic factors ranked as the first possible cause of childhood cancer (88.2% medical guild and 97.7% undergraduate students). However, 70.6% of medical guild and 64.6% of undergraduate students reported that they have ever suspected that childhood cancer could be related to the environmental conditions in which children live. More than 95% of the participants reported that they would find it useful to have more knowledge about environmental risks and cancer. When data were analyzed by profession (medical guild) and academic year (undergraduate students), no significant differences were observed. Nonetheless, comparisons by academic discipline between undergraduate students, showed that a higher percentage of medicine and environmental sciences and health (over 98%) reported environmental exposure as risk factors associated with childhood cancer compared to 75% from physiotherapy, (p = 0.001).

CONCLUSIONS

In this study, the environmental contribution to childhood cancer is not clear among the medical guild and undergraduate students. They should be trained on the topic of cancer and the environment.

[Patients' experience of neoplasia care by their general practitioner. Qualitative study of case histories]

BACKGROUND

Little research has been done on the follow-up of patients in the active phase of treatment in primary care. This study aimed to build up a corpus of authentic clinical situations and carry out an inductive analysis of the data.

METHOD

Research in two stages: case study and qualitative analysis of verbatims. The authors conducted individual interviews using an interview guide. The questions targeted their experiences, focusing on their relationship with their general practitioner.

RESULTS

Six themes were identified. The announcement of the diagnosis was a key moment. Patients emphasised their general practitioner's responsiveness and coordination, and stressed his involvement. They consulted him regularly during the active phase of treatment, and asked for information. They felt confident. The need to facilitate access to the general practitioner was noted, particularly in the event of a real or perceived emergency.

DISCUSSION

The increase in the prevalence and incidence of cancer means that general practitioners need to be heavily involved. The authorities are advocating a strengthening of the general practitioner's "pivotal role", without clearly defining it. A perceived lack of skills may be an obstacle to general practitioner involvement. Training in cancer during the 3rd cycle of general medical studies is inadequate. By compiling and analysing a corpus of cases, it would be possible to redefine the training objectives and list the skills required to manage cancer patients.

Adapting a Preparatory Skills-Building Programme for Carers of People With Cancer Through Co-Design: The iCanSupport Project

INTRODUCTION

Health services rely upon carers to provide care for loved ones with cancer, yet many carers often feel ill-prepared for this role. Despite a multitude of programmes to support carer mental health, programmes that help carers feel better equipped to support a person with cancer are lacking. This study aimed to address this need by adapting an evidence-based intervention to be suitable for carers of people with cancer.

METHODS

This study used an exploratory, qualitative design consisting of experienced-based co-design and an in-depth stakeholder engagement strategy. An existing evidence-based programme to promote resilience in the context of providing care was adapted for relevance to carers for people with cancer via two co-design workshops with carers and healthcare professionals (n = 8). The resulting prototype programme was refined based on stakeholder consultations with staff and consumer members of cancer and carer support organisations across Australia (n = 16). Transcripts of the workshops, meetings and written feedback from carers were thematically analysed.

RESULTS

Major programme developments were guided by three themes that emerged from the co-design workshops: 'creating value for carers', 'multiple contributors to carer distress' and 'the need for flexible implementation'. Analysis of the stakeholder consultation data showed that the themes of 'diversity in carer journeys' and 'creating impact for carers' were key to further tailoring the programme for applicability to practice. An adapted programme called 'iCanSupport' resulted from the process, with key adaptations being more relevant case study scenarios for carers and greater flexibility in accessing and engaging with the intervention to accommodate a range of carer circumstances.

CONCLUSION

Programmes to build skills for becoming a carer for someone with cancer are absent, yet they are desired by carers. Using co-design provided a user-centric approach to adapt an existing evidence-based programme. Programme evaluation is required to determine the effectiveness of the co-designed approach in improving carer preparedness among a range of cohorts.

PATIENT OR PUBLIC CONTRIBUTION

Carers and consumers with lived experience and others involved in supporting consumers made valuable contributions to co-designing and refining the programme in addition to providing ongoing guidance in the unfolding analysis and reporting of this research.

Primary care physicians' knowledge and confidence in providing cancer survivorship care: a systematic review

PURPOSE

To systematically review existing literature on knowledge and confidence of primary care physicians (PCPs) in cancer survivorship care.

METHODS

PubMed, Ovid MEDLINE, CINAHL, Embase, and PsycINFO were searched from inception to July 2022 for quantitative and qualitative studies. Two reviewers independently assessed studies for eligibility and quality. Outcomes were characterized by domains of quality cancer survivorship care.

RESULTS

Thirty-three papers were included, representing 28 unique studies; 22 cross-sectional surveys, 8 qualitative, and 3 mixed-methods studies. Most studies were conducted in North America (n = 23) and Europe (n = 8). For surveys, sample sizes ranged between 29 and 1124 PCPs. Knowledge and confidence in management of physical (n = 19) and psychosocial effects (n = 12), and surveillance for recurrences (n = 14) were described most often. Generally, a greater proportion of PCPs reported confidence in managing psychosocial effects (24-47% of PCPs, n= 5 studies) than physical effects (10-37%, n = 8). PCPs generally thought they had the necessary knowledge to detect recurrences (62-78%, n = 5), but reported limited confidence to do so (6-40%, n = 5). There was a commonly perceived need for education on long-term and late physical effects (n = 6), and cancer surveillance guidelines (n = 9).

CONCLUSIONS

PCPs' knowledge and confidence in cancer survivorship care varies across care domains. Suboptimal outcomes were identified in managing physical effects and recurrences after cancer.

IMPLICATIONS FOR CANCER SURVIVORS

These results provide insights into the potential role of PCPs in cancer survivorship care, medical education, and development of targeted interventions.

The focus on life-prolonging anticancer treatment hampers shared decision-making in people with advanced cancer: A qualitative embedded multiple-case study

BACKGROUND

Implementing shared decision-making in oncology practice is often limited, particularly integrating the patient's context into decision-making. To improve this, we conducted a quality improvement project, CONtext. CONtext attempts to accomplish this by: (1) Integrating the patient's context into shared decision-making during consultation with the medical oncologist; (2) Actively involving the GP and case manager (a specialized oncology nurse), who often have knowledge about the patient's context, and; (3) Giving the person with advanced cancer a time-out period of up to 2 weeks to consider and discuss treatment options with others, including close family and friends.

AIM

To explore how persons with advanced cancer and their involved professionals experienced shared decision-making after the introduction of CONtext.

DESIGN

A qualitative embedded multiple-case study using in-depth interviews analysed with inductive content analysis.

PARTICIPANTS

A purposive sample of 14 cases, each case consisting of a patient with advanced cancer and ideally their medical oncologist, case manager, and GP.

RESULTS

Four themes were identified: shared decision-making is a dynamic and continuous process (1), in which the medical oncologist's treatment recommendation is central (2), fuelled by the patients' experience of not having a choice (3), and integrating the patient's context into shared decision-making was considered important but hampered (4), for example, by the association with the terminal phase.

CONCLUSIONS

The prevailing tendency among medical oncologists and persons with advanced cancer to prioritize life-prolonging anticancer treatments restricts the potential for shared decision-making. This undermines integrating individual context into decision-making, a critical aspect of the palliative care continuum.

Supporting Carers: Study Protocol of a Meta-Review of Psychosocial Interventions for Carers of People With Cancer

BACKGROUND

While there is a clear need for psychosocial interventions that promote the well-being of carers of patients with cancer, the corresponding evidence base is disparate, complex, and difficult for end users to navigate and interpret. Carers remain undersupported with a lack of dedicated, effective, evidence-based programs. We will conduct a meta-review to synthesize this evidence and determine the state of science in this field.

OBJECTIVE

This study aims to address the question, "what psychosocial interventions are available to promote the well-being of carers for people with cancer?"

METHODS

A meta-review will synthesize the relevant reviews of psychosocial interventions that have been developed and evaluated with carers for people with cancer. A total of 4 electronic databases (PsycInfo, MEDLINE, CINAHL, and Cochrane Database of Systematic Reviews) will be searched for reviews published between January 2013 and December 2023. A team-based approach will be taken for screening and assessment of the returned records against the eligibility criteria to determine inclusion. Included reviews will be critically appraised using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses. Relevant data on study characteristics, carer and patient populations, intervention details, and psychosocial outcomes will be extracted, synthesized, and the findings will be presented in a narrative format.

RESULTS

It is anticipated that the study will be completed by October 2024.

CONCLUSIONS

Ensuring that carers have access to evidence-based programs that promote their well-being as they care for loved ones is critical. This meta-review will contribute to program development and translation efforts by providing a clear picture of the intervention evidence base of carers of patients with cancer and identifying notable strengths, weaknesses, and gaps across the literature. The findings are anticipated to offer future directions to advance research in the field.

TRIAL REGISTRATION

PROSPERO (CRD42023403219); https://tinyurl.com/4tnzv49s.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56403.

The WHO guidelines: the new and the old

PURPOSE OF THE REVIEW

The original World Health Organisation (WHO) cancer pain guidelines were published in 1986 and used globally. Updated guidance was released in 2018. This review compares the 'old' with the 'new' with a closer look at the relevance of the WHO analgesic ladder in the current climate.

