Search

Objective: The objective of this study is to investigate primary care use by men with recent onset of lower urinary tract symptoms (LUTS) to identify differences in presentation and investigation that may explain ethnic inequality in prostate cancer outcomes. Methods: This is a multi‐method study of men presenting LUTS to primary care. Two hundred seventy‐four men completed a self‐administered questionnaire, and 23 participated in face‐to‐face interviews. Regression analyses investigated ethnic differences in (a) the period between symptom onset and first primary care presentation (patient interval) and (b) the interval between first primary care presentation and investigation with prostate‐specific antigen (PSA) and digital rectal examination (DRE). Interview data were analysed using thematic analysis. Results: Half (144, 53%) reported a solitary first symptom, although multiple first symptoms were also common, particularly in Asian and Black men. There was no difference between ethnicities in patient interval or time from presentation to investigation. However, Asian men were offered less PSA testing (odds ratio 0.39; 95% confidence interval 0.17–0.92; p = 0.03). Qualitative data revealed ethnic differences in general practitioners' offer of DRE and PSA testing and highlighted limitations in doctor–patient communication and safety netting. Conclusion: Our study showed only small differences in primary care experiences, insufficient to explain ethnic inequalities in prostate cancer outcomes. [ABSTRACT FROM AUTHOR]

Background/Objectives: Some international guidelines recommend a risk‐based approach to screening for melanoma, but few suggest how to account for multiple risk factors or how to implement risk‐based screening in practice. This study investigated the acceptability and feasibility of identifying patients at increased risk of melanoma in Australian general practice using a self‐completed risk assessment tool. Stratification of risk was based on the validated Williams melanoma risk prediction model. Methods: Patients and companions aged 18 or older in Australian general practices were approached in the waiting room and invited to enter information about their melanoma risk factors into the tool using an iPad. Acceptability was measured by the proportion of people willing to participate from those invited and feasibility by the number of people able to complete the tool unaided. Risk of developing melanoma was stratified into four risk categories using the Williams model. Results: 1535 (90.4%) participants were recruited from two general practices. Only 200 participants (13%) needed assistance to complete the tool. The mean risk score for participants was 15.2 (±SD 9.8). The Williams model estimated between 5% and 19% of the sample were at increased risk accounting for an estimated 30% to 60% of future incident melanomas. Conclusions: A risk‐stratified tool using the Williams model was acceptable and feasible for patients to self‐complete in general practice clinics. This could be an effective way to identify people in primary care for implementing risk‐based targeted melanoma screening and prevention. [ABSTRACT FROM AUTHOR]

Objectives: To explore the evidence for cognitive heuristics or "rules of thumb" used within patients' reports of symptom appraisal and decisions to seek help for symptoms of cancer.Methods: A secondary analysis of interviews from existing studies that explored symptom appraisal in patients who had sought help for potential symptoms of cancer. Transcripts from n = 50 in-depth interviews with patients referred with symptoms suspicious of cancer (pancreas, colorectal, oral, lung, melanoma, breast, and prostate) were re-analysed using a deductive thematic approach underpinned by the heuristics outlined in the Common Sense Model of Illness Self-regulation as set within the Model of Pathways to Treatment.Results: The most dominant heuristic in patient reports was the Rate of change rule (ie, symptoms that are worsening, increasing, or have a sudden onset [rather than improving, stable or decreasing in number] are more likely to indicate illness). There was also support for the Duration rule, Pattern rule, Chronology rule, Severity (of interference) rule, Age-illness rule, Novelty rule, Similarity rule, Location rule, and Optimistic bias rule. There was a lack of evidence for the Prevalence and Stress-illness rules.Conclusions: People do appear to use heuristics to guide their appraisal of symptoms and their perceived need for healthcare. Heuristics may be an important aspect underlying symptom misinterpretation, thus making them key targets for interventions. For instance, campaigns could tackle cognitive biases rather than focusing on specific symptom awareness. Myth-busting messages could highlight that intermittent, mild symptoms, and symptoms that are not worsening can be signs of a serious health problem. [ABSTRACT FROM AUTHOR]

Background: In sub-Saharan Africa (SSA), breast cancer is the most commonly diagnosed cancer among women, while cervical cancer remains the leading cause of cancer death. Women often fail to recognise or misinterpret possible symptoms, so breast and cervical cancer symptom awareness information can promote timely help-seeking behaviour, diagnosis and start of treatment. Aim: To identify tools that have been utilised to measure breast and cervical cancer symptom awareness in SSA and to establish if such tools have been validated in SSA populations. Methods: A scoping review of articles published between January 1997 and February 2017, written in English and describing primary research in breast and/or cervical cancer symptom awareness-related topics in SSA contexts, was undertaken across five databases. The approach was supported by Colquhoun et al.'s methodological framework for scoping reviews. Results: A total of 41 studies were included from 11 SSA countries. Almost half (20/41) used breast and/or cervical cancer symptom awareness tools but did not report on tool validation processes. The rest (21/41) made reference to some tool validation, yet only two reported a detailed account of their tool validation processes. One explored lay perceptions of breast cancer, while the other sought to establish the validity and reliability of a UK tool in a Kenyan context. Conclusion: The findings point to the dearth of comprehensively validated and culturally relevant tools to measure breast and cervical cancer symptom awareness in the SSA context. They have informed the development and validation of an African Women Awareness of CANcer (AWACAN) tool, which can support the development and evaluation of interventions relevant to the SSA context. [ABSTRACT FROM AUTHOR]

Background: The early detection and diagnosis of cancer to reduce avoidable mortality and morbidity is a challenging task in primary health care. There is a growing evidence base on how to enable earlier cancer diagnosis, but well-recognised gaps and delays exist around the translation of new research findings into routine clinical practice. Implementation research aims to accelerate the uptake of evidence by health care systems and professionals. We aimed to identify priorities for implementation research in early cancer diagnosis in primary care. Methods: We used a RAND/UCLA modified Delphi consensus process to identify and rank research priorities. We asked primary care physicians, patients and researchers to complete an online survey suggesting priorities for implementation research in cancer detection and diagnosis. We summarised and presented these suggestions to an 11-member consensus panel comprising nine primary care physicians and two patients. Panellists independently rated the importance of suggestions on a 1–9 scale (9 = very high priority; 1 = very low priority) before and after a structured group discussion. We ranked suggestions using median ratings. Results: We received a total of 115 suggested priorities for implementation research from 32 survey respondents (including 16 primary care professionals, 11 researchers, and 4 patient and public representatives; 88% of respondents were UK-based). After removing duplicates and ineligible suggestions, we presented 37 suggestions grouped within 17 categories to the consensus panel. Following two rounds of rating, 27 suggestions were highly supported (median rating 7–9). The most highly rated suggestions concerned diagnostic support (e.g., access to imaging) interventions (e.g., professional or patient education), organisation of the delivery of care (e.g., communication within and between teams) and understanding variations in care and outcomes. Conclusions: We have identified a set of priorities for implementation research on the early diagnosis of cancer, ranked in importance by primary care physicians and patients. We suggest that researchers and research funders consider these in directing further efforts and resources to improve population outcomes. [ABSTRACT FROM AUTHOR]

This Viewpoint discusses the need to expand early cancer detection to include both screening and symptom detection to achieve the goal of diagnostic excellence for cancer. [ABSTRACT FROM AUTHOR]

Background: The objective of this study is to investigate symptoms, clinical factors and socio-demographic factors associated with colorectal cancer (CRC) diagnosis and time to diagnosis.Methods: Prospective cohort study of participants referred for suspicion of CRC in two English regions. Data were collected using a patient questionnaire, primary care and hospital records. Descriptive and regression analyses examined associations between symptoms and patient factors with total diagnostic interval (TDI), patient interval (PI), health system interval (HSI) and stage.Results: A total of 2677 (22%) participants responded; after exclusions, 2507 remained. Participants were diagnosed with CRC (6.1%, 56% late stage), other cancers (2.0%) or no cancer (91.9%). Half the cohort had a solitary first symptom (1332, 53.1%); multiple first symptoms were common. In this referred population, rectal bleeding was the only initial symptom more frequent among cancer than non-cancer cases (34.2% vs 23.9%, P=0.004). There was no evidence of differences in TDI, PI or HSI for those with cancer vs non-cancer diagnoses (median TDI CRC 124 vs non-cancer 138 days, P=0.142). First symptoms associated with shorter TDIs were rectal bleeding, change in bowel habit, 'feeling different' and fatigue/tiredness. Anxiety, depression and gastro-intestinal co-morbidities were associated with longer HSIs and TDIs. Symptom duration-dependent effects were found for rectal bleeding and change in bowel habit.Conclusions: Doctors and patients respond less promptly to some symptoms of CRC than others. Healthcare professionals should be vigilant to the possibility of CRC in patients with relevant symptoms and mental health or gastro-intestinal comorbidities. [ABSTRACT FROM AUTHOR]

