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Usher-Smith JA, Godoy A, Kitt J, Farquhar F, Waller J, Sharp SJ, Shinkins B, Cartledge J, Kimuli M, Burge SW, Burbidge S, Eckert C, Hancock N, Marshall C, Rogerson S, Rossi SH, Smith A, Simmonds I, Wallace T, Ward M, Callister MEJ, Stewart GD. Short-term psychosocial outcomes of adding a non-contrast abdominal computed tomography (CT) scan to the thoracic CT within lung cancer screening. BJU Int 2024; 133:539-547. [PMID: 38097529 DOI: 10.1111/bju.16260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
OBJECTIVES To evaluate psychological, social, and financial outcomes amongst individuals undergoing a non-contrast abdominal computed tomography (CT) scan to screen for kidney cancer and other abdominal malignancies alongside the thoracic CT within lung cancer screening. SUBJECTS AND METHODS The Yorkshire Kidney Screening Trial (YKST) is a feasibility study of adding a non-contrast abdominal CT scan to the thoracic CT within lung cancer screening. A total of 500 participants within the YKST, comprising all who had an abnormal CT scan and a random sample of one-third of those with a normal scan between 14/03/2022 and 24/08/2022 were sent a questionnaire at 3 and 6 months. Outcomes included the Psychological Consequences Questionnaire (PCQ), the short-form of the Spielberger State-Trait Anxiety Inventory, and the EuroQoL five Dimensions five Levels scale (EQ-5D-5L). Data were analysed using regression adjusting for participant age, sex, socioeconomic status, education, baseline quality of life (EQ-5D-5L), and ethnicity. RESULTS A total of 380 (76%) participants returned questionnaires at 3 months and 328 (66%) at 6 months. There was no difference in any outcomes between participants with a normal scan and those with abnormal scans requiring no further action. Individuals requiring initial further investigations or referral had higher scores on the negative PCQ than those with normal scans at 3 months (standardised mean difference 0.28 sd, 95% confidence interval 0.01-0.54; P = 0.044). The difference was greater in those with anxiety or depression at baseline. No differences were seen at 6 months. CONCLUSION Screening for kidney cancer and other abdominal malignancies using abdominal CT alongside the thoracic CT within lung cancer screening is unlikely to cause significant lasting psychosocial or financial harm to participants with incidental findings.
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Affiliation(s)
- Juliet A Usher-Smith
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Angela Godoy
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Jessica Kitt
- Department of Surgery, University of Cambridge, Cambridge, UK
| | | | - Jo Waller
- Faculty of Life Sciences and Medicine, Kings College London, London, UK
| | - Stephen J Sharp
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Bethany Shinkins
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | | | | | - Sarah W Burge
- Department of Oncology, University of Cambridge, Cambridge, UK
| | | | - Claire Eckert
- Leeds Institute of Health Science, University of Leeds, Leeds, UK
| | - Neil Hancock
- Leeds Institute of Health Science, University of Leeds, Leeds, UK
| | | | | | - Sabrina H Rossi
- Department of Surgery, University of Cambridge, Cambridge, UK
| | | | - Irene Simmonds
- Leeds Institute of Health Science, University of Leeds, Leeds, UK
| | - Tom Wallace
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthew Ward
- Leeds Institute of Health Science, University of Leeds, Leeds, UK
| | - Matthew E J Callister
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Health Science, University of Leeds, Leeds, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Cambridge, UK
- CRUK Cambridge Centre, Cambridge, UK
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Kenning C, Usher-Smith JA, Jamison J, Jones J, Boaz A, Little P, Mallen C, Bower P, Park S. Impact of research activity on performance of general practices: a qualitative study. BJGP Open 2024:BJGPO.2024.0073. [PMID: 38649161 DOI: 10.3399/bjgpo.2024.0073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 03/26/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND There is evidence that engaging in research is directly associated with better performance. If this relationship is to be strengthened, it is necessary to understand the mechanisms which might underlie that relationship. AIM To explore the perspectives of staff and wider stakeholders about mechanisms by which research activity might impact on the performance of general practices. DESIGN & SETTING Qualitative study using semi-structured interviews with general practice professionals and wider stakeholders in England. METHOD Individual interviews with 41 purposively sampled staff in 'research ready' or 'research active' general practices and 21 other stakeholders. Interviews were independently coded by three researchers using a Framework approach. RESULTS Participants described potential 'direct' and 'indirect' impacts on their work. 'Direct' impacts included research changing practice work (eg, additional records searches for particular conditions), bringing in additional resources (eg, access to investigations or staff) and improving relationships with patients. 'Indirect' impacts included job satisfaction (eg, perception of practice as a centre of excellence and innovation, and the variety afforded by research activity reducing burnout) and staff recruitment (increasing the attractiveness of the practice as a place to work). Respondents identified few negative impacts. CONCLUSIONS Staff and stakeholders identified a range of potential impacts of research activity on practice performance, with impacts on their working lives most salient. Negative impacts were not generally raised. Nevertheless, respondents generally discussed potential impacts rather than providing specific examples of those impacts. This may reflect the type of research activity conducted in general practice, often led by external collaborators.
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Affiliation(s)
- Cassandra Kenning
- Centre for Primary Care and Health Services Research, The University of Manchester 6 Floor, Williamson Building, Oxford Road, Manchester, United Kingdom
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, East Forvie Building, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - James Jamison
- Division of Psychiatry, University College London, London, United Kingdom
| | - Jennifer Jones
- Department of Population Health Sciences, University of Leicester, University Road, Leicester, United Kingdom
| | - Annette Boaz
- NIHR Health and Social Care Workforce Research Unit, Policy Institute, Virginia Woolf Building, Kingsway, King's College London, London, United Kingdom
| | - Paul Little
- Primary Care Research Centre, University of Southampton, Southampton, United Kingdom
| | | | - Peter Bower
- Centre for Primary Care and Health Services Research, The University of Manchester 6 Floor, Williamson Building, Oxford Road, Manchester, United Kingdom
| | - Sophie Park
- Research Dept of Primary Care and Population Health, University College London, Royal Free Campus, Rowland Hill St., Hampstead, United Kingdom
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Shah V, Geller G, Xu D, Taylor L, Griffin S, Usher-Smith JA. Evaluating the potential impact of lifestyle-based behavior change interventions delivered at the time of colorectal cancer screening. Cancer Causes Control 2024; 35:561-574. [PMID: 37925646 PMCID: PMC10838843 DOI: 10.1007/s10552-023-01773-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/01/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE To analyze interventions implemented at the time of colorectal cancer (CRC) screening, or among individuals who have previously undergone investigation for CRC, focused on reducing CRC risk through promotion of lifestyle behavior change. Additionally, this review evaluated to what extent such interventions apply behavior change techniques (BCTs) to achieve their objectives. METHODS Five databases were systematically searched to identify randomized control trials seeking to reduce CRC risk through behavior change. Outcomes were changes in health-related lifestyle behaviors associated with CRC risk, including changes in dietary habits, body mass index, smoking behaviors, alcohol consumption, and physical activity. Standardized mean differences (SMDs) with 95% confidence intervals (CIs) were pooled using random effects models. BCT's were coded from a published taxonomy of 93 techniques. RESULTS Ten RCT's met the inclusion criteria. Greater increase in fruit/vegetable consumption in the intervention group were observed with respect to the control (SMD 0.13, 95% CI 0.08 to 0.18; p < 0.001). Across fiber, alcohol, fat, red meat, and multivitamin consumption, and smoking behaviors, similar positive outcomes were observed (SMD 0.09-0.57 for all, p < 0.01). However, among physical activity and body mass index, no difference between the intervention groups compared with controls were observed. A median of 7.5 BCTs were applied across included interventions. CONCLUSION While magnitude of the observed effect sizes varied, they correspond to potentially important changes in lifestyle behaviors when considered on a population scale. Future interventions should identify avenues to maximize long-term engagement to promote sustained lifestyle behavior change.
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Affiliation(s)
- Veeraj Shah
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK.
| | - Greta Geller
- School of Clinical Medicine, University of Cambridge, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0SP, UK
| | - Diane Xu
- School of Clinical Medicine, University of Cambridge, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0SP, UK
| | - Lily Taylor
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK
| | - Simon Griffin
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK
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Rossi SH, Harrison H, Usher-Smith JA, Stewart GD. Risk-stratified screening for the early detection of kidney cancer. Surgeon 2024; 22:e69-e78. [PMID: 37993323 DOI: 10.1016/j.surge.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/22/2023] [Accepted: 10/30/2023] [Indexed: 11/24/2023]
Abstract
Earlier detection and screening for kidney cancer has been identified as a key research priority, however the low prevalence of the disease in unselected populations limits the cost-effectiveness of screening. Risk-stratified screening for kidney cancer may improve early detection by targeting high-risk individuals whilst limiting harms in low-risk individuals, potentially increasing the cost-effectiveness of screening. A number of models have been identified which estimate kidney cancer risk based on both phenotypic and genetic data, and while several of the former have been shown to identify individuals at high-risk of developing kidney cancer with reasonable accuracy, current evidence does not support including a genetic component. Combined screening for lung cancer and kidney cancer has been proposed, as the two malignancies share some common risk factors. A modelling study estimated that using lung cancer risk models (currently used for risk-stratified lung cancer screening) could capture 25% of patients with kidney cancer, which is only slightly lower than using the best performing kidney cancer-specific risk models based on phenotypic data (27%-33%). Additionally, risk-stratified screening for kidney cancer has been shown to be acceptable to the public. The following review summarises existing evidence regarding risk-stratified screening for kidney cancer, highlighting the risks and benefits, as well as exploring the management of potential harms and further research needs.
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Affiliation(s)
- Sabrina H Rossi
- Department of Surgery, University of Cambridge, Cambridge, UK.
| | - Hannah Harrison
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Juliet A Usher-Smith
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Cambridge, UK
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Espressivo A, Pan ZS, Usher-Smith JA, Harrison H. Risk Prediction Models for Oral Cancer: A Systematic Review. Cancers (Basel) 2024; 16:617. [PMID: 38339366 PMCID: PMC10854942 DOI: 10.3390/cancers16030617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
In the last 30 years, there has been an increasing incidence of oral cancer worldwide. Earlier detection of oral cancer has been shown to improve survival rates. However, given the relatively low prevalence of this disease, population-wide screening is likely to be inefficient. Risk prediction models could be used to target screening to those at highest risk or to select individuals for preventative interventions. This review (a) systematically identified published models that predict the development of oral cancer and are suitable for use in the general population and (b) described and compared the identified models, focusing on their development, including risk factors, performance and applicability to risk-stratified screening. A search was carried out in November 2022 in the Medline, Embase and Cochrane Library databases to identify primary research papers that report the development or validation of models predicting the risk of developing oral cancer (cancers of the oral cavity or oropharynx). The PROBAST tool was used to evaluate the risk of bias in the identified studies and the applicability of the models they describe. The search identified 11,222 articles, of which 14 studies (describing 23 models), satisfied the eligibility criteria of this review. The most commonly included risk factors were age (n = 20), alcohol consumption (n = 18) and smoking (n = 17). Six of the included models incorporated genetic information and three used biomarkers as predictors. Including information on human papillomavirus status was shown to improve model performance; however, this was only included in a small number of models. Most of the identified models (n = 13) showed good or excellent discrimination (AUROC > 0.7). Only fourteen models had been validated and only two of these validations were carried out in populations distinct from the model development population (external validation). Conclusions: Several risk prediction models have been identified that could be used to identify individuals at the highest risk of oral cancer within the context of screening programmes. However, external validation of these models in the target population is required, and, subsequently, an assessment of the feasibility of implementation with a risk-stratified screening programme for oral cancer.
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Affiliation(s)
- Aufia Espressivo
- Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK; (Z.S.P.); (J.A.U.-S.); (H.H.)
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Hindmarch S, Howell SJ, Usher-Smith JA, Gorman L, Evans DG, French DP. Feasibility and acceptability of offering breast cancer risk assessment to general population women aged 30-39 years: a mixed-methods study protocol. BMJ Open 2024; 14:e078555. [PMID: 38199637 PMCID: PMC10806663 DOI: 10.1136/bmjopen-2023-078555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/30/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Breast cancer incidence starts to increase exponentially when women reach 30-39 years, hence before they are eligible for breast cancer screening. The introduction of breast cancer risk assessment for this age group could lead to those at higher risk receiving benefits of earlier screening and preventive strategies. Currently, risk assessment is limited to women with a family history of breast cancer only. The Breast CANcer Risk Assessment in Younger women (BCAN-RAY) study is evaluating a comprehensive breast cancer risk assessment strategy for women aged 30-39 years incorporating a questionnaire of breast cancer risk factors, low-dose mammography to assess breast density and polygenic risk. This study will assess the feasibility and acceptability of the BCAN-RAY risk assessment strategy. METHODS AND ANALYSIS This study involves women undergoing risk assessment as part of the BCAN-RAY case-control study (n=750). They will be aged 30-39 years without a strong family history of breast cancer and invited to participate via general practice. A comparison of uptake rates by socioeconomic status and ethnicity between women who participated in the BCAN-RAY study and women who declined participation will be conducted. All participants will be asked to complete self-report questionnaires to assess key potential harms including increased state anxiety (State Trait Anxiety Inventory), cancer worry (Lerman Cancer Worry Scale) and satisfaction with the decision to participate (Decision Regret Scale), alongside potential benefits such as feeling more informed about breast cancer risk. A subsample of approximately 24 women (12 at average risk and 12 at increased risk) will additionally participate in semistructured interviews to understand the acceptability of the risk assessment strategy and identify any changes needed to it to increase uptake. ETHICS AND DISSEMINATION Ethical approval was granted by North West-Greater Manchester West Research Ethics Committee (reference: 22/NW/0268). Study results will be disseminated through peer-reviewed journals, conference presentations and charitable organisations. TRIAL REGISTRATION NUMBER NCT05305963.
