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Damhus CS, Risør MB, Brodersen JB, Jønsson ABR. Rethinking the logic of early diagnosis in cancer. Health (London) 2024:13634593241234481. [PMID: 38407179 DOI: 10.1177/13634593241234481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
To reduce morbidity and mortality of cancer, more countries have implemented strategies to detect cancer, based on the logic of 'the sooner the better'. Time is thereby an essential component in how cancer research, policies, and prevention are practiced today. Where the logic of early diagnosis benefits some, the logic also produces harms. In this article, we use a cross-disciplinary case-study design to discuss how different notions of time and linearity are essential in today's research ontology of cancer, describe the individual and societal consequences of such ontology, and invite a rethinking of time in cancer. Drawing on theoretical concepts of time together with cancer epidemiological, historical and ethnographical data, we analyse how the logic of early diagnosis has been established as a stable concept. Although evidence supporting the logic points in different directions, the message 'the sooner the better' is currently not being challenged by research, policy or society. This at least partly, can be explained by a linear perception of time and societal traces of neoliberalism and acceleration in our society together with cancer still being a somewhat enigmatic disease that requires acute action. To support a sustainable healthcare sector, we argue there is a need to nuance the logic of early diagnosis. Continuing the linear perception of symptoms and cancer, risks doing more harm than good by making more people patients unnecessarily and by spending health resources on those with the least need.
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Affiliation(s)
- Christina Sadolin Damhus
- The Centre of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- The Research Unit for General Practice in Region Zealand, Denmark
| | - Mette Bech Risør
- The Centre of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Community Medicine, General Practice Research Unit, Faculty of Health Sciences, UiT, The Arctic University of Norway, Norway
| | - John Brandt Brodersen
- The Centre of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- The Research Unit for General Practice in Region Zealand, Denmark
- Department of Community Medicine, General Practice Research Unit, Faculty of Health Sciences, UiT, The Arctic University of Norway, Norway
| | - Alexandra Brandt Ryborg Jønsson
- The Centre of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Community Medicine, General Practice Research Unit, Faculty of Health Sciences, UiT, The Arctic University of Norway, Norway
- Department of People and Technology, Roskilde University, Denmark
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de Chiffre JMD, Ormstrup TE, Kusk MW, Hess S. Patients from general practice with non-specific cancer symptoms: a retrospective study of symptoms and imaging. BJGP Open 2024:BJGPO.2023.0058. [PMID: 37604580 DOI: 10.3399/bjgpo.2023.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/10/2023] [Accepted: 07/23/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Patients with non-specific symptoms or signs of cancer (NSSC) present a challenge as they are a heterogeneous population who are not candidates for fast-track work-up in an organ-specific cancer pre-planned pathway (CPP). Denmark has a cancer pre-planned pathway for this population (NSSC-CPP), but several issues remain unclarified, for example, distribution and significance of symptoms and findings, and choice of imaging. AIM To investigate symptoms, cancer diagnoses, and diagnostic yield of computed tomography (CT) and fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) in patients on NSSC-CPP to improve the overall diagnostic process. DESIGN & SETTING A retrospective medical chart review in a 1-year consecutive cohort (2020). METHOD A total of 802 referrals were reviewed for diagnostic imaging in patients with NSSP from general practices, specialist practices, or the local hospital diagnostic centre responsible for NSSC-CPP. RESULTS The study included 248 patients; 21% had cancer, most frequently gastrointestinal cancer (27%). The most frequent symptom was weight loss (56%). CT had a sensitivity of 85%, specificity of 87%, positive predictive value (PPV) of 65%, and negative predictive value (NPV) of 96%. For 18F-FDG-PET/CT, the numbers were sensitivity 82%, specificity 62%, PPV 33%, and NPV 94%. Patients frequently underwent subsequent examinations following initial imaging. CONCLUSION The findings were in accordance with the literature. Patients with NSSC had a cancer prevalence of 21%, most frequently gastrointestinal. The most frequent symptom was weight loss and, even as the only symptom, it is a potential marker for cancer. CT and 18F-FDG-PET/CT were sensitive with high NPV, whereas PPV was superior in CT. Better stratification by symptoms or findings is an obvious focus point for future studies to further optimise the NSSC-CPP work-up strategy.
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Affiliation(s)
- Jonas Michele Dorph de Chiffre
- Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Radiology and Nuclear Medicine, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Tina Elisabeth Ormstrup
- Department of Radiology and Nuclear Medicine, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Martin Weber Kusk
- Department of Radiology and Nuclear Medicine, University Hospital of Southern Denmark, Esbjerg, Denmark
- IRIS - Imaging Research Initiative Southwest, University Hospital of Southern Denmark, Esbjerg, Denmark
- Radiography & Diagnostic Imaging, School of Medicine, University College Dublin, Dublin, Ireland
| | - Søren Hess
- Department of Radiology and Nuclear Medicine, University Hospital of Southern Denmark, Esbjerg, Denmark
- IRIS - Imaging Research Initiative Southwest, University Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
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Quinn-Scoggins HD, Cannings-John R, Moriarty Y, Whitelock V, Whitaker KL, Grozeva D, Hughes J, Townson J, Osborne K, Goddard M, McCutchan GM, Waller J, Robling M, Hepburn J, Moore G, Gjini A, Brain K. Cancer symptom experience and help-seeking behaviour during the COVID-19 pandemic in the UK: a cross-sectional population survey. BMJ Open 2021; 11:e053095. [PMID: 34531224 PMCID: PMC8449845 DOI: 10.1136/bmjopen-2021-053095] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/11/2021] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES To understand self-reported potential cancer symptom help-seeking behaviours and attitudes during the first 6 months (March-August 2020) of the UK COVID-19 pandemic. DESIGN UK population-based survey conducted during August and September 2020. Correlates of help-seeking behaviour were modelled using logistic regression in participants reporting potential cancer symptoms during the previous 6 months. Qualitative telephone interviews with a purposeful subsample of participants, analysed thematically. SETTING Online UK wide survey. PARTICIPANTS 7543 adults recruited via Cancer Research UK online panel provider (Dynata) and HealthWise Wales (a national register of 'research ready' participants) supplemented with social media (Facebook and Twitter) recruitment. 30 participants were also interviewed. MAIN OUTCOME MEASURES Survey measures included experiences of 15 potential cancer symptoms, help-seeking behaviour, barriers and prompts to help-seeking. RESULTS Of 3025 (40.1%) participants who experienced a potential cancer symptom, 44.8% (1355/3025) had not contacted their general practitioner (GP). Odds of help-seeking were higher among participants with disability (adjusted OR (aOR)=1.38, 95% CI 1.11 to 1.71) and who experienced more symptoms (aOR=1.68, 95% CI 1.56 to 1.82), and lower among those who perceived COVID-19 as the cause of symptom(s) (aOR=0.36, 95% CI 0.25 to 0.52). Barriers included worries about wasting the doctor's time (1158/7543, 15.4%), putting strain on healthcare services (945, 12.6%) and not wanting to make a fuss (907, 12.0%). Interviewees reported reluctance to contact the GP due to concerns about COVID-19 and fear of attending hospitals, and described putting their health concerns on hold. CONCLUSIONS Many people avoided healthcare services despite experiencing potential cancer symptoms during the COVID-19 pandemic. Alongside current help-seeking campaigns, well-timed and appropriate nationally coordinated campaigns should signal that services are open safely for those with unusual or persistent symptoms. TRIAL REGISTRATION NUMBER ISRCTN17782018.
