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Disbeschl SL, Hendry AK, Surgey A, Walker D, Goulden N, Anthony BF, Neal R, Williams NH, Hoare ZSJ, Hiscock J, Edwards RTR, Lewis R, Wilkinson C. 'ThinkCancer!': randomised feasibility trial of a novel practice-based early cancer diagnosis intervention. BJGP Open 2024:BJGPO.2023.0220. [PMID: 38702056 DOI: 10.3399/bjgpo.2023.0220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND UK cancer deaths remain high; primary care is key for earlier cancer diagnosis as half of avoidable delays occur here. Improvement is possible through lower referral thresholds, better guideline adherence, and better safety-netting systems. Few interventions target whole practice teams. We developed a novel whole-practice team intervention to address this. AIM To test the feasibility and acceptability of a novel, complex behavioural intervention, 'ThinkCancer!', for assessment in a subsequent Phase III trial. DESIGN & SETTING Pragmatic, superiority pilot randomised controlled trial (RCT) with an embedded process evaluation and feasibility economic analysis in Welsh general practices. METHOD Clinical outcome data were collected from practices (the unit of randomisation). Practice characteristics and cancer safety-netting systems were assessed. Individual practice staff completed evaluation and feedback forms and qualitative interviews. The intervention was adapted and refined. RESULTS Trial recruitment and workshop deliveries took place between March 2020 and May 2021. Trial progression criteria for recruitment, intervention fidelity, and routine data collection were met. Staff-level fidelity, retention, and individual level data collection processes were reviewed and amended. Interviews highlighted positive participant views on all aspects of the intervention. All practices set out to liberalise referral thresholds appropriately, implement guidelines, and address safety-netting plans in detail. CONCLUSION 'ThinkCancer!' appears feasible and acceptable. The new iteration of the workshops was completed and the Phase III trial has been funded to assess the effectiveness and cost-effectiveness of this novel professional behaviour change intervention. Delivery at scale to multiple practices will likely improve fidelity and reach.
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Affiliation(s)
| | - Annie K Hendry
- North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
- North Wales Organisation for Randomised Trials in Health and Social Care (NWORTH CTU), Bangor University, Bangor, UK
| | - Alun Surgey
- North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
| | - Daniel Walker
- North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
| | - Nia Goulden
- North Wales Organisation for Randomised Trials in Health and Social Care (NWORTH CTU), Bangor University, Bangor, UK
| | - Bethany F Anthony
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, Bangor, UK
| | - Richard Neal
- Department of Health and Community Sciences, Exeter Collaboration for Academic Primary Care, University of Exeter, Exeter, UK
| | - Nefyn H Williams
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Zoë Susannah Jane Hoare
- North Wales Organisation for Randomised Trials in Health and Social Care (NWORTH CTU), Bangor University, Bangor, UK
| | - Julia Hiscock
- North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
| | | | - Ruth Lewis
- North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
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Bradley PT, Lee YK, Albutt A, Hardman J, Kellar I, Odo C, Randell R, Rousseau N, Tikka T, Patterson JM, Paleri V. Nomenclature of the symptoms of head and neck cancer: a systematic scoping review. Front Oncol 2024; 14:1404860. [PMID: 38952557 PMCID: PMC11216301 DOI: 10.3389/fonc.2024.1404860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 05/03/2024] [Indexed: 07/03/2024] Open
Abstract
Introduction Evolution of a patient-reported symptom-based risk stratification system to redesign the suspected head and neck cancer (HNC) referral pathway (EVEREST-HN) will use a broad and open approach to the nomenclature and symptomatology. It aims to capture and utilise the patient reported symptoms in a modern way to identify patients' clinical problems more effectively and risk stratify the patient. Method The review followed the PRISMA checklist for scoping reviews. A search strategy was carried out using Medline, Embase and Web of Science between January 1st 2012 and October 31st 2023. All titles, abstracts and full paper were screened for eligibility, papers were assessed for inclusion using predetermined criteria. Data was extracted pertaining to the aims, type of study, cancer type, numbers of patients included and symptoms, presenting complaints or signs and symptoms. Results There were 9,331 publications identified in the searches, following title screening 350 abstracts were reviewed for inclusion and 120 were considered for eligibility for the review. 48 publications met the eligibility criteria and were included in the final review. Data from almost 11,000 HNC patients was included. Twenty-one of the publications were from the UK, most were retrospective examination of patient records. Data was extracted and charted according to the anatomical area of the head and neck where the symptoms are subjectively and objectively found, and presented according to lay terms for symptoms, clinical terms for symptoms and the language of objective clinical findings. Discussion Symptoms of HNC are common presenting complaints, interpreting these along with clinical history, examination and risk factors will inform a clinician's decision to refer as suspected cancer. UK Head and Neck specialists believe a different way of triaging the referrals is needed to assess the clinical risk of an undiagnosed HNC. EVEREST-HN aims to achieve this using the patient history of their symptoms. This review has highlighted issues in terms of what is considered a symptom, a presenting complaint and a clinical finding or sign.