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Affiliation(s)
- Sarah Hindmarch
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Sacha J Howell
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Louise Gorman
- NIHR Greater Manchester Patient Safety Research Collaboration, Division of Population Health, Health Services Research & Primary Care, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - D Gareth Evans
- Manchester Academic Health Science Centre, Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - David P French
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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Dennison RA, Thomas CV, Morris S, Usher-Smith JA. A discrete choice experiment to understand public preferences and priorities for risk-stratified bowel cancer screening programmes in the UK. Prev Med 2023; 177:107786. [PMID: 37984646 DOI: 10.1016/j.ypmed.2023.107786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE Public acceptability of bowel cancer screening programmes must be maintained, including if risk stratification is introduced. We aimed to describe and quantify preferences for different attributes of risk-stratified screening programmes amongst the UK population, focussing on who to invite for bowel screening. METHODS We conducted a discrete choice experiment (DCE) including the following attributes: risk factors used to estimate bowel cancer risk (age plus/minus sex, lifestyle factors and genetics); personalisation of risk feedback; risk stratification strategy plus resource implications; default screening in the case of no risk information; number of deaths prevented by screening; and number experiencing physical harm from screening. We used the results of conditional logit regression models to estimate the importance of each attribute, willingness to trade-off between the attributes, and preferences for different programmes using contemporary risk scores and models. RESULTS 1196 respondents completed the survey, generating 21,528 DCE observations. Deaths prevented was the most influential attribute on respondents' decision-making (contributing to 58.8% of the choice), followed by harms experienced (15.9%). For every three additional deaths prevented, respondents were willing to accept an additional screening harm per 100,000 people. Risk factors and risk stratification strategy contributed to just 11.1% and 3.6% of the choice, respectively. Although the influence on decision-making was small, respondents favoured more personalised feedback. CONCLUSIONS Bowel cancer screening programmes that improve cancer outcomes, particularly by preventing more deaths amongst those screened, are most preferred by the public. Optimising risk prediction models, developing public communication, and readying infrastructure should be prioritised for implementation.
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Affiliation(s)
- Rebecca A Dennison
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK.
| | - Chloe V Thomas
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - Stephen Morris
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
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8
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Toes-Zoutendijk E, de Jonge L, Breekveldt EC, Korfage IJ, Usher-Smith JA, Lansdorp-Vogelaar I, Dennison RA. Personalised colorectal cancer screening strategies: Information needs of the target population. Prev Med Rep 2023; 35:102325. [PMID: 37601828 PMCID: PMC10433032 DOI: 10.1016/j.pmedr.2023.102325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 08/22/2023] Open
Abstract
Prior faecal Hemoglobin (f-Hb) concentrations of a negative fecal immunochemical test (FIT) can be used for risk stratification in colorectal cancer (CRC) screening. Individuals with higher f-Hb concentrations may benefit from a shorter screening interval (1 year), whereas individuals with undetectable f-Hb concentrations could benefit from a longer screening interval (3 year). Individuals' views on personalised CRC screening and information needed to make a well-informed decision is unknown. We conducted three semi-structured focus groups among individuals eligible for CRC screening (i.e. men and women aged 55 to 75) in the Netherlands. Thematic analysis was used to analyse participants' information need on personalised CRC screening strategies. Fourteen individuals took part. The majority were positive about CRC screening and indicated that they would participate in personalised CRC screening. The rationale for a longer interval among those at lowest risk was, however, unclear for many. The preferred information on individual risk was variable: ranging from full information to only information on the personalised strategy without mentioning the risk. It was not possible to address everyone's need with a single approach. Additional communications, e.g. public media campaigns, billboards, videos on social media, were also suggested as necessary. This study showed that preferences on receiving information on individual CRC risk varied substantially and no consensus was reached. Introducing a personalised screening programme will require careful communication, particularly around the rationale for the strategy, and a layered approach to deliver information.
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Affiliation(s)
- Esther Toes-Zoutendijk
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Lucie de Jonge
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Emilie C.H. Breekveldt
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Ida J. Korfage
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Juliet A. Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Rebecca A. Dennison
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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9
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Chung R, Xu Z, Arnold M, Stevens D, Keogh R, Barrett J, Harrison H, Pennells L, Kim LG, DiAngelantonio E, Paige E, Usher-Smith JA, Wood AM. Prioritising cardiovascular disease risk assessment to high risk individuals based on primary care records. PLoS One 2023; 18:e0292240. [PMID: 37773956 PMCID: PMC10540947 DOI: 10.1371/journal.pone.0292240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 09/14/2023] [Indexed: 10/01/2023] Open
Abstract
OBJECTIVE To provide quantitative evidence for systematically prioritising individuals for full formal cardiovascular disease (CVD) risk assessment using primary care records with a novel tool (eHEART) with age- and sex- specific risk thresholds. METHODS AND ANALYSIS eHEART was derived using landmark Cox models for incident CVD with repeated measures of conventional CVD risk predictors in 1,642,498 individuals from the Clinical Practice Research Datalink. Using 119,137 individuals from UK Biobank, we modelled the implications of initiating guideline-recommended statin therapy using eHEART with age- and sex-specific prioritisation thresholds corresponding to 5% false negative rates to prioritise adults aged 40-69 years in a population in England for invitation to a formal CVD risk assessment. RESULTS Formal CVD risk assessment on all adults would identify 76% and 49% of future CVD events amongst men and women respectively, and 93 (95% CI: 90, 95) men and 279 (95% CI: 259, 297) women would need to be screened (NNS) to prevent one CVD event. In contrast, if eHEART was first used to prioritise individuals for formal CVD risk assessment, we would identify 73% and 47% of future events amongst men and women respectively, and a NNS of 75 (95% CI: 72, 77) men and 162 (95% CI: 150, 172) women. Replacing the age- and sex-specific prioritisation thresholds with a 10% threshold identify around 10% less events. CONCLUSIONS The use of prioritisation tools with age- and sex-specific thresholds could lead to more efficient CVD assessment programmes with only small reductions in effectiveness at preventing new CVD events.
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Affiliation(s)
- Ryan Chung
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Zhe Xu
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Matthew Arnold
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - David Stevens
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Ruth Keogh
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, London, United Kingdom
| | - Jessica Barrett
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, United Kingdom
| | - Hannah Harrison
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Lisa Pennells
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Lois G. Kim
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, United Kingdom
| | - Emanuele DiAngelantonio
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, United Kingdom
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, United Kingdom
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, United Kingdom
- Health Data Science Research Centre, Human Technopole, Milan, Italy
| | - Ellie Paige
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia
| | - Juliet A. Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Angela M. Wood
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, United Kingdom
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, United Kingdom
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, United Kingdom
- Cambridge Centre of Artificial Intelligence in Medicine, Cambridge, United Kingdom
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Taylor LC, Dennison RA, Griffin SJ, John SD, Lansdorp-Vogelaar I, Thomas CV, Thomas R, Usher-Smith JA. Implementation of risk stratification within bowel cancer screening: a community jury study exploring public acceptability and communication needs. BMC Public Health 2023; 23:1798. [PMID: 37715213 PMCID: PMC10503141 DOI: 10.1186/s12889-023-16704-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 09/05/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Population-based cancer screening programmes are shifting away from age and/or sex-based screening criteria towards a risk-stratified approach. Any such changes must be acceptable to the public and communicated effectively. We aimed to explore the social and ethical considerations of implementing risk stratification at three different stages of the bowel cancer screening programme and to understand public requirements for communication. METHODS We conducted two pairs of community juries, addressing risk stratification for screening eligibility or thresholds for referral to colonoscopy and screening interval. Using screening test results (where applicable), and lifestyle and genetic risk scores were suggested as potential stratification strategies. After being informed about the topic through a series of presentations and discussions including screening principles, ethical considerations and how risk stratification could be incorporated, participants deliberated over the research questions. They then reported their final verdicts on the acceptability of risk-stratified screening and what information should be shared about their preferred screening strategy. Transcripts were analysed using codebook thematic analysis. RESULTS Risk stratification of bowel cancer screening was acceptable to the informed public. Using data within the current system (age, sex and screening results) was considered an obvious next step and collecting additional data for lifestyle and/or genetic risk assessment was also preferable to age-based screening. Participants acknowledged benefits to individuals and health services, as well as articulating concerns for people with low cancer risk, potential public misconceptions and additional complexity for the system. The need for clear and effective communication about changes to the screening programme and individual risk feedback was highlighted, including making a distinction between information that should be shared with everyone by default and additional details that are available elsewhere. CONCLUSIONS From the perspective of public acceptability, risk stratification using current data could be implemented immediately, ahead of more complex strategies. Collecting additional data for lifestyle and/or genetic risk assessment was also considered acceptable but the practicalities of collecting such data and how the programme would be communicated require careful consideration.
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Affiliation(s)
- Lily C Taylor
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
| | - Rebecca A Dennison
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Simon J Griffin
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
- MRC Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Stephen D John
- Department of History and Philosophy of Science, University of Cambridge, Cambridge, UK
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Chloe V Thomas
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Rae Thomas
- Department of Public Health and Tropical Medicine, James Cook University, Queensland, Australia
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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11
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Dennison RA, Usher-Smith JA, John SD. The ethics of risk-stratified cancer screening. Eur J Cancer 2023; 187:1-6. [PMID: 37094523 DOI: 10.1016/j.ejca.2023.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/08/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023]
Abstract
Cancer screening programmes aim to save lives and reduce cancer burden through prevention or early detection of specific cancers. Risk stratification, where one or more elements of a screening programme are systematically tailored based on multiple individual-level risk factors, could improve the balance of screening benefits and harms and programme efficiency. In this article, we explore the resulting ethical issues and how they impact risk-stratified screening policymaking using Beauchamp and Childress's principles of medical ethics. First, in line with universal screening programme principles, we acknowledge that risk-stratified screening should be introduced only when the expected total benefits outweigh the harms, and where it has a favourable overall impact compared to alternative options. We then discuss how these are difficult to both value and quantify, and that risk models typically perform differently in sub-populations. Second, we consider whether screening is an individual right and whether it is fair to offer more or less intensive screening to some and not others based on personal characteristics. Third, we discuss the need to maintain respect for autonomy, including ensuring informed consent and considering the screening implications for those who cannot or choose not to participate in the risk assessment. In summary, from an ethical perspective, focusing on population-level effectiveness alone is insufficient when planning risk-stratified screening programmes and the range of ethical principles must be considered.
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Affiliation(s)
- Rebecca A Dennison
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK.
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
| | - Stephen D John
- Department of History and Philosophy of Science, University of Cambridge, Cambridge CB2 3RH, UK
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12
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Harrison H, Wood A, Pennells L, Rossi SH, Callister M, Cartledge J, Stewart GD, Usher-Smith JA. Estimating the Effectiveness of Kidney Cancer Screening Within Lung Cancer Screening Programmes: A Validation in UK Biobank. Eur Urol Oncol 2023; 6:351-353. [PMID: 37003861 DOI: 10.1016/j.euo.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 02/07/2023] [Accepted: 02/23/2023] [Indexed: 04/03/2023]
Abstract
In the absence of population-based screening, addition of screening for kidney cancer to lung cancer screening could provide an efficient and low-resource means to improve early detection. In this study, we used the UK Biobank cohort (n = 442 865) to determine the performance of the Yorkshire Lung Cancer Screening Trial (YLST) eligibility criteria for selecting individuals for kidney cancer screening. We measured the performance of two models widely used to determine eligibility for lung cancer screening (PLCO[m2012] and the Liverpool-Lung-Project-v2) and the performance of the combined YLST criteria. We found that the lung cancer models have discrimination (area under the receiver operating curve) between 0.60 and 0.68 for kidney cancer. In the UK, one in four cases (25%) of kidney cancer cases is expected to occur in those eligible for lung cancer screening, and one case of kidney cancer detected for every 200 people invited to lung cancer screening. These results suggest that adding kidney cancer screening to lung cancer screening would be an effective strategy to improve early detection rates of kidney cancer. However, most kidney cancers would not be picked up by this approach. This analysis does not address other important considerations about kidney cancer screening, such as overdiagnosis. PATIENT SUMMARY: It has been proposed that adding-on kidney cancer screening to lung cancer screening (both carried out by a computed tomography scan of the chest/abdomen) would be an easy and low-cost way of detecting cases of kidney cancer earlier, when these can be treated more easily. Lung cancer screening is usually targeted at people who are at a high risk (eg, older smokers); therefore, here we look at whether the same group of people are also at a high risk of kidney cancer. Our analysis shows that one in four people later diagnosed with kidney cancer are also at a high risk of lung cancer; hence, a combined screening programme could detect up to a quarter of kidney cancers.
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Affiliation(s)
- Hannah Harrison
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
| | - Angela Wood
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Lisa Pennells
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sabrina H Rossi
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Matthew Callister
- Department of Respiratory Medicine, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Jon Cartledge
- St James University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Juliet A Usher-Smith
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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13
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Usher-Smith JA, Shah VP, Nahreen S, Fairey M, Betts K, Ide-Walters C. Evaluation of the reach and impact of a UK campaign highlighting obesity as a cause of cancer among the general public and Members of Parliament. Public Health 2023; 219:131-138. [PMID: 37167643 DOI: 10.1016/j.puhe.2023.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVES 'Overweight and obesity' is the second biggest preventable cause of cancer after smoking. In 2018, Cancer Research UK launched an awareness raising campaign about the link between overweight and obesity and cancer risk. This study aimed to evaluate the reach and impact of the campaign. STUDY DESIGN This study was a repeated cross-sectional online survey. METHODS The campaign consisted of six elements including the main message that 'Obesity is a cause of cancer'. UK adults and Members of Parliament (MPs) were surveyed before the campaign (W1; n = 2124 and n = 151), 1 month (W2; n = 2050 and n = 151) and 3 months after the campaign (W3; n = 2059 and MPs not surveyed). Outcome measures were campaign reach, awareness of overweight and obesity as risk factors for cancer, attitudes towards individuals who are overweight or obese, support for policies to reduce obesity and reactions to the campaign. RESULTS Overall, 76.2% of MPs and just under half of the public (47.5% in W2 and 36.8% in W3) reported having seen the campaign. Unprompted awareness of obesity as a risk factor increased among the public from 17.1% at W1 to 43.3% in W2 (odds ratio 3.71, 95% confidence interval 3.18-4.33) and 30.3% in W3 (odds ratio 2.11, 95% confidence interval 1.80-2.47). A similar pattern was seen for prompted awareness and among MPs. There were no consistent changes in attitudes towards overweight individuals or support for policies to reduce obesity. CONCLUSIONS This evaluation suggests that the campaign achieved the primary objective of increasing awareness of the link between obesity and cancer without increasing negative attitudes towards individuals who are overweight or obese.