Background: Emotions may be important in patients' decisions to seek medical help for symptoms suggestive of cancer. Objectives: The aim of this systematic literature review was to examine quantitative literature on the influence of emotion on patients' help-seeking for symptoms suggestive of cancer. The objectives were to identify the following: (a) which types of emotions influence help-seeking behaviour, (b) whether these form a barrier or trigger for seeking medical help and (c) how the role of emotions varies between different cancers and populations. Methods: We searched four electronic databases and conducted a narrative synthesis. Inclusion criteria were studies that reported primary, quantitative research that examined any emotion specific to symptom appraisal or help-seeking for symptoms suggestive of cancer. Results: Thirty-three papers were included. The studies were heterogeneous in their methods and quality, and very few had emotion as the main focus of the research. Studies reported a limited range of emotions, mainly related to fear and worry. The impact of emotions appears mixed, sometimes acting as a barrier to consultation whilst at other times being a trigger or being unrelated to time to presentation. It is plausible that different emotions play different roles at different times prior to presentation. Conclusions: This systematic review provides some quantitative evidence for the role of emotions in help-seeking behaviour. However, it also highlighted widespread methodological, definition and design issues among the existing literature. The conflicting results around the role of emotions on time to presentation may be due to the lack of definition of each specific emotion. [ABSTRACT FROM AUTHOR]

Background: Worldwide, the incidence of cutaneous melanoma has been reported to be highest in the summer and lowest in the winter. Northern Irish data suggested seasonal variation for women only, especially those with thinner melanomas, sited on limbs. We interrogated two larger UK cancer registries for temporal differences in melanoma diagnosis and associated patient characteristics. Methods: Melanomas diagnosed from 2006 to 2010 in the Eastern England and Scottish cancer registries (n = 11,611) were analysed by month of diagnosis, patient demographics and melanoma characteristics, using descriptive and multivariate modelling methods. Results: More patients with melanoma were diagnosed in the summer months (June 9.9%, July 9.7%, August 9.8%) than the winter months (December 7.2%, January 7.2%, February 7.1%) and this pattern was consistent in both regions. There was evidence that the seasonal patterns varied by sex (p = 0.015), melanoma thickness (p = 0.002), body site (p = 0.006), and type (superficial spreading melanomas p = 0.005). The seasonal variation was greatest for diagnosis of melanomas occurring on the limbs. Conclusion: This study has confirmed seasonal variation in melanoma diagnosis in Eastern England and Scotland across almost all population demographics and melanoma characteristics studied, with higher numbers diagnosed in the summer months, particularly on the limbs. Seasonal patterns in skin awareness and related help-seeking are likely to be implicated. Targeted patient interventions to increase sun awareness and encourage year-long skin inspection are warranted. [ABSTRACT FROM AUTHOR]

Background. Previous studies have focused on the treatment received by rural cancer patients and have not examined their diagnostic pathways as reasons for poorer outcomes in rural Australia. Objectives. To compare and explore diagnostic pathways and diagnostic intervals in patients with breast, lung, prostate or colorectal cancer from rural Western Australia (WA) to inform future interventions aimed at reducing time to cancer diagnosis. Methods. Mixed methods study of people recently diagnosed with breast, lung, prostate or colorectal cancer from the Goldfields and Great Southern Regions of WA. Qualitative interviews explored participants’ diagnostic pathways and factors underlying differences observed between individuals and cancers. Data were extracted from general practice and hospital records to calculate intervals from first presentation in general practice to final diagnosis. Results. Sixty-six participants were recruited (43 Goldfields and 23 Great Southern region; 24 breast, 20 colorectal, 14 prostate and 8 lung cancers). There were significant overall differences between cancers in time from presentation in general practice to referral (P = 0.045), from referral to seeing a specialist (P = 0.010) and from specialist appointment to cancer diagnosis (P ≤ 0.001). These differences were due to the nature of presenting symptoms, access to diagnostic tests and multiple visits to specialists. Breast cancer was diagnosed more quickly because its symptoms are more specific and due to better access to diagnostic tests and specialist one-stop clinics. Conclusions. Interventions to improve cancer diagnosis in rural Australia should focus on better case selection in general practice and better access to diagnostic tests, especially for prostate and colorectal cancers. [ABSTRACT FROM AUTHOR]

Background. Previous studies have focused on the treatment received by rural cancer patients and have not examined their diagnostic pathways as reasons for poorer outcomes in rural Australia. Objectives. To compare and explore symptom appraisal and help-seeking behaviour in patients with breast, lung, prostate or colorectal cancer from rural Western Australia (WA). Methods. A mixed-methods study of people recently diagnosed with breast, lung, prostate or colorectal cancer from rural WA. The time from first symptom to diagnosis (i.e. total diagnostic interval, TDI) was calculated from interviews and medical records. Results. Sixty-six participants were recruited (24 breast, 20 colorectal, 14 prostate and 8 lung cancer patients). There was a highly significant difference in time from symptom onset to seeking help between cancers (P = 0.006). Geometric mean symptom appraisal for colorectal cancer was significantly longer than that for breast and lung cancers [geometric mean differences: 2.58 (95% confidence interval, CI: 0.64–4.53), P = 0.01; 3.97 (1.63–6.30), P = 0.001, respectively]. There was a significant overall difference in arithmetic mean TDI (P = 0.046); breast cancer TDI was significantly shorter than colorectal or prostate cancer TDI [mean difference : 266.3 days (95% CI: 45.9–486.8), P = 0.019; 277.0 days, (32.1–521.9), P = 0.027, respectively]. These differences were explained by the nature and personal interpretation of symptoms, perceived as well as real problems of access to health care, optimism, stoicism, machismo, fear, embarrassment and competing demands. Conclusions. Longer symptom appraisal was observed for colorectal cancer. Participants defined core characteristics of rural Australians as optimism, stoicism and machismo. These features, as well as access to health care, contribute to later presentation of cancer. [ABSTRACT FROM AUTHOR]

Background: Melanoma incidence in the UK has doubled over two decades, yet there is conflicting evidence about factors which prompt or delay patients seeking advice. Aim: To explore patient understanding of pigmented skin lesions (moles) and skin cancer, and factors which influence seeking help in primary care. Method: Semi-structured interviews with forty MoleMate Trial participants, analysed using the theoretical framework of the Safer-Andersen model of Total Patient Delay. Results: Patient understanding and awareness was influenced by personal, family and friends' experiences of moles, skin cancer and other cancers, knowledge of risk factors, and the lay media. The route to consulting was complex and often iterative. For lesions that people could see, detecting and appraising change was influenced by comparisons with a normal mole on themselves, a family member, friend or image. Inferring illness came about with recognition of changes (particularly size) as serious, and associated 'internal' symptoms such as pain. For lesions that people could not see, family, friends and health professionals detected and appraised changes. Deciding to seek help was often prompted by another person or triggered by rapid or multiple changes in a mole. Three of four people subsequently diagnosed with melanoma did not seek help; instead, their GP opportunistically noticed the lesion. Conclusions: Changing moles are often perceived as trivial and not signifying possible skin cancer. This study contributes to current national strategies to improve patient awareness and earlier diagnosis of cancer by highlighting factors that can trigger or act as barriers to seeking help. [ABSTRACT FROM AUTHOR]

