Five misconceptions in cancer diagnosis. Br J Gen Pract. 2009;59:441-445, 447; discussion 446. [PMID: 19520027 DOI: 10.3399/bjgp09x420860]

Psychiatric disorders and the cancer diagnostic process in general practice: a combined questionnaire and register study exploring the patients' experiences in Denmark

OBJECTIVE

Patients with psychiatric disorders are at risk of experiencing suboptimal cancer diagnostics and treatment. This study investigates how this patient group perceives the cancer diagnostic process in general practice.

DESIGN

Cross-sectional study using questionnaire and register data.

SETTING

General practice in Denmark.

SUBJECTS

Patients diagnosed with cancer in late 2016 completed a questionnaire about their experiences with their general practitioner (GP) in the cancer diagnostic process (n = 3411). Information on pre-existing psychiatric disorders was obtained from register data on psychiatric hospital contacts and primary care treated psychiatric disorders through psychotropic medications. Logistic regression was used to analyse the association between psychiatric disorders and the patients' experiences.

MAIN OUTCOME MEASURES

Patients' experiences, including cancer worry, feeling being taken seriously, and the perceived time between booking an appointment and the first GP consultation.[Box: see text].

RESULTS

A total of 13% of patients had an indication of a psychiatric disorder. This group more often perceived the time interval as too short between the first booking of a consultation and the first GP consultation. Patients with primary care treated psychiatric disorders were more likely to worry about cancer at the first presentation and to share this concern with their GP compared with patients without psychiatric disorders. We observed no statistically significant association between patients with psychiatric disorders and perceiving the waiting time to referral from general practice, being taken seriously, trust in the GP's abilities, and the patients' knowledge of the process following the GP referral.

CONCLUSION

The patients' experiences with the cancer diagnostic process in general practice did not vary largely between patients with and without psychiatric disorders. Worrying about cancer may be a particular concern for patients with primary care treated psychiatric disorders.

Validation of a diagnostic prediction tool for colorectal cancer: a case-control replication study

BACKGROUND

Early detection of colorectal cancer (CRC) is crucial for survival. Primary care, the first point of contact in most cases, needs supportive risk assessment tools. We aimed to replicate the Swedish Colorectal Cancer Risk Assessment Tool (SCCRAT) for non-metastatic CRC in primary care and examine if risk factor patterns depend on sex and age.

METHODS

2,920 adults diagnosed with non-metastatic CRC during the years 2015-2019 after having visited a general practitioner the year before the diagnosis were selected from the Swedish Cancer Register and matched with 11,628 controls, using the same inclusion criteria except for the CRC diagnosis. Diagnostic codes from primary care consultations were collected from a regional health care database. Positive predictive values (PPVs) were estimated for the same 5 symptoms and combinations thereof as in the baseline study.

RESULTS

The results for patients aged ≥50 years old in the present study were consistent with the results of the SCCRAT study. All symptoms and combinations thereof with a PPV >5% in the present study had a PPV >5% in the baseline study. The combination of bleeding with abdominal pain (PPV 9.9%) and bleeding with change in bowel habit (PPV 7.8%) were the highest observed PPVs in both studies. Similar risk patterns were seen for all ages and when men and women were studied separately.

CONCLUSION

This external validation of the SCCRAT for non-metastatic CRC in primary care replicated the baseline study successfully and identified patients at high risk for CRC.

Priorities for implementation research on diagnosing cancer in primary care: a consensus process

BACKGROUND

The early detection and diagnosis of cancer to reduce avoidable mortality and morbidity is a challenging task in primary health care. There is a growing evidence base on how to enable earlier cancer diagnosis, but well-recognised gaps and delays exist around the translation of new research findings into routine clinical practice. Implementation research aims to accelerate the uptake of evidence by health care systems and professionals. We aimed to identify priorities for implementation research in early cancer diagnosis in primary care.

METHODS

We used a RAND/UCLA modified Delphi consensus process to identify and rank research priorities. We asked primary care physicians, patients and researchers to complete an online survey suggesting priorities for implementation research in cancer detection and diagnosis. We summarised and presented these suggestions to an 11-member consensus panel comprising nine primary care physicians and two patients. Panellists independently rated the importance of suggestions on a 1-9 scale (9 = very high priority; 1 = very low priority) before and after a structured group discussion. We ranked suggestions using median ratings.

RESULTS

We received a total of 115 suggested priorities for implementation research from 32 survey respondents (including 16 primary care professionals, 11 researchers, and 4 patient and public representatives; 88% of respondents were UK-based). After removing duplicates and ineligible suggestions, we presented 37 suggestions grouped within 17 categories to the consensus panel. Following two rounds of rating, 27 suggestions were highly supported (median rating 7-9). The most highly rated suggestions concerned diagnostic support (e.g., access to imaging) interventions (e.g., professional or patient education), organisation of the delivery of care (e.g., communication within and between teams) and understanding variations in care and outcomes.

CONCLUSIONS

We have identified a set of priorities for implementation research on the early diagnosis of cancer, ranked in importance by primary care physicians and patients. We suggest that researchers and research funders consider these in directing further efforts and resources to improve population outcomes.

Are There Ethnic Differences in Recorded Features among Patients Subsequently Diagnosed with Cancer? An English Longitudinal Data-Linked Study

We investigated ethnic differences in the presenting features recorded in primary care before cancer diagnosis.

METHODS

English population-based cancer-registry-linked primary care data were analysed. We identified the coded features of six cancers (breast, lung, prostate, colorectal, oesophagogastric, and myeloma) in the year pre-diagnosis. Logistic regression models investigated ethnic differences in first-incident cancer features, adjusted for age, sex, smoking status, deprivation, and comorbidity.

RESULTS

Of 130,944 patients, 92% were White. In total, 188,487 incident features were recorded in the year pre-diagnosis, with 48% (89,531) as sole features. Compared with White patients, Asian and Black patients with breast, colorectal, and prostate cancer were more likely than White patients to have multiple features; the opposite was seen for the Black and Other ethnic groups with lung or prostate cancer. The proportion with relevant recorded features was broadly similar by ethnicity, with notable cancer-specific exceptions. Asian and Black patients were more likely to have low-risk features (e.g., cough, upper abdominal pain) recorded. Non-White patients were less likely to have alarm features.

CONCLUSION

The degree to which these differences reflect disease, patient or healthcare factors is unclear. Further research examining the predictive value of cancer features in ethnic minority groups and their association with cancer outcomes is needed.

Faecal immunochemical testing reduces demand and improves yield of Leicester's 2-week pathway for change in bowel habit

AIM

We look at the effect of introducing the faecal immunochemical test (FIT) in the straight-to-test 2-week pathway for change in bowel habit (CIBH).

METHOD

The FIT in primary care triages 2-week wait (2WW) colorectal referrals for patients aged 60 years and above for straight-to-test CT colonography (CTC). We compare the impact of the FIT on numbers of 2WW CTCs, in the year before and after FIT, in both colorectal cancer (CRC) detection and cost-effectiveness at both 4 μg Hb/g faeces and 10 μg Hb/g faeces.

RESULTS

At a threshold of 4 μg Hb/g faeces, the positive predictive value of the FIT for diagnosis of CRC is 5.0% with a negative predictive value of 99.8% and a polyp detection rate of 25.5%. The introduction of the FIT resulted in a reduction in the number of CTCs performed through the CIBH pathway from a mean of 143.9 per month prior to the FIT to 66.8 CTCs per month once the FIT was well established. Given a FIT threshold of 10 μg Hb/g the number of CTCs would be predicted to fall by 70.4% to 42.6 CTCs per month resulting in higher CRC and polyp detection rate, and an estimated annual cost saving of £238 258 in our institution.

CONCLUSION

The FIT use in primary care improves the yield of 2WW referrals for CIBH alone and reduces the burden and cost of investigations to exclude CRC. Improvements may be possible by increasing the cut-off employed, without adversely affecting the risk of missing a cancer.

Real-world colorectal cancer diagnostic pathways in Ontario, Canada: A population-based study

OBJECTIVE

This study aimed to identify colorectal cancer (CRC) diagnostic pathways and describe patients in those pathway groups.

METHODS

This was a cross-sectional study of CRC patients in Ontario, Canada, diagnosed 2009-2012 that used linked administrative data at ICES. We used cluster analysis on 11 pathway variables characterising patient presentation, symptoms, procedures and referrals. We assessed associations between patient- and disease-related characteristics and diagnostic pathway group. We further characterised the pathways by diagnostic interval and number of related physician visits.

RESULTS

Six diagnostic pathways were identified, with three adhering to provincial diagnostic guidelines: screening (N = 4494), colonoscopy (N = 10,066) and imaging plus colonoscopy (N = 3427). Non-adherent pathways were imaging alone (N = 2238), imaging and emergency presentation (N = 2849) and no pre-diagnostic workup (N = 887). Patients in adherent pathways were younger, had fewer comorbidities, lived in less deprived areas and had earlier stage disease. The median diagnostic interval length varied across pathways from 12 to 126 days, correlating with the number of CRC-related visits.

CONCLUSIONS

This study demonstrated substantial variations in real-world CRC diagnostic pathways and 25% were diagnosed through non-adherent pathways. Those patients were older, had more comorbid disease and had higher stage cancer. Further research needs to identify and describe the reasons for divergent diagnostic processes.