RECENT FINDINGS

The new guidelines provide a more evidence based, rigorously developed document including recommendations relating to radiotherapeutic management. There is a more detailed focus on safe opioid prescribing, opioid stewardship and the importance of integrating pain management expertise early on in the cancer journey. There remains a lack of evidence for certain therapies despite their widespread use particularly in relation to adjuvants. The pitfalls of the original renowned analgesic ladder are highlighted including a recognition that omitting 'step 2' is safe, feasible and cost effective.

SUMMARY

The new guidelines offer more detailed recommendations relevant to clinical practice with a strong focus on safety of opioid prescribing making it relevant in the current climate. The original WHO analgesic ladder is no longer recommended as a strict protocol for cancer pain management.

Implementation of cancer prevention practices in primary care: results of a cohort study in Chile 2018-2022

OBJECTIVES

The burden of cancer is increasing rapidly in Latin America. Primary care has an essential role in cancer prevention, but implementation levels of prevention practices are not well known. This study evaluated implementation levels and associated factors of cancer preventive practices in primary care over time.

STUDY DESIGN

The study incorporated a retrospective multicentre cohort study.

METHODS

A population of 59,949 patients registered at three primary care clinics was followed from January 2018 to December 2022 in Santiago, Chile. We studied human papillomavirus (HPV) and hepatitis B virus (HBV) immunisation, brief counselling for smoking cessation and alcohol consumption, and cervical and breast cancer screening practices. Standardised electronic medical records were utilised as the source of information. Social, clinical, and organisational factors associated with prevention practices were studied.

RESULTS

The cohort attrition level was 17.1%. Most of the population was of a low socioeconomic status, and 70% visited a primary health centre yearly. Implementation rates of immunisation practices were 90.84% for HPV and 80.94% for HBV in 2022. In contrast, brief counselling for smoking and alcohol consumption was below 20% during the study period. Cervical cancer screening decreased by 25.58% between 2018 and 2022, whereas breast cancer screening reached only 41.71% of the target population. Opportunistic medical visits were strongly associated with brief counselling and breast cancer screening.

CONCLUSION

Implementation practices for cancer prevention in a Chilean primary care cohort are high for immunisation and very low for brief counselling and screening practices. A comprehensive non-medical-based model is needed to improve cancer prevention in primary care.

Follow-up cancer care in Danish general practice: a questionnaire study

BACKGROUND

The number of patients who have survived cancer has increased substantially owing to improved cancer treatment. This has reinforced the need for effective strategies for follow-up cancer care in general practice.

AIM

To investigate the organisation of follow-up cancer care in Danish general practice and to analyse GPs' self-assessment of competences regarding patients who have survived cancer and late effects.

DESIGN & SETTING

A total of 500 Danish general practices were invited to a web-based survey.

METHOD

Questions comprised organisation of follow-up cancer care, and GPs' self-assessment of their competences in follow-up care and evaluation of late effects. Covariates considered included sex, age, seniority, and practice type. Analyses were conducted using descriptive statistics and multivariable logistic regression models.

RESULTS

Some 28% of the GPs reported systematic organisation of follow-up cancer care in their clinic. More than half of the GPs assessed themselves as competent in evaluating mental sequelae, existential considerations, and the impact on comorbidities. In contrast, only 19% and 33% of GPs reported competences in sexual and physical sequelae, respectively. Female GPs were less likely to report competences regarding physical and mental sequelae as well as sexual disturbances, and GPs from partnership practices were more likely to report competence in assessing mental sequelae.

CONCLUSION

Fewer than one in three general practices have organised systematic follow-up cancer care and GPs assess their competence as low with respect to physical sequelae and sexual challenges. This emphasises the need for more systematic organisation and focus on knowledge of late effects in general practice.

Advancing healthcare: the role and impact of AI and foundation models

BACKGROUND

The integration of artificial intelligence (AI) into the healthcare domain is a monumental shift with profound implications for diagnostics, medical interventions, and the overall structure of healthcare systems.

PURPOSE

This study explores the transformative journey of foundation AI models in healthcare, shedding light on the challenges, ethical considerations, and vast potential they hold for improving patient outcome and system efficiency. Notably, in this investigation we observe a relatively slow adoption of AI within the public sector of healthcare. The evolution of AI in healthcare is un-paralleled, especially its prowess in revolutionizing diagnostic processes.

RESULTS

This research showcases how these foundational models can unravel hidden patterns within complex medical datasets. The impact of AI reverberates through medical interventions, encompassing pathology, imaging, genomics, and personalized healthcare, positioning AI as a cornerstone in the quest for precision medicine. The paper delves into the applications of generative AI models in critical facets of healthcare, including decision support, medical imaging, and the prediction of protein structures. The study meticulously evaluates various AI models, such as transfer learning, RNN, autoencoders, and their roles in the healthcare landscape. A pioneering concept introduced in this exploration is that of General Medical AI (GMAI), advocating for the development of reusable and flexible AI models.

CONCLUSION

The review article discusses how AI can revolutionize healthcare by stressing the significance of transparency, fairness and accountability, in AI applications regarding patient data privacy and biases. By tackling these issues and suggesting a governance structure the article adds to the conversation about AI integration in healthcare environments.

Exploring physicians' expectations of telehealth services implementation in primary care: An application of the social cognitive theory

Background

Understanding healthcare professionals' expectations in telehealth is crucial for successful implementation. The present study used an adaptation of the antecedents-expectations model, supported by the social cognitive theory to evaluate physicians' expectations regarding the implementation of telehealth in primary healthcare (PHC) and to investigate the potential influence, on expectations, of a prior telehealth experience (antecedents) during the Coronavirus disease 2019 (COVID-19) pandemic.

Materials and Methods

A questionnaire-based survey was conducted online, targeting PHC physicians. Expectations covered four telehealth performance domains including public health and health promotion, Care Quality and Workflow Organization, Patient's Convenience and Engagement and Providers' Value and Training. Antecedents included six domains including gain in self-efficacy, gain in knowledge, gain in participation/engagement, gain in experience, enjoyment and satisfaction. Stepwise linear regression was performed to analyse the effect of antecedents on overall expectations.

Results

A total of 54 physicians participated in the study. The mean expectation score was 114.15/154 (SD = 28.26), with highest expectations concerning cost-effectiveness, care timeliness and patients' convenience. A previous experience with smart apps and dedicated telehealth platforms was associated with lower expectations scores. Expectations scores were positively correlated with antecedents scores; however, satisfaction was the sole independent factor of overall expectations (regression coefficient B = 4.40, 95%CI: 3.11-5.68).

Conclusion

The findings highlight the significance of previous experience and various antecedents in shaping physicians' expectations about telehealth. These insights can inform the development of strategies and interventions to enhance healthcare professionals' expectations and facilitate the successful implementation of telehealth services.

Using an mHealth approach to collect patient-generated health data for predicting adverse health outcomes among adult survivors of childhood cancer

Introduction

Cancer therapies predispose childhood cancer survivors to various treatment-related late effects, which contribute to a higher symptom burden, chronic health conditions (CHCs), and premature mortality. Regular monitoring of symptoms between clinic visits is useful for timely medical consultation and interventions that can improve quality of life (QOL). The Health Share Study aims to utilize mHealth to collect patient-generated health data (PGHD; daily symptoms, momentary physical health status) and develop survivor-specific risk prediction scores for mitigating adverse health outcomes including poor QOL and emergency room admissions. These personalized risk scores will be integrated into the hospital-based electronic health record (EHR) system to facilitate clinician communications with survivors for timely management of late effects.

Methods

This prospective study will recruit 600 adult survivors of childhood cancer from the St. Jude Lifetime Cohort study. Data collection include 20 daily symptoms via a smartphone, objective physical health data (physical activity intensity, sleep performance, and biometric data including resting heart rate, heart rate variability, oxygen saturation, and physical stress) via a wearable activity monitor, patient-reported outcomes (poor QOL, unplanned healthcare utilization) via a smartphone, and clinically ascertained outcomes (physical performance deficits, onset of/worsening CHCs) assessed in the survivorship clinic. Participants will complete health surveys and physical/functional assessments in the clinic at baseline, 2) report daily symptoms, wear an activity monitor, measure blood pressure at home over 4 months, and 3) complete health surveys and physical/functional assessments in the clinic 1 and 2 years from the baseline. Socio-demographic and clinical data abstracted from the EHR will be included in the analysis. We will invite 20 cancer survivors to investigate suitable formats to display predicted risk information on a dashboard and 10 clinicians to suggest evidence-based risk management strategies for adverse health outcomes.

Analysis

Machine and statistical learning will be used in prediction modeling. Both approaches can handle a large number of predictors, including longitudinal patterns of daily symptoms/other PGHD, along with cancer treatments and socio-demographics.

Conclusion

The individualized risk prediction scores and added communications between providers and survivors have the potential to improve survivorship care and outcomes by identifying early clinical presentations of adverse events.

The journey of lung cancer patients from symptoms to diagnosis in Greece. A mixed methods approach

The early diagnosis of lung cancer improves the probability of successful treatment. However, patients and physicians face several difficulties that can considerably delay the diagnostic process. A mixed-methods study that would follow the patient's journey throughout the diagnostic process could alleviate these difficulties. This study aimed to (a) track the patients' journey from the onset of symptoms until diagnosis and, (b) explore the patients' perspective of the journey until diagnosis, on the largest island of Greece. A convergent mixed-methods study was conducted with 94 patients with lung cancer. Patients completed a self-report questionnaire and were interviewed about their symptoms and journey through the healthcare system before their diagnosis. Our findings revealed several problems and delays in the diagnostic process. Both quantitative and qualitative data showed that patients did not recognize their symptoms and sought medical advice in time because they overlooked or attributed their symptoms to 'simpler'/'more common' causes. Furthermore, most patients were diagnosed 1-3 months after their first visit to a physician for their symptoms. Qualitative data analysis revealed three broad categories of problems that delayed diagnosis: (1) physician missteps, (2) administrative problems, and (3) the effect of the Covid-19 pandemic. This study found that major issues and delays prolong the diagnostic process for lung cancer. Therefore, optimization of diagnostic processes at each level of healthcare and interspecialty cooperation programs are needed. Furthermore, population-based interventions and patient education can help lung cancer patients be diagnosed early and improve their quality of life and disease outcomes.