Background: Suspicious pigmented lesions are a common presenting problem in general practice consultations; while the majority are benign a small minority are melanomas. Differentiating melanomas from other pigmented lesions in primary care is challenging: currently, 95% of all lesions referred to a UK specialist are benign. The MoleMate system is a new diagnostic aid, incorporating a hand-held SIAscopy scanner with a primary care diagnostic algorithm. This trial tests the hypothesis that adding the MoleMate system to current best primary care practice will increase the proportion of appropriate referrals of suspicious pigmented lesions to secondary care compared with current best practice alone. Methods/design: The MoleMate UK Trial is a primary care based multi-centre randomised controlled trial, with randomisation at patient level using a validated block randomisation method for two age groups (45 years and under; 46 years and over). We aim to recruit adult patients seen in general practice with a pigmented skin lesion that cannot immediately be diagnosed as benign and the patient reassured. The trial has a 'two parallel groups' design, comparing 'best practice' with 'best practice' plus the MoleMate system in the intervention group. The primary outcome is the positive predictive value (PPV) of referral defined as the proportion of referred lesions seen by secondary care experts that are considered 'clinically significant' (i.e. biopsied or monitored). Secondary outcomes include: the sensitivity, specificity and negative predictive value (NPV) of the decision not to refer; clinical outcomes (melanoma thickness, 5 year melanoma incidence and mortality); clinician outcomes (Index of Suspicion, confidence, learning effects); patient outcomes (satisfaction, general and cancer-specific worry), and cost-utility. Discussion: The MoleMate UK Trial tests a new technology designed to improve the management of suspicious pigmented lesions in primary care. If effective, the MoleMate system could reduce the burden on skin cancer clinics of patients with benign pigmented skin lesions, and improve patient care in general practice. [ABSTRACT FROM AUTHOR]

Background: Spectrophotometric intracutaneous analysis (SIAscopy™) is a multispectral imaging technique that is used to identify 'suspicious' (i.e. potentially malignant) pigmented skin lesions for further investigation. The MoleMate™ system is a hand-held scanner that captures SIAscopy™ images that are then classified by the clinician using a computerized diagnostic algorithm designed for the primary health care setting. The objectives of this study were to test the effectiveness of a computer program designed to train health care workers to identify the diagnostic features of SIAscopy™ images and compare the results of a group of Australian and a group of English general practitioners (GPs). Methods: Thirty GPs recruited from the Perth (Western Australia) metropolitan area completed the training program at a workshop held in March 2008. The accuracy and speed of their pre- and post-test scores were then compared with those of a group of 18 GPs (including 10 GP registrars) who completed a similar program at two workshops held in Cambridge (U.K.) in March and April, 2007. Results: The median test score of the Australian GPs improved from 79.5% to 86.5% (median increase 5.5%; p < 0.001) while the median test score of the English GPs improved from 74.5% to 86.5% (median increase 9.5%; p < 0.001). The Australian GPs had significantly higher pre-test scores but there were no significant differences in post-test scores between the Australian and English GPs or between the GPs and GP registrars. There was no significant difference in scores between GPs with previous dermoscopy experience or dermatology training. Conclusion: Most of the SIAscopy™ features can be learnt to a reasonable degree of accuracy with this brief computer training program. Although the Australian GPs scored higher in the pre- test, both groups had similar levels of accuracy and speed in interpreting the SIAscopy™ features after completing the program. Scores were not affected by previous dermoscopy experience or dermatology training, which suggests that the MoleMate&trade ; system is relatively easy to learn. [ABSTRACT FROM AUTHOR]

This article presents a research that focuses on how patients in primary care understand and come to terms with their family history of chronic diseases. Social science research suggests that while the professional perspective is informed by biomedical models, the patient's perspective is more likely to be based on their illness experiences. Once a person acknowledges that an illness runs in the family, the family history grows in meaning through many routes until there is gained a sense of vulnerability to the disease, which the person then attempts to cope with or control.

Evaluates the qualitative literature that explores understanding about familial risk held by persons with a family history of cancer, coronary artery disease, and diabetes mellitus. Increase in the use of family history for genetic risk assessment to common chronic diseases in primary care; Development of a personal sense of vulnerability by persons with a family history of a common chronic disease; Role of patients' understanding about a disease, its cause, and its treatment in conflicting with the medical perspective.

Primary care consultations about the menopause and hormone replacement therapy (HRT) involve decision making in the face of clinical uncertainty. This qualitative study used focus groups and semi-structured interviews with primary care patients to explore patients’ perspectives of optimal risk communication and decision making, and their views on how to improve its effectiveness. The study was set in two general practices in Cambridge, and the participants were 40 women aged between 50 and 55 years, known to be Current-Users (CU), Ex-Users (EU), or Never-Users (NU) of HRT. The majority of participants favoured communication of risks and benefits to facilitate an informed and personalised choice resulting in informed shared decision making, while some wanted a more directive approach. Women felt that risk communication would be optimised by the provision of unbiased, truthful and summarised information, and also by the personalisation of both this risk information and subsequent management of the menopause and treatment with HRT. Barriers to optimal risk communication and decision making included lack of time, GP attitudes and poor communication in the primary care consultation. In summary, consultations concerning the menopause and HRT involve complex decision making in the face of uncertainty, and most patients favour evidence-based, individualised risk information and shared decision making leading to informed choices. Some patients wish for a more directive approach, and practitioners need to develop skills to evaluate each patient’s needs at each consultation. [Copyright &y& Elsevier]

A study published in the British Journal of Dermatology examines the use of artificial intelligence (AI) technology in the diagnosis and early detection of melanoma in primary care. The study implemented a smartphone-based AI app that analyzed dermoscopic images to provide feedback on evidence of melanoma. The app showed high accuracy rates, with a sensitivity of 95.2% and specificity of 60.3%. However, there are concerns that the app may fail to detect rarer skin cancers or unusual presentations of melanoma, and that its use may exacerbate healthcare inequities for individuals with darker skin types. Further research is needed to address these concerns before implementing AI technologies in primary care. [Extracted from the article]

Simple Summary: In England, patients with alarm features of cancer should be assessed by a specialist within 14 days based on national guidelines. However, it is not known how quickly these patients are actually diagnosed. We therefore examined how quickly patients who met these fast-track referral criteria were actually diagnosed, using bladder and kidney cancer patients as exemplars. We found that of the patients who qualified for fast-track referral, more than one-quarter did not receive a timely diagnosis. Those with recurrent urinary tract infections, of female sex and in the extremes of age, were most likely to have a non-timely diagnosis. Our findings suggest that opportunities exist to improve timely referral in patients with bladder and kidney cancer. Background: In England, patients who meet National Institute for Health and Care Excellence (NICE) guideline criteria for suspected cancer should receive a specialist assessment within 14 days. We examined how quickly bladder and kidney cancer patients who met fast-track referral criteria were actually diagnosed. Methods: We used linked primary care and cancer registration data on bladder and kidney cancer patients who met fast-track referral criteria and examined the time from their first presentation with alarm features to diagnosis. Using logistic regression we examined factors most likely to be associated with non-timely diagnosis (defined as intervals exceeding 90 days), adjusting for age, sex and cancer type, positing that such occurrences represent missed opportunity for timely referral, possibly due to sub-optimal guideline adherence. Results: 28%, 42% and 31% of all urological cancer patients reported no, one or two or more relevant symptoms respectively in the year before diagnosis. Of the 2105 patients with alarm features warranting fast-track assessment, 1373 (65%) presented with unexplained haematuria, 382 (18%) with recurrent urinary tract infections (UTIs), 303 (14%) with visible haematuria, and 45 (2%) with an abdominal mass. 27% overall, and 24%, 45%, 18% and 27% of each group respectively, had a non-timely diagnosis. Presentation with recurrent UTI was associated with longest median diagnostic interval (median 83 days, IQR 43–151) and visible haematuria with the shortest (median 50 days, IQR 30–79). After adjustment, presentation with recurrent UTIs, being in the youngest or oldest age group, female sex, and diagnosis of kidney and upper tract urothelial cancer, were associated with greater odds of non-timely diagnosis. Conclusion: More than a quarter of patients presenting with fast-track referral features did not achieve a timely diagnosis, suggesting inadequate guideline adherence for some patients. The findings highlight a substantial number of opportunities for expediting the diagnosis of patients with bladder or kidney cancers. [ABSTRACT FROM AUTHOR]