Earlier diagnosis of lung cancer

The purpose of this article is to review options for more rapid diagnosis of lung cancer at an earlier stage, thereby improving survival. These options include screening, allowing general practitioners to refer patients directly to low-dose computed tomography scan instead of a chest X-ray and the abolition of the "visitation filter", i.e. hospital doctors' ability to reject referrals from general practitioners without prior discussion with the referring doctor.

Using cancer risk algorithms to improve risk estimates and referral decisions

Background

Cancer risk algorithms were introduced to clinical practice in the last decade, but they remain underused. We investigated whether General Practitioners (GPs) change their referral decisions in response to an unnamed algorithm, if decisions improve, and if changing decisions depends on having information about the algorithm and on whether GPs overestimated or underestimated risk.

Methods

157 UK GPs were presented with 20 vignettes describing patients with possible colorectal cancer symptoms. GPs gave their risk estimates and inclination to refer. They then saw the risk score of an unnamed algorithm and could update their responses. Half of the sample was given information about the algorithm's derivation, validation, and accuracy. At the end, we measured their algorithm disposition. We analysed the data using multilevel regressions with random intercepts by GP and vignette.

Results

We find that, after receiving the algorithm's estimate, GPs' inclination to refer changes 26% of the time and their decisions switch entirely 3% of the time. Decisions become more consistent with the NICE 3% referral threshold (OR 1.45 [1.27, 1.65], p < .001). The algorithm's impact is greatest when GPs have underestimated risk. Information about the algorithm does not have a discernible effect on decisions but it results in a more positive GP disposition towards the algorithm. GPs' risk estimates become better calibrated over time, i.e., move closer to the algorithm.

Conclusions

Cancer risk algorithms have the potential to improve cancer referral decisions. Their use as learning tools to improve risk estimates is promising and should be further investigated.

What factors empower general practitioners for early cancer diagnosis? A 20-country European Delphi Study

Background:

Some symptoms are recognised as red flags for cancer, causing the General Practitioner (GP) to refer the patient for investigation without delay. However, many early symptoms of cancer are vague and unspecific, and in these cases, a delay in referral risks a diagnosis of cancer that is too late. Empowering GPs in their management of patients that may have cancer is likely to lead to more timely cancer diagnoses.

Aim:

To identify the factors that affect European GPs’ empowerment in making an early diagnosis of cancer.

Methods:

This was a Delphi study involving GPs in 20 European countries. We presented GPs with 52 statements representing factors that could empower GPs to increase the number of early cancer diagnoses. Over three Delphi rounds, we asked GPs to indicate the clinical relevance of each statement on a Likert scale.

The final list of statements indicated those that were considered by consensus to be the most relevant.

Results:

In total, 53 GPs from 20 European countries completed the Delphi process, out of the 68 GPs who completed round one. Twelve statements satisfied the pre-defined criteria for relevance. Five of the statements related to screening and four to the primary/secondary care interface. The other selected statements concerned information technology (IT) and GPs’ working conditions. Statements relating to training, skills and working efficiency were not considered priority areas.

Conclusion:

GPs consider that system factors relating to screening, the primary-secondary care interface, IT and their working conditions are key to enhancing their empowerment in patients that could have cancer. These findings provide the basis for seeking actions and policies that will support GPs in their efforts to achieve timely cancer diagnosis.

Primary care use by men with symptoms of possible prostate cancer: A multi-method study with an ethnically diverse sample in London

OBJECTIVE

The objective of this study is to investigate primary care use by men with recent onset of lower urinary tract symptoms (LUTS) to identify differences in presentation and investigation that may explain ethnic inequality in prostate cancer outcomes.

METHODS

This is a multi-method study of men presenting LUTS to primary care. Two hundred seventy-four men completed a self-administered questionnaire, and 23 participated in face-to-face interviews. Regression analyses investigated ethnic differences in (a) the period between symptom onset and first primary care presentation (patient interval) and (b) the interval between first primary care presentation and investigation with prostate-specific antigen (PSA) and digital rectal examination (DRE). Interview data were analysed using thematic analysis.

RESULTS

Half (144, 53%) reported a solitary first symptom, although multiple first symptoms were also common, particularly in Asian and Black men. There was no difference between ethnicities in patient interval or time from presentation to investigation. However, Asian men were offered less PSA testing (odds ratio 0.39; 95% confidence interval 0.17-0.92; p = 0.03). Qualitative data revealed ethnic differences in general practitioners' offer of DRE and PSA testing and highlighted limitations in doctor-patient communication and safety netting.

CONCLUSION

Our study showed only small differences in primary care experiences, insufficient to explain ethnic inequalities in prostate cancer outcomes.

Faecal immunochemical test outside colorectal cancer screening?

Faecal immunochemical tests (FITs) are the most widely colorectal cancer (CRC) diagnostic biomarker available. Many population screening programmes are based on this biomarker, with the goal of reducing CRC mortality. Moreover, in recent years, a large amount of evidence has been produced on the use of FIT to detect CRC in patients with abdominal symptoms in primary healthcare as well as in surveillance after adenoma resection. The aim of this review is to highlight the available evidence on these two topics. We will summarize the evidence on diagnostic yield in symptomatic patients with CRC and significant colonic lesion and the different options to use this (thresholds, brands, number of determinations, prediction models and combinations). We will include recommendations on FIT strategies in primary healthcare proposed by regulatory bodies and scientific societies and their potential effects on healthcare resources and CRC prognosis. Finally, we will show information regarding FIT-based surveillance as an alternative to endoscopic surveillance after high-risk polyp resection. To conclude, due to the coronavirus disease 2019 pandemic, FIT-based strategies have become extremely relevant since they enable a reduction of colonoscopy demand and access to the healthcare system by selecting individuals with the highest risk of CRC.

COVID-19 and the multidisciplinary care of patients with lung cancer: an evidence-based review and commentary

Delivering lung cancer care during the COVID-19 pandemic has posed significant and ongoing challenges. There is a lack of published COVID-19 and lung cancer evidence-based reviews, including for the whole patient pathway. We searched for COVID-19 and lung cancer publications and brought together a multidisciplinary group of stakeholders to review and comment on the evidence and challenges. A rapid review of the literature was undertaken up to 28 October 2020, producing 144 papers, with 113 full texts screened. We focused on new primary data collection (qualitative or quantitative evidence) and excluded case reports, editorials and commentaries. Following exclusions, 15 published papers were included in the review and are summarised. They included one qualitative paper and 14 quantitative studies (surveys or cohort studies), with a total of 2295 lung cancer patients data included (mean study size 153 patients; range 7-803). Review of current evidence and commentary included awareness and help-seeking; lung cancer screening; primary care assessment and referral; diagnosis and treatment in secondary care, including oncology and surgery; patient experience and palliative care. Cross-cutting themes and challenges were identified using qualitative methods for patients, healthcare professionals and service delivery, with a clear need for continued studies to guide evidence-based decision-making.

Alignment between the patient's cancer worry and the GP's cancer suspicion and the association with the interval between first symptom presentation and referral: a cross-sectional study in Denmark

BACKGROUND

General practitioners (GPs) have a key role in the diagnosis of cancer. It is crucial to identify factors influencing the decision to refer for suspected cancer. The aim of this study was to investigate the alignment between the patient's cancer worry and the GP's suspicion of cancer in the first clinical encounter and the association with the time interval from the first symptom presentation until the first referral to specialist care, i.e. the primary care interval (PCI).

METHOD

The study was performed as a cross-sectional study using survey data on patients diagnosed with incident cancer in 2010 or 2016 and their GPs in Denmark. We defined four alignment groups: 1) patient worry and GP suspicion, 2)  GP suspicion only, 3) patient worry only, and 4) none of the two. A long PCI was defined as an interval longer than the 75th percentile.

RESULTS

Among the 3333 included patients, both patient worry and GP suspicion was seen in 39.5%, only GP suspicion was seen in 28.2%, only patient worry was seen in 13.6%, and neither patient worry nor GP suspicion was seen in 18.2%. The highest likelihood of long PCI was observed in group 4 (group 4 vs. group 1: PPR 3.99 (95% CI 3.34-4.75)), mostly pronounced for easy-to-diagnose cancer types.

CONCLUSION

Misalignment between the patient's worry and the GP's suspicion was common at the first cancer-related encounter. Importance should be given to the patient interview, due to a potential delayed GP referral among patients diagnosed with "easy-to-diagnose" cancer types presenting with unspecific symptoms.

Second primary cancers: a retrospective analysis of real world data using the enhanced medical research engine ConSoRe in a French comprehensive cancer center

BACKGROUND

Second primary cancers (SPC) account for 18% of all cancers. We used the enhanced medical/health data mining tool ConSoRe to search aggregated data, analyze electronic patient records (EPR), and better characterize patients with SPC.

METHODS

This retrospective cohort study used ConSoRe to identify EPRs from patients with SPC referred to the regional cancer center Leon Bérard from 1993 to 2017, and examined characteristics of patients with SPC, frequencies of first primary cancer (FPC) localization in the global population of patients with SPC, and time to SPC. Data set was extracted on January 1, 2018.