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Affiliation(s)
- J A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB2 0SR, UK.
| | - V P Shah
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB2 0SR, UK
| | - S Nahreen
- University of Cambridge School of Clinical Medicine, Addenbrookes' Hospital, Hills Road, Cambridge, CB2 0SP, UK
| | - M Fairey
- University of Cambridge School of Clinical Medicine, Addenbrookes' Hospital, Hills Road, Cambridge, CB2 0SP, UK
| | - K Betts
- Cancer Research UK, 2 Redman Place, London, E20 1JQ, UK
| | - C Ide-Walters
- Cancer Research UK, 2 Redman Place, London, E20 1JQ, UK
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14
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Sheppard JP, Koshiaris C, Stevens R, Lay-Flurrie S, Banerjee A, Bellows BK, Clegg A, Hobbs FDR, Payne RA, Swain S, Usher-Smith JA, McManus RJ. The association between antihypertensive treatment and serious adverse events by age and frailty: A cohort study. PLoS Med 2023; 20:e1004223. [PMID: 37075078 PMCID: PMC10155987 DOI: 10.1371/journal.pmed.1004223] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 05/03/2023] [Accepted: 03/24/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Antihypertensives are effective at reducing the risk of cardiovascular disease, but limited data exist quantifying their association with serious adverse events, particularly in older people with frailty. This study aimed to examine this association using nationally representative electronic health record data. METHODS AND FINDINGS This was a retrospective cohort study utilising linked data from 1,256 general practices across England held within the Clinical Practice Research Datalink between 1998 and 2018. Included patients were aged 40+ years, with a systolic blood pressure reading between 130 and 179 mm Hg, and not previously prescribed antihypertensive treatment. The main exposure was defined as a first prescription of antihypertensive treatment. The primary outcome was hospitalisation or death within 10 years from falls. Secondary outcomes were hypotension, syncope, fractures, acute kidney injury, electrolyte abnormalities, and primary care attendance with gout. The association between treatment and these serious adverse events was examined by Cox regression adjusted for propensity score. This propensity score was generated from a multivariable logistic regression model with patient characteristics, medical history and medication prescriptions as covariates, and new antihypertensive treatment as the outcome. Subgroup analyses were undertaken by age and frailty. Of 3,834,056 patients followed for a median of 7.1 years, 484,187 (12.6%) were prescribed new antihypertensive treatment in the 12 months before the index date (baseline). Antihypertensives were associated with an increased risk of hospitalisation or death from falls (adjusted hazard ratio [aHR] 1.23, 95% confidence interval (CI) 1.21 to 1.26), hypotension (aHR 1.32, 95% CI 1.29 to 1.35), syncope (aHR 1.20, 95% CI 1.17 to 1.22), acute kidney injury (aHR 1.44, 95% CI 1.41 to 1.47), electrolyte abnormalities (aHR 1.45, 95% CI 1.43 to 1.48), and primary care attendance with gout (aHR 1.35, 95% CI 1.32 to 1.37). The absolute risk of serious adverse events with treatment was very low, with 6 fall events per 10,000 patients treated per year. In older patients (80 to 89 years) and those with severe frailty, this absolute risk was increased, with 61 and 84 fall events per 10,000 patients treated per year (respectively). Findings were consistent in sensitivity analyses using different approaches to address confounding and taking into account the competing risk of death. A strength of this analysis is that it provides evidence regarding the association between antihypertensive treatment and serious adverse events, in a population of patients more representative than those enrolled in previous randomised controlled trials. Although treatment effect estimates fell within the 95% CIs of those from such trials, these analyses were observational in nature and so bias from unmeasured confounding cannot be ruled out. CONCLUSIONS Antihypertensive treatment was associated with serious adverse events. Overall, the absolute risk of this harm was low, with the exception of older patients and those with moderate to severe frailty, where the risks were similar to the likelihood of benefit from treatment. In these populations, physicians may want to consider alternative approaches to management of blood pressure and refrain from prescribing new treatment.
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Affiliation(s)
- James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, United Kingdom
| | - Brandon K Bellows
- Columbia University Irving Medical Center, New York, New York, United States of America
| | - Andrew Clegg
- Academic Unit for Ageing & Stroke Research, University of Leeds, Leeds, United Kingdom
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, United Kingdom
- Department of Health and Community Sciences, University of Exeter Medical School, Exeter, United Kingdom
| | - Subhashisa Swain
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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15
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Dennison RA, Taylor LC, Morris S, Boscott RA, Harrison H, Moorthie SA, Rossi SH, Stewart GD, Usher-Smith JA. Public Preferences for Determining Eligibility for Screening in Risk-Stratified Cancer Screening Programs: A Discrete Choice Experiment. Med Decis Making 2023; 43:374-386. [PMID: 36786399 PMCID: PMC10021112 DOI: 10.1177/0272989x231155790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND Risk stratification has been proposed to improve the efficiency of population-level cancer screening. We aimed to describe and quantify the relative importance of different attributes of potential screening programs among the public, focusing on stratifying eligibility. METHODS We conducted a discrete choice experiment in which respondents selected between 2 hypothetical screening programs in a series of 9 questions. We presented the risk factors used to determine eligibility (age, sex, or lifestyle or genetic risk scores) and anticipated outcomes based on eligibility criteria with different sensitivity and specificity levels. We performed conditional logit regression models and used the results to estimate preferences for different approaches. We also analyzed free-text comments on respondents' views on the programs. RESULTS A total of 1,172 respondents completed the survey. Sensitivity was the most important attribute (7 and 11 times more important than specificity and risk factors, respectively). Eligibility criteria based on age and sex or genetics were preferred over age alone and lifestyle risk scores. Phenotypic and polygenic risk prediction models would be more acceptable than screening everyone aged 55 to 70 y if they had high discrimination (area under the receiver-operating characteristic curve ≥0.75 and 0.80, respectively). LIMITATIONS Although our sample was representative with respect to age, sex, and ethnicity, it may not be representative of the UK population regarding other important characteristics. Also, some respondents may have not understood all the information provided to inform decision making. CONCLUSIONS The public prioritized lives saved from cancer over reductions in numbers screened or experiencing unnecessary follow-up. Incorporating personal-level risk factors into screening eligibility criteria is acceptable to the public if it increases sensitivity; therefore, maximizing sensitivity in model development and communication could increase uptake. HIGHLIGHTS The public prioritized lives saved when considering changing from age-based eligibility criteria to risk-stratified cancer screening over reductions in numbers of people being screened or experiencing unnecessary follow-up.The risk stratification strategy used to do this was the least important component, although age plus sex or genetics were relatively preferable to using age alone and lifestyle risk scores.Communication strategies that emphasize improvements in the numbers of cancers detected or not missed across the population are more likely to be salient than reductions in unnecessary investigations or follow-up among some groups.Future research should focus on developing implementation strategies that maximize gains in sensitivity within the context of resource constraints and how to present attributes relating to specificity to facilitate understanding and informed decision making.
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Affiliation(s)
- Rebecca A Dennison
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Lily C Taylor
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephen Morris
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Rachel A Boscott
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Hannah Harrison
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Sabrina H Rossi
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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16
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Taylor LC, Hutchinson A, Law K, Shah V, Usher-Smith JA, Dennison RA. Acceptability of risk stratification within population-based cancer screening from the perspective of the general public: A mixed-methods systematic review. Health Expect 2023; 26:989-1008. [PMID: 36852880 PMCID: PMC10154794 DOI: 10.1111/hex.13739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 03/01/2023] Open
Abstract
INTRODUCTION Risk-stratified cancer screening has the potential to improve resource allocation and the balance of harms and benefits by targeting those most likely to benefit. Public acceptability has implications for engagement, uptake and the success of such a programme. Therefore, this review seeks to understand whether risk stratification of population-based cancer screening programmes is acceptable to the general public and in what context. METHODS Four electronic databases were searched from January 2010 to November 2021. Qualitative, quantitative and mixed-methods papers were eligible for inclusion. The Joanna Briggs Institute convergent integrated approach was used to synthesize the findings and the quality of included literature was assessed using the Mixed Methods Appraisal Tool. The Theoretical Framework of Acceptability was used as a coding frame for thematic analysis. PROSPERO record 2021 CRD42021286667. RESULTS The search returned 12,039 citations, 22 of which were eligible for inclusion. The majority of studies related to breast cancer screening; other cancer types included ovarian, kidney, colorectal and prostate cancer. Risk stratification was generally acceptable to the public, who considered it to be logical and of wider benefit than existing screening practices. We identified 10 priorities for implementation across four key areas: addressing public information needs; understanding communication preferences for risk estimates; mitigating barriers to accessibility to avoid exacerbating inequalities; and the role of healthcare professionals in relation to supporting reduced screening for low-risk individuals. CONCLUSION The public generally find risk stratification of population-based cancer screening programmes to be acceptable; however, we have identified areas that would improve implementation and require further consideration. PATIENT OR PUBLIC CONTRIBUTION This paper is a systematic review and did not formally involve patients or the public; however, three patient and public involvement members were consulted on the topic and scope before the review commenced.
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Affiliation(s)
- Lily C Taylor
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | - Katie Law
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Veeraj Shah
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Rebecca A Dennison
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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17
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Taylor LC, Law K, Hutchinson A, Dennison RA, Usher-Smith JA. Acceptability of risk stratification within population-based cancer screening from the perspective of healthcare professionals: A mixed methods systematic review and recommendations to support implementation. PLoS One 2023; 18:e0279201. [PMID: 36827432 PMCID: PMC9956883 DOI: 10.1371/journal.pone.0279201] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 12/01/2022] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Introduction of risk stratification within population-based cancer screening programmes has the potential to optimise resource allocation by targeting screening towards members of the population who will benefit from it most. Endorsement from healthcare professionals is necessary to facilitate successful development and implementation of risk-stratified interventions. Therefore, this review aims to explore whether using risk stratification within population-based cancer screening programmes is acceptable to healthcare professionals and to identify any requirements for successful implementation. METHODS We searched four electronic databases from January 2010 to October 2021 for quantitative, qualitative, or primary mixed methods studies reporting healthcare professional and/or other stakeholder opinions on acceptability of risk-stratified population-based cancer screening. Quality of the included studies was assessed using the Mixed Methods Appraisal Tool. Data were analysed using the Joanna Briggs Institute convergent integrated approach to mixed methods analysis and mapped onto the Consolidated Framework for Implementation Research using a 'best fit' approach. PROSPERO record CRD42021286667. RESULTS A total of 12,039 papers were identified through the literature search and seven papers were included in the review, six in the context of breast cancer screening and one considering screening for ovarian cancer. Risk stratification was broadly considered acceptable, with the findings covering all five domains of the framework: intervention characteristics, outer setting, inner setting, characteristics of individuals, and process. Across these five domains, key areas that were identified as needing further consideration to support implementation were: a need for greater evidence, particularly for de-intensifying screening; resource limitations; need for staff training and clear communication; and the importance of public involvement. CONCLUSIONS Risk stratification of population-based cancer screening programmes is largely acceptable to healthcare professionals, but support and training will be required to successfully facilitate implementation. Future research should focus on strengthening the evidence base for risk stratification, particularly in relation to reducing screening frequency among low-risk cohorts and the acceptability of this approach across different cancer types.
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Affiliation(s)
- Lily C. Taylor
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Katie Law
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Alison Hutchinson
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Rebecca A. Dennison
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Juliet A. Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
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18
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Usher-Smith JA, Hindmarch S, French DP, Tischkowitz M, Moorthie S, Walter FM, Dennison RA, Stutzin Donoso F, Archer S, Taylor L, Emery J, Morris S, Easton DF, Antoniou AC. Proactive breast cancer risk assessment in primary care: a review based on the principles of screening. Br J Cancer 2023; 128:1636-1646. [PMID: 36737659 PMCID: PMC9897164 DOI: 10.1038/s41416-023-02145-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 02/05/2023] Open
Abstract
In the UK, the National Institute for Health and Care Excellence (NICE) recommends that women at moderate or high risk of breast cancer be offered risk-reducing medication and enhanced breast screening/surveillance. In June 2022, NICE withdrew a statement recommending assessment of risk in primary care only when women present with concerns. This shift to the proactive assessment of risk substantially changes the role of primary care, in effect paving the way for a primary care-based screening programme to identify those at moderate or high risk of breast cancer. In this article, we review the literature surrounding proactive breast cancer risk assessment within primary care against the consolidated framework for screening. We find that risk assessment for women under 50 years currently satisfies many of the standard principles for screening. Most notably, there are large numbers of women at moderate or high risk currently unidentified, risk models exist that can identify those women with reasonable accuracy, and management options offer the opportunity to reduce breast cancer incidence and mortality in that group. However, there remain a number of uncertainties and research gaps, particularly around the programme/system requirements, that need to be addressed before these benefits can be realised.
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Affiliation(s)
- Juliet A. Usher-Smith
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sarah Hindmarch
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - David P. French
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Marc Tischkowitz
- grid.5335.00000000121885934Department of Medical Genetics, National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Sowmiya Moorthie
- grid.5335.00000000121885934PHG Foundation, University of Cambridge, Cambridge, UK
| | - Fiona M. Walter
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK ,grid.4868.20000 0001 2171 1133Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Rebecca A. Dennison
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Francisca Stutzin Donoso
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephanie Archer
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Department of Psychology, University of Cambridge, Cambridge, UK
| | - Lily Taylor
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jon Emery
- grid.1008.90000 0001 2179 088XCentre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, VIC Australia
| | - Stephen Morris
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Douglas F. Easton
- grid.5335.00000000121885934Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Antonis C. Antoniou
- grid.5335.00000000121885934Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Rugg-Gunn CEM, Dixon E, Jorgensen AL, Usher-Smith JA, Marcovecchio ML, Deakin M, Hawcutt DB. Factors Associated With Diabetic Ketoacidosis at Onset of Type 1 Diabetes Among Pediatric Patients: A Systematic Review. JAMA Pediatr 2022; 176:1248-1259. [PMID: 36215053 DOI: 10.1001/jamapediatrics.2022.3586] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
IMPORTANCE Presenting with diabetic ketoacidosis (DKA) at onset of type 1 diabetes (T1D) remains a risk. Following a 2011 systematic review, considerable additional articles have been published, and the review required updating. OBJECTIVE To evaluate factors associated with DKA at the onset of T1D among pediatric patients. EVIDENCE REVIEW In this systematic review, PubMed, Embase, Scopus, CINAHL, Web of Science, and article reference lists were searched using the population, intervention, comparison, outcome search strategy for primary research studies on DKA and T1D onset among individuals younger than 18 years that were published from January 2011 to November 2021. These studies were combined with a 2011 systematic review on the same topic. Data were pooled using a random-effects model. FINDINGS A total of 2565 articles were identified; 149 were included, along with 46 from the previous review (total 195 articles). Thirty-eight factors were identified and examined for their association with DKA at T1D onset. Factors associated with increased risk of DKA were younger age at T1D onset (<2 years vs ≥2 years; odds ratio [OR], 3.51; 95% CI, 2.85-4.32; P < .001), belonging to an ethnic minority population (OR, 0.40; 95% CI, 0.21-0.74; P = .004), and family history of T1D (OR, 0.46; 95% CI, 0.37-0.57; P < .001), consistent with the 2011 systematic review. Some factors that were not associated with DKA in the 2011 systematic review were associated with DKA in the present review (eg, delayed diagnosis: OR, 2.27; 95% CI, 1.72-3.01; P < .001). Additional factors associated with risk of DKA among patients with new-onset T1D included participation in screening programs (OR, 0.35; 95% CI, 0.21-0.59; P < .001) and presentation during the COVID-19 pandemic (OR, 2.32; 95% CI, 1.76-3.06; P < .001). CONCLUSIONS AND RELEVANCE In this study, age younger than 2 years at T1D onset, belonging to an ethnic minority population, delayed diagnosis or misdiagnosis, and presenting during the COVID-19 pandemic were associated with increased risk of DKA. Factors associated with decreased risk of DKA included greater knowledge of key signs or symptoms of DKA, such as a family history of T1D or participation in screening programs. Future work should focus on identifying and implementing strategies related to these factors to reduce risk of DKA among new patients with T1D.