Objective: Lung cancer patients from ethnic minorities have poorer outcomes than their Caucasian counterparts. We compared lung cancer intervals between culturally and linguistically diverse (CALD) and Anglo‐Australian patients to identify ethnic disparities. Methods: This was a prospective, observational cohort study comprising a patient survey and reviews of patients' hospital and general practice records. Across three states, 577 (407 Anglo‐Australian and 170 CALD) patients were recruited and their hospital records reviewed. The survey was returned by 189 (135 Anglo‐Australian and 54 CALD) patients, and a review was completed by general practitioners (GPs) of 99 (76 Anglo‐Australian and 23 CALD) patients. Survival and Cox regression analyses were conducted. Results: CALD patients had longer hospital diagnostic interval [median 30 days, 95% confidence interval (CI) 26–34] than Anglo‐Australian patients (median 17, 95% CI 14–20), p = 0.005, hazard ratio (HR) = 1.32 (95% CI 1.09–1.60). This difference persisted after relevant factors were taken into consideration, adjusted HR = 1.26 (95% CI 1.03–1.54, p = 0.022). CALD patients also reported longer prehospital intervals; however, these differences were not statistically significant. Conclusion: Target interventions need to be developed to address ethnic disparity in hospital diagnostic interval. [ABSTRACT FROM AUTHOR]

Background: Novel diagnostic triage and testing strategies to support early detection of cancer could improve clinical outcomes. Most apparently promising diagnostic tests ultimately fail because of inadequate performance in real-world, low prevalence populations such as primary care or general community populations. They should therefore be systematically evaluated before implementation to determine whether they lead to earlier detection, are cost-effective, and improve patient safety and quality of care, while minimising over-investigation and over-diagnosis.Methods: We performed a systematic scoping review of frameworks for the evaluation of tests and diagnostic approaches.Results: We identified 16 frameworks: none addressed the entire continuum from test development to impact on diagnosis and patient outcomes in the intended population, nor the way in which tests may be used for triage purposes as part of a wider diagnostic strategy. Informed by these findings, we developed a new framework, the 'CanTest Framework', which proposes five iterative research phases forming a clear translational pathway from new test development to health system implementation and evaluation.Conclusion: This framework is suitable for testing in low prevalence populations, where tests are often applied for triage testing and incorporated into a wider diagnostic strategy. It has relevance for a wide range of stakeholders including patients, policymakers, purchasers, healthcare providers and industry. [ABSTRACT FROM AUTHOR]

Cancer affects one in two people in the UK and the incidence is set to increase. The UK National Health Service is facing major workforce deficits and cancer services have struggled to recover after the COVID-19 pandemic, with waiting times for cancer care becoming the worst on record. There are severe and widening disparities across the country and survival rates remain unacceptably poor for many cancers. This is at a time when cancer care has become increasingly complex, specialised, and expensive. The current crisis has deep historic roots, and to be reversed, the scale of the challenge must be acknowledged and a fundamental reset is required. The loss of a dedicated National Cancer Control Plan in England and Wales, poor operationalisation of plans elsewhere in the UK, and the closure of the National Cancer Research Institute have all added to a sense of strategic misdirection. The UK finds itself at a crossroads, where the political decisions of governments, the cancer community, and research funders will determine whether we can, together, achieve equitable, affordable, and high-quality cancer care for patients that is commensurate with our wealth, and position our outcomes among the best in the world. In this Policy Review, we describe the challenges and opportunities that are needed to develop radical, yet sustainable plans, which are comprehensive, evidence-based, integrated, patient-outcome focused, and deliver value for money. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: In South Africa, breast cancer is the most commonly diagnosed cancer and cervical cancer the leading cause of cancer mortality. Most cancers are diagnosed at a late-stage and following symptomatic presentation. The overall purpose of the study was to inform interventions aimed at improving timely diagnosis of breast and cervical cancer.Methods: In-depth interviews were conducted with women with potential breast or cervical cancer symptoms from urban and rural South Africa. Participants were recruited from a community-based cross-sectional study on breast and cervical cancer awareness. Data were analysed using a thematic analysis approach.Results: Eighteen women were interviewed (10 urban, 8 rural): the median age was 34.5 years (range 22-58). Most were unemployed, and five were HIV positive. Themes included impact and attribution of bodily changes; influence of social networks and health messaging in help-seeking; management of symptoms and help-seeking barriers. Breast changes were often attributed to manual activities or possible cancer. Women were often unsure how to interpret vaginal symptoms, attributing them to HIV, hormonal contraceptives, or partner infidelity. Concerns about cancer were based on health information from the radio, social networks, or from primary care providers. Prompt care seeking was triggered by impact of symptoms on personal lives. Rural women, especially with possible symptoms of cervical cancer, experienced challenges during help-seeking including judgmental attitudes of clinic staff. Most participants were skeptical of traditional medicine.Conclusions: This is the first study exploring interpretation of possible breast and cervical cancer symptoms at a community level in South Africa. The process of interpreting bodily changes, symptom attribution and help-seeking is complex and influenced by women's everyday life experiences. Timely diagnosis interventions should not only include cancer symptom awareness but also address individual, structural and health systems related barriers to care. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Lung cancer is the leading cause of cancer mortality worldwide. Early diagnosis and treatment is a key factor in reducing mortality and improving patient outcomes. To achieve this, it is important to understand the diagnostic pathways of cancer patients. Patients from Culturally and Linguistically Diverse (CALD) are a vulnerable group for lung cancer with higher mortality rates than Caucasian patients. The aim of this study is to explore differences in the lung cancer diagnostic pathways between CALD and Anglo-Australian patients and factors underlying these differences.Methods: This is a prospective, observational cohort study using a mixed-method approach. Quantitative data regarding time intervals in the lung cancer diagnostic pathways will be gathered via patient surveys, General practitioner (GP) review of general practice records, and case-note analysis of hospital records. Qualitative data will be gathered via structured interviews with lung cancer patients, GPs, and hospital specialists. The study will be conducted in five study sites across three states in Australia. Anglo-Australian patients and patients from five CALD groups (i.e., Arabic, Chinese, Greek, Italian and Vietnamese communities) will mainly be identified through the list of new cases presented at lung multidisciplinary team meetings. For the quantitative component, it is anticipated that 724 patients (362 Anglo-Australian and 362 CALD patients) will be recruited to obtain a final sample of 290 (145 per group) assuming a 50% patient survey completion rate and a 80% GP record review completion rate. For the qualitative component, 60 interviews with lung cancer patients (10 Anglo-Australian and 10 patients per CALD group), 20 interviews with GPs, and 20 interviews with specialists will be conducted.Discussion: This is the first Australian study to compare the time intervals along the lung cancer diagnostic pathway between CALD and Anglo-Australian patients. The study will also explore the underlying patient, healthcare provider, and health system factors that influence the time intervals in the two groups. This information will improve our understanding of the effect of ethnicity on health outcomes among lung cancer patients and will inform future interventions aimed at early diagnosis and treatment for lung cancer, particularly patients from CALD backgrounds.Trial Registration: The project was retrospectively registered with Australian New Zealand Clinical Trials Registry (registration number: ACTRN12617000957392 , date registered: 4th July 2017). [ABSTRACT FROM AUTHOR]

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

Background: Rural Australians have poorer survival for most common cancers, due partially to later diagnosis. Internationally, several initiatives to improve cancer outcomes have focused on earlier presentation to healthcare and timely diagnosis. We aimed to measure the effect of community-based symptom awareness and general practice-based educational interventions on the time to diagnosis in rural patients presenting with breast, prostate, colorectal or lung cancer in Western Australia.Methods: 2 × 2 factorial cluster randomised controlled trial. Community Intervention: cancer symptom awareness campaign tailored for rural Australians. GP intervention: resource card with symptom risk assessment charts and local cancer referral pathways implemented through multiple academic detailing visits. Trial Area A received the community symptom awareness and Trial Area B acted as the community campaign control region. Within both Trial Areas general practices were randomised to the GP intervention or control.Primary Outcome: total diagnostic interval (TDI).Results: 1358 people with incident breast, prostate, colorectal or lung cancer were recruited. There were no significant differences in the median or ln mean TDI at either intervention level (community intervention vs control: median TDI 107.5 vs 92 days; ln mean difference 0.08 95% CI -0.06-0.23 P=0.27; GP intervention vs control: median TDI 97 vs 96.5 days; ln mean difference 0.004 95% CI -0.18-0.19 P=0.99). There were no significant differences in the TDI when analysed by factorial design, tumour group or sub-intervals of the TDI.Conclusions: This is the largest trial to test the effect of community campaign or GP interventions on timeliness of cancer diagnosis. We found no effect of either intervention. This may reflect limited dose of the interventions, or the limited duration of follow-up. Alternatively, these interventions do not have a measurable effect on time to cancer diagnosis. [ABSTRACT FROM AUTHOR]