The Association between Blood Test Trends and Undiagnosed Cancer: A Systematic Review and Critical Appraisal

Clinical guidelines include monitoring blood test abnormalities to identify patients at increased risk of undiagnosed cancer. Noting blood test changes over time may improve cancer risk stratification by considering a patient's individual baseline and important changes within the normal range. We aimed to review the published literature to understand the association between blood test trends and undiagnosed cancer. MEDLINE and EMBASE were searched until 15 May 2023 for studies assessing the association between blood test trends and undiagnosed cancer. We used descriptive summaries and narratively synthesised studies. We included 29 articles. Common blood tests were haemoglobin (24%, n = 7), C-reactive protein (17%, n = 5), and fasting blood glucose (17%, n = 5), and common cancers were pancreatic (29%, n = 8) and colorectal (17%, n = 5). Of the 30 blood tests studied, an increasing trend in eight (27%) was associated with eight cancer types, and a decreasing trend in 17 (57%) with 10 cancer types. No association was reported between trends in 11 (37%) tests and breast, bile duct, glioma, haematological combined, liver, prostate, or thyroid cancers. Our review highlights trends in blood tests that could facilitate the identification of individuals at increased risk of undiagnosed cancer. For most possible combinations of tests and cancers, there was limited or no evidence.

Exploring diagnostic events and first referrals in cancer patient pathways in primary care. A questionnaire survey

BACKGROUND

Cancer diagnostic pathways in general practice are often nonlinear, and several events can delay timely diagnosis.

OBJECTIVES

To explore cancer diagnostic processes in general practice, examining how patients' symptom presentations, sex, and age are associated with the occurrence of predefined potentially delaying events and the first referrals.

METHOD

General practices in 3 Danish Regions were invited to participate in a questionnaire survey, addressing patient's symptom presentation, diagnostic process events, and first referral. The general practitioners (GPs) received a list of their incident cancer patients from the preceding 2 years.

RESULTS

In total 187 general practices participated, including 5,908 patients with the cancer diagnostic pathways initiated in general practice. Presenting with nonspecific symptoms was associated with potentially delaying events, even when the patient also had specific symptoms. Almost half of the patients were referred to a cancer patient pathway (CPP) first, men more often than women, and 10% were referred for acute hospitalization. In 23% of the diagnostic processes, GPs initially treated or referred patients on suspicion of another disease rather than cancer and waited due to normal examinations in 1 out of 20 patients. Excluding sex-specific cancers, these 2 events were more prevalent in women. Men less often complied to the follow-up agreement. Younger patients were less often first referred to a CPP and together with older patients more often first acutely hospitalized.

CONCLUSION

In cancer diagnostic processes in general practice, first referrals and the occurrence of potentially delaying events are associated with the patient's age, sex, and specificity of symptoms.

Effect of comorbidity and multimorbidity on adherence to follow-up recommendations among long-term breast cancer survivors

OBJECTIVES

To study the impact of comorbidities, multimorbidity, and multimorbidity clusters on adherence to recommended follow-up guidelines among long-term breast cancer survivors.

STUDY DESIGN

Retrospective cohort study based on 2078 women diagnosed with breast cancer from 2000 to 2006 and followed up from 2012 to 2016.

MAIN OUTCOME MEASURES

Adherence to breast cancer follow-up recommendations (annual medical visit and imaging) was determined. Comorbidities were classified as acute/chronic. Multimorbidity was defined as the presence of two or more chronic comorbidities aside from breast cancer. Five multimorbidity clusters were considered. Multivariate logistic regression models were fitted to determine the relationship between adherence to recommendations and the presence of comorbidities and multimorbidity, considering both sociodemographic and clinical characteristics.

RESULTS

Overall adherence to recommendations was 79.5 %. Adherence was lower among long-term breast cancer survivors with no comorbidities (75.8 %). Among multimorbidity clusters, adherence was highest in the anxiety and fractures cluster (84.3 %) and was lowest in the musculoskeletal and cardiovascular cluster (76.4 %). In adjusted multivariate models, multimorbidity was associated with higher levels of adherence (OR = 1.52 95 %CI 1.16-1.99), and adherence was highest in the metabolic and degenerative cluster (OR = 2.2 95 %CI 1.4-3.5).

CONCLUSION

Adherence to follow-up recommendations was higher among long-term breast cancer survivors with multimorbidity than among those without. Adherence also differed by multimorbidity cluster. These results suggest suboptimal adherence to the current follow-up recommendations in certain groups, suggesting the need to adapt clinical practice guidelines to reflect patients' comorbidities and different characteristics.

A systematic review of risk factors associated with depression and anxiety in cancer patients

Depression and anxiety are common comorbid conditions associated with cancer, however the risk factors responsible for the onset of depression and anxiety in cancer patients are not fully understood. Also, there is little clarity on how these factors may vary across the cancer phases: diagnosis, treatment and depression. We aimed to systematically understand and synthesise the risk factors associated with depression and anxiety during cancer diagnosis, treatment and survivorship. We focused our review on primary and community settings as these are likely settings where longer term cancer care is provided. We conducted a systematic search on PubMed, PsychInfo, Scopus, and EThOS following the PRISMA guidelines. We included cross-sectional and longitudinal studies which assessed the risk factors for depression and anxiety in adult cancer patients. Quality assessment was undertaken using the Newcastle-Ottawa assessment checklists. The quality of each study was further rated using the Agency for Healthcare Research and Quality Standards. Our search yielded 2645 papers, 21 of these were eligible for inclusion. Studies were heterogenous in terms of their characteristics, risk factors and outcomes measured. A total of 32 risk factors were associated with depression and anxiety. We clustered these risk factors into four domains using an expanded biopsychosocial model of health: cancer-specific, biological, psychological and social risk factors. The cancer-specific risk factors domain was associated with the diagnosis, treatment and survivorship phases. Multifactorial risk factors are associated with the onset of depression and anxiety in cancer patients. These risk factors vary across cancer journey and depend on factors such as type of cancer and individual profile of the patients. Our findings have potential applications for risk stratification in primary care and highlight the need for a personalised approach to psychological care provision, as part of cancer care.

"Opportunistic Care": A Focus Group Study of Nurses' Perspective on Caring for Long-term Cancer Survivors and Their Families

BACKGROUND

The global population of long-term cancer survivors is increasing, thanks to advances in treatments and care. Healthcare systems are working to address the unique needs of these individuals. However, there remains a knowledge gap concerning nurses' view on cancer survivorship care.

OBJECTIVE

To identify nurses' perspective of care for long-term cancer survivors and their families.

METHODS

This qualitative descriptive study used 5 focus groups comprising 33 nurses from primary healthcare and specialized oncology care. Data analysis was conducted through thematic analysis, and the study received ethical approval.

RESULTS

Long-term cancer survivors and their families often remained unrecognized as a distinct group within the healthcare system. Consequently, nurses provide what can be termed as "opportunistic care" during nurse-survivor encounters, addressing health needs beyond the purpose of the initial healthcare visit. This absence of a systematic or structured approach for this patient group has prompted nurses to seek the establishment of a comprehensive framework through survivorship care plans, thus ensuring a continuum of care for this specific population.

CONCLUSION

The lack of a structured approach to caring for long-term cancer survivors and their families, often invisible as a distinct population group, results in nurses providing care on an opportunistic basis.

IMPLICATIONS FOR PRACTICE

It is crucial to develop and implement survivorship care plans tailored to this population's needs. Simultaneously, it is important to advance research in this area and establish an educational framework for nurses, enabling them to effectively address the care of long-term cancer survivors and their families.

The Acceptance and Use of Digital Technologies for Self-Reporting Medication Safety Events After Care Transitions to Home in Patients With Cancer: Survey Study

BACKGROUND

Actively engaging patients with cancer and their families in monitoring and reporting medication safety events during care transitions is indispensable for achieving optimal patient safety outcomes. However, existing patient self-reporting systems often cannot address patients' various experiences and concerns regarding medication safety over time. In addition, these systems are usually not designed for patients' just-in-time reporting. There is a significant knowledge gap in understanding the nature, scope, and causes of medication safety events after patients' transition back home because of a lack of patient engagement in self-monitoring and reporting of safety events. The challenges for patients with cancer in adopting digital technologies and engaging in self-reporting medication safety events during transitions of care have not been fully understood.

OBJECTIVE

We aim to assess oncology patients' perceptions of medication and communication safety during care transitions and their willingness to use digital technologies for self-reporting medication safety events and to identify factors associated with their technology acceptance.

METHODS

A cross-sectional survey study was conducted with adult patients with breast, prostate, lung, or colorectal cancer (N=204) who had experienced care transitions from hospitals or clinics to home in the past 1 year. Surveys were conducted via phone, the internet, or email between December 2021 and August 2022. Participants' perceptions of medication and communication safety and perceived usefulness, ease of use, attitude toward use, and intention to use a technology system to report their medication safety events from home were assessed as outcomes. Potential personal, clinical, and psychosocial factors were analyzed for their associations with participants' technology acceptance through bivariate correlation analyses and multiple logistic regressions.