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Affiliation(s)
- Harriet D Quinn-Scoggins
- PRIME Centre Wales, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | | | | | | | | | | | - Julia Townson
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Mark Goddard
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Grace M McCutchan
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Jo Waller
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Michael Robling
- Centre for Trials Research, Cardiff University, Cardiff, UK
- DECIPHer (Centre for Development, Evaluation, Complexity and Implementation in Public Health Improvement), School of Social Sciences, Cardiff University, Cardiff, UK
| | - Julie Hepburn
- Public Involvement Community, Health and Care Research Wales Support Centre, Cardiff, UK
| | - Graham Moore
- DECIPHer (Centre for Development, Evaluation, Complexity and Implementation in Public Health Improvement), School of Social Sciences, Cardiff University, Cardiff, UK
| | - Ardiana Gjini
- Public Health Wales, Cardiff, UK
- Cardiff University, Cardiff, UK
| | - Kate Brain
- PRIME Centre Wales, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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Damhus CS, Siersma V, Dalton SO, Brodersen J. Non-specific symptoms and signs of cancer: different organisations of a cancer patient pathway in Denmark. Scand J Prim Health Care 2021; 39:23-30. [PMID: 33629891 PMCID: PMC7971193 DOI: 10.1080/02813432.2021.1880094] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE We aimed to investigate the Non-specific Symptoms and Signs of Cancer-Cancer Patient Pathway (NSSC-CPP) in order to describe organisational and clinical practice similarities and differences in the diagnostic work-up of suspected cancer in Denmark. MATERIAL AND METHODS A questionnaire on the organisation and practice pertaining to the NSSC-CPP was completed by all 21 diagnostic units in the five healthcare regions in Denmark. RESULTS The questionnaire responses revealed regional and intraregional differences in the organisation and clinical practice of the NSSC-CPP. CT scan was the most often used imaging in the NSSC-CPP but there was no consensus whether the CT scan should be ordered and evaluated by general practitioners (GPs) or by the diagnostic units. Two regions were consistent but had different modalities regarding referrals from GPs. Three regions had intra-regional differences. The units reported on different types and frequency of forum for patient plan discussion and how to end a NSSC-CPP. CONCLUSION The NSSC-CPP is implemented with great regional and intra-regional differences in Denmark. GPs face different requirements when referring to the NSSC-CPP, which indicates that the division of role and responsibility between GPs and the diagnostic units is not well defined.KEY POINTSIn Denmark, the cancer patient pathway for non-specific symptoms and signs of cancer (NSSC-CPP) has been implemented with variations, but little is known about these different modalities. This study showed that both at a regional and an intra-regional level:•General practitioners meet different implementation of national guidelines in the diagnostic units when referring to the NSSCP-CPP•The suitable patient group for the NSSC-CPP is not well defined•Quality criteria are needed to monitor, evaluate and improve the diagnostic work-up for patients with non-specific symptoms and signs of cancer.
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Affiliation(s)
- Christina Sadolin Damhus
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- The Primary Health Care Research Unit, Region Zealand, Denmark
- Survivorship and Inequality in Cancer, The Danish Cancer Society Research Center, Copenhagen, Denmark
- CONTACT Christina Sadolin Damhus The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Susanne Oksbjerg Dalton
- Survivorship and Inequality in Cancer, The Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Naestved, Denmark
| | - John Brodersen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- The Primary Health Care Research Unit, Region Zealand, Denmark
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Hultstrand C, Coe AB, Lilja M, Hajdarevic S. GPs' perspectives of the patient encounter - in the context of standardized cancer patient pathways. Scand J Prim Health Care 2020; 38:238-247. [PMID: 32314634 PMCID: PMC8570742 DOI: 10.1080/02813432.2020.1753388] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective: We aim to explore how GPs assign meanings and act upon patients' symptoms in primary care encounters in the context of standardized cancer patient pathways (CPPs).Design, setting and subjects: Thirteen individual interviews were conducted with GPs, at primary healthcare centers (n = 4) in one county in northern Sweden. Interviews were analyzed using grounded theory method. The results were then linked to symbolic interactionism.Main outcome measures: GPs' perspectives about assigning meanings to patients' presented symptoms and perception about CPPs.Results: In the encounter, GPs engaged in two simultaneous interactions, one with patients' symptoms - and the other with CPPs. The core category Disentangling patients' care trajectory consists of three categories, interpreted as GPs' strategies developed to assign meaning to symptoms. These strategies are carried out not in a straightforward manner but rather in a conflicting way, illuminating the complexity of GPs' daily work.Conclusions: Interacting with patients is vital for assigning meaning to presented symptoms. However, nowadays GPs are not only required to interact with patients, they are also required to interact with CPPs. These standardized routines might create pressure and demands on GPs, especially for those experiencing a lack of information about CPPs. Beside of carrying out the challenging patient/person-centered dialogues and interpreting presented symptoms, GPs also need to link the interpreted symptoms to CPPs. Therefore, it is essential that GPs are given opportunities at their workplaces to continuously be informed and be supported in order to practice CPPs and thereby optimize trajectories for patients undergoing cancer diagnostics.Key points Current awareness: • GPs deliberation about patients' trajectories is a complex process, often dealing with vague symptoms. How CPPs influence this process within the encounter has not been studied. Main statements: • GPs in our study were involved in two simultaneous interactions, one with patients' symptoms in the encounter - and the other with CPPs within the healthcare organization. • Symbolic interactionism helped capture how GPs deliberated about conflicting and paradoxical aspects of the encounter, in terms of balancing two contradictory ways of action that GPs face when providing patient/person-centered care and linking to CPPs. • Based on our results, primary care needs support from healthcare organizations to build capacity about CPPs and how to use them.
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Affiliation(s)
- Cecilia Hultstrand
- Department of Nursing, Umeå University, Umeå, Sweden;
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden;
- CONTACT Cecilia Hultstrand Department of Nursing, Umeå University, Umeå, SE-901 87, Sweden
| | | | - Mikael Lilja
- Department of Public Health and Clinical Medicine, Unit of Research, Education, and Development, Östersund Hospital, Umeå University, Umeå, Sweden
| | - Senada Hajdarevic
- Department of Nursing, Umeå University, Umeå, Sweden;
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden;
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Vejlgaard AS, Rasmussen S, Jarbøl DE, Balasubramaniam K. Is healthcare-seeking with gynaecological alarm symptoms influenced by personal and professional relations? A Danish population-based, cross-sectional study. BMJ Open 2020; 10:e033471. [PMID: 32404386 PMCID: PMC7228492 DOI: 10.1136/bmjopen-2019-033471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To identify the personal and professional relations of women experiencing gynaecological alarm symptoms, to analyse if involving a personal relation is related to healthcare-seeking with gynaecological alarm symptoms, and to analyse if having an available social network is associated with involvement of this relation. DESIGN Web-based, population-based, cross-sectional questionnaire survey. SETTING The general population in Denmark. PARTICIPANTS The study invited 100 000 individuals randomly drawn from the Danish Civil Registration System. Pregnant women and women who did not answer relevant questions about social network were excluded. A total of 5053 women who experienced at least one gynaecological alarm symptom were included in the study. PRIMARY AND SECONDARY OUTCOMES: (1) Personal and professional relations that women experiencing gynaecological alarm symptoms involve; (2) the association between involving a personal relation and healthcare-seeking; and (3) the association between having an available social network and involvement of this relation. RESULTS The general practitioner (GP) was the most involved professional relation, while the spouse/partner was the most involved personal relation. When experiencing gynaecological alarm symptoms, more than 50% of women did not involve a professional relation and 20% did not involve a personal relation. For all four gynaecological alarm symptoms, the odds of involving the GP were higher in the oldest age group. Women were two to seven times more likely to involve their GP if they had personal relation involvement. No statistically significant association was found between having an available social network and involving the GP. CONCLUSION Involving a personal relation in healthcare-seeking was associated with increased involvement of the GP, who consequently was the most involved professional relation when experiencing gynaecological alarm symptoms. Spouse/partner was the most involved personal relation. The oldest age group had the highest odds of involving the GP. No association was found between having an available social network and involving the GP.