Simple Summary: Bladder cancer (BC) is one of the most common cancers worldwide. Early-stage diagnosis is associated with better survival rates and, as such, the timely referral of suspected cases is paramount. Urinary biomarkers have been developed to aid diagnosis, and are largely tested in patients who have been referred for further investigation. Evidence, however, on their diagnostic performance for both detecting and ruling out BC, especially in the general population, is limited. In this review, we systematically identified studies reporting on the diagnostic performance of biomarkers suitable for use in primary and community care settings. Three biomarkers, with relatively little difference in diagnostic performance between them, and some novel biomarkers were identified showing potential to be used as a triage tool in such settings. While promising, further validation studies in the general population are needed. Evidence on the use of biomarkers to detect bladder cancer in the general population is scarce. This study aimed to systematically review evidence on the diagnostic performance of biomarkers which might be suitable for use in community and primary care settings [PROSPERO Registration: CRD42021258754]. Database searches on MEDLINE and EMBASE from January 2000 to May 2022 resulted in 4914 unique citations, 44 of which met inclusion criteria. Included studies reported on 112 biomarkers and combinations. Heterogeneity of designs, populations and outcomes allowed for the meta-analysis of three biomarkers identified in at least five studies (NMP-22, UroVysion, uCyt+). These three biomarkers showed similar discriminative ability (adjusted AUC estimates ranging from 0.650 to 0.707), although for NMP-22 and UroVysion there was significant unexplained heterogeneity between included studies. Narrative synthesis revealed the potential of these biomarkers for use in the general population based on their reported clinical utility, including effects on clinicians, patients, and the healthcare system. Finally, we identified some promising novel biomarkers and biomarker combinations (N < 3 studies for each biomarker/combination) with negative predictive values of ≥90%. These biomarkers have potential for use as a triage tool in community and primary care settings for reducing unnecessary specialist referrals. Despite promising emerging evidence, further validation studies in the general population are required at different stages within the diagnostic pathway. [ABSTRACT FROM AUTHOR]

Background: The Cytosponge is a cell-collection device, which, coupled with a test for trefoil factor 3 (TFF3), can be used to diagnose Barrett's oesophagus, a precursor condition to oesophageal adenocarcinoma. BEST3, a large pragmatic, randomised, controlled trial, investigated whether offering the Cytosponge-TFF3 test would increase detection of Barrett's. Overall, participants reported mostly positive experiences. This study reports the factors associated with the least positive experience. Methods: Patient experience was assessed using the Inventory to Assess Patient Satisfaction (IAPS), a 22-item questionnaire, completed 7–14 days after the Cytosponge test. Study cohort: All BEST3 participants who answered ≥ 15 items of the IAPS (N = 1458). Statistical analysis: A mean IAPS score between 1 and 5 (5 indicates most negative experience) was calculated for each individual. 'Least positive' experience was defined according to the 90th percentile. 167 (11.4%) individuals with a mean IAPS score of ≥ 2.32 were included in the 'least positive' category and compared with the rest of the cohort. Eleven patient characteristics and one procedure-specific factor were assessed as potential predictors of the least positive experience. Multivariable logistic regression analysis using backwards selection was conducted to identify factors independently associated with the least positive experience and with failed swallow at first attempt, one of the strongest predictors of least positive experience. Results: The majority of responders had a positive experience, with an overall median IAPS score of 1.7 (IQR 1.5–2.1). High (OR = 3.01, 95% CI 2.03–4.46, p < 0.001) or very high (OR = 4.56, 95% CI 2.71–7.66, p < 0.001) anxiety (relative to low/normal anxiety) and a failed swallow at the first attempt (OR = 3.37, 95% CI 2.14–5.30, p < 0.001) were highly significant predictors of the least positive patient experience in multivariable analyses. Additionally, sex (p = 0.036), height (p = 0.032), alcohol intake (p = 0.011) and education level (p = 0.036) were identified as statistically significant predictors. Conclusion: We have identified factors which predict patient experience. Identifying anxiety ahead of the procedure and discussing particular concerns with patients or giving them tips to help with swallowing the capsule might help improve their experience. Trial registration ISRCTN68382401. [ABSTRACT FROM AUTHOR]

The article presents a study that determines the effectiveness of adding MoleMate system to appropriately manage referrals of pigmented lesions from primary to secondary care settings. It cites the randomized controlled trial in general practices in England on adults with pigmented skin lesions. The result of the study indicates that adding MoleMate approach to the systematic applications of the best practice guidelines did not increase the proportion of appropriately referred lesions.

Simple Summary: Lung cancer is the most common cause of cancer related death in the US, but survival is far better when people are diagnosed at an earlier stage. There are currently no clinical quality measures that are routinely used to measure the quality or timeliness of diagnosis of lung cancer in the US. We used Natural Language Processing (NLP) to extract information on the symptoms and signs that had been recorded in the electronic medical records of patients presenting in ambulatory care over the 2 years prior to their diagnosis with lung cancer. We found that the time from the first recorded symptoms/signs associated with lung cancer to diagnosis was 570 days. The time intervals from chest CT or chest X-ray imaging to diagnosis, and from specialist consultation to diagnosis were shorter—at 43 and 72 days, respectively. Advanced techniques such as NLP can be used to extract detailed information from electronic medical records, that could potentially be used to create clinical quality measures with the goal of improving the timeliness of diagnosis of this cancer. The diagnosis of lung cancer in ambulatory settings is often challenging due to non-specific clinical presentation, but there are currently no clinical quality measures (CQMs) in the United States used to identify areas for practice improvement in diagnosis. We describe the pre-diagnostic time intervals among a retrospective cohort of 711 patients identified with primary lung cancer from 2012–2019 from ambulatory care clinics in Seattle, Washington USA. Electronic health record data were extracted for two years prior to diagnosis, and Natural Language Processing (NLP) applied to identify symptoms/signs from free text clinical fields. Time points were defined for initial symptomatic presentation, chest imaging, specialist consultation, diagnostic confirmation, and treatment initiation. Median and interquartile ranges (IQR) were calculated for intervals spanning these time points. The mean age of the cohort was 67.3 years, 54.1% had Stage III or IV disease and the majority were diagnosed after clinical presentation (94.5%) rather than screening (5.5%). Median intervals from first recorded symptoms/signs to diagnosis was 570 days (IQR 273–691), from chest CT or chest X-ray imaging to diagnosis 43 days (IQR 11–240), specialist consultation to diagnosis 72 days (IQR 13–456), and from diagnosis to treatment initiation 7 days (IQR 0–36). Symptoms/signs associated with lung cancer can be identified over a year prior to diagnosis using NLP, highlighting the need for CQMs to improve timeliness of diagnosis. [ABSTRACT FROM AUTHOR]

Multicancer early detection (MCED) tests represent a potentially game‐changing early cancer detection technology. Modeling efforts, such as those of Hudnut et al. in this issue of Cancer, as well as systematic clinical studies and data collection, along with public health and primary care efforts, need to be undertaken to determine whether MCED tests become an opportunity to decrease the heavy burden of cancer for all. [ABSTRACT FROM AUTHOR]

Background: Polygenic risk scores (PRSs) can predict the risk of colorectal cancer (CRC) and target screening more precisely than current guidelines using age and family history alone. Primary care, as a far-reaching point of healthcare and routine provider of cancer screening and risk information, may be an ideal location for their widespread implementation.Methods: This trial aims to determine whether the SCRIPT intervention results in more risk-appropriate CRC screening after 12 months in individuals attending general practice, compared with standard cancer risk reduction information. The SCRIPT intervention consists of a CRC PRS, tailored risk-specific screening recommendations and a risk report for participants and their GP, delivered in general practice. Patients aged between 45 and 70 inclusive, attending their GP, will be approached for participation. For those over 50, only those overdue for CRC screening will be eligible to participate. Two hundred and seventy-four participants will be randomised to the intervention or control arms, stratified by general practice, using a computer-generated allocation sequence. The primary outcome is risk-appropriate CRC screening after 12 months. For those in the intervention arm, risk-appropriate screening is defined using PRS-derived risk; for those in the control arm, it is defined using family history and national screening guidelines. Timing, type and results of the previous screening are considered in both arms. Objective health service data will capture screening behaviour. Secondary outcomes include cancer-specific worry, risk perception, predictors of CRC screening behaviour, screening intentions and health service use at 1, 6 and 12 months post-intervention delivery.Discussion: This trial aims to determine whether a PRS-derived personalised CRC risk estimate delivered in primary care increases risk-appropriate CRC screening. A future population risk-stratified CRC screening programme could incorporate risk assessment within primary care while encouraging adherence to targeted screening recommendations.Trial Registration: Australian and New Zealand Clinical Trial Registry ACTRN12621000092897p. Registered on 1 February 2021. [ABSTRACT FROM AUTHOR]