RESULTS

Participants reported strong perceptions of medication and communication safety, positively correlated with medication self-management ability and patient activation. Although most participants perceived a medication safety self-reporting system as useful (158/204, 77.5%) and easy to use (157/204, 77%), had a positive attitude toward use (162/204, 79.4%), and were willing to use such a system (129/204, 63.2%), their technology acceptance was associated with their activation levels (odds ratio [OR] 1.83, 95% CI 1.12-2.98), their perceptions of communication safety (OR 1.64, 95% CI 1.08-2.47), and whether they could receive feedback after self-reporting (OR 3.27, 95% CI 1.37-7.78).

CONCLUSIONS

In general, oncology patients were willing to use digital technologies to report their medication events after care transitions back home because of their high concerns regarding medication safety. As informed and activated patients are more likely to have the knowledge and capability to initiate and engage in self-reporting, developing a patient-centered reporting system to empower patients and their families and facilitate safety health communications will help oncology patients in addressing their medication safety concerns, meeting their care needs, and holding promise to improve the quality of cancer care.

What would primary care practitioners do differently after a delayed cancer diagnosis? Learning lessons from their experiences

OBJECTIVE

Diagnosis of cancer is challenging in primary care due to the low incidence of cancer cases in primary care practice. A prolonged diagnostic interval may be due to doctor, patient or system factors, or may be due to the characteristics of the cancer itself. The objective of this study was to learn from Primary Care Physicians' (PCP) experiences of incidents when they had failed to think of, or act on, a cancer diagnosis.

DESIGN

A qualitative, online survey eliciting PCP narratives. Thematic analysis was used to analyse the data.

SETTING AND SUBJECTS

A primary care study, with narratives from 159 PCPs in 23 European countries.

MAIN OUTCOME MEASURES

PCPs' narratives on the question 'If you saw this patient with cancer presenting in the same way today, what would you do differently?

RESULTS

The main themes identified were: thinking broadly; improvement in communication and clinical management; use of other available resources and 'I wouldn't do anything differently'.

CONCLUSION (IMPLICATIONS)

To achieve more timely cancer diagnosis, PCPs need to provide a long-term, holistic and active approach with effective communication, and to ensure shared decision-making, follow-up and continuing re-assessment of the patients' clinical conditions.

Are Australian Cancer and Palliative Care Nurses Ready to Prescribe Medicines? A National Survey

OBJECTIVES

Registered nurse prescribing has been put forth, for decades, as an innovative approach to meet growing healthcare needs, particularly in areas of care where medications are essential and highly controlled such as for patients requiring cancer and palliative care. However, the adoption of innovative health delivery models requires acceptance by key stakeholders. This study explores cancer and palliative care nurses' attitudes toward nurse prescribing and their perceptions about educational requirements for a nurse prescriber.

DATA SOURCES

A cross-sectional survey was distributed to Australian nurses between March and July 2021. Data were collected using the Advancing Implementation of Nurse Prescribing in Australia online survey. Pearson χ2 tests were used to examine associations between nurses in cancer care, palliative care, and all other specialties on demographics, attitudes to nurse prescribing, and educational perspectives to become prescribers. Of the 4,424 nurses who participated in the survey, 161 nurses identified they worked in cancer care and 109 in palliative care settings.

CONCLUSION

Although nurses have a common set of core capabilities, their work contexts and their professional experiences shape their attitudes toward practice. Nurses in cancer care were significantly less certain than nurses in palliative care [χ2(2) = 6.68, P = .04], and nurses from all other specialties [χ2(2) =13.87, P = <.01] of the benefits of nurse prescribing (ie, nurse prescribing would decrease health care system costs, reduce patient risk). Nurses in cancer care were more certain that successfully implementing nurse prescribing requires strong support from their medical and pharmacy colleagues. In addition, nurses working in cancer and palliative care agreed that improving patient care was their primary motivator for becoming a prescriber.

IMPLICATIONS FOR NURSING PRACTICE

Open to expanding their role and responsibilities, nurses in cancer and palliative care settings reported that successfully adopting nurse prescribing must be supported by their other healthcare colleagues within the same environment, which demands strong interprofessional collaborative efforts.

Cancer worry is associated with increased use of supportive health care-results from the multinational InCHARGE study

PURPOSE

To assess use of health care following a diagnosis of endometrial, cervical, and ovarian cancer in the Netherlands, Norway, and Denmark. Furthermore, to analyze the association between cancer worry and use of supportive care.

METHODS

An international multicenter cross-sectional questionnaire study was undertaken among female cancer survivors with endometrial, cervical, or ovarian cancer 1-7 years post diagnosis. We investigated different aspects of cancer survivorship and follow-up care. Health care use included information on the use of supportive health care, general practitioner (GP), and follow-up visits to the department of gynecology. Cancer worry was assessed with the Impact of Cancer (IoCv2) questionnaire.

RESULTS

A total of 1433 women completed the questionnaire. Health care use decreased from time of diagnosis and was higher among cervical and ovarian cancer survivors than endometrial cancer survivors. Twenty-five percent of the women with ovarian cancer reported severe cancer worry, in contrast to 10 and 15% of women diagnosed with endometrial and cervical cancer, respectively. Women with severe worry had significantly higher use of supportive care activities. In a multivariable regression analysis, cancer worry remained a significant correlate for use of supportive health care services irrespective of disease severity or prognosis. The strongest association was found for use of a psychologist (OR 2.1 [1.71-2.58]).

CONCLUSION

Cancer worry is associated with increased use of supportive care.

IMPLICATIONS FOR CANCER SURVIVORS

Targeted, timely, and accessible psychological support aimed at severe cancer worry may improve survivorship care and ensure optimal referral of patients in need of additional care.

Healthcare experiences among Black and White sexual and gender minority cancer survivors: a qualitative study

PURPOSE

The purpose of this study was to explore healthcare experiences of Black and White sexual and gender minority (SGM) cancer survivors across the cancer care continuum.

METHODS

This was a qualitative analysis of two focus groups and eight individual interviews completed as part of a larger initiative using a community-engaged research approach to reduce cancer disparities in marginalized communities. There was a total of 16 participants in the study (9 were White, 7 were Black) and data were collected between 2019 and 2020.

RESULTS

Three main themes emerged from the thematic analysis: strategically coming out, provider preferences, and health system challenges. Participants noted that they often came out through their support system, decided to come out based on the relevance of their SGM identity that they perceived, and expressed a desire for privacy. Lack of an accessible and competent PCP was tied to delayed cancer diagnosis and many participants voiced a preference for consistency when they found a provider they liked.

CONCLUSIONS

Providers across specialties can address barriers for SGM patients by not making assumptions about patient sexual orientation or gender identity. Institutions should systematically collect sexual orientation and gender identity information. Primary care providers should be aware that due to resistance to switching from trusted providers, they may need to take greater initiative to facilitate cancer screenings for their patients when appropriate or take special care when making referrals to ensure they are using SGM-affirming providers.

IMPLICATIONS FOR CANCER SURVIVORS

SGM cancer survivors often benefit from a cultivating relationship with a trusted PCP or other provider.

Referral challenges for early-onset colorectal cancer: a qualitative study in UK primary care

BACKGROUND

The incidence of early-onset colorectal cancer (EOCRC) in adults aged <50 years has increased in several Western nations. National surveys have highlighted significant barriers to accessing timely care for patients with EOCRC, which may be contributing to a late stage of presentation in this population group.

AIM

To explore awareness of the increasing incidence of EOCRC, and to understand the potential barriers or facilitators faced by GPs when referring younger adults to secondary care with features indicative of EOCRC.

DESIGN & SETTING

Qualitative methodology, via virtual semi-structured interviews with 17 GPs in Northern Ireland.

METHOD

Reflective thematic analysis was conducted with reference to Braun and Clarke's framework.

RESULTS

Three main themes were identified among participating GPs: awareness, diagnostic, and referral challenges. Awareness challenges focused on perceptions of EOCRC being solely associated with hereditary cancer syndromes, and colorectal cancer being a condition of older adults. Key diagnostic challenges centred around the commonality of lower gastrointestinal complaints and overlap in EOCRC symptoms with benign conditions. Restrictions in age-based referral guidance and a GP 'guilt complex' surrounding over-referral to secondary care summarised the referral challenges. Young females were perceived as being particularly disadvantaged with regard to delays in diagnosis.

CONCLUSION

This novel research outlines potential reasons for the diagnostic delays seen in patients with EOCRC from a GP perspective, and highlights many of the complicating factors that contribute to the diagnostic process.

SCORE: a randomised controlled trial evaluating shared care (general practitioner and oncologist) follow-up compared to usual oncologist follow-up for survivors of colorectal cancer

BACKGROUND

SCORE is the first randomised controlled trial (RCT) to examine shared oncologist and general practitioner (GP) follow-up for survivors of colorectal cancer (CRC). SCORE aimed to show that shared care (SC) was non-inferior to usual care (UC) on the EORTC QLQ-C30 Global Health Status/Quality of Life (GHQ-QoL) scale to 12 months.