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Affiliation(s)
| | - Sanne Rasmussen
- Research Unit for General Practice, University of Southern Denmark, Odense C, Denmark
| | - Dorte Ejg Jarbøl
- Research Unit for General Practice, University of Southern Denmark, Odense C, Denmark
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Hannaford PC, Thornton AJ, Murchie P, Whitaker KL, Adam R, Elliott AM. Patterns of symptoms possibly indicative of cancer and associated help-seeking behaviour in a large sample of United Kingdom residents-The USEFUL study. PLoS One 2020; 15:e0228033. [PMID: 31978177 PMCID: PMC6980617 DOI: 10.1371/journal.pone.0228033] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/06/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Cancer awareness campaigns aim to increase awareness of the potential seriousness of signs and symptoms of cancer, and encourage their timely presentation to healthcare services. Enhanced understanding of the prevalence of symptoms possibly indicative of cancer in different population subgroups, and associated general practitioner (GP) help-seeking behaviour, will help to target cancer awareness campaigns more effectively. AIM To determine: i) the prevalence of 21 symptoms possibly indicative of breast, colorectal, lung or upper gastrointestinal cancer in the United Kingdom (UK), including six 'red flag' symptoms; ii) whether the prevalence varies among population subgroups; iii) the proportion of symptoms self-reported as presented to GPs; iv) whether GP help-seeking behaviour varies within population subgroups. METHODS Self-completed questionnaire about experience of, and response to, 25 symptoms (including 21 possibly indicative of the four cancers of interest) in the previous month and year; sent to 50,000 adults aged 50 years or more and registered with 21 general practices in Staffordshire, England or across Scotland. RESULTS Completed questionnaires were received from 16,778 respondents (corrected response rate 34.2%). Almost half (45.8%) of respondents had experienced at least one symptom possibly indicative of cancer in the last month, and 58.5% in the last year. The prevalence of individual symptoms varied widely (e.g. in the last year between near zero% (vomiting up blood) and 15.0% (tired all the time). Red flag symptoms were uncommon. Female gender, inability to work because of illness, smoking, a history of a specified medical diagnosis, low social support and lower household income were consistently associated with experiencing at least one symptom possibly indicative of cancer in both the last month and year. The proportion of people who had contacted their GP about a symptom experienced in the last month varied between 8.1% (persistent cough) and 39.9% (unexplained weight loss); in the last year between 32.8% (hoarseness) and 85.4% (lump in breast). Nearly half of respondents experiencing at least one red flag symptom in the last year did not contact their GP about it. Females, those aged 80+ years, those unable to work because of illness, ex-smokers and those previously diagnosed with a specified condition were more likely to report a symptom possibly indicative of cancer to their GP; and those on high household income less likely. CONCLUSION Symptoms possibly indicative of cancer are common among adults aged 50+ years in the UK, although they are not evenly distributed. Help-seeking responses to different symptoms also vary. Our results suggest important opportunities to provide more nuanced messaging and targeting of symptom-based cancer awareness campaigns.
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Affiliation(s)
- Philip C. Hannaford
- Centre for Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Alison J. Thornton
- Centre for Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Peter Murchie
- Centre for Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Katriina L. Whitaker
- School of Health Sciences, University of Surrey, Guildford, Surrey, United Kingdom
| | - Rosalind Adam
- Centre for Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
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Sakthivel M, Krishnamoorthy Y, Sarveswaran G, Jayalakshmy R, Priyan S, Bharathnag N. Screening for red flag symptoms of cancer: A community-based cross-sectional study from urban Puducherry, India. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2018; 7:174. [PMID: 30788377 PMCID: PMC6333027 DOI: 10.4103/jehp.jehp_89_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 06/11/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Patients with cancer often delay seeking medical advice in developing countries. In India, only 20%-30% of cancers are being diagnosed in Stages I and II. Screening for red flag symptoms of cancer can be used to identify high-risk individuals in the community. METHODOLOGY A community-based cross-sectional study was conducted in February 2017 among 302 participants in one of the service areas of Jawaharlal Institute of Postgraduate Medical Education and Research urban health center selected by universal sampling. Data on the presence of red flag symptoms of cancer (persistent cough, persistent change in bowel/bladder habits, nonhealing ulcer, persistent difficulty in swallowing, unexplained weight loss, unexplained lump, persistent unexplained pain, unexplained bleeding, and change in the appearance of mole) and presence of risk factors were collected through interviews. The collected data were entered using EpiData version 3.0. RESULTS The mean (standard deviation) age of the study participants was 44 (11) years and 50.6% of them were male. At least one red flag symptom of cancer was present in 22 (7.3%) individuals; 9 (2.8%) had unexplained pain, 4 (1.3%) had change in bowel habits, 4 (1.3%) had change in bladder habits, 3 (1%) had cough, 3 (1%) had nonhealing ulcer, 2 (0.6%) had unexplained bleeding, 1 (0.3%) had difficulty in swallowing, 1 (0.3%) had weight loss, 1 (0.3%) had lump, and 1 (0.3%) had change in the appearance of mole. CONCLUSION Screening for red flag symptoms of cancer is an easy tool that can be used in the community to identify high-risk individuals, which will facilitate early diagnosis of cancer.
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Affiliation(s)
- Manikandanesan Sakthivel
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Yuvaraj Krishnamoorthy
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Gokul Sarveswaran
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - R. Jayalakshmy
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Shanthosh Priyan
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - N. Bharathnag
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Nielsen N, Vedsted P, Jensen H. Risk of cancer and repeated urgent referral after negative investigation for cancer. Fam Pract 2018; 35:582-588. [PMID: 29420706 DOI: 10.1093/fampra/cmx138] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Many countries have implemented cancer patient pathways (CPPs) for organ-specific cancers. However, due to high symptom diversity, it can be difficult for the General Practitioner (GP) to decide on the appropriate CPP. OBJECTIVE The aim of this study was to estimate the proportion of patients who were referred to a second CPP, were diagnosed with cancer or died within 6 months after receiving a negative result from clinical investigation through an initial CPP. METHODS We conducted a historical cohort study using routinely collected data with 6 months of follow-up. Data were collected from Danish registries. RESULTS We included 109998 study subjects: 0.6% received a cancer diagnosis, 2.3% died and 6.1% were referred to a second CPP within 6 months. A total of 48.9% of the re-referrals after a first CPP in the gastrointestinal (GI) area were also referred to a second CPP in the GI area. Re-referral to a second CPP corresponded to a positive predictive value (PPV) of 4.4% to be diagnosed with cancer. CONCLUSION A total of 6% of patients who received a negative result after investigation in an organ-specific CPP were re-referred within 6 months to a new organ-specific CPP; many of these were in the same anatomical area as the first CPP. The PPV of 4.4% to be diagnosed with cancer indicates that some cancers may be missed in the diagnostic investigation through the first CPP. This calls for reconsideration of how CPPs may best support the primary cancer diagnosis.