Objective: There is limited evidence on the development of pancreatic and oesophagogastric cancer, how patients decide to seek help and the factors impacting help‐seeking. Our study, the first in Australia, aimed to explore symptom appraisal and diagnostic pathways in these patients. A secondary aim was to examine the potential to recruit cancer patients through a cancer quality registry. Methods: Patients diagnosed with pancreatic or oesophagogastric cancer were recruited through Monash University's Upper‐Gastrointestinal Cancer Registry. Data collected through general practitioners (GP) and patient questionnaires included symptoms and their onset, whereas patient interviews focused on the patient's decision‐making in seeking help from healthcare pracitioners. Data collection and analysis was informed by the Aarhus statement. Coding was inductive, and themes were mapped onto the Model of Pathways to Treatment. Results: Between November 2018 and March 2020, 27 patient questionnaires and 13 phone interviews were completed. Prior to diagnosis, patients lacked awareness of pancreatic and oesophagogastric cancer symptoms, leading to the normalisation, dismissal and misattribution of the symptoms. Patients initially self‐managed symptoms, but worsening of symptoms and jaundice triggered help‐seeking. Competing priorities, beliefs about illnesses and difficulties accessing healthcare delayed help‐seeking. Conclusion: Increased awareness of insidious pancreatic and oesophagogastric cancer symptoms in patients and general practitioners may prompt more urgent investigations and lead to earlier diagnosis. [ABSTRACT FROM AUTHOR]

Background: Safety netting in primary care is considered an important intervention for managing diagnostic uncertainty. This is the first study to examine how patients understand and interpret safety netting advice around low-risk potential lung cancer symptoms, and how this affects reconsultation behaviours. Methods: Qualitative interview study in UK primary care. Pre-covid-19, five patients were interviewed in person within 2–3 weeks of a primary care consultation for potential lung cancer symptom(s), and again 2–5 months later. The general practitioner (GP) they last saw was interviewed face-to-face once. During the covid-19 pandemic, an additional 15 patients were interviewed only once via telephone, and their GPs were not interviewed or contacted in any way. Audio-recorded interviews were transcribed verbatim and analysed using inductive thematic analysis. Results: The findings from our thematic analysis suggest that patients prefer active safety netting, as part of thorough and logical diagnostic uncertainty management. Passive or ambiguous safety netting may be perceived as dismissive and cause delayed reconsultation. GP safety netting strategies are not always understood, potentially causing patient worry and dissatisfaction. Telephone consultations and the diagnostic overshadowing of COVID-19 on respiratory symptoms impacted GPs' safety netting strategies and patients' appetite for active follow up measures. Conclusions: Safety netting guidelines do not yet offer solutions that have been proven to promote symptom vigilance and timely reconsultation for low-risk lung cancer symptoms. This may have been affected by primary care practices during the COVID-19 pandemic. Patients prefer active or pre-planned safety netting coupled with thorough consultation techniques and a comprehensible diagnostic strategy, and may respond adversely to passive safety netting advice. [ABSTRACT FROM AUTHOR]

Academic networks are expected to enhance scientific collaboration and thereby increase research outputs. However, little is known about whether and how the initial steps of getting to know other researchers translates into effective collaborations. In this paper, we investigate the evolution and co-evolution of an academic social network and a collaborative research network (using co-authorship as a proxy measure of the latter), and simultaneously examine the effect of individual researcher characteristics (e.g. gender, seniority or workplace) on their evolving relationships. We used longitudinal data from an international network in primary care cancer research: the CanTest Collaborative (CanTest). Surveys were distributed amongst CanTest researchers to map who knows who (the 'academic social network'). Co-authorship relations were derived from Scopus (the 'collaborative network'). Stochastic actor-oriented models were employed to investigate the evolution and co-evolution of both networks. Visualizing the development of the CanTest network revealed that researchers within CanTest get to know each other quickly and also start collaborating over time (evolution of the academic social network and collaborative network respectively). Results point to a stable and solid academic social network that is particularly encouraging towards more junior researchers; yet differing for male and female researchers (the effect of individual researcher characteristics). Moreover, although the academic social network and the research collaborations do not grow at the same pace, the benefit of creating academic social relationships to stimulate effective research collaboration is clearly demonstrated (co-evolution of both networks). [ABSTRACT FROM AUTHOR]

Background: Safety netting in primary care is considered an important intervention for managing diagnostic uncertainty. This is the first study to examine how patients understand and interpret safety netting advice around low-risk potential lung cancer symptoms, and how this affects reconsultation behaviours. Methods: Qualitative interview study in UK primary care. Pre-covid-19, five patients were interviewed in person within 2–3 weeks of a primary care consultation for potential lung cancer symptom(s), and again 2–5 months later. The general practitioner (GP) they last saw was interviewed face-to-face once. During the covid-19 pandemic, an additional 15 patients were interviewed only once via telephone, and their GPs were not interviewed or contacted in any way. Audio-recorded interviews were transcribed verbatim and analysed using inductive thematic analysis. Results: The findings from our thematic analysis suggest that patients prefer active safety netting, as part of thorough and logical diagnostic uncertainty management. Passive or ambiguous safety netting may be perceived as dismissive and cause delayed reconsultation. GP safety netting strategies are not always understood, potentially causing patient worry and dissatisfaction. Telephone consultations and the diagnostic overshadowing of COVID-19 on respiratory symptoms impacted GPs' safety netting strategies and patients' appetite for active follow up measures. Conclusions: Safety netting guidelines do not yet offer solutions that have been proven to promote symptom vigilance and timely reconsultation for low-risk lung cancer symptoms. This may have been affected by primary care practices during the COVID-19 pandemic. Patients prefer active or pre-planned safety netting coupled with thorough consultation techniques and a comprehensible diagnostic strategy, and may respond adversely to passive safety netting advice. [ABSTRACT FROM AUTHOR]

Background: Prostate-specific antigen (PSA) is a commonly used test to detect prostate cancer. Attention has mostly focused on the use of PSA in screening asymptomatic patients, but the diagnostic accuracy of PSA for prostate cancer in patients with symptoms is less well understood.Methods: A systematic database search was conducted of Medline, EMBASE, Web of Science, and the Cochrane library. Studies reporting the diagnostic accuracy of PSA for prostate cancer in patients with symptoms were included. Two investigators independently assessed the titles and abstracts of all database search hits and full texts of potentially relevant studies against the inclusion criteria, and data extracted into a proforma. Study quality was assessed using the QUADAS-2 tool by two investigators independently. Summary estimates of diagnostic accuracy were calculated with meta-analysis using bivariate mixed effects regression.Results: Five hundred sixty-three search hits were assessed by title and abstract after de-duplication, with 75 full text papers reviewed. Nineteen studies met the inclusion criteria, 18 of which were conducted in secondary care settings with one from a screening study cohort. All studies used histology obtained by transrectal ultrasound-guided biopsy (TRUS) as a reference test; usually only for patients with elevated PSA or abnormal prostate examination. Pooled data from 14,489 patients found estimated sensitivity of PSA for prostate cancer was 0.93 (95% CI 0.88, 0.96) and specificity was 0.20 (95% CI 0.12, 0.33). The area under the hierarchical summary receiver operator characteristic curve was 0.72 (95% CI 0.68, 0.76). All studies were assessed as having a high risk of bias in at least one QUADAS-2 domain.Conclusions: Currently available evidence suggests PSA is highly sensitive but poorly specific for prostate cancer detection in symptomatic patients. However, significant limitations in study design and reference test reduces the certainty of this estimate. There is very limited evidence for the performance of PSA in primary care, the healthcare setting where most PSA testing is performed. [ABSTRACT FROM AUTHOR]