RESULTS

Among 296,530 EPRs, we identified 157,187 patients with FPC, including 13,002 (8%) patients with SPC. Between 2000 and 2010, the rate of SPC was 34%, and 52% of SPC were identified in the last years (2010-2017). In men, main cancers were head and neck cancer, lymphoma, and prostate carcinoma accounting for 15.6%, 12.8%, and 10.5% of FPC, while the three most common SPC were head and neck cancer (13.2%), lung cancer (11.8%) and lymphoma (9.2%). In women, breast cancers, lymphoma, and skin cancers accounted for 48.8%, 8%, and 5.1% of first cancers, and for 31.1%, 7% and 6% of SPC.

CONCLUSION

The data mining tool ConSoRe contributes to access to real world data, and to better characterize patients with SPC. Expanding such approach to any comprehensive center will allow a global overview of the follow-up of patients with cancer, and help to improve long-term management and adapt surveillance.

Describing the potential of non-specific symptoms-based pathways for diagnosing less common cancers

BACKGROUND

Although less common cancers account for over half of all cancer diagnoses in England, their relative scarcity and complex presentation, often with non-specific symptoms, means that patients often experience multiple primary care consultations, longer times to diagnosis and poorer clinical outcomes. An urgent referral pathway for non-specific symptoms, the Multidisciplinary Diagnostic Centre (MDC), may address this problem.

AIM

To examine the less common cancers identified during the MDC pilots and consider if such an approach improves the diagnosis of these cancers.

DESIGN AND SETTING

A service evaluation of five MDC pilot projects in England to 31st March 2019.

METHOD

Data items were collected by pilot sites in near-real time, based mainly on the English cancer outcomes and services dataset, with additional project specific items. Simple descriptive and comparative statistics were used, including chi-squared tests for proportions and t-tests for means where appropriate.

RESULTS

From 5,134 referrals, 378 cancers were diagnosed, of which 218 (58%) were less common. Over 30 different less common tumour types were diagnosed within this cohort. 23% of MDC patients with less common cancers had ≥3 more GP consultations before referral and, at programme level, a median time of 57 days was recorded from GP urgent referral to treatment for these tumour types.

CONCLUSION

A non-specific symptomatic referral route diagnoses a broad range of less common cancers, and can support primary care case management for patients with symptoms of possible cancer that do not qualify for a site-specific urgent referral.

COVID-19 and the multidisciplinary care of patients with lung cancer: an evidence-based review and commentary

Delivering lung cancer care during the COVID-19 pandemic has posed significant and ongoing challenges. There is a lack of published COVID-19 and lung cancer evidence-based reviews, including for the whole patient pathway. We searched for COVID-19 and lung cancer publications and brought together a multidisciplinary group of stakeholders to review and comment on the evidence and challenges. A rapid review of the literature was undertaken up to 28 October 2020, producing 144 papers, with 113 full texts screened. We focused on new primary data collection (qualitative or quantitative evidence) and excluded case reports, editorials and commentaries. Following exclusions, 15 published papers were included in the review and are summarised. They included one qualitative paper and 14 quantitative studies (surveys or cohort studies), with a total of 2295 lung cancer patients data included (mean study size 153 patients; range 7-803). Review of current evidence and commentary included awareness and help-seeking; lung cancer screening; primary care assessment and referral; diagnosis and treatment in secondary care, including oncology and surgery; patient experience and palliative care. Cross-cutting themes and challenges were identified using qualitative methods for patients, healthcare professionals and service delivery, with a clear need for continued studies to guide evidence-based decision-making.

Colorectal cancer screening and diagnosis: omics-based technologies for development of a non-invasive blood-based method

Introduction: Colorectal cancer (CRC) is one of the most important health problems in the Western world. In order to reduce the burden of the disease, two strategies are proposed: screening and prompt detection in symptomatic patients. Although diagnosis and prevention are mainly based on colonoscopy, fecal hemoglobin detection has been widely implemented as a noninvasive strategy. Various studies aiming to discover blood-based biomarkers have recently emerged.Areas covered: The burgeoning omics field provides diverse high-throughput approaches for CRC blood-based biomarker discovery. In this review, we appraise the most robust and commonly used technologies within the fields of genomics, transcriptomics, epigenomics, proteomics, and metabolomics, together with their targeted validation approaches. We summarize the transference process from the discovery phase until clinical translation. Finally, we review the best candidate biomarkers and their potential clinical applicability.Expert opinion: Some available biomarkers are promising, especially in the field of epigenomics: DNA methylation and microRNA. Transference requires the joint collaboration of basic researchers, intellectual property experts, technology transfer officers and clinicians. Blood-based biomarkers will be selected not only based on their diagnostic accuracy and cost but also on their reliability, applicability to clinical analysis laboratories and their acceptance by the population.

Are cancer care pathways associated with longer waiting times. Analysing crowding out effects in radiology, pathology, and surgery

Introduction

In 2015, Sweden initiated the implementation of standardised cancer care pathways (CCPs). With short, nationally imposed target times from diagnosis to first treatment, the issue of crowding out effects has been debated. This study investigate whether the implementation of CCPs is associated with longer waiting times for surgery, radiology scans and pathology analyses for other patient groups.

Methods

Data from the internal computer systems used in radiology, pathology and surgery to plan and follow the production at a county hospital in Sweden during 2014–2017 were analysed. By utilising the different priority categories used in these specialties, changes in waiting times before and after the implementation of CCPs could be analysed.

Results

The results are consistent with an association between the implementation of CCPs and longer waiting times for the priority category prioritised immediately after the CCP category in all specialties. In addition, none of the lowest priority categories within each subspecialty have experienced increased waiting times after CCP implementation.

Discussion

These results are consistent with a change in prioritisation where CCP patients are receiving shorter waiting times after CCP implementation at the expense of other patient groups. Crowding out effects related to CCP implementation have not been previously researched. This study therefore fills a gap in present literature. With an increased awareness of these challenges, and a more holistic perspective in the implementation process, actions can be put in place to identify and counteract crowding out effects.

Routes to diagnosis of symptomatic cancer in sub-Saharan Africa: systematic review

BACKGROUND

Most cancers in sub-Saharan Africa (SSA) are diagnosed at advanced stages, with limited treatment options and poor outcomes. Part of this may be linked to various events occurring in patients' journey to diagnosis. Using the model of pathways to treatment, we examined the evidence regarding the routes to cancer diagnosis in SSA.

DESIGN AND SETTINGS

A systematic review of available literature was performed.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Between 30 September and 30 November 2019, seven electronic databases were searched using terms relating to SSA countries, cancer and routes to diagnosis comprising the population, exposure and outcomes, respectively. Citation lists of included studies were manually searched to identify relevant studies. Furthermore, ProQuest Dissertations & Theses Global was searched to identify appropriate grey literature on the subject.

RESULTS

18 of 5083 references identified met the inclusion criteria: eight focused on breast cancer; three focused on cervical cancer; two each focused on lymphoma, Kaposi's sarcoma and childhood cancers; and one focused on colorectal cancer. With the exception of Kaposi's sarcoma, definitive diagnoses were made in tertiary healthcare centres, including teaching and regional hospitals. The majority of participants initially consulted within primary care, although a considerable proportion first used complementary medicine before seeking conventional medical help. The quality of included studies was a major concern, but their findings provided important insight into the pathways to cancer diagnosis in the region.

CONCLUSION

The proportion of patients who initially use complementary medicine in their cancer journey may explain a fraction of advanced-stage diagnosis and poor survival of cancer in SSA. However, further research would be necessary to fully understand the exact role (or activities) of primary care and alternative care providers in patient cancer journeys.

Understanding the role of GPs' gut feelings in diagnosing cancer in primary care: a systematic review and meta-analysis of existing evidence

BACKGROUND

Growing evidence for the role of GPs' gut feelings in cancer diagnosis raises questions about their origin and role in clinical practice.

AIM

To explore the origins of GPs' gut feelings for cancer, their use, and their diagnostic utility.

DESIGN AND SETTING

Systematic review and meta-analysis of international research on GPs' gut feelings in primary care.

METHOD

Six databases were searched from inception to July 2019, and internet searches were conducted. A segregated method was used to analyse, then combine, quantitative and qualitative findings.

RESULTS

Twelve articles and four online resources were included that described varied conceptualisations of gut feelings. Gut feelings were often initially associated with patients being unwell, rather than with a suspicion of cancer, and were commonly experienced in response to symptoms and non-verbal cues. The pooled odds of a cancer diagnosis were four times higher when gut feelings were recorded (OR 4.24, 95% confidence interval = 2.26 to 7.94); they became more predictive of cancer as clinical experience and familiarity with the patient increased. Despite being included in some clinical guidelines, GPs had varying experiences of acting on gut feelings as some specialists questioned their diagnostic value. Consequently, some GPs ignored or omitted gut feelings from referral letters, or chose investigations that did not require specialist approval.

CONCLUSION

GPs' gut feelings for cancer were conceptualised as a rapid summing up of multiple verbal and non-verbal patient cues in the context of the GPs' clinical knowledge and experience. Triggers of gut feelings not included in referral guidance deserve further investigation as predictors of cancer. Non-verbal cues that trigger gut feelings appear to be reliant on continuity of care and clinical experience; they tend to remain poorly recorded and are, therefore, inaccessible to researchers.