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Affiliation(s)
- Ninna Nielsen
- Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark.,Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Henry Jensen
- Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark.,Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Aarhus, Denmark
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Jørgensen SF, Ravn P, Thorsen S, Worm SW. Characteristics and outcome in patients with non-specific symptoms and signs of cancer referred to a fast track cancer patient pathway; a retrospective cohort study. BMC Cancer 2017; 17:809. [PMID: 29197366 PMCID: PMC5712161 DOI: 10.1186/s12885-017-3826-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 11/23/2017] [Indexed: 11/21/2022] Open
Abstract
Background In 2012 a new cancer patient pathway for patients with non-specific symptoms and signs of cancer (NSSC-CPP) was introduced in Denmark. Limited information is available about the patients referred to the NSSC-CPP and the investigational course. The aim was to describe the population and the investigational course, estimate the prevalence of cancer and one-year mortality, and identify factors associated with a subsequent cancer diagnosis in patients referred to the NSSC-CPP. Method This cohort study included patients with at least one visit at the NSSC-CPP at North Zealand Hospital in Denmark (NOH) from October 1st 2013 to September 30th 2014. Data was based on retrospective reviews of the patient files. Logistic regression identified factors associated with a subsequent cancer diagnosis. Multivariate analyses were adjusted by age, gender, smoking status and alcohol consumption. Kaplan-Meier survival plots were made at one-year follow-up. Results Eight hundred twenty-five patients were included with a median age of 67 years, 47.4% were male. Prevalence of cancer within one year was 16.7% (138/825). 70.3% (97/138) were solid cancers and 29.7% (41/138) were haematological cancers. During the investigational course 76.7% went through advanced diagnostic imaging (ultrasound, CT, FDG-PET/CT or MRI). Anaemia (OR1.63 CI1.02–2.60), leucocytosis (OR 2.06 CI 1.34–3.15), thrombocytopenia (OR 4.13 CI 2.02–8.47) and elevated LDH (OR 1.64 CI 1.07–2.52) and CRP (OR 2.56 CI 1.66–3.95) were associated with a cancer diagnosis when adjusting for possible confounders. No single non-specific symptom was significantly associated with a cancer diagnosis. One-year mortality for those diagnosed with cancer was 44.2%. Conclusion The prevalence of cancer matches that of another NSSC-CPP in Denmark. Deviations in basic biochemistry were associated with a higher probability of underlying cancer and could possibly raise the level of suspicion of malignancy among physicians. High one-year mortality was seen amongst patients diagnosed with cancer.
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Affiliation(s)
- Sara Falk Jørgensen
- Department of Pulmonary and Infectious Diseases, University Hospital, North Zealand Hospital, Hillerød, Denmark. .,Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark.
| | - Pernille Ravn
- Department of Pulmonary and Infectious Diseases, University Hospital, North Zealand Hospital, Hillerød, Denmark.,Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Søren Thorsen
- Department of Pulmonary and Infectious Diseases, University Hospital, North Zealand Hospital, Hillerød, Denmark
| | - Signe Westring Worm
- Department of Infectious Diseases, University Hospital Rigshospitalet, Copenhagen, Denmark
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11
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Simpkins SJ, Pinto-Sanchez MI, Moayyedi P, Bercik P, Morgan DG, Bolino C, Ford AC. Poor predictive value of lower gastrointestinal alarm features in the diagnosis of colorectal cancer in 1981 patients in secondary care. Aliment Pharmacol Ther 2017; 45:91-99. [PMID: 27807884 DOI: 10.1111/apt.13846] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 10/02/2016] [Accepted: 10/06/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Clinicians are advised to refer patients with lower gastrointestinal (GI) alarm features for urgent colonoscopy to exclude colorectal cancer (CRC). However, the utility of alarm features is debated. AIM To assess whether performance of alarm features is improved by using a symptom frequency threshold to trigger referral, or by combining them into composite variables, including minimum age thresholds, as recommended by the National Institute for Health and Care Excellence (NICE). METHODS We collected data prospectively from 1981 consecutive adults with lower GI symptoms. Assessors were blinded to symptom status. The reference standard to define CRC was histopathological confirmation of adenocarcinoma in biopsy specimens from a malignant-looking colorectal lesion. Controls were patients without CRC. Sensitivity, specificity, positive predictive values (PPVs) and negative predictive values were calculated for individual alarm features, as well as combinations of these. RESULTS In identifying 47 (2.4%) patients with CRC, individual alarm features had sensitivities ranging from 11.1% (family history of CRC) to 66.0% (loose stools), and specificities from 30.5% (loose stools) to 75.6% (family history of CRC). Using higher symptom frequency thresholds improved specificity, but to the detriment of sensitivity. NICE referral criteria also had higher specificities and lower sensitivity, with PPVs above 4.8%. More than 80% of those with CRC met at least one of the NICE referral criteria. CONCLUSIONS Using higher symptom frequency thresholds for alarm features improved specificity, but sensitivity was low. NICE referral criteria had PPVs above 4.8%, but sensitivities ranged from 2.2% to 32.6%, meaning many cancers would be missed.
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Affiliation(s)
- S J Simpkins
- Academic Unit of Primary Care, University of Leeds, Leeds, UK
| | - M I Pinto-Sanchez
- Gastroenterology Division, Farncombe Family Digestive Health Research Institute, Health Sciences Center, McMaster University, Hamilton, ON, Canada
| | - P Moayyedi
- Gastroenterology Division, Farncombe Family Digestive Health Research Institute, Health Sciences Center, McMaster University, Hamilton, ON, Canada
| | - P Bercik
- Gastroenterology Division, Farncombe Family Digestive Health Research Institute, Health Sciences Center, McMaster University, Hamilton, ON, Canada
| | - D G Morgan
- Gastroenterology Department, St. Joseph's Healthcare, Hamilton, ON, Canada
| | - C Bolino
- Gastroenterology Division, Farncombe Family Digestive Health Research Institute, Health Sciences Center, McMaster University, Hamilton, ON, Canada
| | - A C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
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12
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Ewing M, Naredi P, Nemes S, Zhang C, Månsson J. Increased consultation frequency in primary care, a risk marker for cancer: a case-control study. Scand J Prim Health Care 2016; 34:205-12. [PMID: 27189513 PMCID: PMC4977944 DOI: 10.1080/02813432.2016.1183692] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To identify early diagnostic profiles such as diagnostic codes and consultation patterns of cancer patients in primary care one year prior to cancer diagnosis. DESIGN Total population-based case-control study. SETTING AND SUBJECTS 4562 cancer patients and 17,979 controls matched by age, sex, and primary care unit. Data were collected from the Swedish Cancer Register and the Regional Healthcare Database. METHOD We identified cancer patients in the Västra Götaland Region of Sweden diagnosed in 2011 with prostate, breast, colorectal, lung, gynaecological, and skin cancers including malignant melanoma. We studied the symptoms and diagnoses identified by diagnostic codes during a diagnostic interval of 12 months before the cancer diagnosis. MAIN OUTCOME MEASURES Consultation frequency, symptom density by cancer type, prevalence and odds ratios (OR) for the diagnostic codes in the cancer population as a whole. RESULTS The diagnostic codes with the highest OR were unspecified lump in breast, neoplasm of uncertain behaviour, and abnormal serum enzyme levels. The codes with the highest prevalence were hyperplasia of prostate, other skin changes and abdominal and pelvic pain. The frequency of diagnostic codes and consultations in primary care rose in tandem 50 days before diagnosis for breast and gynaecological cancer, 60 days for malignant melanoma and skin cancer, 80 days for prostate cancer and 100 days for colorectal and lung cancer. CONCLUSION Eighty-seven percent of patients with the most common cancers consulted a general practitioner (GP) a year before their diagnosis. An increase in consultation frequency and presentation of any symptom should raise the GP's suspicion of cancer. Key points Knowledge about the prevalence of early symptoms and other clinical signs in cancer patients in primary care remains insufficient. • Eighty-seven percent of the patients with the seven most common cancers consulted a general practitioner 12 months prior to cancer diagnosis. • Both the frequency of consultation and the number of symptoms and diseases expressed in diagnostic codes rose in tandem 50-100 days before the cancer diagnosis. • Unless it is caused by a previously known disease, an increased consultation rate for any symptom should result in a swift investigation or referral from primary care to confirm or exclude cancer.