PURPOSE Despite the compelling evidence supporting cardiovascular medications in the secondary prevention of coronary artery disease, many patients discontinue treatment. In this synthesis, we sought to understand from a patient perspective the factors that promote medication persistence. METHODS We systematically searched 7 databases (MEDLINE, Embase, PsycINFO, SCOPUS, CINAHL, ASSIA, and SSCI) for published qualitative research about the medication-taking experiences of patients with coronary artery disease and their partners. Articles were assessed for quality using a modified CASP (Critical Appraisal Skills Programme) checklist. Synthesis was undertaken using well-established meta-ethnographic approaches. RESULTS We included 17 articles in the final synthesis from the United Kingdom (6), Europe (5), United States (4), China (1), and Australia (1), with a total sample size of 391 patients. Analyses suggested that some patients hold fatalistic beliefs about their disease, whereas others believe they have been cured by interventions; both can lead to failure to take medication. Patients who adapt to being a "heart patient" are positive about medication taking. Some individuals dislike taking tablets generally and are wary of long-term effects. Relationships with prescribing clinicians are of critical importance for patients, with inaccessibility and insensitive terminology negatively affecting patients' perceptions about treatments. CONCLUSIONS Strategies to promote higher persistence of secondary prevention medications in patients with coronary artery disease need to recognize the key role of the prescribing clinician. Providing medication-specific information at the time of initiating therapy, improving the transition between secondary and primary care, and explaining the risk of disease recurrence may all help to modify patient attitudes toward drugs to prevent further cardiovascular disease. [ABSTRACT FROM AUTHOR]

A positive patient experience has been long recognised as a key feature of a high-quality health service, however, often assessment of patient experience excludes diagnostic care. Experience of diagnostic services and the acceptability of diagnostic tests are often conflated, with lack of clarity about when and how either should be measured. These problems contrast with the growth in the development and marketing of new tests and investigation strategies. Building on the appraisal of current practice, we propose that the experience of diagnostic services and the acceptability of tests should be assessed separately, and describe distinct components of each. Such evaluations will enhance the delivery of patient-centred care, and facilitate patient choice. [ABSTRACT FROM AUTHOR]

Developments within genetic testing may increase demands on general practitioners to advise about family history of breast cancer (FHBC). This descriptive, qualitative study, investigated women’s views of GP consultations about FHBC and their context. Participants were women from the general population who had experienced a primary care consultation in which FHBC was mentioned, as reported by the practitioner. Information about women’s views of consultation context was obtained from 72 telephone interviews. More in-depth information about context and women’s evaluations of FHBC consultations were obtained from a sub-sample of 20 face to face interviews. FHBC was rarely the main focus of consultations. It featured as a part of an overall discussion of breast symptoms, treatment and cancer risk. Women’s understanding of heredity and disease was often idiosyncratic and might differ from biomedical models. A main task for clinicians appeared to be appropriate reassurance. Failure to reassure was linked to a failure to provide explanations at the woman’s level of understanding. Clinicians cannot assume that patients share their perceptions of the mechanisms of disease and heredity. Instead they need to ascertain the patient’s understanding and provide explanations accordingly. GPs need to have, or access, enough knowledge to inform and reassure. [Copyright &y& Elsevier]

Background: Australian guidelines recommend that all people aged 50-70 years old actively consider taking daily low-dose aspirin (100-300 mg per day) for 2.5 to 5 years to reduce their risk of colorectal cancer (CRC). Despite the change of national CRC prevention guidelines, there has been no active implementation of the guidelines into clinical practice. We aim to test the efficacy of a health consultation and decision aid, using a novel expected frequency tree (EFT) to present the benefits and harms of low dose aspirin prior to a general practice consultation with patients aged 50-70 years, on informed decision-making and uptake of aspirin.Methods: Approximately five to seven general practices in Victoria, Australia, will be recruited to participate. Patients 50-70 years old, attending an appointment with their general practitioner (GP) for any reason, will be invited to participate in the trial. Two hundred fifty-eight eligible participants will be randomly allocated 1:1 to intervention or active control arms using a computer-generated allocation sequence stratified by general practice, sex, and mode of trial delivery (face-to-face or teletrial). There are two co-primary outcomes: informed decision-making at 1-month post randomisation, measured by the Multi-dimensional Measure of Informed Choice (MMIC), and self-reported daily use of aspirin at 6 months. Secondary outcomes include decisional conflict at 1-month and other behavioural changes to reduce CRC risk at both time points.Discussion: This trial will test the efficacy of novel methods for implementing national guidelines to support informed decision-making about taking aspirin in 50-70-year-olds to reduce the risk of CRC and other chronic diseases.Trial Registration: The Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620001003965 . Registered on 10 October 2020. [ABSTRACT FROM AUTHOR]

Background: The faecal immunochemical test (FIT) was introduced to triage patients with low-risk symptoms of possible colorectal cancer in English primary care in 2017, underpinned by little primary care evidence.Methods: All healthcare providers in the South West of England (population 4 million) participated in this evaluation. 3890 patients aged ≥50 years presenting in primary care with low-risk symptoms of colorectal cancer had a FIT from 01/06/2018 to 31/12/2018. A threshold of 10 μg Hb/g faeces defined a positive test.Results: Six hundred and eighteen (15.9%) patients tested positive; 458 (74.1%) had an urgent referral to specialist lower gastrointestinal (GI) services within three months. Forty-three were diagnosed with colorectal cancer within 12 months. 3272 tested negative; 324 (9.9%) had an urgent referral within three months. Eight were diagnosed with colorectal cancer within 12 months. Positive predictive value was 7.0% (95% CI 5.1-9.3%). Negative predictive value was 99.8% (CI 99.5-99.9%). Sensitivity was 84.3% (CI 71.4-93.0%), specificity 85.0% (CI 83.8-86.1%). The area under the ROC curve was 0.92 (CI 0.86-0.96). A threshold of 37 μg Hb/g faeces would identify patients with an individual 3% risk of cancer.Conclusions: FIT performs exceptionally well to triage patients with low-risk symptoms of colorectal cancer in primary care; a higher threshold may be appropriate in the wake of the COVID-19 crisis. [ABSTRACT FROM AUTHOR]

Background: The serum biomarker cancer antigen 125 (CA125) is widely used as an investigation for possible ovarian cancer in symptomatic women presenting to primary care. However, its diagnostic performance in this setting is unknown. We evaluated the performance of CA125 in primary care for the detection of ovarian and non-ovarian cancers.Methods and Findings: We studied women in the United Kingdom Clinical Practice Research Datalink with a CA125 test performed between 1 May 2011-31 December 2014. Ovarian and non-ovarian cancers diagnosed in the year following CA125 testing were identified from the cancer registry. Women were categorized by age: <50 years and ≥50 years. Conventional measures of test diagnostic accuracy, including sensitivity, specificity, and positive predictive value, were calculated for the standard CA125 cut-off (≥35 U/ml). The probability of a woman having cancer at each CA125 level between 1-1,000 U/ml was estimated using logistic regression. Cancer probability was also estimated on the basis of CA125 level and age in years using logistic regression. We identified CA125 levels equating to a 3% estimated cancer probability: the "risk threshold" at which the UK National Institute for Health and Care Excellence advocates urgent specialist cancer investigation. A total of 50,780 women underwent CA125 testing; 456 (0.9%) were diagnosed with ovarian cancer and 1,321 (2.6%) with non-ovarian cancer. Of women with a CA125 level ≥35 U/ml, 3.4% aged <50 years and 15.2% aged ≥50 years had ovarian cancer. Of women with a CA125 level ≥35 U/ml who were aged ≥50 years and who did not have ovarian cancer, 20.4% were diagnosed with a non-ovarian cancer. A CA125 value of 53 U/ml equated to a 3% probability of ovarian cancer overall. This varied by age, with a value of 104 U/ml in 40-year-old women and 32 U/ml in 70-year-old women equating to a 3% probability. The main limitations of our study were that we were unable to determine why CA125 tests were performed and that our findings are based solely on UK primary care data, so caution is need in extrapolating them to other healthcare settings.Conclusions: CA125 is a useful test for ovarian cancer detection in primary care, particularly in women ≥50 years old. Clinicians should also consider non-ovarian cancers in women with high CA125 levels, especially if ovarian cancer has been excluded, in order to prevent diagnostic delay. Our results enable clinicians and patients to determine the estimated probability of ovarian cancer and all cancers at any CA125 level and age, which can be used to guide individual decisions on the need for further investigation or referral. [ABSTRACT FROM AUTHOR]