Association between use of urgent suspected cancer referral and mortality and stage at diagnosis: a 5-year national cohort study

BACKGROUND

There is considerable variation between GP practices in England in their use of urgent referral pathways for suspected cancer.

AIM

To determine the association between practice use of urgent referral and cancer stage at diagnosis and cancer patient mortality, for all cancers and the most common types of cancer (colorectal, lung, breast, and prostate).

DESIGN AND SETTING

National cohort study of 1.4 million patients diagnosed with cancer in England between 2011 and 2015.

METHOD

The cohort was stratified according to quintiles of urgent referral metrics. Cox proportional hazards regression was used to quantify risk of death, and logistic regression to calculate odds of late-stage (III/IV) versus early-stage (I/II) cancers in relation to referral quintiles and cancer type.

RESULTS

Cancer patients from the highest referring practices had a lower hazard of death (hazard ratio [HR] = 0.96; 95% confidence interval [CI] = 0.95 to 0.97), with similar patterns for individual cancers: colorectal (HR = 0.95; CI = 0.93 to 0.97); lung (HR = 0.95; CI = 0.94 to 0.97); breast (HR = 0.96; CI = 0.93 to 0.99); and prostate (HR = 0.88; CI = 0.85 to 0.91). Similarly, for cancer patients from these practices, there were lower odds of late-stage diagnosis for individual cancer types, except for colorectal cancer.

CONCLUSION

Higher practice use of referrals for suspected cancer is associated with lower mortality for the four most common types of cancer. A significant proportion of the observed mortality reduction is likely due to earlier stage at diagnosis, except for colorectal cancer. This adds to evidence supporting the lowering of referral thresholds and consequent increased use of urgent referral for suspected cancer.

The use of electronic healthcare records for colorectal cancer screening referral decisions and risk prediction model development

BACKGROUND

The database used for the NHS Bowel Cancer Screening Programme (BCSP) derives participant information from primary care records. Combining predictors with FOBTs has shown to improve referral decisions and accuracy. The richer data available from GP databases could be used to complement screening referral decisions by identifying those at greatest risk of colorectal cancer. We determined the availability of data for key predictors and whether this information could be used to inform more accurate screening referral decisions.

METHODS

An English BCSP cohort was derived using the electronic notifications received from the BCSP database to GP records. The cohort covered a period between 13th May 2009 to 17th January 2017. Completeness of variables and univariable associations were assessed. Risk prediction models were developed using Cox regression and multivariable fractional polynomials with backwards elimination. Optimism adjusted performance metrics were reported. The sensitivity and specificity of a combined approach using the negative FOBT model plus FOBT positive patients was determined using a probability equivalent to a 3% PPV NICE guidelines level.

RESULTS

292,059 participants aged 60-74 were derived for the BCSP screening cohort. A model including the screening test result had a C-statistic of 0.860, c-slope of 0.997, and R² of 0.597. A model developed for negative screening results only had a C-statistic of 0.597, c-slope of 0.940, and R² of 0.062. Risk predictors included in the models included; age, sex, alcohol consumption, IBS diagnosis, family history of gastrointestinal cancer, smoking status, previous negatives and whether a GP had ordered a blood test. For the combined screening approach, sensitivity increased slightly from 53.90% (FOBT only) to 58.82% but at the expense of an increased referral rate.

CONCLUSIONS

This research has identified several potential predictors for CRC in a BCSP population. A risk prediction model developed for BCSP FOBT negative patients was not clinically useful due to a low sensitivity and increased referral rate. The predictors identified in this study should be investigated in a refined algorithm combining the quantitative FIT result. Combining data from multiple sources enables fuller patient profiles using the primary care and screening database interface.

Ethnic differences in barriers to symptomatic presentation in primary care: A survey of women in England

OBJECTIVE

The majority of cancers are diagnosed following a decision to access medical help for symptoms. People from ethnic minority backgrounds have longer patient intervals following identification of cancer symptoms. This study quantified ethnic differences in barriers to symptomatic presentation including culturally specific barriers. Correlates of barriers (eg, migration status, health literacy, and fatalism) were also explored.

METHODS

A cross-sectional survey of 720 White British, Caribbean, African, Indian, Pakistani, and Bangladeshi women aged 30 to 60 (n = 120/group) was carried out in England. Barrier items were taken from the widely used cancer awareness measure; additional culturally specific barriers to symptomatic presentation were included following qualitative work (11 barriers in total). Migration status, health literacy, and fatalism were included as correlates to help-seeking barriers.

RESULTS

Ethnic minority women reported a higher number of barriers (P < .001, 2.6-3.8 more than White British women). Emotional barriers were particularly prominent. Women from ethnic minority groups were more likely to report "praying about a symptom" (P < .001, except Bangladeshi women) and "using traditional remedies" (P < .001, except Caribbean women). Among ethnic minority women, adult migration to the United Kingdom, low health literacy, and high fatalistic beliefs increased likelihood of reporting barriers to symptomatic presentation. For example, women who migrated as adults were more likely to be embarrassed (OR = 1.83; CI, 1.06-3.15), worry what the GP might find (OR = 1.91; CI, 1.12-3.26), and be low on body vigilance (OR = 4.44; CI, 2.72-7.23).

CONCLUSIONS

Campaigns addressing barriers to symptomatic presentation among ethnic minority women should be designed to reach low health literacy populations and include messages challenging fatalistic views. These would be valuable for reducing ethnic inequalities in cancer outcomes.

Decision support tools to improve cancer diagnostic decision making in primary care: a systematic review

BACKGROUND

The diagnosis of cancer in primary care is complex and challenging. Electronic clinical decision support tools (eCDSTs) have been proposed as an approach to improve GP decision making, but no systematic review has examined their role in cancer diagnosis.

AIM

To investigate whether eCDSTs improve diagnostic decision making for cancer in primary care and to determine which elements influence successful implementation.

DESIGN AND SETTING

A systematic review of relevant studies conducted worldwide and published in English between 1 January 1998 and 31 December 2018.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched, and a consultation of reference lists and citation tracking was carried out. Exclusion criteria included the absence of eCDSTs used in asymptomatic populations, and studies that did not involve support delivered to the GP. The most relevant Joanna Briggs Institute Critical Appraisal Checklists were applied according to study design of the included paper.

RESULTS

Of the nine studies included, three showed improvements in decision making for cancer diagnosis, three demonstrated positive effects on secondary clinical or health service outcomes such as prescribing, quality of referrals, or cost-effectiveness, and one study found a reduction in time to cancer diagnosis. Barriers to implementation included trust, the compatibility of eCDST recommendations with the GP's role as a gatekeeper, and impact on workflow.

CONCLUSION

eCDSTs have the capacity to improve decision making for a cancer diagnosis, but the optimal mode of delivery remains unclear. Although such tools could assist GPs in the future, further well-designed trials of all eCDSTs are needed to determine their cost-effectiveness and the most appropriate implementation methods.

Colorectal cancer patients under the age of 50 experience delays in primary care leading to emergency diagnoses: a population-based study

AIM

The incidence of colorectal cancer in the under 50s is increasing. In this national population-based study we aim to show that missed opportunities for diagnosis in primary care are leading to referral delays and emergency diagnoses in young patients.

METHOD

We compared the interval before diagnosis, presenting symptom(s) and the odds ratio (OR) of an emergency diagnosis for those under the age of 50 with older patients sourced from the cancer registry with linkage to a national database of primary-care records.

RESULTS

The study included 7315 patients, of whom 508 (6.9%) were aged under 50 years, 1168 (16.0%) were aged 50-59, 2294 (31.4%) were aged 60-69 and 3345 (45.7%) were aged 70-79 years. Young patients were more likely to present with abdominal pain and via an emergency, and had the lowest percentage of early stage cancer. They experienced a longer interval between referral and diagnosis (12.5 days) than those aged 60-69, reflecting the higher proportion of referrals via the nonurgent pathway (33.3%). The OR of an emergency diagnosis did not differ with age if a red-flag symptom was noted at presentation, but increased significantly for young patients if the symptom was nonspecific.

CONCLUSION

Young patients present to primary care with symptoms outside the national referral guidelines, increasing the likelihood of an emergency diagnosis.

The effects of cancer care pathways on waiting times

Purpose

The Swedish health-care system currently implements cancer care pathways (CCPs) for better and more timely cancer diagnostics. The purpose of this paper is to elucidate and define “crowding out” effects associated with the CCP implementation.

Design/methodology/approach

A document study based on implementation reports and action plans from Swedish county councils (n = 21) and a case study in one county council were conducted. Qualitative data collection and analysis were used to acquire more knowledge about the “crowding out” effects associated with the CCP implementation.

Findings

Three effects discussed under “crowding out” were defined. The first effect, called the push-out effect, occurs when other patients have to wait for care longer in favour of CCP patients. Another effect is the inclusion effect, whereby “crowding out” is reduced for vulnerable patients due to the standardised procedures and criteria in the referral process. The final effect is the exclusion effect, where patients in need of cancer diagnostics are, for some reason, not referred to CCP. These patients are either not diagnosed at all or diagnosed outside CCP by a non-standard process, with the risk of longer waiting times.

Originality/value

“Crowding out” effects are an urgent topic related to CCP implementation. While these effects have been reported in international research studies, no shared definition has been established to describe them. The present paper creates a common base to measure the “crowding out” effects and support further development of CCPs to avoid the negative effects on waiting times.