METHODS

The study recruited patients from five public hospitals in Melbourne, Australia between February 2017 and May 2021. Patients post curative intent treatment for stage I-III CRC underwent 1:1 randomisation to SC and UC. SC replaced two oncologist visits with GP visits and included a survivorship care plan and primary care management guidelines. Assessments were at baseline, 6 and 12 months. Difference between groups on GHQ-QoL to 12 months was estimated from a mixed model for repeated measures (MMRM), with a non-inferiority margin (NIM) of -10 points. Secondary endpoints included quality of life (QoL); patient perceptions of care; costs and clinical care processes (CEA tests, recurrences). Registration ACTRN12617000004369p.

FINDINGS

150 consenting patients were randomised to SC (N = 74) or UC (N = 76); 11 GPs declined. The mean (SD) GHQ-QoL scores at 12 months were 72 (20.2) for SC versus 73 (17.2) for UC. The MMRM mean estimate of GHQ-QoL across the 6 month and 12 month follow-up was 69 for SC and 73 for UC, mean difference -4.0 (95% CI: -9.0 to 0.9). The lower limit of the 95% CI did not cross the NIM. There was no clear evidence of differences on other QoL, unmet needs or satisfaction scales. At 12 months, the majority preferred SC (40/63; 63%) in the SC group, with equal preference for SC (22/62; 35%) and specialist care (22/62; 35%) in UC group. CEA completion was higher in SC. Recurrences similar between arms. Patients in SC on average incurred USD314 less in health costs versus UC patients.

INTERPRETATION

SC seems to be an appropriate and cost-effective model of follow-up for CRC survivors.

FUNDING

Victorian Cancer Agency and Cancer Australia.

Research-practice partnership: supporting rural cancer survivors in Montana

The objective of this Research-Practice Partnership was to disseminate and implement strategies to assist Community Health Centers in improving the care of rural cancer survivors in Montana. Funded by the National Cancer Institute's Community Outreach and Engagement mechanism, this project utilized the MAP-IT (Mobilize, Assess, Plan, Implement, Track) program planning framework from Healthy People 2020. Partners included Montana's Department of Public Health and Human Services' Cancer Control Program, Montana Primary Care Association, One Health Community Health Center, and Huntsman Cancer Institute at the University of Utah. Project activities focused on (1) Planning, creating, implementing, and evaluating provider/care team education sessions through the Project ECHO tele-mentoring platform and through short webinars and (2) Building processes for identifying, documenting, and connecting with survivors using electronic health records (EHRs) and other resources. Lessons learned from this project include the value of aligning partner goals from the outset to foster sustained commitment, the importance of adapting implementation plans to address challenges and leverage opportunities, and the need for accurate EHR data and formal processes for identifying and engaging with cancer survivors.

Acceptability of a shared cancer follow-up model of care between general practitioners and radiation oncologists: A qualitative evaluation

INTRODUCTION

Facilitators to implement shared cancer follow-up care into clinical practice include mechanisms to allow the oncologist to continue overseeing the care of their patient, two-way information sharing and clear follow-up protocols for general practitioners (GPs). This paper aimed to evaluate patients, GPs and radiation oncologists (ROs) acceptance of a shared care intervention.

METHODS

Semi-structured interviews were conducted pre- and post intervention with patients that were 3 years post radiotherapy treatment for breast, colorectal or prostate cancer, their RO, and their GP. Inductive and deductive thematical analysis was employed.

RESULTS

Thirty-two participants were interviewed (19 patients, 9 GPs, and 4 ROs). Pre intervention, there was support for GPs to play a greater role in cancer follow-up care, however, patients were concerned about the GPs cancer-specific skills. Patients, GPs and ROs were concerned about increasing the GPs workload. Post intervention, participants were satisfied that the GPs had specific skills and that the impact on GP workload was comparable to writing a referral. However, GPs expressed concern about remuneration. GPs and ROs felt the model provided patient choice and were suitable for low-risk, stable patients around 2-3 years post treatment. Patients emphasised that they trusted their RO to advise them on the most appropriate follow-up model suited to their individual situation. The overall acceptance of shared care depended on successful health technology to connect the GP and RO. There were no differences in patient acceptance between rural, regional, and cancer types. ROs presented differences in acceptance for the different cancer types, with breast cancer strongly supported.

CONCLUSION

Patients, GPs and ROs felt this shared cancer follow-up model of care was acceptable, but only if the RO remained directly involved and the health technology worked. There is a need to review funding and advocate for health technology advances to support integration.

PATIENT OR PUBLIC CONTRIBUTION

Patients treated with curative radiotherapy for breast, colorectal and prostate cancer, their RO and their GPs were actively involved in this study by giving their consent to be interviewed.

Exploring GPs' assessments of their patients' cancer diagnostic processes: a questionnaire study

BACKGROUND

Most cancer diagnostic pathways start from primary care and several factors affect the diagnostic processes.

AIM

To analyse the associations between patient characteristics, symptom presentation, and cancer type and the GP's assessment of the diagnostic processes.

DESIGN AND SETTING

General practices in the North, Central, and Southern regions of Denmark were invited to participate in a questionnaire survey.

METHOD

Participating GPs received a list of patients with incident cases of cancer in the period between 1 March 2019 and 28 February 2021 based on administrative hospital data. A questionnaire was completed for each patient, addressing symptom presentation and the GP's assessment of the diagnostic process both overall and in four subcategories (the patient's role, the GP's role, the transition between primary and secondary care, and the secondary sector's role).

RESULTS

A total of 187 general practices informed on 8240 patients. For 5868 patients, diagnostic pathways started in general practice. Almost half (48.3%, 2837/5868) presented with specific cancer symptoms. GPs assessed 55.6% (3263) and 32.3% (1897) of the diagnostic processes as 'very good' and 'predominantly good', respectively; 11.9% (700) were 'predominantly poor' or 'very poor' for these 5868 patients. Long symptom duration of ≥2 months prior to GP contact and presenting with non-specific or a combination of non-specific and specific symptoms were associated with a poor overall assessment of the diagnostic process. Assessment in the four subcategories showed that the patient's role was assessed less positively than the other three categories.

CONCLUSION

A longer symptom duration and presenting without cancer-specific symptoms were associated with GPs assessing the diagnostic process as poor.

Adopting standardized cancer patient pathways as a policy at different organizational levels in the Swedish Health System

BACKGROUND

Standardized cancer patient pathways as a new policy has been adopted in healthcare to improve the quality of cancer care. Within the health systems, actors at different levels manage the adoption of new policies to develop healthcare. The various actors on different levels play an important role and influence the policy adoption process. Thus, knowledge about how these actors use strategies when adopting cancer patient pathways as a policy in the health system becomes central.

METHOD

The study's aim was to explore how actors at different organizational levels in the health system adopted cancer patient pathways. Our overarching case was the Swedish health system at the national, regional, and local levels. Constructivist Grounded Theory Method was used to collect and analyze qualitative interviews with persons working in organizations directly involved in adopting cancer patient pathways at each level. Twelve individual and nine group interviews were conducted including 53 participants.

RESULTS

Organizational actors at three different levels used distinct strategies during the adoption of cancer patient pathways: acting as-missionaries, fixers, and doers. Acting as missionaries consisted of preaching the idea of cancer patient pathways and framing it with a common purpose to agree upon. Acting as fixers entailed creating a space to put cancer patient pathways into practice and overcome challenges to this. Acting as doers comprised balancing breadth and speed in healthcare provision with not being involved in the development of cancer patient pathways for the local context. These strategies were not developed in isolation from the other organizational levels but rather, each level interacted with one another.

CONCLUSIONS

When adopting new policies, it is important to be aware of the different strategies and actors at various organizational levels in health systems. Even when actors on different levels developed separate strategies, if these contribute to fulfilling the four domains of inter-organizational collaboration, they can work well together to adopt new policies. Our study highlighted that the application of two domains was lacking, which meant that local actors were not sufficiently involved in collaboration, thus constricting the local use and optimization of cancer patient pathways in practice.

Test, evidence, transition projects in Scotland: developing the evidence needed for transition of effective interventions in cancer care from innovation into mainstream practice

BACKGROUND

A robust evidence base is required to assist healthcare commissioners and providers in selecting effective and sustainable approaches to improve cancer diagnosis and treatment. Such evidence can be difficult to build, given the fast-paced and highly pressured nature of healthcare delivery, the absence of incentives, and the presence of barriers in conducting pragmatic yet robust research evaluations. Cancer Research UK (CRUK) has played an active part in building the evidence base through its funding of programmes to identify, evaluate and scale-up innovative approaches across the UK. The aim of this paper is to describe and explain the research design and intended approach and activities for two cancer services improvement projects in Scotland funded by CRUK.

METHODS

A hybrid effectiveness-implementation study design will assess both the efficiency of the new pathways and their implementation strategies, with the aim of generating knowledge for scale-up. A range of implementation, service and clinical outcomes will be assessed as determined by the projects' Theories of Change (ToCs). A naturalistic case study approach will enable in-depth exploration of context and process, and the collection and synthesis of data from multiple sources including routine datasets, patient and staff surveys, in-depth interviews and observational and other data. The evaluations are informed throughout by a patient/public representatives' group, and by small group discussions with volunteer cancer patients.

DISCUSSION

Our approach has been designed to provide a holistic understanding of how (well) the improvement projects work (in relation to their anticipated outcomes), and how they interact with their wider contexts. The evaluations will help identify barriers, facilitators, and unanticipated consequences that can impact scalability, sustainability and spread. By opting for a pragmatic, participatory evaluation research design, we hope to inform strategies for scaling up successful innovations while addressing challenges in a targeted manner.