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Affiliation(s)
| | - Eleanor Dixon
- Usher Institute, University of Edinburgh, Edinburgh, Scotland
| | - Andrea L Jorgensen
- Department of Biostatistics, University of Liverpool, Liverpool, England
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge, England
| | | | - Mark Deakin
- Alder Hey Children's Hospital, Liverpool, England
| | - Daniel B Hawcutt
- NIHR Alder Hey Clinical Research Facility, Liverpool, England.,Department of Women's and Children's Health, University of Liverpool, Liverpool, England
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Archer L, Koshiaris C, Lay-Flurrie S, Snell KIE, Riley RD, Stevens R, Banerjee A, Usher-Smith JA, Clegg A, Payne RA, Hobbs FDR, McManus RJ, Sheppard JP. Development and external validation of a risk prediction model for falls in patients with an indication for antihypertensive treatment: retrospective cohort study. BMJ 2022; 379:e070918. [PMID: 36347531 PMCID: PMC9641577 DOI: 10.1136/bmj-2022-070918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To develop and externally validate the STRAtifying Treatments In the multi-morbid Frail elderlY (STRATIFY)-Falls clinical prediction model to identify the risk of hospital admission or death from a fall in patients with an indication for antihypertensive treatment. DESIGN Retrospective cohort study. SETTING Primary care data from electronic health records contained within the UK Clinical Practice Research Datalink (CPRD). PARTICIPANTS Patients aged 40 years or older with at least one blood pressure measurement between 130 mm Hg and 179 mm Hg. MAIN OUTCOME MEASURE First serious fall, defined as hospital admission or death with a primary diagnosis of a fall within 10 years of the index date (12 months after cohort entry). Model development was conducted using a Fine-Gray approach in data from CPRD GOLD, accounting for the competing risk of death from other causes, with subsequent recalibration at one, five, and 10 years using pseudo values. External validation was conducted using data from CPRD Aurum, with performance assessed through calibration curves and the observed to expected ratio, C statistic, and D statistic, pooled across general practices, and clinical utility using decision curve analysis at thresholds around 10%. RESULTS Analysis included 1 772 600 patients (experiencing 62 691 serious falls) from CPRD GOLD used in model development, and 3 805 366 (experiencing 206 956 serious falls) from CPRD Aurum in the external validation. The final model consisted of 24 predictors, including age, sex, ethnicity, alcohol consumption, living in an area of high social deprivation, a history of falls, multiple sclerosis, and prescriptions of antihypertensives, antidepressants, hypnotics, and anxiolytics. Upon external validation, the recalibrated model showed good discrimination, with pooled C statistics of 0.833 (95% confidence interval 0.831 to 0.835) and 0.843 (0.841 to 0.844) at five and 10 years, respectively. Original model calibration was poor on visual inspection and although this was improved with recalibration, under-prediction of risk remained (observed to expected ratio at 10 years 1.839, 95% confidence interval 1.811 to 1.865). Nevertheless, decision curve analysis suggests potential clinical utility, with net benefit larger than other strategies. CONCLUSIONS This prediction model uses commonly recorded clinical characteristics and distinguishes well between patients at high and low risk of falls in the next 1-10 years. Although miscalibration was evident on external validation, the model still had potential clinical utility around risk thresholds of 10% and so could be useful in routine clinical practice to help identify those at high risk of falls who might benefit from closer monitoring or early intervention to prevent future falls. Further studies are needed to explore the appropriate thresholds that maximise the model's clinical utility and cost effectiveness.
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Affiliation(s)
- Lucinda Archer
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Kym I E Snell
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Richard D Riley
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, UK
| | - Andrew Clegg
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, University of Leeds, UK
| | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
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21
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Usher-Smith JA, Li L, Roberts L, Harrison H, Rossi SH, Sharp SJ, Coupland C, Hippisley-Cox J, Griffin SJ, Klatte T, Stewart GD. Risk models for recurrence and survival after kidney cancer: a systematic review. BJU Int 2022; 130:562-579. [PMID: 34914159 DOI: 10.1111/bju.15673] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To systematically identify and compare the performance of prognostic models providing estimates of survival or recurrence of localized renal cell cancer (RCC) in patients treated with surgery with curative intent. MATERIALS AND METHODS We performed a systematic review (PROSPERO CRD42019162349). We searched Medline, EMBASE and the Cochrane Library from 1 January 2000 to 12 December 2019 to identify studies reporting the performance of one or more prognostic model(s) that predict recurrence-free survival (RFS), cancer-specific survival (CSS) or overall survival (OS) in patients who have undergone surgical resection for localized RCC. For each outcome we summarized the discrimination of each model using the C-statistic and performed multivariate random-effects meta-analysis of the logit transformed C-statistic to rank the models. RESULTS Of a total of 13 549 articles, 57 included data on the performance of 22 models in external populations. C-statistics ranged from 0.59 to 0.90. Several risk models were assessed in two or more external populations and had similarly high discriminative performance. For RFS, these were the Sorbellini, Karakiewicz, Leibovich and Kattan models, with the UCLA Integrated Staging System model also having similar performance in European/US populations. All had C-statistics ≥0.75 in at least half of the validations. For CSS, they the models with the highest discriminative performance in two or more external validation studies were the Zisman, Stage, Size, Grade and Necrosis (SSIGN), Karakiewicz, Leibovich and Sorbellini models (C-statistic ≥0.80 in at least half of the validations), and for OS they were the Leibovich, Karakiewicz, Sorbellini and SSIGN models. For all outcomes, the models based on clinical features at presentation alone (Cindolo and Yaycioglu) had consistently lower discrimination. Estimates of model calibration were only infrequently included but most underestimated survival. CONCLUSION Several models had good discriminative ability, with there being no single 'best' model. The choice from these models for each setting should be informed by both the comparative performance and availability of factors included in the models. All would need recalibration if used to provide absolute survival estimates.
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Affiliation(s)
- Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Lanxin Li
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Lydia Roberts
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Hannah Harrison
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sabrina H Rossi
- Department of Oncology, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Stephen J Sharp
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Carol Coupland
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Julia Hippisley-Cox
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon J Griffin
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Grant D Stewart
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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22
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Usher-Smith JA, Godoy A, Burge SW, Burbidge S, Cartledge J, Crosbie PAJ, Eckert C, Farquhar F, Hammond D, Hancock N, Iball GR, Kimuli M, Masson G, Neal RD, Rogerson S, Rossi SH, Sala E, Smith A, Sharp SJ, Simmonds I, Wallace T, Ward M, Callister MEJ, Stewart GD. The Yorkshire Kidney Screening Trial (YKST): protocol for a feasibility study of adding non-contrast abdominal CT scanning to screen for kidney cancer and other abdominal pathology within a trial of community-based CT screening for lung cancer. BMJ Open 2022; 12:e063018. [PMID: 36127097 PMCID: PMC9490622 DOI: 10.1136/bmjopen-2022-063018] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Kidney cancer (renal cell cancer (RCC)) is the seventh most common cancer in the UK. As RCC is largely curable if detected at an early stage and most patients have no symptoms, there is international interest in evaluating a screening programme for RCC. The Yorkshire Kidney Screening Trial (YKST) will assess the feasibility of adding non-contrast abdominal CT scanning to screen for RCC and other abdominal pathology within the Yorkshire Lung Screening Trial (YLST), a randomised trial of community-based CT screening for lung cancer. METHODS AND ANALYSIS In YLST, ever-smokers aged 55-80 years registered with a general practice in Leeds have been randomised to a Lung Health Check assessment, including a thoracic low-dose CT (LDCT) for those at high risk of lung cancer, or routine care. YLST participants randomised to the Lung Health Check arm who attend for the second round of screening at 2 years without a history of RCC or abdominal CT scan within the previous 6 months will be invited to take part in YKST. We anticipate inviting 4700 participants. Those who consent will have an abdominal CT immediately following their YLST thoracic LDCT. A subset of participants and the healthcare workers involved will be invited to take part in a qualitative interview. Primary objectives are to quantify the uptake of the abdominal CT, assess the acceptability of the combined screening approach and pilot the majority of procedures for a subsequent randomised controlled trial of RCC screening within lung cancer screening. ETHICS AND DISSEMINATION YKST was approved by the North West-Preston Research Ethics Committee (21/NW/0021), and the Health Research Authority on 3 February 2021. Trial results will be disseminated at clinical meetings, in peer-reviewed journals and to policy-makers. Findings will be made available to participants via the study website (www.YKST.org). TRIAL REGISTRATION NUMBERS NCT05005195 and ISRCTN18055040.
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Affiliation(s)
- Juliet A Usher-Smith
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Angela Godoy
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Sarah W Burge
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Simon Burbidge
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK, Leeds, UK
| | - Jon Cartledge
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK, Leeds, UK
| | - Philip A J Crosbie
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Claire Eckert
- Leeds Institiute of Health Sciences, University of Leeds, Leeds, UK
| | - Fiona Farquhar
- Research and Innovation, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - David Hammond
- Research and Innovation, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Neil Hancock
- Leeds Diagnosis & Screening Unit, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Gareth R Iball
- Department of Medical Physics & Engineering, Leeds teaching hospitals NHS Trust, Leeds, UK
| | - Michael Kimuli
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK, Leeds, UK
| | - Golnessa Masson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Pitcairn Practice, Balmullo Surgery, Fife, UK
| | - Richard D Neal
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Suzanne Rogerson
- Research and Innovation, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sabrina H Rossi
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Evis Sala
- Department of Radiology, University of Cambridge, Cambridge, UK
- Department of Radiology, Catholic University Sacro Cuore and Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Andrew Smith
- Upper Gastro-intestinal and Pancreas Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Stephen J Sharp
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Irene Simmonds
- Leeds Institiute of Health Sciences, University of Leeds, Leeds, UK
| | - Tom Wallace
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthew Ward
- Leeds Institiute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Grant D Stewart
- Department of Surgery, University of Cambridge, Cambridge, UK
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23
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Harrison H, Pennells L, Wood A, Rossi SH, Stewart GD, Griffin SJ, Usher-Smith JA. Validation and public health modelling of risk prediction models for kidney cancer using the UK Biobank. BJU Int 2022; 129:498-511. [PMID: 34538014 DOI: 10.1111/bju.15598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/20/2021] [Accepted: 09/04/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To externally validate risk models for the detection of kidney cancer, as early detection of kidney cancer improves survival and stratifying the population using risk models could enable an individually tailored screening programme. METHODS We validated the performance of 30 existing phenotypic models predicting the risk of kidney cancer in the UK Biobank cohort (n = 450 687). We compared the discrimination and calibration of models for men, women, and a mixed-sex cohort. Population level data were used to estimate model performance in a screening scenario for a range of risk thresholds (6-year risk: 0.1-1.0%). RESULTS In all, 10 models had reasonable discrimination (area under the receiver-operating characteristic curve >0.60), although some had poor calibration. Modelling demonstrated similar performance of the best models over a range of thresholds. The models showed an improvement in ability to identify cases compared to age- and sex-based screening. All the models performed less well in women than men. CONCLUSIONS The present study is the first comprehensive external validation of risk models for kidney cancer. The best-performing models are better at identifying individuals at high risk of kidney cancer than age and sex alone; however, the benefits are relatively small. Feasibility studies are required to determine applicability to a screening programme.
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Affiliation(s)
- Hannah Harrison
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Lisa Pennells
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Angela Wood
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sabrina H Rossi
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Simon J Griffin
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Juliet A Usher-Smith
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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24
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Hollands GJ, Usher-Smith JA, Hasan R, Alexander F, Clarke N, Griffin SJ. Visualising health risks with medical imaging for changing recipients' health behaviours and risk factors: Systematic review with meta-analysis. PLoS Med 2022; 19:e1003920. [PMID: 35239659 PMCID: PMC8893626 DOI: 10.1371/journal.pmed.1003920] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 01/19/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There is ongoing clinical and research interest in determining whether providing personalised risk information could motivate risk-reducing health behaviours. We aimed to assess the impact on behaviours and risk factors of feeding back to individuals' images of their bodies generated via medical imaging technologies in assessing their current disease status or risk. METHODS AND FINDINGS A systematic review with meta-analysis was conducted using Cochrane methods. MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched up to July 28, 2021, with backward and forward citation searches up to July 29, 2021. Eligible studies were randomised controlled trials including adults who underwent medical imaging procedures assessing current health status or risk of disease, for which personal risk may be reduced by modifying behaviour. Trials included an intervention group that received the imaging procedure plus feedback of visualised results and assessed subsequent risk-reducing health behaviour. We examined 12,620 abstracts and included 21 studies, involving 9,248 randomised participants. Studies reported on 10 risk-reducing behaviours, with most data for smoking (8 studies; n = 4,308), medication use (6 studies; n = 4,539), and physical activity (4 studies; n = 1,877). Meta-analysis revealed beneficial effects of feedback of visualised medical imaging results on reduced smoking (risk ratio 1.11, 95% confidence interval [CI] 1.01 to 1.23, p = 0.04), healthier diet (standardised mean difference [SMD] 0.30, 95% CI 0.11 to 0.50, p = 0.003), increased physical activity (SMD 0.11, 95% CI 0.003 to 0.21, p = 0.04), and increased oral hygiene behaviours (SMD 0.35, 95% CI 0.13 to 0.57, p = 0.002). In addition, single studies reported increased skin self-examination and increased foot care. For other behavioural outcomes (medication use, sun protection, tanning booth use, and blood glucose testing) estimates favoured the intervention but were not statistically significant. Regarding secondary risk factor outcomes, there was clear evidence for reduced systolic blood pressure, waist circumference, and improved oral health, and some indication of reduced Framingham risk score. There was no evidence of any adverse effects, including anxiety, depression, or stress, although these were rarely assessed. A key limitation is that there were some concerns about risk of bias for all studies, with evidence for most outcomes being of low certainty. In particular, valid and precise measures of behaviour were rarely used, and there were few instances of preregistered protocols and analysis plans, increasing the likelihood of selective outcome reporting. CONCLUSIONS In this study, we observed that feedback of medical images to individuals has the potential to motivate risk-reducing behaviours and reduce risk factors. Should this promise be corroborated through further adequately powered trials that better mitigate against risk of bias, such interventions could usefully capitalise upon the widespread and growing use of medical imaging technologies in healthcare.