Impact of GP gatekeeping on quality of care, and health outcomes, use, and expenditure: a systematic review

BACKGROUND

GPs often act as gatekeepers, authorising patients' access to specialty care. Gatekeeping is frequently perceived as lowering health service use and health expenditure. However, there is little evidence suggesting that gatekeeping is more beneficial than direct access in terms of patient- and health-related outcomes.

AIM

To establish the impact of GP gatekeeping on quality of care, health use and expenditure, and health outcomes and patient satisfaction.

DESIGN AND SETTING

A systematic review.

METHOD

The databases MEDLINE, PreMEDLINE, Embase, and the Cochrane Library were searched for relevant articles using a search strategy. Two authors independently screened search results and assessed the quality of studies.

RESULTS

Electronic searches identified 4899 studies (after removing duplicates), of which 25 met the inclusion criteria. Gatekeeping was associated with better quality of care and appropriate referral for further hospital visits and investigation. However, one study reported unfavourable outcomes for patients with cancer under gatekeeping, and some concerns were raised about the accuracy of diagnoses made by gatekeepers. Gatekeeping resulted in fewer hospitalisations and use of specialist care, but inevitably was associated with more primary care visits. Patients were less satisfied with gatekeeping than direct-access systems.

CONCLUSION

Gatekeeping was associated with lower healthcare use and expenditure, and better quality of care, but with lower patient satisfaction. Survival rate of patients with cancer in gatekeeping schemes was significantly lower than those in direct access, although primary care gatekeeping was not otherwise associated with delayed patient referral. The long-term outcomes of gatekeeping arrangements should be carefully studied before devising new gatekeeping policies.

Predictive values of colorectal cancer alarm symptoms in the general population: a nationwide cohort study

Background

Alarm symptoms are used in many cancer referral guidelines. The objectives were to determine the 1-year predictive values (PVs) of colorectal cancer (CRC) alarm symptoms in the general population and to describe the proportion of alarm symptoms reported prior to diagnosis.

Methods

A nationwide prospective cohort of 69,060 individuals ≥40 years randomly selected from the Danish population was invited to complete a survey regarding symptoms and healthcare-seeking in 2012. Information on CRC diagnoses in a 12-month follow-up came from the Danish Cancer Registry. PVs and positive and negative likelihood ratios were calculated.

Results

A total of 37,455 individuals participated (response rate 54.2%). Sixty-four individuals were diagnosed with CRC. The single symptom with the highest positive PVs (PPV) and LR+ was rectal bleeding. PPVs were generally higher among individuals aged ≥75 years and highest among those reporting at least one specific alarm symptom that led to a GP contact.

Conclusion

In general, the PPVs of CRC alarm symptoms are low and the NPVs high, especially in the youngest age groups. The LR +  show a relative association with specific symptoms like rectal bleeding. Future campaigns on early diagnosis of CRC should focus on healthcare-seeking when experiencing rectal bleeding and target older people with the highest incidence.

Making sense of bodily sensations: Do shared cancer narratives influence symptom appraisal?

Though new or altered bodily sensations are a common occurrence they rarely transition to biomedically defined symptoms. When they do, sensations are subject to an appraisal process that can culminate in help-seeking. The transition has particular relevance for cancer diagnoses. Studies of 'symptom appraisal' in cancer patients typically conclude that failure to regard sensations as serious or 'symptom misattribution' results in lengthier help-seeking intervals. Though multiple influences on appraisal processes are acknowledged, including the socio-cultural context, detailed description and analyses of how socio-cultural factors shape appraisal is lacking. In this paper we explore one substantial component of the sociocultural context, namely, publicly recognised shared cancer narratives, and their impact on appraisal. We undertook a secondary analysis of 24 interviews with Scottish colorectal cancer patients originally completed in 2006-2007. Our analysis showed that fear, death and severity dominated cancer narratives and were frequently restated throughout interviews. Yet, early bodily changes were often mild and vague, were commonly experienced in the context of 'feeling well' and failed to match preconceived ideas of what cancer 'feels like'. Moreover, few perceived themselves to be 'at risk' of cancer and diagnoses were characterised as 'shocking' events. Participants engaged in self-monitoring strategies and severe or painful changes prompted help-seeking. Far from misattributing symptoms, responses to bodily changes were sensible and measured; responses are particularly apt in relation to current policy rhetoric, which urges measured use of services. Our findings have resonance across healthcare settings as patients are required to negotiate a narrow and challenging space when making decisions to seek help. There is a pressing need for a more realistic approach to symptom appraisal in order to reduce help-seeking intervals. Future awareness campaigns should emphasise the importance of vague/minor bodily changes although this will necessitate discussions with health professionals on referral thresholds to achieve earlier detection.

Global epidemiology, risk factors, and histological types of ovarian cancers in Trinidad

Background

Ovarian cancer is the seventh most common cancer in women in the world and Trinidad and Tobago is ranked 18^th in the world with respect to the rate of occurrence. About 68% cases are diagnosed at a late stage, resulting in low survival rates. Since there is very scanty literature available on the epidemiology of ovarian cancer in the Caribbean region, this study was undertaken to assess the most common risk factors, presenting symptoms and common histological varieties in Trinidad.

Methods

A hospital-based, cross-sectional study was designed, and all the 23 diagnosed ovarian cancer cases registered during 2015-2017 were considered. Information on sociodemographics, presenting symptoms, and histological type of cancers were collected after getting the ethical approval. Of the total 23 cases, 17 cases were included in this study after ensuring completeness of data as detailed analysis of patient data was done using Microsoft Excel.

Results

The common risk factors identified were previous pregnancies, previous surgeries, and irregularities in the menstrual cycle. The commonest histological variety was granulosa tumors and the most common associated symptoms were irregular menses and abdominal pain in premenstrual women, and abdominal distention in postmenopausal women.

Conclusions

It would greatly enhance the detection rate if screening and testing for the CA-125 gene were a mandatory practice, for any patient found with more than three risk factors. The public health authorities should identify the modifiable risk factors and implement cancer reduction and health promotion activities to reduce the mortality related to ovarian cancers.

Recognising Lung Cancer in Primary Care

Significant advances in the management of both early and advanced stage lung cancer have not yet led to the scale of improved outcomes which have been achieved in other cancers over the last 40 years. Diagnosis of lung cancer at the earliest stage of disease is strongly associated with improved survival. Therefore, although recent advances in oncology may herald breakthroughs in effective treatment, achieving early diagnosis will remain crucial to obtaining optimal outcomes. This is challenging, as most lung cancer symptoms are non-specific or are common respiratory symptoms which usually represent benign disease. Identification of patients at risk of lung cancer who require further investigation is an important responsibility for general practitioners (GPs). Diagnosis has historically relied upon plain chest X-ray (CXR), organised in response to symptoms. The sensitivity of this modality, however, compares unfavourably with that of computed tomography (CT). In some jurisdictions screening high-risk individuals with low dose CT (LDCT) is now recommended. However uptake remains low and the eligibility for screening programmes is restricted. Therefore, even if screening is widely adopted, most patients will continue to be diagnosed after presenting with symptoms. Achieving early diagnosis requires GPs to maintain an appropriate level of suspicion and readiness to investigate in high-risk patients or those with non-resolving symptoms. This article discusses the early detection of lung cancer from a primary care perspective. We outline risk factors and epidemiology, the role of screening and offer guidance on the recognition of symptomatic presentation and the investigation and referral of suspected lung cancer.

The Aarhus statement on cancer diagnostic research: turning recommendations into new survey instruments

BACKGROUND

Over recent years there has been a growth in cancer early diagnosis (ED) research, which requires valid measurement of routes to diagnosis and diagnostic intervals. The Aarhus Statement, published in 2012, provided methodological guidance to generate valid data on these key pre-diagnostic measures. However, there is still a wide variety of measuring instruments of varying quality in published research. In this paper we test comprehension of self-completion ED questionnaire items, based on Aarhus Statement guidance, and seek input from patients, GPs and ED researchers to refine these questions.

METHODS

We used personal interviews and consensus approaches to generate draft ED questionnaire items, then a combination of focus groups and telephone interviews to test comprehension and obtain feedback. A framework analysis approach was used, to identify themes and potential refinements to the items.

RESULTS

We found that many of the questionnaire items still prompted uncertainty in respondents, in both routes to diagnosis and diagnostic interval measurement. Uncertainty was greatest in the context of multiple or vague symptoms, and potentially ambiguous time-points (such as 'date of referral').

CONCLUSIONS

There are limits on the validity of self-completion questionnaire responses, and refinements to the wording of questions may not be able to completely overcome these limitations. It's important that ED researchers use the best identifiable measuring instruments, but accommodate inevitable uncertainty in the interpretation of their results. Every effort should be made to increase clarity of questions and responses, and use of two or more data sources should be considered.

Differences in diagnostic activity in general practice and findings for individuals invited to the danish screening programme for colorectal cancer: a population-based cohort study

OBJECTIVE

To investigate the diagnostic activity in general practice and the cumulative incidence of colorectal cancer (CRC) in individuals invited to the Danish national screening programme for CRC.

DESIGN

A historical population-based cohort study.