Experiences of colorectal cancer survivors in returning to primary coordinated healthcare following treatment

BACKGROUND

Advances in screening and treatments for colorectal cancer (CRC) have improved survival rates, leading to a large population of CRC survivors. Treatment for CRC can cause long-term side-effects and functioning impairments. General practitioners (GPs) have a role in meeting survivorship care needs of this group of survivors. We explored CRC survivors' experiences of managing the consequences of treatment in the community and their perspective on the GP's role in post-treatment care.

METHODS

This was a qualitative study using an interpretive descriptive approach. Adult participants no longer actively receiving treatment for CRC were asked about: side-effects post-treatment; experiences of GP-coordinated care; perceived care gaps; and perceived GP role in post-treatment care. Thematic analysis was used for data analysis.

RESULTS

A total of 19 interviews were conducted. Participants experienced side-effects that significantly impacted their lives; many they felt ill-prepared for. Disappointment and frustration was expressed with the healthcare system when expectations about preparation for post-treatment effects were not met. The GP was considered vital in survivorship care. Participants' unmet needs led to self-management, self-directed information seeking and sourcing referral options, leaving them feeling like their own care coordinator. Disparities in post-treatment care between metropolitan and rural participants were observed.

CONCLUSION

There is a need for improved discharge preparation and information for GPs, and earlier recognition of concerns following CRC treatment to ensure timely management and access to services in the community, supported by system-level initiatives and appropriate interventions.

Latin America and the Caribbean Code Against Cancer 1st Edition: 17 cancer prevention recommendations to the public and to policy-makers (World Code Against Cancer Framework)

Preventable risk factors are responsible of at least 40% of cases and almost 45% of all cancer deaths worldwide. Cancer is already the leading cause of death in almost half of the Latin American and the Caribbean countries constituting a public health problem. Cost-effective measures to reduce exposures through primary prevention and screening of certain types of cancers are critical in the fight against cancer but need to be tailored to the local needs and scenarios. The Latin America and the Caribbean (LAC) Code Against Cancer, 1st edition, consists of 17 evidence-based recommendations for the general public, based on the most recent solid evidence on lifestyle, environmental, occupational, and infectious risk factors, and medical interventions. Each recommendation is accompanied by recommendations for policymakers to guide governments establishing the infrastructure needed to enable the public adopting the recommendations. The LAC Code Against Cancer has been developed in a collaborative effort by a large number of experts from the region, under the umbrella strategy and authoritative methodology of the World Code Against Cancer Framework. The Code is a structured instrument ideal for cancer prevention and control that aims to raise awareness and educate the public, while building capacity and competencies to policymakers, health professionals, stakeholders, to contribute to reduce the burden of cancer in LAC.

Rates and predictors of visits to primary care physicians during and after treatment of childhood acute lymphoblastic leukemia: A population-based cohort study

INTRODUCTION

Patient re-engagement with primary care physicians (PCPs) after cancer treatment is essential to facilitate survivorship care and to meet non-oncology primary care needs. We identified rates and predictors of PCP visits both during and after treatment among a population-based cohort of children with acute lymphoblastic leukemia (ALL).

METHODS

Children of age less than 18 years at ALL diagnosis in Ontario between 2002 and 2012 were linked to administrative data and matched to controls without cancer. PCPs at diagnosis were identified and PCP visit rates during treatment compared between patients and controls. Post-treatment PCP visit rates were also calculated. Predictors included demographic-, disease-, and PCP-related variables.

RESULTS

A total of 743/793 (94%) patients and 3112/3947 (79%) controls had a PCP at diagnosis. Almost half of patients (361/743, 45%) did not visit their PCP during treatment. Visit rate during treatment was 0.64 per person per year (PPPY) versus 1.4 PPPY among controls (adjusted rate ratio [aRR] 0.47, 95th confidence interval [95CI]: 0.40-0.54; p < .0001). No disease- or PCP-related factors were associated with visit rates. Total 711 patients completed frontline therapy; 287 (40.4%) did not have a PCP visit after treatment. Nonetheless, survivors overall visited PCPs post treatment more often than controls (aRR 1.4, 95CI: 1.2-1.6; p < .0001). Survivors who saw their PCP during treatment had post-treatment visit rates twice that of other survivors (aRR 2.0, 95CI: 1.6-2.5; p < .0001).

CONCLUSIONS

Only a portion of children with ALL see their PCPs during treatment and return to PCP care following treatment completion. Post-treatment engagement with PCPs may be improved by PCP involvement during ALL treatment.

Primary care practitioners' priorities for improving the timeliness of cancer diagnosis in primary care: a European cluster-based analysis

BACKGROUND

Diagnosing cancer at an early stage increases the likelihood of survival, and more advanced cancers are more difficult to treat successfully. Primary care practitioners (PCPs) play a key role in timely diagnosis of cancer. PCPs' knowledge of their own patient populations and health systems could help improve the planning of more effective approaches to earlier cancer recognition and referral. How PCPs act when faced with patients who may have cancer is likely to depend on how their health systems are organised, and this may be one explanation for the wide variation on cancer survival rates across Europe.

OBJECTIVES

To identify and characterise clusters of countries whose PCPs perceive the same factors as being important in improving the timeliness of cancer diagnosis.

METHODS

A cluster analysis of qualitative data from an online survey was carried out. PCPs answered an open-ended survey question on how the speed of diagnosis of cancer in primary care could be improved. Following coding and thematic analysis, we identified the number of times per country that an item in a theme was mentioned. k-means clustering identified clusters of countries whose PCPs perceived the same themes as most important. Post-hoc testing explored differences between these clusters.

SETTING

Twenty-five primary care centres in 20 European countries. Each centre was asked to recruit at least 50 participants.

PARTICIPANTS

Primary care practitioners of each country.

RESULTS

In all, 1,351 PCPs gave free-text answers. We identified eighteen themes organising the content of the responses. Based on the frequency of the themes, k-means clustering identified three groups of countries. There were significant differences between clusters regarding the importance of: access to tests (p = 0.010); access to specialists (p = 0.014), screening (p < 0.001); and finances, quotas & limits (p < 0.001).

CONCLUSIONS

Our study identified three distinct clusters of European countries within which PCPs had similar views on the factors that would improve the timeliness of cancer diagnosis. Further work is needed to understand what it is about the clusters that have produced these patterns, allowing healthcare systems to share best practice and to reduce disparities.

Earlier Diagnosis of Pancreatic Cancer: Is It Possible?

Pancreatic ductal adenocarcinoma has a very high mortality rate which has been only minimally improved in the last 30 years. This high mortality is closely related to late diagnosis, which is usually made when the tumor is large and has extensively infiltrated neighboring tissues or distant metastases are already present. This is a paradoxical situation for a tumor that requires nearly 15 years to develop since the first founding mutation. Response to chemotherapy under such late circumstances is poor, resistance is frequent, and prolongation of survival is almost negligible. Early surgery has been, and still is, the only approach with a slightly better outcome. Unfortunately, the relapse percentage after surgery is still very high. In fact, early surgery clearly requires early diagnosis. Despite all the advances in diagnostic methods, the available tools for improving these results are scarce. Serum tumor markers permit a late diagnosis, but their contribution to an improved therapeutic result is very limited. On the other hand, effective screening methods for high-risk populations have not been fully developed as yet. This paper discusses the difficulties of early diagnosis, evaluates whether the available diagnostic tools are adequate, and proposes some simple and not-so-simple measures to improve it.

Gut feeling for the diagnosis of cancer in general practice: a diagnostic accuracy review

OBJECTIVES

Diagnostic delay in cancer is a challenge in primary care. Although screening tests are effective in diagnosing some cancers such as breast, colorectal and cervical cancers, symptom-based cancer diagnosis is often difficult due to its low incidence in primary care and the influence of patient anxiety, doctor-patient relationship and psychosocial context. A general practitioner's gut feeling for cancer may play a role in the early diagnosis of cancer in primary care where diagnostic resources are limited. The aim of this study is to summarise existing evidence about the test accuracy of gut feeling (index test) in symptomatic adult patients presenting to general practice, compared with multidisciplinary team-confirmed diagnosis of cancer (reference standard).

DESIGN

Diagnostic accuracy review following Cochrane methods was performed.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Library, the Database of Abstracts of Reviews of Effects and Medion databases.

ELIGIBILITY CRITERIA

Cross-sectional, cohort and randomised studies of test accuracy that compared gut feeling (index test) with an appropriate cancer diagnosis (reference standard). No language or publication status restrictions were applied. We included all studies published before 25 March 2022.

DATA EXTRACTION AND SYNTHESIS

Methodological quality was appraised, using Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) criteria. Meta-analysis with hierarchical summary receiver operating characteristic (HSROC) models was used.

RESULTS

Of 1286 potentially relevant studies identified, six met the inclusion criteria. For two of the six studies, data could not be extracted despite contacting authors. No studies satisfied all QUADAS-2 criteria. After meta-analysis of data from the remaining studies, the summary point of HSROC had a sensitivity of 0.40 (95% CI: 0.28, 0.53) and a specificity of 0.85 (95% CI: 0.75, 0.92).

CONCLUSIONS

Gut feeling for cancer when used in symptomatic adult patients in general practice has a relatively low sensitivity and high specificity. When the prevalence of cancer in the symptomatic population presenting in general practice exceeds 1.15%, the performance of gut feeling reaches the National Institute for Health and Care Excellence 3% positive predictive value threshold for action, which recommends urgent access to specialist care and further investigations. The findings support the continued and expanded use of gut feeling items in referral pathways.