Background: Recently, faecal immunochemical tests (FITs) have been introduced for investigation of primary care patients with low-risk symptoms of colorectal cancer (CRC), but recommendations vary across the world. This systematic review of clinical practice guidelines aimed to determine how FITs are used in symptomatic primary care patients and the underpinning evidence for these guidelines.Methods: MEDLINE, Embase and TRIP databases were systematically searched, from 1 November 2008 to 1 November 2018 for guidelines on the assessment of patients with symptoms suggestive of CRC. Known guideline databases, websites and references of related literature were searched. The following questions were addressed: (i) which countries use FIT for symptomatic primary care patients; (ii) in which populations is FIT used; (iii) what is the cut-off level used for haemoglobin in the faeces (FIT) and (iv) on what evidence are FIT recommendations based.Results: The search yielded 2433 publications; 25 covered initial diagnostic assessment of patients with symptoms of CRC in 15 countries (Asia, n = 1; Europe, n = 13; Oceania, n = 4; North America, n = 5; and South America, n = 2). In three countries (Australia, Spain and the UK), FIT was recommended for patients with abdominal symptoms, unexplained weight loss, change in bowel habit or anaemia despite a low level of evidence in the symptomatic primary care patient population.Conclusions: Few countries recommend FITs in symptomatic patients in primary care either because of limited evidence or because symptomatic patients are directly referred to secondary care without triage. These results demonstrate a clear need for research on FIT in the symptomatic primary care population. [ABSTRACT FROM AUTHOR]

The article discusses the COVID-19 pandemic has a profound and direct impact on the health and lives of the global population and has placed a huge burden on healthcare systems. Topics include fear of contracting COVID-19 led to patient reluctance towards attending in-person visits; and to avoid local, regional and national health care services.

Background: Treatment of dysplastic Barrett's oesophagus prevents progression to adenocarcinoma; however, the optimal diagnostic strategy for Barrett's oesophagus is unclear. The Cytosponge-trefoil factor 3 (TFF3) is a non-endoscopic test for Barrett's oesophagus. The aim of this study was to investigate whether offering this test to patients on medication for gastro-oesophageal reflux would increase the detection of Barrett's oesophagus compared with standard management.Methods: This multicentre, pragmatic, randomised controlled trial was done in 109 socio-demographically diverse general practice clinics in England. Randomisation was done both at the general practice clinic level (cluster randomisation) and at the individual patient level, and the results for each type of randomisation were analysed separately before being combined. Patients were eligible if they were aged 50 years or older, had been taking acid-suppressants for symptoms of gastro-oesophageal reflux for more than 6 months, and had not undergone an endoscopy procedure within the past 5 years. General practice clinics were selected by the local clinical research network and invited to participate in the trial. For cluster randomisation, clinics were randomly assigned (1:1) by the trial statistician using a computer-generated randomisation sequence; for individual patient-level randomisation, patients were randomly assigned (1:1) by the general practice clinics using a centrally prepared computer-generated randomisation sequence. After randomisation, participants received either standard management of gastro-oesophageal reflux (usual care group), in which participants only received an endoscopy if required by their general practitioner, or usual care plus an offer of the Cytosponge-TFF3 procedure, with a subsequent endoscopy if the procedure identified TFF3-positive cells (intervention group). The primary outcome was the diagnosis of Barrett's oesophagus at 12 months after enrolment, expressed as a rate per 1000 person-years, in all participants in the intervention group (regardless of whether they had accepted the offer of the Cytosponge-TFF3 procedure) compared with all participants in the usual care group. Analyses were intention-to-treat. The trial is registered with the ISRCTN registry, ISRCTN68382401, and is completed.Findings: Between March 20, 2017, and March 21, 2019, 113 general practice clinics were enrolled, but four clinics dropped out shortly after randomisation. Using an automated search of the electronic prescribing records of the remaining 109 clinics, we identified 13 657 eligible patients who were sent an introductory letter with 14 days to opt out. 13 514 of these patients were randomly assigned (per practice or at the individual patient level) to the usual care group (n=6531) or the intervention group (n=6983). Following randomisation, 149 (2%) of 6983 participants in the intervention group and 143 (2%) of 6531 participants in the usual care group, on further scrutiny, did not meet all eligibility criteria or withdrew from the study. Of the remaining 6834 participants in the intervention group, 2679 (39%) expressed an interest in undergoing the Cytosponge-TFF3 procedure. Of these, 1750 (65%) met all of the eligibility criteria on telephone screening and underwent the procedure. Most of these participants (1654 [95%]; median age 69 years) swallowed the Cytosponge successfully and produced a sample. 231 (3%) of 6834 participants had a positive Cytosponge-TFF3 result and were referred for an endoscopy. Patients who declined the offer of the Cytosponge-TFF3 procedure and all participants in the usual care group only had an endoscopy if deemed necessary by their general practitioner. During an average of 12 months of follow-up, 140 (2%) of 6834 participants in the intervention group and 13 (<1%) of 6388 participants in the usual care group were diagnosed with Barrett's oesophagus (absolute difference 18·3 per 1000 person-years [95% CI 14·8-21·8]; rate ratio adjusted for cluster randomisation 10·6 [95% CI 6·0-18·8], p<0·0001). Nine (<1%) of 6834 participants were diagnosed with dysplastic Barrett's oesophagus (n=4) or stage I oesophago-gastric cancer (n=5) in the intervention group, whereas no participants were diagnosed with dysplastic Barrett's oesophagus or stage I gastro-oesophageal junction cancer in the usual care group. Among 1654 participants in the intervention group who swallowed the Cytosponge device successfully, 221 (13%) underwent endoscopy after testing positive for TFF3 and 131 (8%, corresponding to 59% of those having an endoscopy) were diagnosed with Barrett's oesophagus or cancer. One patient had a detachment of the Cytosponge from the thread requiring endoscopic removal, and the most common side-effect was a sore throat in 63 (4%) of 1654 participants.Interpretation: In patients with gastro-oesophageal reflux, the offer of Cytosponge-TFF3 testing results in improved detection of Barrett's oesophagus. Cytosponge-TFF3 testing could also lead to the diagnosis of treatable dysplasia and early cancer. This strategy will lead to additional endoscopies with some false positive results.Funding: Cancer Research UK, National Institute for Health Research, the UK National Health Service, Medtronic, and the Medical Research Council. [ABSTRACT FROM AUTHOR]

Background: There is a growing focus on the development of multi-factorial cancer risk prediction algorithms alongside tools that operationalise them for clinical use. BOADICEA is a breast and ovarian cancer risk prediction model incorporating genetic and other risk factors. A new user-friendly Web-based tool (CanRisk.org) has been developed to apply BOADICEA. This study aimed to explore the acceptability of the prototype CanRisk tool among two healthcare professional groups to inform further development, evaluation and implementation. Method: A multi-methods approach was used. Clinicians from primary care and specialist genetics clinics in England, France and Germany were invited to use the CanRisk prototype with two test cases (either face-to-face with a simulated patient or via a written vignette). Their views about the tool were examined via a semi-structured interview or equivalent open-ended questionnaire. Qualitative data were subjected to thematic analysis and organised around Sekhon's Theoretical Framework of Acceptability. Results: Seventy-five clinicians participated, 21 from primary care and 54 from specialist genetics clinics. Participants were from England (n = 37), France (n = 23) and Germany (n = 15). The prototype CanRisk tool was generally acceptable to most participants due to its intuitive design. Primary care clinicians were concerned about the amount of time needed to complete, interpret and communicate risk information. Clinicians from both settings were apprehensive about the impact of the CanRisk tool on their consultations and lack of opportunities to interpret risk scores before sharing them with their patients. Conclusions: The findings highlight the challenges associated with developing a complex tool for use in different clinical settings; they also helped refine the tool. This prototype may not have been versatile enough for clinical use in both primary care and specialist genetics clinics where the needs of clinicians are different, emphasising the importance of understanding the clinical context when developing cancer risk assessment tools. [ABSTRACT FROM AUTHOR]