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Affiliation(s)
- Marcela Ewing
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
- CONTACT Marcela Ewing Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Naredi
- Department of Surgery, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
| | | | - Chenyang Zhang
- Regional Cancer Center West, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jörgen Månsson
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
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13
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Baird R, Banks I, Cameron D, Chester J, Earl H, Flannagan M, Januszewski A, Kennedy R, Payne S, Samuel E, Taylor H, Agarwal R, Ahmed S, Archer C, Board R, Carser J, Copson E, Cunningham D, Coleman R, Dangoor A, Dark G, Eccles D, Gallagher C, Glaser A, Griffiths R, Hall G, Hall M, Harari D, Hawkins M, Hill M, Johnson P, Jones A, Kalsi T, Karapanagiotou E, Kemp Z, Mansi J, Marshall E, Mitchell A, Moe M, Michie C, Neal R, Newsom-Davis T, Norton A, Osborne R, Patel G, Radford J, Ring A, Shaw E, Skinner R, Stark D, Turnbull S, Velikova G, White J, Young A, Joffe J, Selby P. An Association of Cancer Physicians' strategy for improving services and outcomes for cancer patients. Ecancermedicalscience 2016; 10:608. [PMID: 26913066 PMCID: PMC4762575 DOI: 10.3332/ecancer.2016.608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Indexed: 12/02/2022] Open
Abstract
The Association of Cancer Physicians in the United Kingdom has developed a strategy to improve outcomes for cancer patients and identified the goals and commitments of the Association and its members.
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Affiliation(s)
- Richard Baird
- ACP Executive Member
- ACP Strategy Drafting Group
- Supporting Chapter Author
- Addenbrooke’s Hospital, Cambridge, UK
| | - Ian Banks
- ACP Strategy Drafting Group
- Supporting Chapter Author
- University of Leeds, Leeds LS2 9JT, UK
| | - David Cameron
- ACP Executive Member
- ACP Strategy Drafting Group
- Edinburgh Cancer Research Centre, UK
| | - John Chester
- ACP Executive Member
- ACP Strategy Drafting Group
- Supporting Chapter Author
- Wales Cancer Research Centre, Cardiff, UK
| | - Helena Earl
- ACP Executive Member
- ACP Strategy Drafting Group
- Supporting Chapter Author
- Addenbrooke’s Hospital, Cambridge, UK
| | - Mark Flannagan
- ACP Strategy Drafting Group
- Supporting Chapter Author
- Beating Bowel Cancer, Harlequin House, 7 High St, Teddington, Middlesex TW11 8EE, UK
| | - Adam Januszewski
- ACP Executive Member
- ACP Strategy Drafting Group
- Supporting Chapter Author
- London Deanery, Stewart House, 32 Russell Square, London WC1B 5DN, UK
| | | | - Sarah Payne
- ACP Executive Member
- ACP Strategy Drafting Group
- Supporting Chapter Author
- Guy’s and St Thomas’s Hospital, London, UK and Medical Affairs Manager, Pfizer
| | - Emlyn Samuel
- ACP Strategy Drafting Group
- Cancer Research UK, Angel Building, 407 St John Street, London EC1V 4AD, UK
| | - Hannah Taylor
- ACP Executive Member
- ACP Strategy Drafting Group
- Supporting Chapter Author
- Severn Deanery, Vantage Office Park Old Gloucester Road, Hambrook, Avon, Bristol BS16 1GW, UK
| | - Roshan Agarwal
- ACP Executive Member
- Northampton General Hospital, Cliftonville, Northampton NN1 5BD, UK
| | - Samreen Ahmed
- ACP Executive Member
- University Hospitals of Leicester, Infirmary Square, Leicester LE1 5WW, UK
| | - Caroline Archer
- ACP Executive Member
- Queen Alexandra Hospital, Portsmouth, UK
| | - Ruth Board
- ACP Executive Member
- Lancashire Teaching Hospitals, UK
| | - Judith Carser
- ACP Executive Member
- Southern Health and Social Care Trust, Southern College of Nursing, Craigavon Area Hospital, 68 Lurgan Road, Portadown, BT63 5QQ, UK
| | - Ellen Copson
- Supporting Chapter Author
- University of Southampton, University Rd, Southampton SO17 1BJ, UK
| | - David Cunningham
- ACP Executive Member
- Supporting Chapter Author
- NIHR Biomedical Research Centre, Royal Marsden Hospital, London, UK
| | - Rob Coleman
- ACP Executive Member
- Weston Park Hospital, Sheffield, UK
| | - Adam Dangoor
- ACP Executive Member
- Supporting Chapter Author
- University Hospitals Bristol, Bristol, UK
| | - Graham Dark
- Supporting Chapter Author
- Freeman Hospital, Newcastle, UK
| | - Diana Eccles
- Supporting Chapter Author
- University of Southampton, University Rd, Southampton SO17 1BJ, UK
| | | | - Adam Glaser
- Supporting Chapter Author
- University of Leeds, Leeds LS2 9JT, UK
| | - Richard Griffiths
- ACP Executive Member
- Supporting Chapter Author
- Clatterbridge Cancer Centre, Clatterbridge Health Park, Clatterbridge Rd, Wirral, Merseyside CH63 4JY, UK
| | - Geoff Hall
- Supporting Chapter Author
- Leeds Cancer Centre, St James’s University Hospital, Leeds, UK
| | - Marcia Hall
- ACP Executive Member
- Mount Vernon Cancer Centre, Northwood, UK
| | - Danielle Harari
- Supporting Chapter Author
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Michael Hawkins
- Supporting Chapter Author
- University of Birmingham, Edgbaston, Birmingham, West Midlands B15 2TT, UK
| | - Mark Hill
- ACP Executive Member
- Kent Oncology Centre, Maidstone, Kent, UK
| | - Peter Johnson
- Supporting Chapter Author
- University of Southampton, University Rd, Southampton SO17 1BJ, UK
| | - Alison Jones
- ACP Executive Member
- Royal Free and University College Hospital, London, UK
| | - Tania Kalsi
- Supporting Chapter Author
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | | | - Zoe Kemp
- Supporting Chapter Author
- Royal Marsden Hospital, London, UK
| | - Janine Mansi
- ACP Executive Member
- Supporting Chapter Author
- Guy’s and St Thomas’ Hospitals, London, UK
| | - Ernie Marshall
- Supporting Chapter Author
- Clatterbridge Cancer Centre, Clatterbridge Health Park, Clatterbridge Rd, Wirral, Merseyside CH63 4JY, UK
| | - Alex Mitchell
- Supporting Chapter Author
- University of Leicester, University Rd, Leicester LE1 7RH, UK
| | - Maung Moe
- ACP Executive Member
- North Middlesex University Hospital, UK
| | | | - Richard Neal
- Supporting Chapter Author
- University of Bangor, Bangor, Gwynedd LL57 2DG , Wales, UK
| | - Tom Newsom-Davis
- Supporting Chapter Author
- Chelsea and Westminster Hospital, London, UK
| | | | - Richard Osborne
- Supporting Chapter Author
- Poole Hospital, Longfleet Rd, Poole, Dorset BH15 2JB, UK
| | - Gargi Patel
- ACP Executive Member
- Brighton and Sussex University Hospitals, UK
| | - John Radford
- Supporting Chapter Author
- University of Manchester, Oxford Rd, Manchester M13 9PL, UK
| | - Alistair Ring
- Supporting Chapter Author
- Royal Marsden Hospital, London, UK
| | - Emily Shaw
- Supporting Chapter Author
- Southampton General Hospital, Tremona Rd, Southampton, Hampshire SO16 6YD, UK