SETTING

The Danish CRC screening programme and general practice.

SUBJECTS

The 376,198 individuals invited to the Danish CRC screening programme from 1 March to 31 December 2014.

MAIN OUTCOME MEASURES

The diagnostic activity (consultations and haemoglobin measures) in general practice in the year preceding the screening invitation and the cumulated incidence of CRC in the year following the screening invitation.

RESULTS

Screening participants had significantly higher diagnostic activity than non-participants. Individuals with a positive faecal immunochemical test (FIT) had higher diagnostic activity compared to individuals with a negative FIT, and a small increase in the months leading up to the invitation. Individuals with a screen-detected CRC had lower diagnostic activity than individuals with no CRC. In total, 308 (25.3%) of CRCs diagnosed in the invited population were diagnosed outside the screening programme. Non-participants with CRC more often had low socio-economic status, high comorbidity and stage IV CRC than participants with CRC.

CONCLUSIONS

There was a tendency that participants and those with a positive FIT had a higher diagnostic activity the year before the screening. This was not seen for those with CRC detected through screening. CRC must still be diagnosed in general practice in the invited population and non-participants are of special interest as they have higher risk of late stage CRC. Key Points Current awareness:Individuals with colorectal cancer (CRC) in screening may be symptomatic and CRC may still occur outside screening in the invited population. Most important points:The majority of individuals with CRC in screening cannot be expected to be diagnosed on symptomatic presentation in general practice GPs have to be aware that CRC still occurs outside screening in the invited population Non-participants with CRC are often deprived and have late stage CRC.

Direct access cancer testing in primary care: a systematic review of use and clinical outcomes

BACKGROUND

Direct access (DA) testing allows GPs to refer patients for investigation without consulting a specialist. The aim is to reduce waiting time for investigations and unnecessary appointments, enabling treatment to begin without delay.

AIM

To establish the proportion of patients diagnosed with cancer and other diseases through DA testing, time to diagnosis, and suitability of DA investigations.

DESIGN AND SETTING

Systematic review assessing the effectiveness of GP DA testing in adults.

METHOD

MEDLINE, Embase, and the Cochrane Library were searched. Where possible, study data were pooled and analysed quantitatively. Where this was not possible, the data are presented narratively.

RESULTS

The authors identified 60 papers that met pre-specified inclusion criteria. Most studies were carried out in the UK and were judged to be of poor quality. The authors found no significant difference in the pooled cancer conversion rate between GP DA referrals and patients who first consulted a specialist for any test, except gastroscopy. There were also no significant differences in the proportions of patients receiving any non-cancer diagnosis. Referrals for testing were deemed appropriate in 66.4% of those coming from GPs, and in 80.9% of those from consultants; this difference was not significant. The time from referral to testing was significantly shorter for patients referred for DA tests. Patient and GP satisfaction with DA testing was consistently high.

CONCLUSION

GP DA testing performs as well as, and on some measures better than, consultant triaged testing on measures of disease detection, appropriateness of referrals, interval from referral to testing, and patient and GP satisfaction.

The value of using the faecal immunochemical test in general practice on patients presenting with non-alarm symptoms of colorectal cancer

Background

Around 50% of individuals with colorectal cancer (CRC) initially present with non-alarm symptoms.

Methods

We investigated the value of using the faecal immunochemical test (FIT) in the diagnostic process of CRC and other serious bowel disease in individuals presenting with non-alarm symptoms in general practice. The study was conducted in the Central Denmark Region from 1 September 2015 to 30 August 2016. The FIT was used as a rule-in test on patients aged ≥30 years with non-alarm symptoms of CRC. The cut-off value was set to 10 µg Hb/g faeces.

Results

A total of 3462 valid FITs were performed. Of these, 540 (15.6%) were positive. Three months after FIT performance, 51 (PPV: 9.4% (95% CI: 7.0;11.9)) individuals with a positive FIT were diagnosed with CRC and 73 (PPV: 13.5% (95%CI: 10.6;16.4)) with other serious bowel disease. Of CRCs, 66.7% were diagnosed in UICC stage I & II and 19.6% in stage IV. The false negative rate for CRC was <0.1% for the initial 3 months after FIT performance.

Conclusion

The FIT may be used as a supplementary diagnostic test in the diagnostic process of CRC and other serious bowel disease in individuals with non-alarm symptoms of CRC in general practice.

Lifestyle, socioeconomic status and healthcare seeking among women with gynaecological cancer alarm symptoms: a combined questionnaire-based and register-based population study

OBJECTIVES

To determine the proportion of contacts to general practitioner (GP) with recent onset gynaecological cancer alarm symptoms (pelvic pain, postmenopausal bleeding, bleeding during intercourse or pain during intercourse) and to analyse the associations between lifestyle factors, socioeconomic status and GP contact for these symptoms.

DESIGN

Cross-sectional survey combined with data from national registers.

SETTING

The general Danish population.

PARTICIPANTS

A total of 25 866 non-pregnant women ≥20 years completed the survey. Women reporting at least one of four gynaecological alarm symptoms within the preceding 6 months form the study base (n=2957).

RESULTS

The proportion of women reporting GP contact ranged from 21.1% (pain during intercourse) to 32.6% (postmenopausal bleeding). Women aged 60+ years had higher odds of reporting GP contact for at least one of the four gynaecological cancer alarm symptoms compared with those aged 20-39 years (OR 2.56, 95% CI 1.69 to 3.89), and immigrants had higher odds of reporting GP contact for at least one of the symptoms (OR 1.56, 95% CI 1.13 to 2.15) compared with ethnic Danish individuals. Among those reporting postmenopausal bleeding and/or bleeding during intercourse, women in the age group 60+ years had higher odds of reporting GP contact compared with those aged 20-39 years (OR 2.79, 95% CI 1.33 to 5.87). A high educational level (>12 years) was positively associated with reporting GP contact for postmenopausal bleeding and/or bleeding during intercourse compared with a low educational level (<10 years) (OR 2.23, 95% CI 1.19 to 4.19). No associations were found with lifestyle factors.

CONCLUSIONS

Few women contacted their GP with recent onset gynaecological cancer alarm symptoms. Higher age, being immigrant and higher educational level increased the odds of GP contact. Future studies should explore the reasons for these findings as this may aid in prompting early diagnosis and thereby improve the prognosis of gynaecological cancer.

Weight loss as a predictor of cancer in primary care: a systematic review and meta-analysis

BACKGROUND

Weight loss is a non-specific cancer symptom for which there are no clinical guidelines about investigation in primary care.

AIM

To summarise the available evidence on weight loss as a clinical feature of cancer in patients presenting to primary care.

DESIGN AND SETTING

A diagnostic test accuracy review and meta-analysis.

METHOD

Studies reporting 2 × 2 diagnostic accuracy data for weight loss (index test) in adults presenting to primary care and a subsequent diagnosis of cancer (reference standard) were included. QUADAS-2 was used to assess study quality. Sensitivity, specificity, positive likelihood ratios, and positive predictive values were calculated, and a bivariate meta-analysis performed.

RESULTS

A total of 25 studies were included, with 23 (92%) using primary care records. Of these, 20 (80%) defined weight loss as a physician's coding of the symptom; the remainder collected data directly. One defined unexplained weight loss using objective measurements. Positive associations between weight loss and cancer were found for 10 cancer sites: prostate, colorectal, lung, gastro-oesophageal, pancreatic, non-Hodgkin's lymphoma, ovarian, myeloma, renal tract, and biliary tree. Sensitivity ranged from 2% to 47%, and specificity from 92% to 99%, across cancer sites. The positive predictive value for cancer in male and female patients with weight loss for all age groups ≥60 years exceeded the 3% risk threshold that current UK guidance proposes for further investigation.

CONCLUSION

A primary care clinician's decision to code for weight loss is highly predictive of cancer. For such patients, urgent referral pathways are justified to investigate for cancer across multiple sites.

Acceptability of text messages for safety netting patients with low-risk cancer symptoms: a qualitative study

BACKGROUND

Safety netting is an important diagnostic strategy for patients presenting to primary care with potential (low-risk) cancer symptoms. Typically, this involves asking patients to return if symptoms persist. However, this relies on patients re-appraising their symptoms and making follow-up appointments, which could contribute to delays in diagnosis. Text messaging is increasingly used in primary care to communicate with patients, and could be used to improve safety netting.

AIM

To explore the acceptability and feasibility of using text messages to safety net patients presenting with low-risk cancer symptoms in GP primary care (txt-netting).

DESIGN AND SETTING

Qualitative focus group and interview study with London-based GPs.

METHOD

Participants were identified using convenience sampling methods. Five focus groups and two interviews were conducted with 22 GPs between August and December 2016. Sessions were audiorecorded, transcribed verbatim, and analysed using thematic analysis.

RESULTS

GPs were amenable to the concept of using text messages in cancer safety netting, identifying it as an additional tool that could help manage patients and promote symptom awareness. There was wide variation in GP preferences for text message content, and a number of important potential barriers to txt-netting were identified. Concerns were raised about the difficulties of conveying complex safety netting advice within the constraints of a text message, and about confidentiality, widening inequalities, and workload implications.

CONCLUSION

Text messages were perceived to be an acceptable potential strategy for safety netting patients with low-risk cancer symptoms. Further work is needed to ensure it is cost-effective, user friendly, confidential, and acceptable to patients.