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Affiliation(s)
- Gareth J. Hollands
- Behaviour and Health Research Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
- EPPI-Centre, UCL Social Research Institute, University College London, London, United Kingdom
- * E-mail:
| | - Juliet A. Usher-Smith
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Rana Hasan
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Florence Alexander
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Natasha Clarke
- Behaviour and Health Research Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Simon J. Griffin
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
- MRC Epidemiology Unit, Institute of Metabolic Science, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
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Dennison RA, Griffin SJ, Usher-Smith JA, Fox RA, Aiken CE, Meek CL. "Post-GDM support would be really good for mothers": A qualitative interview study exploring how to support a healthy diet and physical activity after gestational diabetes. PLoS One 2022; 17:e0262852. [PMID: 35061856 PMCID: PMC8782419 DOI: 10.1371/journal.pone.0262852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 01/06/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Women with a history of gestational diabetes mellitus (GDM) are at high risk of developing type 2 diabetes mellitus (T2DM). They are therefore recommended to follow a healthy diet and be physically active in order to reduce that risk. However, achieving and maintaining these behaviours in the postpartum period is challenging. This study sought to explore women's views on suggested practical approaches to achieve and maintain a healthy diet and physical activity to reduce T2DM risk. METHODS Semi-structured interviews with 20 participants in Cambridgeshire, UK were conducted at three to 48 months after GDM. The participants' current diet and physical activity, intentions for any changes, and views on potential interventions to help manage T2DM risk through these behaviours were discussed. Framework analysis was used to analyse the transcripts. The interview schedule, suggested interventions, and thematic framework were based on a recent systematic review. RESULTS Most of the participants wanted to eat more healthily and be more active. A third of the participants considered that postpartum support for these behaviours would be transformative, a third thought it would be beneficial, and a third did not want additional support. The majority agreed that more information about the impact of diet and physical activity on diabetes risk, support to exercise with others, and advice about eating healthily, exercising with a busy schedule, monitoring progress and sustaining changes would facilitate a healthy diet and physical activity. Four other suggested interventions received mixed responses. It would be acceptable for this support to be delivered throughout pregnancy and postpartum through a range of formats. Clinicians were seen to have important roles in giving or signposting to support. CONCLUSIONS Many women would appreciate more support to reduce their T2DM risk after GDM and believe that a variety of interventions to integrate changes into their daily lives would help them to sustain healthier lifestyles.
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Affiliation(s)
- Rebecca A. Dennison
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Simon J. Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
- MRC Epidemiology Unit, Institute of Metabolic Science, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Juliet A. Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Rachel A. Fox
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Catherine E. Aiken
- University Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom
- Department of Obstetrics and Gynaecology, Rosie Hospital, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Claire L. Meek
- Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, United Kingdom
- Department of Clinical Biochemistry, Addenbrooke’s Hospital, Cambridge, United Kingdom
- Wolfson Diabetes and Endocrinology Clinic, Cambridge University Hospitals, Addenbrooke’s Hospital, Cambridge, United Kingdom
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Affiliation(s)
- Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.
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Riedinger C, Campbell J, Klein WMP, Ferrer RA, Usher-Smith JA. Analysis of the components of cancer risk perception and links with intention and behaviour: A UK-based study. PLoS One 2022; 17:e0262197. [PMID: 35025940 PMCID: PMC8757986 DOI: 10.1371/journal.pone.0262197] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 11/30/2021] [Indexed: 11/19/2022] Open
Abstract
Risk perception refers to how individuals interpret their susceptibility to threats, and has been hypothesised as an important predictor of intentions and behaviour in many theories of health behaviour change. However, its components, optimal measurement, and effects are not yet fully understood. The TRIRISK model, developed in the US, conceptualises risk perception as deliberative, affective and experiential components. In this study, we aimed to assess the replicability of the TRIRISK model in a UK sample by confirmatory factor analysis (CFA), explore the inherent factor structure of risk perception in the UK sample by exploratory factor analysis (EFA), and assess the associations of EFA-based factors with intentions to change behaviour and subsequent behaviour change. Data were derived from an online randomised controlled trial assessing cancer risk perception using the TRIRISK instrument and intention and lifestyle measures before and after communication of cancer risk. In the CFA analysis, the TRIRISK model of risk perception did not provide a good fit for the UK data. A revised model developed using EFA consisted of two separate "numerical" and "self-reflective" factors of deliberative risk perception, and a third factor combining affective with a subset of experiential items. This model provided a better fit to the data when cross-validated. Using multivariable regression analysis, we found that the self-reflective and affective-experiential factors of the model identified in this study were reliable predictors of intentions to prevent cancer. There were no associations of any of the risk perception factors with behaviour change. This study confirms that risk perception is clearly a multidimensional construct, having identified self-reflective risk perception as a new distinct component with predictive validity for intention. Furthermore, we highlight the practical implications of our findings for the design of interventions incorporating risk perception aimed at behaviour change in the context of cancer prevention.
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Affiliation(s)
- Christiane Riedinger
- Department of Public Health and Primary Care, Prevention Group, Primary Care Unit, University of Cambridge Clinical School, Cambridge, United Kingdom
| | - Jackie Campbell
- Faculty of Health, Education and Society, University of Northampton, Northampton, United Kingdom
| | - William M. P. Klein
- Behavioral Research Program, National Cancer Institute, Rockville, Maryland, United States of America
| | - Rebecca A. Ferrer
- Behavioral Research Program, National Cancer Institute, Rockville, Maryland, United States of America
| | - Juliet A. Usher-Smith
- Department of Public Health and Primary Care, Prevention Group, Primary Care Unit, University of Cambridge Clinical School, Cambridge, United Kingdom
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Harrison H, Usher-Smith JA, Li L, Roberts L, Lin Z, Thompson RE, Rossi SH, Stewart GD, Walter FM, Griffin S, Zhou Y. Risk prediction models for symptomatic patients with bladder and kidney cancer: a systematic review. Br J Gen Pract 2022; 72:e11-e18. [PMID: 34844922 PMCID: PMC8714528 DOI: 10.3399/bjgp.2021.0319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/25/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Timely diagnosis of bladder and kidney cancer is key to improving clinical outcomes. Given the challenges of early diagnosis, models incorporating clinical symptoms and signs may be helpful to primary care clinicians when triaging at-risk patients. AIM To identify and compare published models that use clinical signs and symptoms to predict the risk of undiagnosed prevalent bladder or kidney cancer. DESIGN AND SETTING Systematic review. METHOD A search identified primary research reporting or validating models predicting the risk of bladder or kidney cancer in MEDLINE and EMBASE. After screening identified studies for inclusion, data were extracted onto a standardised form. The risk models were classified using TRIPOD guidelines and evaluated using the PROBAST assessment tool. RESULTS The search identified 20 661 articles. Twenty studies (29 models) were identified through screening. All the models included haematuria (visible, non-visible, or unspecified), and seven included additional signs and symptoms (such as abdominal pain). The models combined clinical features with other factors (including demographic factors and urinary biomarkers) to predict the risk of undiagnosed prevalent cancer. Several models (n = 13) with good discrimination (area under the receiver operating curve >0.8) were identified; however, only eight had been externally validated. All of the studies had either high or unclear risk of bias. CONCLUSION Models were identified that could be used in primary care to guide referrals, with potential to identify lower-risk patients with visible haematuria and to stratify individuals who present with non-visible haematuria. However, before application in general practice, external validations in appropriate populations are required.
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Affiliation(s)
- Hannah Harrison
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Lanxin Li
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge
| | - Lydia Roberts
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge
| | - Zhiyuan Lin
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge
| | - Rachel E Thompson
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge
| | - Sabrina H Rossi
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge
| | - Fiona M Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, and director, Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Simon Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Yin Zhou
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
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Usher-Smith JA, Häggström C, Wennberg P, Lindvall K, Strelitz J, Sharp SJ, Griffin SJ. Impact of achievement and change in achievement of lifestyle recommendations in middle-age on risk of the most common potentially preventable cancers. Prev Med 2021; 153:106712. [PMID: 34242663 PMCID: PMC8633845 DOI: 10.1016/j.ypmed.2021.106712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/18/2021] [Accepted: 07/03/2021] [Indexed: 11/29/2022]
Abstract
This study aimed to assess the association between achievement, and within-person change in achievement, of lifestyle recommendations in middle-age and incidence of the most common potentially preventable cancers. We used data from 44,572 participants from the Swedish Västerbotten Intervention Programme who had attended at least two health checks 9-11 years apart. We assessed the association between the mean number of healthy lifestyle recommendations achieved (lifestyle score), and change in lifestyle score between the health checks, and risk of one or more of the eight most common potentially preventable cancers using Cox regression. Participants were followed-up for 11.0 (SD 4.9) years. A higher mean lifestyle score was associated with a lower hazard of cancer in men (HR 0.81 (95%CI 0.74-0.90) per unit increase) and women (HR 0.90 (0.84-0.96)). There was no evidence of a linear association between change in lifestyle score and risk (HR 0.93 (0.85-1.03) and HR 1.004 (0.94-1.07) per unit change for men and women respectively). When comparing those with an increase in lifestyle score of ≥2 with those who improved less or declined in achievement the HR was 0.74 (0.54-1.00) and 1.02 (0.84-1.24) for men and women respectively. These findings support the inclusion of lifestyle recommendations in cancer prevention guidelines. They further suggest that interventions to change health behaviours in middle-age may reduce risk of the most common preventable cancers in men, but this association was not observed in women. Strategies to encourage healthy lifestyles earlier in the life course may be more effective.
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Affiliation(s)
- Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Box 113 Cambridge Biomedical Campus, Cambridge CB2 0SR, UK.
| | - Christel Häggström
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden; Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
| | - Patrik Wennberg
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden.
| | - Kristina Lindvall
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
| | - Jean Strelitz
- MRC Epidemiology Unit, University of Cambridge, Institute of Metabolic Science, Cambridge CB2 0QQ, UK.
| | - Stephen J Sharp
- MRC Epidemiology Unit, University of Cambridge, Institute of Metabolic Science, Cambridge CB2 0QQ, UK.
| | - Simon J Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Box 113 Cambridge Biomedical Campus, Cambridge CB2 0SR, UK; MRC Epidemiology Unit, University of Cambridge, Institute of Metabolic Science, Cambridge CB2 0QQ, UK.
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Usher-Smith JA, Harrison H, Dennison R, Kelly S, Jones R, Kuhn I, Griffin SJ. Developing training and opportunities for students in systematic reviews. Med Educ 2021; 55:1333-1334. [PMID: 34467543 DOI: 10.1111/medu.14649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/05/2021] [Indexed: 06/13/2023]
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Harrison H, Thompson RE, Lin Z, Rossi SH, Stewart GD, Griffin SJ, Usher-Smith JA. Risk Prediction Models for Kidney Cancer: A Systematic Review. Eur Urol Focus 2021; 7:1380-1390. [PMID: 32680829 PMCID: PMC8642244 DOI: 10.1016/j.euf.2020.06.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/18/2020] [Accepted: 06/29/2020] [Indexed: 12/24/2022]
Abstract
CONTEXT Early detection of kidney cancer improves survival; however, low prevalence means that population-wide screening may be inefficient. Stratification of the population into risk categories could allow for the introduction of a screening programme tailored to individuals. OBJECTIVE This review will identify and compare published models that predict the risk of developing kidney cancer in the general population. EVIDENCE ACQUISITION A search identified primary research reporting or validating models predicting the risk of kidney cancer in Medline and EMBASE. After screening identified studies for inclusion, we extracted data onto a standardised form. The risk models were classified using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) guidelines and evaluated using the PROBAST assessment tool. EVIDENCE SYNTHESIS The search identified 15 281 articles. Sixty-two satisfied the inclusion criteria; performance measures were provided for 11 models. Some models predicted the risk of prevalent undiagnosed disease and others future incident disease. Six of the models had been validated, two using external populations. The most commonly included risk factors were age, smoking status, and body mass index. Most of the models had acceptable-to-good discrimination (area under the receiver-operating curve >0.7) in development and validation. Many models also had high specificity; however, several had low sensitivity. The highest performance was seen for the models using only biomarkers to detect kidney cancer; however, these were developed and validated in small case-control studies. CONCLUSIONS We identified a small number of risk models that could be used to stratify the population according to the risk of kidney cancer. Most exhibit reasonable discrimination, but a few have been validated externally in population-based studies. PATIENT SUMMARY In this review, we looked at mathematical models predicting the likelihood of an individual developing kidney cancer. We found several suitable models, using a range of risk factors (such as age and smoking) to predict the risk for individuals. Most of the models identified require further testing in the general population to confirm their usefulness.