| | - Rod Skinner
- Supporting Chapter Author
- Royal Victoria Infirmary, Newcastle, UK
| | - Dan Stark
- Supporting Chapter Author
- Leeds Cancer Centre, St James’s University Hospital, Leeds, UK
| | - Sam Turnbull
- ACP Executive Member
- Leeds Cancer Centre, St James’s University Hospital, Leeds, UK
| | - Galina Velikova
- Supporting Chapter Author
- University of Leeds, Leeds LS2 9JT, UK
| | - Jeff White
- Supporting Chapter Author
- Beatson West of Scotland Cancer Centre, Glasgow, Scotland, UK
| | - Alison Young
- ACP Executive Member
- Supporting Chapter Author
- Leeds Cancer Centre, St James’s University Hospital, Leeds, UK
| | - Johnathan Joffe
- ACP Executive Member
- ACP Strategy Drafting Group
- Supporting Chapter Author
- Senior Author
- Huddersfield Royal Infirmary, Acre St, Huddersfield, West Yorkshire HD3 3EA, UK
| | - Peter Selby
- ACP Executive Member
- ACP Strategy Drafting Group
- Supporting Chapter Author
- Senior Author
- Leeds Cancer Centre, St James’s University Hospital, Leeds, UK
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14
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Merrild CH, Risør MB, Vedsted P, Andersen RS. Class, Social Suffering, and Health Consumerism. Med Anthropol 2015; 35:517-528. [DOI: 10.1080/01459740.2015.1102248] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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15
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Sele LMF, Balasubramaniam K, Elnegaard S, Søndergaard J, Jarbøl DE. Lifestyle factors and experience of respiratory alarm symptoms in the general population. BMJ Open Respir Res 2015; 2:e000101. [PMID: 26448866 PMCID: PMC4593171 DOI: 10.1136/bmjresp-2015-000101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 09/05/2015] [Accepted: 09/07/2015] [Indexed: 11/29/2022] Open
Abstract
Background The first step in the diagnosis of lung cancer is for individuals in the general population to recognise respiratory alarm symptoms (RAS). Knowledge is sparse about RAS and factors associated with experiencing RAS in the general population. This study aimed to estimate the prevalence of RAS in the general population, and to analyse possible associations between lifestyle factors and experiencing RAS. Methods A web-based survey comprising 100 000 individuals randomly selected from the Danish Civil Registration System. Items regarding experience of RAS (prolonged coughing, shortness of breath, coughing up blood and prolonged hoarseness) and self-reported lifestyle factors (smoking status, alcohol intake and body mass index) were included in the analysis. Results A total of 49 706 individuals completed the questionnaire. 16 per cent reported at least one RAS. Prolonged coughing (8.4%) and shortness of breath (8%) were most prevalent, while coughing up blood was least prevalent (0.1%). More men than women reported RAS (p<0.001). Odds of reporting RAS increased with age (Ptrend<0.001). In men and women, former and current smoking was associated with reporting at least one RAS (former smoking: ORmen=1.42, 95% CI 1.39 to 1.56; ORwomen=1.25, 95% CI 1.15 to 1.36; current smoking: ORmen=2.58, 95% CI 2.35 to 2.83; ORwomen=2.45, 95% CI 2.25 to 2.68). Individuals who were underweight or obese were significantly more likely to report at least one RAS. Odds of reporting at least one RAS increased with increasing alcohol intake for both genders (Ptrend<0.001). Conclusions RAS are common in the general population. Men experience more symptoms than women, and prevalence increases with age. Being a former or current smoker and being underweight or obese are positively associated with experiencing RAS. The likelihood of experiencing RAS increases with increasing alcohol intake. Future research should investigate healthcare seeking for RAS among individuals with different lifestyles.
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Affiliation(s)
- Lisa Maria Falk Sele
- Department of Public Health, Research Unit of General Practice , University of Southern Denmark , Odense C , Denmark
| | - Kirubakaran Balasubramaniam
- Department of Public Health, Research Unit of General Practice , University of Southern Denmark , Odense C , Denmark
| | - Sandra Elnegaard
- Department of Public Health, Research Unit of General Practice , University of Southern Denmark , Odense C , Denmark
| | - Jens Søndergaard
- Department of Public Health, Research Unit of General Practice , University of Southern Denmark , Odense C , Denmark
| | - Dorte Ejg Jarbøl
- Department of Public Health, Research Unit of General Practice , University of Southern Denmark , Odense C , Denmark
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16
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Predictive values of GPs' suspicion of serious disease: a population-based follow-up study. Br J Gen Pract 2015; 64:e346-53. [PMID: 24868072 DOI: 10.3399/bjgp14x680125] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Knowledge is sparse on the prevalence of suspicion of cancer and other serious diseases in general practice. Likewise, little is known about the possible implications of this suspicion on future healthcare use and diagnoses. AIM To study the prevalence of GPs' suspicions of cancer or other serious diseases and analyse how this suspicion predicted the patients' healthcare use and diagnoses of serious disease. DESIGN AND SETTING Prospective population-based cohort study of 4518 patients consulting 404 GPs in a mix of urban, semi-urban and rural practices in Central Denmark Region during 2008-2009. METHOD The GPs registered consultations in 1 work day, including information on their suspicion of the presence of cancer or another serious disease. The patients were followed up for use of healthcare services and new diagnoses through the use of national registers. RESULTS Prevalence of suspicion was 5.7%. Suspicion was associated with an increase in referrals (prevalence ratio [PR] = 2.56, 95% confidence interval [CI] = 2.22 to 2.96), especially for diagnostic imaging (PR = 3.95, 95% CI = 2.80 to 5.57), increased risk of a new diagnosis of cancer or another serious disease within 2 months (hazard ratio [HR] = 2.98, 95% CI = 1.93 to 4.62)--especially for cancer (HR = 7.55, 95% CI = 2.66 to 21.39)--and increased use of general practice (relative risk [RR] = 1.14, 95% CI = 1.06 to 1.24) and hospital visits (RR = 1.90, 95% CI = 1.62 to 2.23). The positive predictive value of a GP suspicion was 9.8% (95% CI = 6.4 to 14.1) for cancer or another serious disease within 2 months. CONCLUSION A GP suspicion of serious disease warrants further investigation, and the organisation of the healthcare system should ensure direct access from the primary sector to specialised tests.