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Affiliation(s)
- Paula T. Bradley
- Population Health, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ying Ki Lee
- Department of Otolaryngology, Guy’s and St Thomas’ National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Abigail Albutt
- Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - John Hardman
- Department of Otolaryngology, Barts Health NHS Trust, London, United Kingdom
| | - Ian Kellar
- Department of Psychology, The University of Sheffield, Sheffield, United Kingdom
| | - Chinasa Odo
- Faculty of Health Studies, University of Bradford, Bradford, United Kingdom
| | - Rebecca Randell
- Faculty of Health Studies, University of Bradford, Bradford, United Kingdom
| | - Nikki Rousseau
- Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Theofano Tikka
- Department of Otolaryngology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Joanne M. Patterson
- School of Allied Health Professions & Nursing, Institute of Population Health / Liverpool Head and Neck Centre, University of Liverpool, Liverpool, United Kingdom
| | - Vinidh Paleri
- Head and Neck Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
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Bradley P, Deane J, O'Hara J, Kennedy M, Carrard VC, Cheong SC, Sharp L. Teledentistry may help in detecting oral cancers in current GP and dentist shortages. BMJ 2024; 384:q512. [PMID: 38428988 DOI: 10.1136/bmj.q512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Affiliation(s)
| | | | - James O'Hara
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Matt Kennedy
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Vinicius C Carrard
- School of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Linda Sharp
- Newcastle University, Newcastle upon Tyne, UK
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Cocco P, Smith AF, Neal RD, Shinkins B. The National Health Service urgent cancer referral pathway for suspected urological cancers: early economic evaluation of a risk prediction test. Int J Technol Assess Health Care 2024; 40:e9. [PMID: 38213290 PMCID: PMC10859831 DOI: 10.1017/s0266462324000023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 11/14/2023] [Accepted: 01/01/2024] [Indexed: 01/13/2024]
Abstract
OBJECTIVES In the UK, the number of patients urgently referred for suspected cancer is increasing, and providers are struggling to cope with demand. We explore the potential cost-effectiveness of a new risk prediction test - the PinPoint test - to triage and prioritize patients urgently referred with suspected urological cancers. METHODS Two simulation models were developed to reflect the diagnostic pathways for patients with (i) suspected prostate cancer, and (ii) bladder or kidney cancer, comparing the PinPoint test to current practice. An early economic analysis was conducted from a UK National Health Service (NHS) perspective. The primary outcomes were the percentage of individuals seen within 2 weeks and health care costs. An exploratory analysis was conducted to understand the potential impact of the Pinpoint test on quality-adjusted life years gained. RESULTS Across both models and applications, the PinPoint test led to more individuals with urological cancer being seen within 2 weeks. Using PinPoint only to prioritize patients led to increased costs overall, whereas using PinPoint to both triage and prioritize patients led to cost savings. The estimated impact on life years gained/lost was very small and highly uncertain. CONCLUSIONS Using the PinPoint test to prioritize urgent referrals meant that more individuals with urological cancer were seen within 2 weeks, but at additional cost to the NHS. If used as a triage and prioritization tool, the PinPoint test shortens wait times for referred individuals and is cost saving. More data on the impact of short-term delays to diagnosis on health-related quality of life is needed.