National Cancer Diagnosis Audits for England 2018 versus 2014: a comparative analysis

BACKGROUND

Timely diagnosis of cancer in patients who present with symptoms in primary care is a quality-improvement priority.

AIM

To examine possible changes to aspects of the diagnostic process, and its timeliness, before and after publication of the National Institute for Health and Care Excellence's (2015) guidance on the referral of suspected cancer in primary care.

DESIGN AND SETTING

Comparison of findings from population-based clinical audits of cancer diagnosis in general practices in England for patients diagnosed in 2018 or 2014.

METHOD

GPs in 1878 (2018) and 439 (2014) practices collected primary care information on the diagnostic pathway of cancer patients. Key measures including patient characteristics, place of presentation, number of pre-referral consultations, use of primary care investigations, and referral type were compared between the two audits by descriptive analysis and regression models.

RESULTS

Among 64 489 (2018) and 17 042 (2014) records of a new cancer diagnosis, the percentage of patients with same-day referral (denoted by a primary care interval of 0 days) was higher in 2018 (42.7% versus 37.7%) than in 2014, with similar improvements in median diagnostic interval (36 days versus 40 days). Compared with 2014, in 2018: fewer patients had ≥3 pre-referral consultations (18.8% versus 26.2%); use of primary care investigations increased (47.9% versus 45.4%); urgent cancer referrals increased (54.8% versus 51.8%); emergency referrals decreased (13.4% versus 16.5%); and recorded use of safety netting decreased (40.0% versus 44.4%).

CONCLUSION

In the 5-year period, including the year when national guidelines were updated (that is, 2015), there were substantial improvements to the diagnostic process of patients who present to general practice in England with symptoms of a subsequently diagnosed cancer.

Pre-Referral Primary Care Blood Tests and Symptom Presentation before Cancer Diagnosis: National Cancer Diagnosis Audit Data

BACKGROUND

Blood tests can support the diagnostic process in primary care. Understanding how symptomatic presentations are associated with blood test use in patients subsequently diagnosed with cancer can help to benchmark current practices and guide interventions.

METHODS

English National Cancer Diagnosis Audit data on 39,751 patients with incident cancer in 2018 were analysed. The frequency of four generic (full blood count, urea and electrolytes, liver function tests, and inflammatory markers) and five organ-specific (cancer biomarkers (PSA or CA125), serum protein electrophoresis, ferritin, bone profile, and amylase) blood tests was described for a total of 83 presenting symptoms. The adjusted analysis explored variation in blood test use by the symptom-positive predictive value (PPV) group.

RESULTS

There was a large variation in generic blood test use by presenting symptoms, being higher in patients subsequently diagnosed with cancer who presented with nonspecific symptoms (e.g., fatigue 81% or loss of appetite 79%), and lower in those who presented with alarm symptoms (e.g., breast lump 3% or skin lesion 1%). Serum protein electrophoresis (reflecting suspicion of multiple myeloma) was most frequently used in cancer patients who presented with back pain (18%), and amylase measurement (reflecting suspicion of pancreatic cancer) was used in those who presented with upper abdominal pain (14%). Prostate-specific antigen (PSA) use was greatest in men with cancer who presented with lower urinary tract symptoms (88%), and CA125 in women with cancer who presented with abdominal distention (53%). Symptoms with PPV values between 2.00-2.99% were associated with greater test use (64%) compared with 52% and 51% in symptoms with PPVs in the 0.01-0.99 or 1.00-1.99% range and compared with 42% and 31% in symptoms with PPVs in either the 3.00-4.99 or ≥5% range (p < 0.001).

CONCLUSIONS

Generic blood test use reflects the PPV of presenting symptoms, and the use of organ-specific tests is greater in patients with symptomatic presentations with known associations with certain cancer sites. There are opportunities for greater blood test use in patients presenting with symptoms that do not meet referral thresholds (i.e., <3% PPV for cancer) where information gain to support referral decisions is likely greatest. The findings benchmark blood test use in cancer patients, highlighting opportunities for increasing use.

Multi-cancer early detection test in symptomatic patients referred for cancer investigation in England and Wales (SYMPLIFY): a large-scale, observational cohort study

BACKGROUND

Analysis of circulating tumour DNA could stratify cancer risk in symptomatic patients. We aimed to evaluate the performance of a methylation-based multicancer early detection (MCED) diagnostic test in symptomatic patients referred from primary care.

METHODS

We did a multicentre, prospective, observational study at National Health Service (NHS) hospital sites in England and Wales. Participants aged 18 or older referred with non-specific symptoms or symptoms potentially due to gynaecological, lung, or upper or lower gastrointestinal cancers were included and gave a blood sample when they attended for urgent investigation. Participants were excluded if they had a history of or had received treatment for an invasive or haematological malignancy diagnosed within the preceding 3 years, were taking cytotoxic or demethylating agents that might interfere with the test, or had participated in another study of a GRAIL MCED test. Patients were followed until diagnostic resolution or up to 9 months. Cell-free DNA was isolated and the MCED test performed blinded to the clinical outcome. MCED predictions were compared with the diagnosis obtained by standard care to establish the primary outcomes of overall positive and negative predictive value, sensitivity, and specificity. Outcomes were assessed in participants with a valid MCED test result and diagnostic resolution. SYMPLIFY is registered with ISRCTN (ISRCTN10226380) and has completed follow-up at all sites.

FINDINGS

6238 participants were recruited between July 7 and Nov 30, 2021, across 44 hospital sites. 387 were excluded due to staff being unable to draw blood, sample errors, participant withdrawal, or identification of ineligibility after enrolment. Of 5851 clinically evaluable participants, 376 had no MCED test result and 14 had no information as to final diagnosis, resulting in 5461 included in the final cohort for analysis with an evaluable MCED test result and diagnostic outcome (368 [6·7%] with a cancer diagnosis and 5093 [93·3%] without a cancer diagnosis). The median age of participants was 61·9 years (IQR 53·4-73·0), 3609 (66·1%) were female and 1852 (33·9%) were male. The MCED test detected a cancer signal in 323 cases, in whom 244 cancer was diagnosed, yielding a positive predictive value of 75·5% (95% CI 70·5-80·1), negative predictive value of 97·6% (97·1-98·0), sensitivity of 66·3% (61·2-71·1), and specificity of 98·4% (98·1-98·8). Sensitivity increased with increasing age and cancer stage, from 24·2% (95% CI 16·0-34·1) in stage I to 95·3% (88·5-98·7) in stage IV. For cases in which a cancer signal was detected among patients with cancer, the MCED test's prediction of the site of origin was accurate in 85·2% (95% CI 79·8-89·3) of cases. Sensitivity 80·4% (95% CI 66·1-90·6) and negative predictive value 99·1% (98·2-99·6) were highest for patients with symptoms mandating investigation for upper gastrointestinal cancer.

INTERPRETATION

This first large-scale prospective evaluation of an MCED diagnostic test in a symptomatic population demonstrates the feasibility of using an MCED test to assist clinicians with decisions regarding urgency and route of referral from primary care. Our data provide the basis for a prospective, interventional study in patients presenting to primary care with non-specific signs and symptoms.

FUNDING

GRAIL Bio UK.

Trusting relationships between patients with non-curative cancer and healthcare professionals create ethical obstacles for informed consent in clinical trials: a grounded theory study

BACKGROUND

Clinical trial participation for patients with non-curative cancer is unlikely to present personal clinical benefit, which raises the bar for informed consent. Previous work demonstrates that decisions by patients in this setting are made within a 'trusting relationship' with healthcare professionals. The current study aimed to further illuminate the nuances of this relationship from both the patients' and healthcare professionals' perspectives.

METHODS

Face-to-face interviews using a grounded theory approach were conducted at a regional Cancer Centre in the United Kingdom. Interviews were performed with 34 participants (patients with non-curative cancer, number (n) = 16; healthcare professionals involved in the consent process, n = 18). Data analysis was performed after each interview using open, selective, and theoretical coding.

RESULTS

The 'Trusting relationship' with healthcare professionals underpinned patient motivation to participate, with many patients 'feeling lucky' and articulating an unrealistic hope that a clinical trial could provide a cure. Patients adopted the attitude of 'What the doctor thinks is best' and placed significant trust in healthcare professionals, focusing on mainly positive aspects of the information provided. Healthcare professionals recognised that trial information was not received neutrally by patients, with some expressing concerns that patients would consent to 'please' them. This raises the question: Within the trusting relationship between patients and healthcare professionals, 'Is it possible to provide balanced information?'. The theoretical model identified in this study is central to understanding how the trusting professional-patient relationship influences the decision-making process.

CONCLUSION

The significant trust placed on healthcare professionals by patients presented an obstacle to delivering balanced trial information, with patients sometimes participating to please the 'experts'. In this high-stakes scenario, it may be pertinent to consider strategies, such as separation of the clinician-researcher roles and enabling patients to articulate their care priorities and preferences within the informed consent process. Further research is needed to expand on these ethical conundrums and ensure patient choice and autonomy in trial participation are prioritised, particularly when the patient's life is limited.

Enrollee characteristics and receipt of colorectal cancer testing in Pennsylvania after adoption of the Affordable Care Act Medicaid expansion

BACKGROUND

Colorectal cancer (CRC) is the fourth most common cancer and the second leading cause of cancer-related death in the U.S. Despite increased CRC screening rates, they remain low among low-income non-older adults, including Medicaid enrollees who are more likely to be diagnosed at advanced stages.