Abdominal symptoms and cancer in the abdomen: prospective cohort study in European primary care

BACKGROUND

Different abdominal symptoms may signal cancer, but their role is unclear.

AIM

To examine associations between abdominal symptoms and subsequent cancer diagnosed in the abdominal region.

DESIGN AND SETTING

Prospective cohort study comprising 493 GPs from surgeries in Norway, Denmark, Sweden, Scotland, Belgium, and the Netherlands.

METHOD

Over a 10-day period, the GPs recorded consecutive consultations and noted: patients who presented with abdominal symptoms pre-specified on the registration form; additional data on non-specific symptoms; and features of the consultation. Eight months later, data on all cancer diagnoses among all study patients in the participating general practices were requested from the GPs.

RESULTS

Consultations with 61 802 patients were recorded and abdominal symptoms were documented in 6264 (10.1%) patients. Malignancy, both abdominal and non-abdominal, was subsequently diagnosed in 511 patients (0.8%). Among patients with a new cancer in the abdomen (n = 251), 175 (69.7%) were diagnosed within 180 days after consultation. In a multivariate model, the highest sex- and age-adjusted hazard ratio (HR) was for the single symptom of rectal bleeding (HR 19.1, 95% confidence interval = 8.7 to 41.7). Positive predictive values of >3% were found for macroscopic haematuria, rectal bleeding, and involuntary weight loss, with variations according to age and sex. The three symptoms relating to irregular bleeding had particularly high specificity in terms of colorectal, uterine, and bladder cancer.

CONCLUSIONS

A patient with undiagnosed cancer may present with symptoms or no symptoms. Irregular bleeding must always be explained. Abdominal pain occurs with all types of abdominal cancer and several symptoms may signal colorectal cancer. The findings are important as they influence how GPs think and act, and how they can contribute to an earlier diagnosis of cancer.

Symptom Signatures and Diagnostic Timeliness in Cancer Patients: A Review of Current Evidence

Early diagnosis is an important aspect of contemporary cancer prevention and control strategies, as the majority of patients are diagnosed following symptomatic presentation. The nature of presenting symptoms can critically influence the length of the diagnostic intervals from symptom onset to presentation (the patient interval), and from first presentation to specialist referral (the primary care interval). Understanding which symptoms are associated with longer diagnostic intervals to help the targeting of early diagnosis initiatives is an area of emerging research. In this Review, we consider the methodological challenges in studying the presenting symptoms and intervals to diagnosis of cancer patients, and summarize current evidence on presenting symptoms associated with a range of common and rarer cancer sites. We propose a taxonomy of cancer sites considering their symptom signature and the predictive value of common presenting symptoms. Finally, we consider evidence on associations between symptomatic presentations and intervals to diagnosis before discussing implications for the design, implementation, and evaluation of public health or health system interventions to achieve the earlier detection of cancer.

Pathways to diagnosis of a second primary cancer: protocol for a mixed-methods systematic review

INTRODUCTION

As cancer survivors continue to live longer, the incidence of second primary cancers (SPCs) will also rise. Relatively little is understood about the diagnostic pathway for SPCs, how people appraise, interpret symptoms and seek help for a second different cancer and the experiences (including challenges) of healthcare providers relating to SPCs. This study aims to systematically appraise and synthesise the literature on the pathways to diagnosis of an SPC and the associated patient and healthcare provider experiences.

METHODS

The approach taken includes systematic searches of published and unpublished literature without any date or language restrictions. MEDLINE, Embase, CAB Abstracts, MEDLINE In-Process and non-indexed citations, PsycINFO, Epub Ahead of Print, In-Process and other non-indexed citations, Ovid MEDLINE Daily, CINAHL, ASSIA, Sociological Abstracts, Web of Science, PROSPERO and grey literature will be searched to identify observational, systematic reviews, mixed methods and qualitative studies of interest. Titles, abstracts and full texts will be screened against the inclusion-exclusion criteria by at least two reviewers independently. Relevant outcomes of interest and study and population characteristics will be extracted. Synthesis will be used guided by the Pathways to Treatment model and the Olesen model of time intervals.

ETHICS AND DISSEMINATION

Ethical approval is not required. This systematic review will provide a deeper understanding of the complex and heterogeneous diagnostic pathways of SPCs, while identifying common themes across the diagnostic interval, routes to diagnosis and patient and healthcare provider experiences. These findings will help provide a nuanced picture of the diagnostic pathway for SPCs that may inform policy and consistent practice. In particular, approaches to early diagnosis for an SPC; including the timing and reasons behind the decision by the patient to seek care,the challenges faced by healthcare providers, and in the development of future interventions to reduce the delay in patient time-to-presentation.

PROSPERO REGISTRATION NUMBER

CRD42016051692.

Possible missed opportunities for diagnosing colorectal cancer in Dutch primary care: a multimethods approach

BACKGROUND

Early detection of colorectal cancer (CRC) is important to achieve better survival. Discriminating symptoms suggestive of CRC from benign conditions is a challenge for GPs because most known 'alarm symptoms' have low predictive values.

AIM

To further understand the diagnostic process of CRC in general practice in terms of healthcare use and by analysing factors related to diagnostic intervals.

DESIGN AND SETTING

A multimethod approach comprising a historical, prospective registry study and qualitative content analysis.

METHOD

Healthcare use in the year before referral for colonoscopy was compared between patients diagnosed with CRC and an age-, sex,- and GP-matched control population. Qualitative content analysis was performed on free texts in electronic patient records from a purposive sample of patients with CRC.

RESULTS

Patients with CRC (n = 287) had 41% (25-59%) more face-to-face contacts and 21% (7-37%) more medication prescriptions than controls (n = 828). Forty-six per cent of patients with CRC had two or more contacts for digestive reasons, compared with 12.2% of controls, more often for symptoms than diagnoses. From qualitative analysis two themes emerged: 'possible missed diagnostic opportunities' and 'improvements in diagnostic process unlikely'. Possible missed diagnostic opportunities were related to patients waiting before presenting symptoms, doctors attributing symptoms to comorbid conditions or medication use, or doctors sticking to an initial diagnosis.

CONCLUSION

Fewer missed diagnostic opportunities might occur if GPs are aware of pitfalls in diagnosing CRC: the assumption that symptoms are caused by comorbid conditions or medication, or relating complaints to pre-existing medical conditions. GPs also need to be aware that repeated digestive complaints warrant rethinking an earlier diagnosis.

Impact of travel time and rurality on presentation and outcomes of symptomatic colorectal cancer: a cross-sectional cohort study in primary care

BACKGROUND

Several studies have reported a survival disadvantage for rural dwellers who develop colorectal cancer, but the underlying mechanisms remain obscure. Delayed presentation to GPs may be a contributory factor, but evidence is lacking.

AIM

To examine the association between rurality and travel time on diagnosis and survival of colorectal cancer in a cohort from northeast Scotland.

DESIGN AND SETTING

The authors used a database linking GP records to routine data for patients diagnosed between 1997 and 1998, and followed up to 2011.

METHOD

Primary outcomes were alarm symptoms, emergency admissions, stage, and survival. Travel time in minutes from patients to GP was estimated. Logistic and Cox regression were used to model outcomes. Interaction terms were used to determine if travelling time impacted differently on urban versus rural patients.

RESULTS

Rural patients and patients travelling farther to the GP had better 3-year survival. When the travel outcome associations were explored using interaction terms, the associations differed between rural and urban areas. Longer travel in urban areas significantly reduced the odds of emergency admissions (odds ratio [OR] 0.62, P<0.05), and increased survival (hazard ratio 0.75, P<0.05). Longer travel also increased the odds of presenting with alarm symptoms in urban areas; this was nearly significant (OR 1.34, P = 0.06). Presence of alarm symptoms reduced the likelihood of emergency admissions (OR 0.36, P<0.01).

CONCLUSION

Living in a rural area, and travelling farther to a GP in urban areas, may reduce the likelihood of emergency admissions and poor survival. This may be related to how patients present with alarm symptoms.

Primary care and cancer: Facing the challenge of early diagnosis and survivorship

With ageing populations and an increasing lifetime risk of cancer, primary care will continue to play an increasingly important role in early diagnosis and cancer survivorship, especially with the lowering of risk thresholds for referral and diagnostic investigations. However, primary care in many countries is in crisis with increasing workloads for primary care physicians. Potential solutions to these challenges will be outlined including development of multidisciplinary teams, diagnostic decision support, increasing access to diagnostics and cost-effective referral pathways.