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Affiliation(s)
- Hannah Harrison
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
| | - Rachel E Thompson
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Zhiyuan Lin
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Sabrina H Rossi
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Simon J Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Dennison RA, Meek CL, Usher-Smith JA, Fox RA, Aiken CE, Griffin SJ. 'Oh, I've got an appointment': A qualitative interview study exploring how to support attendance at diabetes screening after gestational diabetes. Diabet Med 2021; 38:e14650. [PMID: 34268798 PMCID: PMC7614210 DOI: 10.1111/dme.14650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 07/14/2021] [Indexed: 12/23/2022]
Abstract
AIMS To explore the views of women with a history of gestational diabetes mellitus (GDM) on suggested practical approaches to support diabetes screening attendance after GDM, which is recommended but poorly attended. METHODS We conducted semi-structured interviews with 20 participants in Cambridgeshire, UK who had been diagnosed with GDM and were 3-48 months postpartum. Interviews covered whether participants had been screened and why, plans for future screening and their views on potential interventions to facilitate attendance (at the first postpartum test and annual testing). Framework analysis was used to analyse the transcripts. The interview schedule, suggested interventions and thematic framework were based on a recent systematic review. RESULTS Sixteen participants had undergone screening since pregnancy, explaining that they had an appointment arranged and wanted reassurance that they did not have diabetes. The participants who had not been tested were not aware that it was recommended. Only 13 had planned to attend subsequent tests at the start of the interview. Eight themes to support future attendance were discussed. The majority of the participants agreed that changing the processes for arranging tests, offering choice in test location and combining appointments would facilitate attendance. Child-friendly clinics, more opportunities to understand GDM and the role of postpartum testing, stopping self-testing and increasing their GP's awareness of their pregnancy received inconsistent feedback. The nature of the test used did not appear to influence attendance. CONCLUSIONS The participants wanted to be screened for diabetes after GDM. We have identified interventions that could be relatively simply incorporated into routine practice to facilitate screening attendance, such as flexibility in the appointment location or time and sending invitations for tests.
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Affiliation(s)
- Rebecca A Dennison
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Claire L Meek
- Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
- Department of Clinical Biochemistry, Addenbrooke's Hospital, Cambridge, UK
- Wolfson Diabetes and Endocrinology Clinic, Cambridge University Hospitals, Addenbrooke's Hospital, Cambridge, UK
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Rachel A Fox
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Catherine E Aiken
- University Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, UK
- Department of Obstetrics and Gynaecology, Rosie Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Simon J Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- MRC Epidemiology Unit, Institute of Metabolic Science, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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Saunders CL, Massou E, Waller J, Meads C, Marlow LAV, Usher-Smith JA. Cervical screening attendance and cervical cancer risk among women who have sex with women. J Med Screen 2021; 28:349-356. [PMID: 33476213 PMCID: PMC8366122 DOI: 10.1177/0969141320987271] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 12/02/2020] [Accepted: 12/17/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To describe cervical cancer screening participation among women who have sex exclusively with women (WSEW) and women who have sex with women and men (WSWM) compared with women who have sex exclusively with men (WSEM), and women who have never had sex and compare this with bowel (colorectal) and breast screening participation. To explore whether there is evidence of differential stage 3 cervical intraepithelial neoplasia (CIN3) or cervical cancer risk. METHODS We describe cervical, bowel and breast cancer screening uptake in age groups eligible for the national screening programmes, prevalent CIN3 and cervical cancer at baseline, and incident CIN3 and cervical cancer at five years follow-up, among 218,674 women in UK Biobank, a cohort of healthy volunteers from the UK. RESULTS Compared with WSEM, in adjusted analysis [odds ratio (95% confidence interval)], WSEW 0.10 (0.08-0.13), WSWM 0.73 (0.58-0.91), and women who have never had sex 0.02 (0.01-0.02) were less likely to report ever having attended cervical screening. There were no differences when considering bowel cancer screening uptake (p = 0.61). For breast cancer screening, attendance was lower among WSWM 0.79 (0.68 to 0.91) and women who have never had sex 0.47 (0.29-0.58), compared with WSEM. There were incident and prevalent cases of both CIN3 and cervical cancer among WSEW and WSWM. Compared with WSEM with a single male partner, among WSEW there was a twofold increase in CIN3 1.91 (1.01 to 3.59); among WSWM with only one male partner, this was 2.25 (1.19 to 4.24). CONCLUSIONS These findings highlight the importance of improving uptake of cervical screening among all women who have sex with women and breast screening among WSWM and women who have never had sex.
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Affiliation(s)
| | | | - Jo Waller
- Cancer Prevention Group, King's College London, London, UK
| | - Catherine Meads
- Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Cambridge, UK
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Thomas C, Mandrik O, Saunders CL, Thompson D, Whyte S, Griffin S, Usher-Smith JA. The Costs and Benefits of Risk Stratification for Colorectal Cancer Screening Based On Phenotypic and Genetic Risk: A Health Economic Analysis. Cancer Prev Res (Phila) 2021; 14:811-822. [PMID: 34039685 PMCID: PMC7611464 DOI: 10.1158/1940-6207.capr-20-0620] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/15/2021] [Accepted: 05/24/2021] [Indexed: 01/07/2023]
Abstract
Population-based screening for colorectal cancer is an effective and cost-effective way of reducing colorectal cancer incidence and mortality. Many genetic and phenotypic risk factors for colorectal cancer have been identified, leading to development of colorectal cancer risk scores with varying discrimination. However, these are not currently used by population screening programs. We performed an economic analysis to assess the cost-effectiveness, clinical outcomes, and resource impact of using risk-stratification based on phenotypic and genetic risk, taking a UK National Health Service perspective. Biennial fecal immunochemical test (FIT), starting at an age determined through risk-assessment at age 40, was compared with FIT screening starting at a fixed age for all individuals. Compared with inviting everyone from age 60, using a risk score with area under the receiver operating characteristic curve of 0.721 to determine FIT screening start age, produces 418 QALYs, costs £247,000, and results in 218 fewer colorectal cancer cases and 156 fewer colorectal cancer deaths per 100,000 people, with similar FIT screening invites. There is 96% probability that risk-stratification is cost-effective, with net monetary benefit (based on £20,000 per QALY threshold) estimated at £8.1 million per 100,000 people. The maximum that could be spent on risk-assessment and still be cost-effective is £114 per person. Lower benefits are produced with lower discrimination risk scores, lower mean screening start age, or higher FIT thresholds. Risk-stratified screening benefits men more than women. Using risk to determine FIT screening start age could improve the clinical outcomes and cost effectiveness of colorectal cancer screening without using significant additional screening resources. PREVENTION RELEVANCE: Colorectal cancer screening is essential for early detection and prevention of colorectal cancer, but implementation is often limited by resource constraints. This work shows that risk-stratification using genetic and phenotypic risk could improve the effectiveness and cost-effectiveness of screening programs, without using substantially more screening resources than are currently available.
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Affiliation(s)
- Chloe Thomas
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom.
| | - Olena Mandrik
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Catherine L Saunders
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Deborah Thompson
- Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, United Kingdom
| | - Sophie Whyte
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Simon Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
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Lithgow GE, Rossi J, Griffin SJ, Usher-Smith JA, Dennison RA. Barriers to postpartum diabetes screening: a qualitative synthesis of clinicians' views. Br J Gen Pract 2021; 71:e473-e482. [PMID: 33947667 PMCID: PMC8103924 DOI: 10.3399/bjgp.2020.0928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/11/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Gestational diabetes mellitus (GDM) is an important risk factor for developing type 2 diabetes mellitus (T2DM) later in life. Postpartum screening provides an opportunity for early detection and management of T2DM, but uptake is poor. AIM To explore barriers to screening from clinicians' perspectives to guide future interventions to increase uptake of postpartum screening. DESIGN AND SETTING Systematic review and qualitative synthesis. METHOD Qualitative studies included in a previous review were assessed, and then five electronic databases were searched from January 2013 to May 2019 for qualitative studies reporting clinicians' perspectives on postpartum glucose screening after GDM. Study quality was assessed against the Critical Appraisal Skills Programmes checklist. Qualitative data from the studies were analysed using thematic synthesis. RESULTS Nine studies were included, containing views from 187 clinicians from both community and hospital care. Three main themes were identified: difficulties in handover between primary and secondary care (ambiguous roles and communication difficulties); short-term focus in clinical consultations (underplaying risk so as not to overwhelm patients and competing priorities); and patient-centric barriers such as time pressures. CONCLUSION Barriers to diabetes screening were identified at both system and individual levels. At the system level, clarification of responsibility for testing among healthcare professionals and better systems for recall are needed. These could be achieved through registers, improved clinical protocols, and automatic flagging and prompts within electronic medical records. At the individual level, clinicians should be supported to prioritise the importance of screening within consultations and better educational resources made available for women. Making it more convenient for women to attend may also facilitate screening.
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Affiliation(s)
| | - Jasper Rossi
- School of Clinical Medicine, University of Cambridge, Cambridge
| | - Simon J Griffin
- MRC Epidemiology Unit, Institute of Metabolic Science, School of Clinical Medicine, University of Cambridge, Cambridge
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge
| | - Rebecca A Dennison
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge
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Freer-Smith C, Harvey-Kelly L, Mills K, Harrison H, Rossi SH, Griffin SJ, Stewart GD, Usher-Smith JA. Reasons for intending to accept or decline kidney cancer screening: thematic analysis of free text from an online survey. BMJ Open 2021; 11:e044961. [PMID: 34006549 PMCID: PMC8137225 DOI: 10.1136/bmjopen-2020-044961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 03/17/2021] [Accepted: 04/15/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Kidney cancer has been identified as a disease for which screening might provide significant benefit for patients. The aim of this study was to understand in detail the facilitators and barriers towards uptake of a future kidney cancer screening programme, and to compare these across four proposed screening modalities. DESIGN An online survey including free-text responses. SETTING UK PARTICIPANTS: 668 adults PRIMARY AND SECONDARY OUTCOME MEASURES: The survey assessed participants' self-reported intention to take-up kidney cancer screening with four different test methods (urine test, blood test, ultrasound scan and low-dose CT). We conducted thematic analysis of 2559 free-text comments made within the survey using an inductive approach. RESULTS We identified five overarching themes that influenced screening intention: 'personal health beliefs', 'practicalities', 'opinions of the test', 'attitudes towards screening' and 'cancer apprehension'. Overall, participants considered the tests presented as simple to complete and the benefits of early detection to outweigh any drawbacks to screening. Dominant facilitators and barriers varied with patterns of intention to take up screening across the four tests. Most intended to take up screening by all four tests, and for these participants, screening was seen as a positive health behaviour. A significant minority were driven by practicalities and the risks of the tests offered. A smaller proportion intended to reject all forms of screening offered, often due to fear or worry about results and unnecessary medical intervention or a general negative view of screening. CONCLUSIONS Most individuals would accept kidney cancer screening by any of the four test options presented because of strong positive attitudes towards screening in general and the perceived simplicity of the tests. Providing information about the rationale for screening in general and the potential benefits of early detection will be important to optimise uptake among uncertain individuals.
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Affiliation(s)
| | - Laragh Harvey-Kelly
- School of Clinical Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Katie Mills
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Hannah Harrison
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Sabrina H Rossi
- Department of Oncology, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Simon J Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
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Rubin G, Walter FM, Emery J, Hamilton W, Hoare Z, Howse J, Nixon C, Srivastava T, Thomas C, Ukoumunne OC, Usher-Smith JA, Whyte S, Neal RD. Electronic clinical decision support tool for assessing stomach symptoms in primary care (ECASS): a feasibility study. BMJ Open 2021; 11:e041795. [PMID: 33737422 PMCID: PMC7978254 DOI: 10.1136/bmjopen-2020-041795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 02/15/2021] [Accepted: 02/24/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine the feasibility of a definitive trial in primary care of electronic clinical decision support (eCDS) for possible oesophago-gastric (O-G) cancer. DESIGN AND SETTING Feasibility study in 42 general practices in two regions of England, cluster randomised controlled trial design without blinding, nested qualitative and health economic evaluation. PARTICIPANTS Patients aged 55 years or older, presenting to their general practitioner (GP) with symptoms associated with O-G cancer. 530 patients (mean age 68 years, 58% female) participated. INTERVENTION Practices randomised 1:1 to usual care (control) or to receive a previously piloted eCDS tool for suspected cancer (intervention), for use at the discretion of the GPs, supported by a theory-based implementation package and ongoing support. We conducted semistructured interviews with GPs in intervention practices. Recruitment lasted 22 months. OUTCOMES Patient participation rate, use of eCDS, referrals and route to diagnosis, O-G cancer diagnoses; acceptability to GPs; cost-effectiveness. Participants followed up 6 months after index encounter. RESULTS From control and intervention practices, we screened 3841 and 1303 patients, respectively; 1189 and 434 were eligible, 392 and 138 consented to participate. Ten patients (1.9%) had O-G cancer. eCDS was used eight times in total by five unique users. GPs experienced interoperability problems between the eCDS tool and their clinical system and also found it did not fit with their workflow. Unexpected restrictions on software installation caused major problems with implementation. CONCLUSIONS The conduct of this study was hampered by technical limitations not evident during an earlier pilot of the eCDS tool, and by regulatory controls on software installation introduced by primary care trusts early in the study. This eCDS tool needed to integrate better with clinical workflow; even then, its use for suspected cancer may be infrequent. Any definitive trial of eCDS for cancer diagnosis should only proceed after addressing these constraints. TRIAL REGISTRATION NUMBER ISRCTN125595588.
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Affiliation(s)
- Greg Rubin
- Institute of Population Health Sciences, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Fiona M Walter
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jon Emery
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia
| | - Willie Hamilton
- Primary Care Diagnostics, University of Exeter Medical School, Exeter, UK
| | - Zoe Hoare
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor, UK
| | - Jenny Howse
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| | - Catherine Nixon
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| | - Tushar Srivastava
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Chloe Thomas
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Obioha C Ukoumunne
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, UK
| | - Juliet A Usher-Smith
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sophie Whyte
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Rossi SH, Klatte T, Usher-Smith JA, Fife K, Welsh SJ, Dabestani S, Bex A, Nicol D, Nathan P, Stewart GD, Wilson ECF. A Decision Analysis Evaluating Screening for Kidney Cancer Using Focused Renal Ultrasound. Eur Urol Focus 2021; 7:407-419. [PMID: 31530498 DOI: 10.1016/j.euf.2019.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 08/19/2019] [Accepted: 09/03/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Screening for renal cell carcinoma (RCC) has been identified as a key research priority; however, no randomised control trials have been performed. Value of information analysis can determine whether further research on this topic is of value. OBJECTIVE To determine (1) whether current evidence suggests that screening is potentially cost-effective and, if so, (2) in which age/sex groups, (3) identify evidence gaps, and (4) estimate the value of further research to close those gaps. DESIGN, SETTING, AND PARTICIPANTS A decision model was developed evaluating screening in asymptomatic individuals in the UK. A National Health Service perspective was adopted. INTERVENTION A single focused renal ultrasound scan compared with standard of care (no screening). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Expected lifetime costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER), discounted at 3.5% per annum. RESULTS AND LIMITATIONS Given a prevalence of RCC of 0.34% (0.18-0.54%), screening 60-yr-old men resulted in an ICER of £18 092/QALY (€22 843/QALY). Given a prevalence of RCC of 0.16% (0.08-0.25%), screening 60-yr-old women resulted in an ICER of £37327/QALY (€47 129/QALY). In the one-way sensitivity analysis, the ICER was <£30000/QALY as long as the prevalence of RCC was ≥0.25% for men and ≥0.2% for women at age 60yr. Given the willingness to pay a threshold of £30000/QALY (€37 878/QALY), the population-expected values of perfect information were £194 million (€244 million) and £97 million (€123 million) for 60-yr-old men and women, respectively. The expected value of perfect parameter information suggests that the prevalence of RCC and stage shift associated with screening are key research priorities. CONCLUSIONS Current evidence suggests that one-off screening of 60-yr-old men is potentially cost-effective and that further research into this topic would be of value to society. PATIENT SUMMARY Economic modelling suggests that screening 60-yr-old men for kidney cancer using ultrasound may be a good use of resources and that further research on this topic should be performed.