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17
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Jensen LF, Hvidberg L, Pedersen AF, Vedsted P. Symptom attributions in patients with colorectal cancer. BMC FAMILY PRACTICE 2015; 16:115. [PMID: 26335940 PMCID: PMC4557758 DOI: 10.1186/s12875-015-0315-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 07/29/2015] [Indexed: 11/30/2022]
Abstract
Background Symptoms of cancer may be interpreted differently by different patients before the diagnosis. This study investigated symptom attributions in Danish patients with colorectal cancer and the potential associations with symptom type, socio-demographic characteristics and patient interval. Methods Data were collected among incident colorectal cancer patients (n = 577, response rate 64.2 %), who were asked to think back on the time before their diagnosis when completing the questionnaire. The questionnaire comprised a Danish version of the revised Illness Perception Questionnaire (IPQ-R) with questions on 19 symptom attributions. These 19 attribitutions were categorised into five causal groups for statistical analyses. The patient interval (i.e. the time from the patient’s first symptom experience to presentation to the healthcare system) was assessed in the same questionnaire. Data on socio-demographic characteristics were obtained by using nationwide registers from Statistics Denmark. Results Patients who experienced ‘blood in stool’ as the most important symptom were more likely to attribute this to cancer (PRad 1.90, 95 % CI 1.43-2.54) and benign somatic causes (PRad 1.33, 95 % CI 1.02-1.72), such as haemorrhoids, compared to patients who did not perceive this symptom as the most important. Socio-demographic characteristics were also associated with symptom attribution. Patients with higher educational levels were less likely to attribute their most important symptom to psychological causes (PRad 0.57, 95 % CI 0.35–0.94) than patients with lower educational levels. Patients with rectal cancer attributed their most important symptom to a benign somatic cause more often than patients with colon cancer (PRad 1.39, 95 % CI 1.07–1.80). Conclusions Symptom attribution in patients was associated with aspects of socio-demography and with the symptom type perceived by the patient as the most important. No significant associations were found between symptom attributions and patient interval. These results have implications for general practice as symptom attributions may prompt patients to present symptoms in a certain way and thereby influence the general practitioner’s assessment of presented symptoms.
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Affiliation(s)
- Line Flytkjær Jensen
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark. .,Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.
| | - Line Hvidberg
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark. .,Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.
| | - Anette Fischer Pedersen
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.
| | - Peter Vedsted
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.
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18
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Rasmussen S, Larsen PV, Søndergaard J, Elnegaard S, Svendsen RP, Jarbøl DE. Specific and non-specific symptoms of colorectal cancer and contact to general practice. Fam Pract 2015; 32:387-94. [PMID: 25977134 DOI: 10.1093/fampra/cmv032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND To improve survival rates for colorectal cancer, referral guidelines have been implemented. First step in the diagnostic process is for the individual to recognize the symptoms and contact his/her general practitioner (GP) for evaluation. OBJECTIVES To determine (i) the prevalence of specific and non-specific symptom experiences indicative of colorectal cancer, (ii) the proportion of subsequent contacts to GPs, (iii) to explore the possible differences in symptom experience and contact to GPs between age and sex. METHODS A nationwide study of 100000 adults, aged 20 years and older, were randomly selected in the general population and invited to participate in an internet-based survey. Items regarding experience of specific and non-specific alarm symptoms of colorectal cancer within the preceding 4 weeks and contact to GP were included. RESULTS A total of 49706 subjects completed the questionnaire. Abdominal pain was the most common specific alarm symptom (19.7%) and tiredness was the most common non-specific symptom (49.8%). The experiences of symptoms were more common among women and more common in the youngest age groups for both sexes. The symptom leading to the highest proportion of GP contacts was rectal bleeding (33.8%). When experiencing any combination of two specific alarm symptoms, the proportion who contacted a GP was less than 50%. The combination of a non-specific and a specific alarm symptom gave rise to the highest proportion of GP contacts. CONCLUSION Although specific and non-specific alarm symptoms of colorectal cancer are common in the general population, the proportion of GP contacts is low.
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Affiliation(s)
- Sanne Rasmussen
- Research Unit of General Practice, Department of Public Health, University of Southern, Odense, Denmark.
| | - Pia V Larsen
- Research Unit of General Practice, Department of Public Health, University of Southern, Odense, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern, Odense, Denmark
| | - Sandra Elnegaard
- Research Unit of General Practice, Department of Public Health, University of Southern, Odense, Denmark
| | - Rikke P Svendsen
- Research Unit of General Practice, Department of Public Health, University of Southern, Odense, Denmark
| | - Dorte E Jarbøl
- Research Unit of General Practice, Department of Public Health, University of Southern, Odense, Denmark
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19
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Elnegaard S, Andersen RS, Pedersen AF, Larsen PV, Søndergaard J, Rasmussen S, Balasubramaniam K, Svendsen RP, Vedsted P, Jarbøl DE. Self-reported symptoms and healthcare seeking in the general population--exploring "The Symptom Iceberg". BMC Public Health 2015; 15:685. [PMID: 26195232 PMCID: PMC4509464 DOI: 10.1186/s12889-015-2034-5] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 07/07/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Research has illustrated that the decision-making process regarding healthcare seeking for symptoms is complex and associated with a variety of factors, including gender differences. Enhanced understanding of the frequency of symptoms and the healthcare seeking behaviour in the general population may increase our knowledge of this complex field. The primary objective of this study was to estimate the prevalence of self-reported symptoms and the proportion of individuals reporting GP contact, in a large Danish nationwide cohort. A secondary objective was to explore gender differences in GP contacts in response to experiencing one of the 44 predefined symptoms. METHODS A Danish nationwide cohort study including a random sample of 100,000 individuals, representative of the adult Danish population aged 20 years or above. A web-based questionnaire survey formed the basis of this study. A total of 44 different symptoms covering a wide area of alarm symptoms and non-specific frequently occurring symptoms were selected based on extensive literature search. Further, items regarding contact to the GP were included. Data on socioeconomic factors were obtained from Statistics Denmark. RESULTS A total of 49,706 subjects completed the questionnaire. Prevalence estimates of symptoms varied from 49.4% (24,537) reporting tiredness to 0.11% (54) reporting blood in vomit. The mean number of reported symptoms was 5.4 (men 4.8; women 6.0). The proportion of contact to the GP with at least one symptom was 37%. The largest proportion of GP contacts was seen for individuals reporting blood in the urine (73.2%), whereas only 11.4% of individuals with increase in waist circumference reported GP contact. For almost 2/3 of the symptoms reported, no gender differences were found concerning the proportion leading to GP contacts. CONCLUSION Prevalence of symptoms and GP contacts are common in this overview of 44 different self-reported symptoms. For almost 2/3 of the reported symptoms no gender differences were found concerning the proportion leading to GP contacts. An enhanced understanding of healthcare seeking decisions may assist healthcare professionals in identifying patients who are at risk of postponing contact to the GP and may help development of health campaigns targeting these individuals.
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Affiliation(s)
- Sandra Elnegaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9A, 5000, Odense C, Denmark.
| | - Rikke Sand Andersen
- The Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care - CaP, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.
| | - Anette Fischer Pedersen
- The Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care - CaP, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.
| | - Pia Veldt Larsen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9A, 5000, Odense C, Denmark.