The fecal hemoglobin concentration, age and sex test score: Development and external validation of a simple prediction tool for colorectal cancer detection in symptomatic patients

Prediction models for colorectal cancer (CRC) detection in symptomatic patients, based on easily obtainable variables such as fecal haemoglobin concentration (f-Hb), age and sex, may simplify CRC diagnosis. We developed, and then externally validated, a multivariable prediction model, the FAST Score, with data from five diagnostic test accuracy studies that evaluated quantitative fecal immunochemical tests in symptomatic patients referred for colonoscopy. The diagnostic accuracy of the Score in derivation and validation cohorts was compared statistically with the area under the curve (AUC) and the Chi-square test. 1,572 and 3,976 patients were examined in these cohorts, respectively. For CRC, the odds ratio (OR) of the variables included in the Score were: age (years): 1.03 (95% confidence intervals (CI): 1.02-1.05), male sex: 1.6 (95% CI: 1.1-2.3) and f-Hb (0-<20 µg Hb/g feces): 2.0 (95% CI: 0.7-5.5), (20-<200 µg Hb/g): 16.8 (95% CI: 6.6-42.0), ≥200 µg Hb/g: 65.7 (95% CI: 26.3-164.1). The AUC for CRC detection was 0.88 (95% CI: 0.85-0.90) in the derivation and 0.91 (95% CI: 0.90-093; p = 0.005) in the validation cohort. At the two Score thresholds with 90% (4.50) and 99% (2.12) sensitivity for CRC, the Score had equivalent sensitivity, although the specificity was higher in the validation cohort (p < 0.001). Accordingly, the validation cohort was divided into three groups: high (21.4% of the cohort, positive predictive value-PPV: 21.7%), intermediate (59.8%, PPV: 0.9%) and low (18.8%, PPV: 0.0%) risk for CRC. The FAST Score is an easy to calculate prediction tool, highly accurate for CRC detection in symptomatic patients.

Determinants of general practitioner's cancer-related gut feelings-a prospective cohort study

BACKGROUND

General practitioners (GPs) use gut feelings to diagnose cancer in an early stage, but little is known about its impact.

METHOD

Prospective cohort study of patients in 44 general practices throughout the Netherlands, from January 2010 until December 2013. GPs completed a questionnaire regarding gut feelings, patient and GP characteristics, if they noticed a cancer-related gut feeling during patient consultation. Follow-up questionnaires were sent 3 months later requesting information about the patient's diagnosis. χ(2), univariate and multivariate logistic regression and multilevel analyses were performed.

RESULTS

A gut feeling (N=366) is most often triggered by weight loss (24%, N=85) and rare GP visits (22%, N=76), but all triggers were not predictive of cancer in a multivariate analysis. Most GPs (95%) acted immediately on the gut feeling, either referring to a specialist or by performing additional medical tests. The average positive predictive value of cancer-related gut feeling was 35%, and it increased with 2% for every year a patient becomes older, and with 3% for every year a GP becomes older.

CONCLUSIONS

GP's gut feeling for cancer proves to be a useful tool in diagnosing cancer and its relative high predicting value increases if the GP is older or more experienced and when the patient is older. How can younger GPs be trained to increase the predictive value of their gut feeling?

Development and external validation of a faecal immunochemical test-based prediction model for colorectal cancer detection in symptomatic patients

BACKGROUND

Risk prediction models for colorectal cancer (CRC) detection in symptomatic patients based on available biomarkers may improve CRC diagnosis. Our aim was to develop, compare with the NICE referral criteria and externally validate a CRC prediction model, COLONPREDICT, based on clinical and laboratory variables.

METHODS

This prospective cross-sectional study included consecutive patients with gastrointestinal symptoms referred for colonoscopy between March 2012 and September 2013 in a derivation cohort and between March 2014 and March 2015 in a validation cohort. In the derivation cohort, we assessed symptoms and the NICE referral criteria, and determined levels of faecal haemoglobin and calprotectin, blood haemoglobin, and serum carcinoembryonic antigen before performing an anorectal examination and a colonoscopy. A multivariate logistic regression analysis was used to develop the model with diagnostic accuracy with CRC detection as the main outcome.

RESULTS

We included 1572 patients in the derivation cohort and 1481 in the validation cohorts, with a 13.6 % and 9.1 % CRC prevalence respectively. The final prediction model included 11 variables: age (years) (odds ratio [OR] 1.04, 95 % confidence interval [CI] 1.02-1.06), male gender (OR 2.2, 95 % CI 1.5-3.4), faecal haemoglobin ≥20 μg/g (OR 17.0, 95 % CI 10.0-28.6), blood haemoglobin <10 g/dL (OR 4.8, 95 % CI 2.2-10.3), blood haemoglobin 10-12 g/dL (OR 1.8, 95 % CI 1.1-3.0), carcinoembryonic antigen ≥3 ng/mL (OR 4.5, 95 % CI 3.0-6.8), acetylsalicylic acid treatment (OR 0.4, 95 % CI 0.2-0.7), previous colonoscopy (OR 0.1, 95 % CI 0.06-0.2), rectal mass (OR 14.8, 95 % CI 5.3-41.0), benign anorectal lesion (OR 0.3, 95 % CI 0.2-0.4), rectal bleeding (OR 2.2, 95 % CI 1.4-3.4) and change in bowel habit (OR 1.7, 95 % CI 1.1-2.5). The area under the curve (AUC) was 0.92 (95 % CI 0.91-0.94), higher than the NICE referral criteria (AUC 0.59, 95 % CI 0.55-0.63; p < 0.001). On the basis of the thresholds with 90 % (5.6) and 99 % (3.5) sensitivity, we divided the derivation cohort into three risk groups for CRC detection: high (30.9 % of the cohort, positive predictive value [PPV] 40.7 %, 95 % CI 36.7-45.9 %), intermediate (29.5 %, PPV 4.4 %, 95 % CI 2.8-6.8 %) and low (39.5 %, PPV 0.2 %, 95 % CI 0.0-1.1 %). The discriminatory ability was equivalent in the validation cohort (AUC 0.92, 95 % CI 0.90-0.94; p = 0.7).

CONCLUSIONS

COLONPREDICT is a highly accurate prediction model for CRC detection.

Presentations to general practice before a cancer diagnosis in Victoria: a cross-sectional survey

OBJECTIVE

To assess variations in the number of general practitioner visits preceding a cancer diagnosis, and in the length of the interval between the patient first suspecting a problem and their seeing a hospital specialist.

DESIGN, SETTING AND PARTICIPANTS

Analysis of data provided to the Cancer Patient Experience Survey (CPES; survey response rate, 37.7%) by 1552 patients with one of 19 cancer types and treated in one of five Victorian Comprehensive Cancer Centre hospitals, 1 October 2012 - 30 April 2013.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of patients who had had three or more GP consultations about cancer-related health problems before being referred to hospital. The secondary outcome was the interval between the patient first suspecting a problem and their seeing a hospital specialist.

RESULTS

34% of the patients included in the final analyses (426 of 1248) had visited a GP at least three times before referral to a hospital doctor. The odds ratios (reference: rectal cancer; adjusted for age, sex, language spoken at home, and socio-economic disadvantage index score) varied according to cancer type, being highest for pancreatic cancer (3.2; 95% CI, 1.02-9.9), thyroid cancer (2.5; 95% CI, 0.9-6.6), vulval cancer (2.5; 95% CI, 0.7-8.7) and multiple myeloma (2.4; 95% CI, 1.1-5.5), and lowest for patients with breast cancer (0.4; 95% CI, 0.2-0.8), cervical cancer (0.5; 95% CI, 0.1-2.1), endometrial cancer (0.5; 95% CI, 0.2-1.4) or melanoma (0.7; 95% CI, 0.3-1.5). Cancer type also affected the duration of the interval from symptom onset to seeing a hospital doctor; it took at least 3 months for more than one-third of patients with prostate or colon cancer to see a hospital doctor.

CONCLUSION

Certain cancer types were more frequently associated with multiple GP visits, suggesting they are more challenging to recognise early. In Victoria, longer intervals from the first symptoms to seeing a hospital doctor for colon or prostate cancer may reflect poorer community symptom awareness, later GP referral, or limited access to gastroenterology and urology services.

Implementation of immunochemical faecal occult blood test in general practice: a study protocol using a cluster-randomised stepped-wedge design

BACKGROUND

Colorectal cancer is a common malignancy and a leading cause of cancer-related death. Half of patients with colorectal cancer initially present with non-specific or vague symptoms. In the need for a safe low-cost test, the immunochemical faecal occult blood test (iFOBT) may be part of the evaluation of such patients in primary care. Currently, Danish general practitioners have limited access to this test. The aim of this article is to describe a study that will assess the uptake and clinical use of iFOBT in general practice. Furthermore, it will investigate the diagnostic value and the clinical implications of using iFOBT in general practice on patients presenting with non-alarm symptoms of colorectal cancer.

METHODS/DESIGN

The study uses a cluster-randomised stepped-wedge design and is conducted in the Central Denmark Region among 836 GPs in 381 general practices. The municipalities of the Region and their appertaining general practitioners will be included sequentially in the study during the first 7 months of the 1-year study period. The following intervention has been developed for the study: a mandatory intervention providing all general practitioners with a starting package of 10 iFOBTs, a clinical instruction on iFOBT use in general practice and online information material from the date of inclusion, and an optional intervention consisting of a continuous medical education on colorectal cancer diagnostics and use of iFOBT.

DISCUSSION

This study is among the first and largest trials to investigate the diagnostic use and the clinical value of iFOBT on patients presenting with non-alarm symptoms of colorectal cancer. The findings will be of national and international importance for the future planning of colorectal cancer diagnostics, particularly for 'low-risk-but-not-no-risk' patients with non-alarm symptoms of colorectal cancer.

TRIAL REGISTRATION

A Trial of the Implementation of iFOBT in General Practice NCT02308384 . Date of registration: 26 November 2014.