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Affiliation(s)
- Sabrina H Rossi
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK; Cancer Research UK Cambridge Centre, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - Tobias Klatte
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK; Department of Urology, Royal Bournemouth Hospital, Bournemouth, UK
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Kate Fife
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK; Cancer Research UK Cambridge Centre, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - Sarah J Welsh
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Saeed Dabestani
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Lund, Sweden
| | - Axel Bex
- The Royal Free London NHS Foundation Trust, Specialist Centre for Kidney Cancer, UK; Netherlands Cancer Institute, Division of Surgical Oncology, Department of Urology, Amsterdam, The Netherlands
| | - David Nicol
- Department of Urology, Royal Marsden Hospital, London, UK; Institute of Cancer Research, London, UK
| | - Paul Nathan
- Department of Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK; Cancer Research UK Cambridge Centre, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK.
| | - Edward C F Wilson
- Cambridge Centre for Health Services Research, University of Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge, UK; Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK.
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Williams CYK, Townson AT, Kapur M, Ferreira AF, Nunn R, Galante J, Phillips V, Gentry S, Usher-Smith JA. Interventions to reduce social isolation and loneliness during COVID-19 physical distancing measures: A rapid systematic review. PLoS One 2021; 16:e0247139. [PMID: 33596273 PMCID: PMC7888614 DOI: 10.1371/journal.pone.0247139] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 02/02/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND A significant proportion of the worldwide population is at risk of social isolation and loneliness as a result of the COVID-19 pandemic. We aimed to identify effective interventions to reduce social isolation and loneliness that are compatible with COVID-19 shielding and social distancing measures. METHODS AND FINDINGS In this rapid systematic review, we searched six electronic databases (Medline, Embase, Web of Science, PsycINFO, Cochrane Database of Systematic Reviews and SCOPUS) from inception to April 2020 for systematic reviews appraising interventions for loneliness and/or social isolation. Primary studies from those reviews were eligible if they included: 1) participants in a non-hospital setting; 2) interventions to reduce social isolation and/or loneliness that would be feasible during COVID-19 shielding measures; 3) a relevant control group; and 4) quantitative measures of social isolation, social support or loneliness. At least two authors independently screened studies, extracted data, and assessed risk of bias using the Downs and Black checklist. Study registration: PROSPERO CRD42020178654. We identified 45 RCTs and 13 non-randomised controlled trials; none were conducted during the COVID-19 pandemic. The nature, type, and potential effectiveness of interventions varied greatly. Effective interventions for loneliness include psychological therapies such as mindfulness, lessons on friendship, robotic pets, and social facilitation software. Few interventions improved social isolation. Overall, 37 of 58 studies were of "Fair" quality, as measured by the Downs & Black checklist. The main study limitations identified were the inclusion of studies of variable quality; the applicability of our findings to the entire population; and the current poor understanding of the types of loneliness and isolation experienced by different groups affected by the COVID-19 pandemic. CONCLUSIONS Many effective interventions involved cognitive or educational components, or facilitated communication between peers. These interventions may require minor modifications to align with COVID-19 shielding/social distancing measures. Future high-quality randomised controlled trials conducted under shielding/social distancing constraints are urgently needed.
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Affiliation(s)
| | - Adam T. Townson
- University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Milan Kapur
- University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Alice F. Ferreira
- University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Rebecca Nunn
- University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Julieta Galante
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
- National Institute for Health Research Applied Research Collaboration East of England, England, United Kingdom
| | | | - Sarah Gentry
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Juliet A. Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
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Usher-Smith JA, Mills KM, Riedinger C, Saunders CL, Helsingen LM, Lytvyn L, Buskermolen M, Lansdorp-Vogelaar I, Bretthauer M, Guyatt G, Griffin SJ. The impact of information about different absolute benefits and harms on intention to participate in colorectal cancer screening: A think-aloud study and online randomised experiment. PLoS One 2021; 16:e0246991. [PMID: 33592037 PMCID: PMC7886213 DOI: 10.1371/journal.pone.0246991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 01/30/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND There is considerable heterogeneity in individuals' risk of disease and thus the absolute benefits and harms of population-wide screening programmes. Using colorectal cancer (CRC) screening as an exemplar, we explored how people make decisions about screening when presented with information about absolute benefits and harms, and how those preferences vary with baseline risk, between screening tests and between individuals. METHOD We conducted two linked studies with members of the public: a think-aloud study exploring decision making in-depth and an online randomised experiment quantifying preferences. In both, participants completed a web-based survey including information about three screening tests (colonoscopy, sigmoidoscopy, and faecal immunochemical testing) and then up to nine scenarios comparing screening to no screening for three levels of baseline risk (1%, 3% and 5% over 15 years) and the three screening tests. Participants reported, after each scenario, whether they would opt for screening (yes/no). RESULTS Of the 20 participants in the think-aloud study 13 did not consider absolute benefits or harms when making decisions concerning CRC screening. In the online experiment (n = 978), 60% expressed intention to attend at 1% risk of CRC, 70% at 3% and 77% at 5%, with no differences between screening tests. At an individual level, 535 (54.7%) would attend at all three risk levels and 178 (18.2%) at none. The 27% whose intention varied by baseline risk were more likely to be younger, without a family history of CRC, and without a prior history of screening. CONCLUSIONS Most people in our population were not influenced by the range of absolute benefits and harms associated with CRC screening presented. For an appreciable minority, however, magnitude of benefit was important.
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Affiliation(s)
- Juliet A. Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Katie M. Mills
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Christiane Riedinger
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Catherine L. Saunders
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Lise M. Helsingen
- Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, and Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Lyubov Lytvyn
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Maaike Buskermolen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, and Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Simon J. Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
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Mills K, Paxton B, Walter FM, Griffin SJ, Sutton S, Usher-Smith JA. Incorporating a brief intervention for personalised cancer risk assessment to promote behaviour change into primary care: a multi-methods pilot study. BMC Public Health 2021; 21:205. [PMID: 33485309 PMCID: PMC7824918 DOI: 10.1186/s12889-021-10210-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 01/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Approximately 40% of cancers could be prevented if people lived healthier lifestyles. We have developed a theory-based brief intervention to share personalised cancer risk information and promote behaviour change within primary care. This study aimed to assess the feasibility and acceptability of incorporating this intervention into primary care consultations. METHOD Patients eligible for an NHS Health Check or annual chronic disease review at five general practices were invited to participate in a non-randomised pilot study. In addition to the NHS Health Check or chronic disease review, those receiving the intervention were provided with their estimated risk of developing the most common preventable cancers alongside tailored behaviour change advice. Patients completed online questionnaires at baseline, immediately post-consultation and at 3-month follow-up. Consultations were audio/video recorded. Patients (n = 12) and healthcare professionals (HCPs) (n = 7) participated in post-intervention qualitative interviews that were analysed using thematic analysis. RESULTS 62 patients took part. Thirty-four attended for an NHS Health Check plus the intervention; 7 for a standard NHS Health Check; 16 for a chronic disease review plus the intervention; and 5 for a standard chronic disease review. The mean time for delivery of the intervention was 9.6 min (SD 3) within NHS Health Checks and 9 min (SD 4) within chronic disease reviews. Fidelity of delivery of the intervention was high. Data from the questionnaires demonstrates potential improvements in health-related behaviours following the intervention. Patients receiving the intervention found the cancer risk information and lifestyle advice understandable, useful and motivating. HCPs felt that the intervention fitted well within NHS Health Checks and facilitated conversations around behaviour change. Integrating the intervention within chronic disease reviews was more challenging. CONCLUSIONS Incorporating a risk-based intervention to promote behaviour change for cancer prevention into primary care consultations is feasible and acceptable to both patients and HCPs. A randomised trial is now needed to assess the effect on health behaviours. When designing that trial, and other prevention activities within primary care, it is necessary to consider challenges around patient recruitment, the HCP contact time needed for delivery of interventions, and how best to integrate discussions about disease risk within routine care.
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Affiliation(s)
- Katie Mills
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Box 113 Cambridge Biomedical Campus, Cambridge, CB2 0SR, UK
| | - Ben Paxton
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0SP, UK
| | - Fiona M Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Box 113 Cambridge Biomedical Campus, Cambridge, CB2 0SR, UK
| | - Simon J Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Box 113 Cambridge Biomedical Campus, Cambridge, CB2 0SR, UK
| | - Stephen Sutton
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Box 113 Cambridge Biomedical Campus, Cambridge, CB2 0SR, UK
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Box 113 Cambridge Biomedical Campus, Cambridge, CB2 0SR, UK.
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Dennison RA, Chen ES, Green ME, Legard C, Kotecha D, Farmer G, Sharp SJ, Ward RJ, Usher-Smith JA, Griffin SJ. The absolute and relative risk of type 2 diabetes after gestational diabetes: A systematic review and meta-analysis of 129 studies. Diabetes Res Clin Pract 2021; 171:108625. [PMID: 33333204 PMCID: PMC7610694 DOI: 10.1016/j.diabres.2020.108625] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/27/2020] [Accepted: 12/09/2020] [Indexed: 01/12/2023]
Abstract
AIMS To estimate development of type 2 diabetes (T2DM) in women with previous gestational diabetes (GDM) and investigate characteristics associated with higher diagnoses, building on previous meta-analyses and exploring heterogeneity. METHODS Systematic literature review of studies published up to October 2019. We included studies reporting progression to T2DM ≥6 months after pregnancy, if diagnostic methods were reported and ≥50 women with GDM participated. We conducted random-effects meta-analyses and meta-regression of absolute and relative T2DM risk. PROSPERO ID CRD42017080299. RESULTS In 129 included studies, the percentage diagnosed with T2DM was 12% (95% confidence interval 8-16%) higher for each additional year after pregnancy, with a third developing diabetes within 15 years. Development was 18% (5-34%) higher per unit BMI at follow-up, and 57% (39-70%) lower in White European populations compared to others (adjusted for ethnicity and follow-up). Women with GDM had a relative risk of T2DM of 8.3 (6.5-10.6). 17.0% (15.1-19.0%) developed T2DM overall, although heterogeneity between studies was substantial (I2 99.3%), and remained high after accounting for various study-level characteristics. CONCLUSIONS Percentage developing T2DM after GDM is highly variable. These findings highlight the need for sustained follow-up after GDM through screening, and interventions to reduce modifiable risk factors.
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Affiliation(s)
- Rebecca A Dennison
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
| | - Eileen S Chen
- School of Clinical Medicine, University of Cambridge, UK
| | | | - Chloe Legard
- School of Clinical Medicine, University of Cambridge, UK
| | - Deeya Kotecha
- School of Clinical Medicine, University of Cambridge, UK.
| | - George Farmer
- School of Clinical Medicine, University of Cambridge, UK.
| | - Stephen J Sharp
- MRC Epidemiology Unit, Institute of Metabolic Science, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
| | - Rebecca J Ward
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
| | - Simon J Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK; MRC Epidemiology Unit, Institute of Metabolic Science, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
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Harvey-Kelly LLW, Harrison H, Rossi SH, Griffin SJ, Stewart GD, Usher-Smith JA. Public attitudes towards screening for kidney cancer: an online survey. BMC Urol 2020; 20:170. [PMID: 33115457 PMCID: PMC7592501 DOI: 10.1186/s12894-020-00724-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/17/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Kidney cancer is often asymptomatic, leading to proposals for a screening programme. The views of the public towards introducing a new screening programme for kidney cancer are unknown. The aim of this study was to explore attitudes towards kidney cancer screening and factors influencing intention to attend a future screening programme. METHODS We conducted an online population-based survey of 1021 adults aged 45-77 years. The main outcome measure was intention to attend four possible screening tests (urine, blood, ultrasound scan, low-dose CT) as well as extended low-dose CT scans within lung cancer screening programmes. We used multivariable regression to examine the association between intention and each screening test. RESULTS Most participants stated that they would be 'very likely' or 'likely' to undergo each of the screening tests [urine test: n = 961 (94.1%); blood test: n = 922 (90.3%); ultrasound: n = 914 (89.5%); low-dose CT: n = 804 (78.8%); lung CT: n = 962 (95.2%)]. Greater intention to attend was associated with higher general cancer worry and less perceived burden/inconvenience about the screening tests. Less worry about the screening test was also associated with higher intention to attend, but only in those with low general cancer worry (cancer worry scale ≤ 5). Compared with intention to take up screening with a urine test, participants were half as likely to report that they intended to undergo blood [OR 0.56 (0.43-0.73)] or ultrasound [OR 0.50 (0.38-0.67)] testing, and half as likely again to report that they intended to take part in a screening programme featuring a low dose CT scan for kidney cancer screening alone [OR 0.19 (0.14-0.27)]. CONCLUSION Participants in this study expressed high levels of intention to accept an invitation to screening for kidney cancer, both within a kidney cancer specific screening programme and in conjunction with lung cancer screening. The choice of screening test is likely to influence uptake. Together these findings support on-going research into kidney cancer screening tests and the potential for combining kidney cancer screening with existing or new screening programmes.