OBJECTIVES

Given limited evidence regarding CRC screening service use among Medicaid enrollees, we examined multilevel factors associated with CRC testing among Medicaid enrollees in Pennsylvania after Medicaid expansion in 2015.

RESEARCH DESIGN

Using the 2014-2019 Medicaid administrative data, we performed multivariable logistic regression models to assess factors associated with CRC testing, adjusting for enrollment length and primary care services use.

SUBJECTS

We identified 15,439 adults aged 50-64 years newly enrolled through Medicaid expansion.

MEASURES

Outcome measures include receiving any CRC testing and by modality.

RESULTS

About 32% of our study population received any CRC testing. Significant predictors for any CRC testing include being male, being Hispanic, having any chronic conditions, using primary care services ≤4 times annually, and having a higher county-level median household income. Being 60-64 years at enrollment, using primary care services >4 times annually, and having higher county-level unemployment rates were significantly associated with a decreased likelihood of receiving any CRC tests.

CONCLUSIONS

CRC testing rates were low among adults newly enrolled in Medicaid under the Medicaid expansion in Pennsylvania relative to adults with high income. We observed different sets of significant factors associated with CRC testing by modality. Our findings underscore the urgency to tailor strategies by patients' racial, geographic, and clinical conditions for CRC screening.

Synthesis of Existent Oncology Curricula for Primary Care Providers: A Scoping Review With a Global Equity Lens

PURPOSE

Global increases in cancer, coupled with a shortage of cancer specialists, has led to an increasing role for primary care providers (PCP) in cancer care. This review aimed to examine all extant cancer curricula for PCPs and to analyze the motivations for curriculum development.

METHODS

A comprehensive literature search was conducted from inception to October 13, 2021, with no language restrictions. The initial search yielded 11,162 articles and 10,902 articles underwent title and abstract review. After full-text review, 139 articles were included. Numeric and thematic analyses were conducted and education programs were evaluated using Bloom's taxonomy.

RESULTS

Most curricula were developed in high-income countries (HICs), with 58% in the United States. Cancer-specific curricula focused on HIC priority cancers, such as skin/melanoma, and did not represent the global cancer burden. Most (80%) curricula were developed for staff physicians and 73% focused on cancer screening. More than half (57%) of programs were delivered in person, with a shift toward online delivery over time. Less than half (46%) of programs were codeveloped with PCPs and 34% did not involve PCPs in the program design and development. Curricula were primarily developed to improve cancer knowledge, and 72 studies assessed multiple outcome measures. No studies included the top two levels of Bloom's taxonomy of learning (evaluating; creating).

CONCLUSION

To our knowledge, this is the first review to assess the current state of cancer curricula for PCPs with a global focus. This review shows that extant curricula are primarily developed in HICs, do not represent the global cancer burden, and focus on cancer screening. This review lays a foundation to advance the cocreation of curricula that are aligned to the global cancer burden.

Symptoms and signs of urogenital cancer in primary care

BACKGROUND

Urogenital cancers are common, accounting for approximately 20% of cancer incidence globally. Cancers belonging to the same organ system often present with similar symptoms, making initial management challenging. In this study, 511 cases of cancer were recorded after the date of consultation among 61,802 randomly selected patients presenting in primary care in six European countries: a subgroup analysis of urogenital cancers was carried out in order to study variation in symptom presentation.

METHODS

Initial data capture was by completion of standardised forms containing closed questions about symptoms recorded during the consultation. The general practitioner (GP) provided follow-up data after diagnosis, based on medical record data made after the consultation. GPs also provided free text comments about the diagnostic procedure for individual patients.

RESULTS

The most common symptoms were mainly associated with one or two specific types of cancer: 'Macroscopic haematuria' with bladder or renal cancer (combined sensitivity 28.3%), 'Increased urinary frequency' with bladder (sensitivity 13.3%) or prostatic (sensitivity 32.1%) cancer, or to uterine body (sensitivity 14.3%) cancer, 'Unexpected genital bleeding' with uterine cancer (cervix, sensitivity 20.0%, uterine body, sensitivity 71.4%). 'Distended abdomen, bloating' had sensitivity 62.5% (based on eight cases of ovarian cancer). In ovarian cancer, increased abdominal circumference and a palpable tumour also were important diagnostic elements. Specificity for 'Macroscopic haematuria' was 99.8% (99.7-99.8). PPV > 3% was noted for 'Macroscopic haematuria' and bladder or renal cancer combined, for bladder cancer in male patients. In males aged 55-74, PPV = 7.1% for 'Macroscopic haematuria' and bladder cancer. Abdominal pain was an infrequent symptom in urogenital cancers.

CONCLUSIONS

Most types of urogenital cancer present with rather specific symptoms. If the GP considers ovarian cancer, increased abdominal circumference should be actively determined. Several cases were clarified through the GP's clinical examination, or laboratory investigations.

Time intervals to care and health service use experiences of uninsured cancer patients treated under public financing in Mexico City

BACKGROUND

The present study assesses the time intervals from symptom discovery to treatment start and describes the health service use experiences of uninsured patients with cancer of the breast, cervix uteri, testicle, and prostate before their arrival to the cancer hospital.

METHODS

This cross-sectional study included 1468 patients who were diagnosed between June 2016 and May 2017 and received treatment for the selected cancers in two of the largest public cancer hospitals in Mexico City, financed through Seguro Popular. Data was collected through a survey administered via face-to-face interviews with patients and a review of their medical files.

RESULTS

The median time between detection (symptom discovery or first abnormal screening test) and treatment start was 6.6 months. For all types of cancer, the longest interval was the diagnostic interval -between the first use of healthcare services and the confirmation of cancer. Less than 20% cancer patients were diagnosed in the earliest stages that are associated with the best chances of long-term survival. The participants described a high use of private services for their first consultation, the use of several different types of health services and multiple consultations before arrival to the cancer centers, and 35% perceived being misdiagnosed by the first doctor they consulted.

CONCLUSIONS

Most cancer patients treated in the two largest public institutions available for the uninsured faced long delays to get diagnosed and started treatment at advanced stages. Strengthening quality and access for effective early cancer diagnosis and treatment is key to improve patient outcomes in low and middle-income settings.

Potential Role of Fourier Transform Infrared Spectroscopy as a Screening Approach for Breast Cancer

Breast cancer is a heterogeneous disease, and its spread involves a succession of clinical and pathological stages. Screening is predominantly based on mammography, which has critical limitations related to the effectiveness and production of false-positive or false-negative results, generating discomfort and low adherence. In this context, infrared with attenuated total reflection Fourier transform infrared (ATR FT-IR) spectroscopy emerges as a non-destructive sample tool, which is non-invasive, label-free, has a low operating-cost, and requires only a small amount of sample, including liquid plasma samples. We sought to evaluate the clinical applicability of ATR FT-IR in breast cancer screening. ATR FT-IR spectroscopy through its highest potential spectral biomarker could distinguish, by liquid plasma biopsy, breast cancer patients and healthy controls, obtaining a sensitivity of 97%, specificity of 93%, a receiver operating characteristic ROC curve of 97%, and a prediction accuracy of 94%. The main variance between the groups was mainly in the band 1511 cm^-1 of the control group, 1502 and 1515 cm^-1 of the cancer group, which are the peaks of the bands referring to proteins and amide II. ATR FT-IR spectroscopy has demonstrated to be a promising tool for breast cancer screening, given its time efficiency, cost of approach, and its high ability to distinguish between the liquid plasma samples of breast cancer patients and healthy controls.

Patients' acceptance of a shared cancer follow-up model of care between general practitioners and radiation oncologists: A population-based survey using the theoretical Framework of Acceptability

INTRODUCTION

International and national guidelines highlight the need for general practitioner involvement during and after active cancer treatment and throughout long-term follow-up care. This paper aimed to evaluate patients' acceptance of radiation oncology shared follow-up care using the Theoretical Framework of Acceptability (TFA).

METHODS

This cross-sectional study was conducted at two cancer care centres in the Illawarra Shoalhaven region of Australia. A sample of patients scheduled for a radiation oncology follow-up consultation in 2021 were sent a 32-point self-complete paper-based survey. Data were analysed using descriptive, parametric and non-parametric statistical analysis. This paper followed the Checklist for Reporting of Survey Studies (CROSS).

RESULTS

Of the 414 surveys returned (45% response rate), the acceptance for radiation oncology shared cancer follow-up care was high (80%). Patients treated with only radiotherapy were 1.7 times more likely to accept shared follow-up care than those treated with multiple modalities. Patients who preferred follow-up care for fewer than three years were 7.5 times more likely to accept shared care than those who preferred follow-up care for five years. Patients who travelled more than 20 minutes to their radiation oncologist or to the rural cancer centre were slightly more likely to accept shared care than those who travelled less than twenty minutes to the regional cancer centre. A high understanding of shared care (Intervention Coherence) and a positive feeling towards shared care (Affective Attitude) were significant predictive factors in accepting shared radiation oncology follow-up care.

CONCLUSION

Health services need to ensure patient preferences are considered to provide patient-centred cancer follow-up care. Shared cancer follow-up care implementation should start with patients who prefer a shorter follow-up period and understand the benefits of shared care. However, patients' involvement needs to be considered alongside other clinical risk profiles and organisational factors. Future qualitative research using the TFA constructs is warranted to inform clinical practice change.