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Affiliation(s)
- Paola Cocco
- Academic Unit of Health Economics, Leeds Institute of Health Sciences (LIHS), University of Leeds, Leeds, UK
| | - Alison Florence Smith
- Academic Unit of Health Economics, Leeds Institute of Health Sciences (LIHS), University of Leeds, Leeds, UK
| | - Richard D. Neal
- Department of Health and Community Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Bethany Shinkins
- Division of Health Sciences, University of Warwick, Coventry, UK
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Scott SE, Gildea C, Nicholson BD, Evans RE, Waller J, Smith D, Purushotham A, Round T. Future cancer risk after urgent suspected cancer referral in England when cancer is not found: a national cohort study. Lancet Oncol 2023; 24:1242-1251. [PMID: 37922929 DOI: 10.1016/s1470-2045(23)00435-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Following referral for investigation of urgent suspected cancer within the English National Health Service referral system, 7% of referred individuals are diagnosed with cancer. This study aimed to investigate the risk of cancer occurrence within 1-5 years of finding no cancer following an urgent suspected cancer referral. METHODS This national cohort study used urgent suspected cancer referral data for England from the Cancer Waiting Times dataset and linked it with cancer diagnosis data from the National Cancer Registration dataset. Data were extracted for the eight most commonly referred to urgent suspected cancer referral pathways (breast, gynaecological, head and neck, lower and upper gastrointestinal, lung, skin, and urological) for the period April 1, 2013, to March 31, 2014, with 5-year follow-up for individuals with no cancer diagnosis within 1 year of referral. The primary objective was to investigate the occurrence and type of subsequent cancer in years 1-5 following an urgent suspected cancer referral when no cancer was initially found, both overall and for each of the eight referral pathways. The numbers of subsequent cancers were compared with expected cancer incidence in years 1-5 following referral, using standardised incidence ratios (SIRs) based on matched age-gender distributions of expected cancer incidence in England for the same time period. The analysis was repeated, stratifying by referral group, and by calculating the absolute and expected rate of all cancers and of the same individual cancer as the initial referral. FINDINGS Among 1·18 million referrals without a cancer diagnosis in years 0-1, there were 63 112 subsequent cancers diagnosed 1-5 years post-referral, giving an absolute rate of 1338 (95% CI 1327-1348) cancers per 100 000 referrals per year (1038 [1027-1050] in females, 1888 [1867-1909] in males), compared with an expected rate of 1054 (1045-1064) cancers per 100 000 referrals per year (SIR 1·27 [95% CI 1·26-1·28]). The absolute rate of any subsequent cancer diagnosis 1-5 years after referral was lowest following suspected breast cancer referral (746 [728-763] cancers per 100 000 referrals per year) and highest following suspected urological (2110 [2070-2150]) or lung cancer (1835 [1767-1906]) referral. For diagnosis of the same cancer as the initial referral pathway, the highest absolute rates were for the urological and lung pathways (1011 [984-1039] and 638 [598-680] cancers per 100 000 referrals per year, respectively). The highest relative risks of subsequent diagnosis of the same cancer as the initial referral pathway were for the head and neck pathway (SIR 3·49 [95% CI 3·22-3·78]) and lung pathway (3·00 [2·82-3·20]). INTERPRETATION Cancer risk was higher than expected in the 5 years following an urgent suspected cancer referral. The potential for targeted interventions, such as proactive monitoring, safety-netting, and cancer awareness or risk reduction initiatives should be investigated. FUNDING Cancer Research UK.
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Affiliation(s)
- Suzanne E Scott
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK; King's College London, London, UK.
| | | | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ruth E Evans
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | | | | | | | - Thomas Round
- King's College London, London, UK; National Disease Registration Service, NHS England, UK
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Thomas L, Hyde C, Mullarkey D, Greenhalgh J, Kalsi D, Ko J. Real-world post-deployment performance of a novel machine learning-based digital health technology for skin lesion assessment and suggestions for post-market surveillance. Front Med (Lausanne) 2023; 10:1264846. [PMID: 38020164 PMCID: PMC10645139 DOI: 10.3389/fmed.2023.1264846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Deep Ensemble for Recognition of Malignancy (DERM) is an artificial intelligence as a medical device (AIaMD) tool for skin lesion assessment. Methods We report prospective real-world performance from its deployment within skin cancer pathways at two National Health Service hospitals (UK) between July 2021 and October 2022. Results A total of 14,500 cases were seen, including patients 18-100 years old with Fitzpatrick skin types I-VI represented. Based on 8,571 lesions assessed by DERM with confirmed outcomes, versions A and B demonstrated very high sensitivity for detecting melanoma (95.0-100.0%) or malignancy (96.0-100.0%). Benign lesion specificity was 40.7-49.4% (DERM-vA) and 70.1-73.4% (DERM-vB). DERM identified 15.0-31.0% of cases as eligible for discharge. Discussion We show DERM performance in-line with sensitivity targets and pre-marketing authorisation research, and it reduced the caseload for hospital specialists in two pathways. Based on our experience we offer suggestions on key elements of post-market surveillance for AIaMDs.