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Affiliation(s)
- Laragh L. W. Harvey-Kelly
- University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0SP UK
| | - Hannah Harrison
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB2 0SR UK
| | - Sabrina H. Rossi
- Department of Oncology, University of Cambridge, Addenbrooke’s Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ UK
| | - Simon J. Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB2 0SR UK
| | - Grant D. Stewart
- Department of Surgery, University of Cambridge, Addenbrooke’s Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ UK
| | - Juliet A. Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB2 0SR UK
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Paxton B, Mills K, Usher-Smith JA. Fidelity of the delivery of NHS Health Checks in general practice: an observational study. BJGP Open 2020; 4:bjgpopen20X101077. [PMID: 32967842 PMCID: PMC7606139 DOI: 10.3399/bjgpopen20x101077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 02/02/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The NHS Health Check programme aims to reduce the risk of common preventable diseases by providing risk information and behaviour change advice. Failure to deliver the consultation appropriately could undermine its efficacy. To date, to the authors' knowledge, there are no published data on the fidelity of delivery of NHS Health Checks. AIM To assess the fidelity of delivery of NHS Health Checks in general practice. DESIGN & SETTING Fidelity assessment of video and audio recordings of NHS Health Check consultations conducted in four GP practices across the East of England. METHOD A secondary analysis of 38 NHS Health Check consultations, which were video or audio recorded as part of a pilot study of introducing discussions of cancer risk into NHS Health Checks. Using a checklist based on the NHS Health Check Best Practice Guidance, fidelity of delivery was assessed as the proportion of key elements completed during the consultations. RESULTS The mean number of elements of the NHS Health Check completed across all consultations was 14.5/18 (80.6%), with a range of 10 to 17 (55.6% to 94.4%). The mean fidelity for risk assessment, risk communication, and risk management sections was 8.7/10 (87.0%), 4.1/5 (82.0%), and 1.7/3 (56.7%), respectively. Clinically appropriate lifestyle advice was given in 34/38 consultations. Elements with the lowest fidelity were ethnicity assessment (n = 12/38; 31.6%), family history of cardiovascular disease (CVD) assessment (n = 25/38; 65.8%), AUDIT-C communication (n = 13/38; 34.2%), and dementia risk management (n = 6/38; 15.8%). CONCLUSION Although fidelity of delivery was high overall, important elements of the NHS Health Check were being regularly omitted. Opportunities for behaviour change, particularly relating to alcohol consumption and dementia risk management, may be being missed.
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Affiliation(s)
- Ben Paxton
- University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Katie Mills
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Masson G, Mills K, Griffin SJ, Sharp SJ, Klein WMP, Sutton S, Usher-Smith JA. A randomised controlled trial of the effect of providing online risk information and lifestyle advice for the most common preventable cancers. Prev Med 2020; 138:106154. [PMID: 32473959 PMCID: PMC7378571 DOI: 10.1016/j.ypmed.2020.106154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 05/20/2020] [Accepted: 05/22/2020] [Indexed: 11/01/2022]
Abstract
Few trial data are available concerning the impact of personalised cancer risk information on behaviour. This study assessed the short-term effects of providing personalised cancer risk information on cancer risk beliefs and self-reported behaviour. We randomised 1018 participants, recruited through the online platform Prolific, to either a control group receiving cancer-specific lifestyle advice or one of three intervention groups receiving their computed 10-year risk of developing one of the five most common preventable cancers either as a bar chart, a pictograph or a qualitative scale alongside the same lifestyle advice. The primary outcome was change from baseline in computed risk relative to an individual with a recommended lifestyle (RRI)1 at three months. Secondary outcomes included: health-related behaviours, risk perception, anxiety, worry, intention to change behaviour, and a newly defined concept, risk conviction. After three months there were no between-group differences in change in RRI (p = 0.71). At immediate follow-up, accuracy of absolute risk perception (p < 0.001), absolute and comparative risk conviction (p < 0.001) and intention to increase fruit and vegetables (p = 0.026) and decrease processed meat (p = 0.033) were higher in all intervention groups relative to the control group. The increases in accuracy and conviction were only seen in individuals with high numeracy and low baseline conviction, respectively. These findings suggest that personalised cancer risk information alongside lifestyle advice can increase short-term risk accuracy and conviction without increasing worry or anxiety but has little impact on health-related behaviour. Trial registration: ISRCTN17450583. Registered 30 January 2018.
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Affiliation(s)
- Golnessa Masson
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Box 113, Cambridge Biomedical Campus, Cambridge CB2 0SR, UK.
| | - Katie Mills
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Box 113, Cambridge Biomedical Campus, Cambridge CB2 0SR, UK.
| | - Simon J Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Box 113, Cambridge Biomedical Campus, Cambridge CB2 0SR, UK.
| | - Stephen J Sharp
- MRC Epidemiology Unit, University of Cambridge, Institute of Metabolic Science, Cambridge CB2 0QQ, UK.
| | | | - Stephen Sutton
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Box 113, Cambridge Biomedical Campus, Cambridge CB2 0SR, UK.
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Box 113, Cambridge Biomedical Campus, Cambridge CB2 0SR, UK.
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Saunders CL, Kilian B, Thompson DJ, McGeoch LJ, Griffin SJ, Antoniou AC, Emery JD, Walter FM, Dennis J, Yang X, Usher-Smith JA. External Validation of Risk Prediction Models Incorporating Common Genetic Variants for Incident Colorectal Cancer Using UK Biobank. Cancer Prev Res (Phila) 2020; 13:509-520. [PMID: 32071122 PMCID: PMC7610623 DOI: 10.1158/1940-6207.capr-19-0521] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 01/15/2020] [Accepted: 02/11/2020] [Indexed: 12/22/2022]
Abstract
The aim of this study was to compare and externally validate risk scores developed to predict incident colorectal cancer that include common genetic variants (SNPs), with or without established lifestyle/environmental (questionnaire-based/classical/phenotypic) risk factors. We externally validated 23 risk models from a previous systematic review in 443,888 participants ages 37 to 73 from the UK Biobank cohort who had 6-year prospective follow-up, no prior history of colorectal cancer, and data for incidence of colorectal cancer through linkage to national cancer registries. There were 2,679 (0.6%) cases of incident colorectal cancer. We assessed model discrimination using the area under the operating characteristic curve (AUC) and relative risk calibration. The AUC of models including only SNPs increased with the number of included SNPs and was similar in men and women: the model by Huyghe with 120 SNPs had the highest AUC of 0.62 [95% confidence interval (CI), 0.59-0.64] in women and 0.64 (95% CI, 0.61-0.66) in men. Adding phenotypic risk factors without age improved discrimination in men but not in women. Adding phenotypic risk factors and age increased discrimination in all cases (P < 0.05), with the best performing models including SNPs, phenotypic risk factors, and age having AUCs between 0.64 and 0.67 in women and 0.67 and 0.71 in men. Relative risk calibration varied substantially across the models. Among middle-aged people in the UK, existing polygenic risk scores discriminate moderately well between those who do and do not develop colorectal cancer over 6 years. Consideration should be given to exploring the feasibility of incorporating genetic and lifestyle/environmental information in any future stratified colorectal cancer screening program.
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Affiliation(s)
- Catherine L Saunders
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Britt Kilian
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Deborah J Thompson
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, United Kingdom
| | - Luke J McGeoch
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Simon J Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Antonis C Antoniou
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, United Kingdom
| | - Jon D Emery
- Department of General Practice, Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Fiona M Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Joe Dennis
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, United Kingdom
| | - Xin Yang
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, United Kingdom
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.
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Usher-Smith JA, Harshfield A, Saunders CL, Sharp SJ, Emery J, Walter FM, Muir K, Griffin SJ. Correction: External validation of risk prediction models for incident colorectal cancer using UK Biobank. Br J Cancer 2020; 122:1572-1575. [PMID: 32203217 PMCID: PMC7217758 DOI: 10.1038/s41416-020-0767-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- J A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB2 0SR, UK.
| | - A Harshfield
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB2 0SR, UK
| | - C L Saunders
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB2 0SR, UK
| | - S J Sharp
- MRC Epidemiology Unit, University of Cambridge, Institute of Metabolic Science, Cambridge, CB2 0QQ, UK
| | - J Emery
- Department of General Practice, Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, VIC, 3010, Australia
| | - F M Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB2 0SR, UK
| | - K Muir
- Institute of Population Health, University of Manchester, Manchester, M13 9PL, UK
| | - S J Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB2 0SR, UK.,MRC Epidemiology Unit, University of Cambridge, Institute of Metabolic Science, Cambridge, CB2 0QQ, UK
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Mills K, Griffin SJ, Sutton S, Usher-Smith JA. Development and usability testing of a very brief intervention for personalised cancer risk assessment to promote behaviour change in primary care using normalisation process theory. Prim Health Care Res Dev 2020; 21:e1. [PMID: 31934843 PMCID: PMC7005588 DOI: 10.1017/s146342361900080x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 09/13/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Cancer is the second leading cause of death worldwide. Lifestyle choices play an important role in the aetiology of cancer with up to 4 in 10 cases potentially preventable. Interventions delivered by healthcare professionals (HCPs) that incorporate risk information have the potential to promote behaviour change. Our aim was to develop a very brief intervention incorporating cancer risk, which could be implemented within primary care. METHODS Guided by normalisation process theory (NPT), we developed a prototype intervention using literature reviews, consultation with patient and public representatives and pilot work with patients and HCPs. We conducted focus groups and interviews with 65 HCPs involved in delivering prevention activities. Findings were used to refine the intervention before 22 HCPs completed an online usability test and provided further feedback via a questionnaire incorporating a modified version of the NoMAD checklist. RESULTS The intervention included a website where individuals could provide information on lifestyle risk factors view their estimated 10-year risk of developing one or more of the five most common preventable cancers and access lifestyle advice incorporating behaviour change techniques. Changes incorporated from feedback from the focus groups and interviews included signposting to local services and websites, simplified wording and labelling of risk information. In the usability testing, all participants felt it would be easy to collect the risk information. Ninety-one percent felt the intervention would enable discussion about cancer risk and believed it had potential to be easily integrated into National Health Service (NHS) Health Checks. However, only 36% agreed it could be delivered within 5 min. CONCLUSIONS With the use of NPT, we developed a very brief intervention that is acceptable to HCPs in primary care and could be potentially integrated into NHS Health Checks. However, further work is needed to assess its feasibility and potential effectiveness.
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Affiliation(s)
- Katie Mills
- Research Associate, The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Simon J. Griffin
- Professor of General Practice, The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Stephen Sutton
- Professor of Behavioural Science, The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Juliet A. Usher-Smith
- Clinical Senior Research Associate, The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge, UK
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Harrison H, Griffin SJ, Kuhn I, Usher-Smith JA. Software tools to support title and abstract screening for systematic reviews in healthcare: an evaluation. BMC Med Res Methodol 2020; 20:7. [PMID: 31931747 PMCID: PMC6958795 DOI: 10.1186/s12874-020-0897-3] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 01/02/2020] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Systematic reviews are vital to the pursuit of evidence-based medicine within healthcare. Screening titles and abstracts (T&Ab) for inclusion in a systematic review is an intensive, and often collaborative, step. The use of appropriate tools is therefore important. In this study, we identified and evaluated the usability of software tools that support T&Ab screening for systematic reviews within healthcare research. METHODS We identified software tools using three search methods: a web-based search; a search of the online "systematic review toolbox"; and screening of references in existing literature. We included tools that were accessible and available for testing at the time of the study (December 2018), do not require specific computing infrastructure and provide basic screening functionality for systematic reviews. Key properties of each software tool were identified using a feature analysis adapted for this purpose. This analysis included a weighting developed by a group of medical researchers, therefore prioritising the most relevant features. The highest scoring tools from the feature analysis were then included in a user survey, in which we further investigated the suitability of the tools for supporting T&Ab screening amongst systematic reviewers working in medical research. RESULTS Fifteen tools met our inclusion criteria. They vary significantly in relation to cost, scope and intended user community. Six of the identified tools (Abstrackr, Colandr, Covidence, DRAGON, EPPI-Reviewer and Rayyan) scored higher than 75% in the feature analysis and were included in the user survey. Of these, Covidence and Rayyan were the most popular with the survey respondents. Their usability scored highly across a range of metrics, with all surveyed researchers (n = 6) stating that they would be likely (or very likely) to use these tools in the future. CONCLUSIONS Based on this study, we would recommend Covidence and Rayyan to systematic reviewers looking for suitable and easy to use tools to support T&Ab screening within healthcare research. These two tools consistently demonstrated good alignment with user requirements. We acknowledge, however, the role of some of the other tools we considered in providing more specialist features that may be of great importance to many researchers.
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Affiliation(s)
- Hannah Harrison
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
| | - Simon J Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- MRC Epidemiology Unit, Institute of Metabolic Science, Cambridge, UK
| | - Isla Kuhn
- University of Cambridge Medical Library, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Bayne M, Fairey M, Silarova B, Griffin SJ, Sharp SJ, Klein WMP, Sutton S, Usher-Smith JA. Effect of interventions including provision of personalised cancer risk information on accuracy of risk perception and psychological responses: A systematic review and meta-analysis. Patient Educ Couns 2020; 103:83-95. [PMID: 31439435 PMCID: PMC6919334 DOI: 10.1016/j.pec.2019.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/23/2019] [Accepted: 08/08/2019] [Indexed: 05/21/2023]
Abstract
OBJECTIVE To synthesize the literature on the effect of provision of personalised cancer risk information to individuals at population level risk on accuracy of risk perception and psychological responses. METHODS A systematic review and random effects meta-analysis of articles published from 01/01/2000 to 01/07/2017. RESULTS We included 23 studies. Immediately after provision of risk information 87% of individuals were able to recall the absolute risk estimate. Less than half believed that to be their risk, with up to 71% believing their risk to be higher than the estimate. Provision of risk information increased accuracy of perceived absolute risk immediately after risk information compared with no information (pooled RR 4.16 (95%CI 1.28-13.49), 3 studies). There was no significant effect on comparative risk accuracy (pooled RR 1.39 (0.72-2.69), 2 studies) and either no change or a reduction in cancer worry, anxiety and fear. CONCLUSION These findings highlight the complex cognitive processes involved in the conceptualisation of risk. PRACTICE IMPLICATIONS Individuals who appear to understand and are able to recall risk information most likely do not believe it reflects their own risk.
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Affiliation(s)
- Max Bayne
- University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Madi Fairey
- University of Cambridge School of Clinical Medicine, Cambridge, UK
| | | | - Simon J Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephen J Sharp
- MRC Epidemiology Unit, University of Cambridge, Cambridge UK
| | - William M P Klein
- Behavioral Research Program, National Cancer Institute, Rockville, MD, USA
| | - Stephen Sutton
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
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