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Affiliation(s)
- Lucy Thomas
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Chris Hyde
- Exeter Test Group, Department of Health and Community Sciences, University of Exeter Medical School, Exeter, United Kingdom
| | | | | | | | - Justin Ko
- Department of Dermatology, Stanford Medicine, Stanford, CA, United States
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Nicholson BD, Lyratzopoulos G. Progress and priorities in reducing the time to cancer diagnosis. Br J Cancer 2023; 128:468-470. [PMID: 36344594 PMCID: PMC9640847 DOI: 10.1038/s41416-022-02045-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/10/2022] [Accepted: 10/21/2022] [Indexed: 11/09/2022] Open
Abstract
Key developments in early diagnosis research and policy since the publication of the highly cited BJC review "Is increased time to diagnosis and treatment associated with poorer outcomes?" by Neal et al. in 2015 are summarised. Progress achieved since 2015 is described and priorities for further research identified.
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Affiliation(s)
- B D Nicholson
- Academic Clinical Lecturer and Cancer Research Theme Lead, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, Oxford, UK.
| | - G Lyratzopoulos
- Professor of Cancer Epidemiology and Lead of Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, University College London, 1-19 Torrington Place, WC1E 7HB, London, UK
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Glen P, Botha E. Early detection and prevention of head and neck cancers. Br Dent J 2022; 233:726-730. [DOI: 10.1038/s41415-022-5198-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/11/2022] [Indexed: 11/13/2022]
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Savage R, Messenger M, Neal RD, Ferguson R, Johnston C, Lloyd KL, Neal MD, Sansom N, Selby P, Sharma N, Shinkins B, Skinner JR, Tully G, Duffy S, Hall G. Development and validation of multivariable machine learning algorithms to predict risk of cancer in symptomatic patients referred urgently from primary care: a diagnostic accuracy study. BMJ Open 2022; 12:e053590. [PMID: 35365520 PMCID: PMC8977764 DOI: 10.1136/bmjopen-2021-053590] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 03/04/2022] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES To develop and validate tests to assess the risk of any cancer for patients referred to the NHS Urgent Suspected Cancer (2-week wait, 2WW) clinical pathways. SETTING Primary and secondary care, one participating regional centre. PARTICIPANTS Retrospective analysis of data from 371 799 consecutive 2WW referrals in the Leeds region from 2011 to 2019. The development cohort was composed of 224 669 consecutive patients with an urgent suspected cancer referral in Leeds between January 2011 and December 2016. The diagnostic algorithms developed were then externally validated on a similar consecutive sample of 147 130 patients (between January 2017 and December 2019). All such patients over the age of 18 with a minimum set of blood counts and biochemistry measurements available were included in the cohort. PRIMARY AND SECONDARY OUTCOME MEASURES sensitivity, specificity, negative predictive value, positive predictive value, Receiver Operating Characteristic (ROC) curve Area Under Curve (AUC), calibration curves RESULTS: We present results for two clinical use-cases. In use-case 1, the algorithms identify 20% of patients who do not have cancer and may not need an urgent 2WW referral. In use-case 2, they identify 90% of cancer cases with a high probability of cancer that could be prioritised for review. CONCLUSIONS Combining a panel of widely available blood markers produces effective blood tests for cancer for NHS 2WW patients. The tests are affordable, and can be deployed rapidly to any NHS pathology laboratory with no additional hardware requirements.
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Affiliation(s)
| | - Mike Messenger
- University of Leeds, Leeds, UK
- NIHR MedTech and In Vitro Diagnostic Co-Operative, Leeds, UK
| | - Richard D Neal
- University of Leeds, Leeds, UK
- NIHR MedTech and In Vitro Diagnostic Co-Operative, Leeds, UK
- University of Exeter, Exeter, UK
| | | | | | | | | | | | - Peter Selby
- University of Leeds, Leeds, UK
- NIHR MedTech and In Vitro Diagnostic Co-Operative, Leeds, UK
- Chair of the PinPoint Scientific Advisory Board, Leeds, UK
| | | | | | | | | | - Sean Duffy
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Geoff Hall
- University of Leeds, Leeds, UK
- NIHR MedTech and In Vitro Diagnostic Co-Operative, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
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