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9A, 5000, Odense C, Denmark.
| | - Sanne Rasmussen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9A, 5000, Odense C, Denmark.
| | - Kirubakaran Balasubramaniam
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9A, 5000, Odense C, Denmark.
| | - Rikke Pilsgaard Svendsen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9A, 5000, Odense C, Denmark.
| | - Peter Vedsted
- The Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care - CaP, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.
| | - Dorte Ejg Jarbøl
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9A, 5000, Odense C, Denmark.
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Halligan S, Dadswell E, Wooldrage K, Wardle J, von Wagner C, Lilford R, Yao GL, Zhu S, Atkin W. Computed tomographic colonography compared with colonoscopy or barium enema for diagnosis of colorectal cancer in older symptomatic patients: two multicentre randomised trials with economic evaluation (the SIGGAR trials). Health Technol Assess 2015; 19:1-134. [PMID: 26198205 PMCID: PMC4781284 DOI: 10.3310/hta19540] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Computed tomographic colonography (CTC) is a relatively new diagnostic test that may be superior to existing alternatives to investigate the large bowel. OBJECTIVES To compare the diagnostic efficacy, acceptability, safety and cost-effectiveness of CTC with barium enema (BE) or colonoscopy. DESIGN Parallel randomised trials: BE compared with CTC and colonoscopy compared with CTC (randomisation 2 : 1, respectively). SETTING A total of 21 NHS hospitals. PARTICIPANTS Patients aged ≥ 55 years with symptoms suggestive of colorectal cancer (CRC). INTERVENTIONS CTC, BE and colonoscopy. MAIN OUTCOME MEASURES For the trial of CTC compared with BE, the primary outcome was the detection rate of CRC and large polyps (≥ 10 mm), with the proportion of patients referred for additional colonic investigation as a secondary outcome. For the trial of CTC compared with colonoscopy, the primary outcome was the proportion of patients referred for additional colonic investigation, with the detection rate of CRC and large polyps as a secondary outcome. Secondary outcomes for both trials were miss rates for cancer (via registry data), all-cause mortality, serious adverse events, patient acceptability, extracolonic pathology and cost-effectiveness. RESULTS A total of 8484 patients were registered and 5384 were randomised and analysed (BE trial: 2527 BE, 1277 CTC; colonoscopy trial: 1047 colonoscopy, 533 CTC). Detection rates in the BE trial were 7.3% (93/1277) for CTC, compared with 5.6% (141/2527) for BE (p = 0.0390). The difference was due to better detection of large polyps by CTC (3.6% vs. 2.2%; p = 0.0098), with no significant difference for cancer (3.7% vs. 3.4%; p = 0.66). Significantly more patients having CTC underwent additional investigation (23.5% vs. 18.3%; p = 0.0003). At the 3-year follow-up, the miss rate for CRC was 6.7% for CTC (three missed cancers) and 14.1% for BE (12 missed cancers). Significantly more patients randomised to CTC than to colonoscopy underwent additional investigation (30% vs. 8.2%; p < 0.0001). There was no significant difference in detection rates for cancer or large polyps (10.7% for CTC vs. 11.4% for colonoscopy; p = 0.69), with no difference when cancers (p = 0.94) and large polyps (p = 0.53) were analysed separately. At the 3-year follow-up, the miss rate for cancer was nil for colonoscopy and 3.4% for CTC (one missed cancer). Adverse events were uncommon for all procedures. In 1042 of 1748 (59.6%) CTC examinations, at least one extracolonic finding was reported, and this proportion increased with age (p < 0.0001). A total of 149 patients (8.5%) were subsequently investigated, and extracolonic neoplasia was diagnosed in 79 patients (4.5%) and malignancy in 29 (1.7%). In the short term, CTC was significantly more acceptable to patients than BE or colonoscopy. Total costs for CTC and colonoscopy were finely balanced, but CTC was associated with higher health-care costs than BE. The cost per large polyp or cancer detected was £4235 (95% confidence interval £395 to £9656). CONCLUSIONS CTC is superior to BE for detection of cancers and large polyps in symptomatic patients. CTC and colonoscopy detect a similar proportion of large polyps and cancers and their costs are also similar. CTC precipitates significantly more additional investigations than either BE or colonoscopy, and evidence-based referral criteria are needed. Further work is recommended to clarify the extent to which patients initially referred for colonoscopy or BE undergo subsequent abdominopelvic imaging, for example by computed tomography, which will have a significant impact on health economic estimates. TRIAL REGISTRATION Current Controlled Trials ISRCTN95152621.
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Affiliation(s)
- Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
| | - Edward Dadswell
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kate Wooldrage
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jane Wardle
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, UK
| | - Christian von Wagner
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, UK
| | - Richard Lilford
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK
- Population Evidence and Technologies, University of Warwick, Warwick, UK
| | - Guiqing L Yao
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Shihua Zhu
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Wendy Atkin
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
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Vedsted P, Olesen F. A differentiated approach to referrals from general practice to support early cancer diagnosis - the Danish three-legged strategy. Br J Cancer 2015; 112 Suppl 1:S65-9. [PMID: 25734387 PMCID: PMC4385978 DOI: 10.1038/bjc.2015.44] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
When aiming to provide more expedited cancer diagnosis and treatment of cancer at an earlier stage, it is important to take into account the symptom epidemiology throughout the pathway, from first bodily sensation until the start of cancer treatment. This has implications for how primary-care providers interpret the presentation and decisions around patient management and investigation. Symptom epidemiology has consequences for how the health-care system might best be organised. This paper argues for and describes the organisation of the Danish three-legged strategy in diagnosing cancer, which includes urgent referral pathways for symptoms suspicious of a specific cancer, urgent referral to diagnostic centres when we need quick and profound evaluation of patients with nonspecific, serious symptoms and finally easy and fast access to ‘No-Yes-Clinics' for cancer investigations for those patients with common symptoms in whom the diagnosis of cancer should not be missed. The organisation of the health-care system must reflect the reality of symptoms presented in primary care. The organisational change is evaluated and monitored with a comprehensive research agenda, data infrastructure and education.
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Affiliation(s)
- P Vedsted
- Research Unit for General Practice, The Research Centre for Cancer Diagnosis in Primary Care (CaP), Institute of Public Health, Aarhus University, Bartholins Alle 2, 8000 Aarhus C, Denmark
| | - F Olesen
- Research Unit for General Practice, The Research Centre for Cancer Diagnosis in Primary Care (CaP), Institute of Public Health, Aarhus University, Bartholins Alle 2, 8000 Aarhus C, Denmark
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22
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Attributions of cancer 'alarm' symptoms in a community sample. PLoS One 2014; 9:e114028. [PMID: 25461959 PMCID: PMC4252079 DOI: 10.1371/journal.pone.0114028] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 11/03/2014] [Indexed: 02/07/2023] Open
Abstract
Background Attribution of early cancer symptoms to a non-serious cause may lead to longer diagnostic intervals. We investigated attributions of potential cancer ‘alarm’ and non-alarm symptoms experienced in everyday life in a community sample of adults, without mention of a cancer context. Methods A questionnaire was mailed to 4858 adults (≥50 years old, no cancer diagnosis) through primary care, asking about symptom experiences in the past 3 months. The word cancer was not mentioned. Target 'alarm' symptoms, publicised by Cancer Research UK, were embedded in a longer symptom list. For each symptom experienced, respondents were asked for their attribution (‘what do you think caused it'), concern about seriousness (‘not at all’ to ‘extremely’), and help-seeking (‘did you contact a doctor about it’: Yes/No). Results The response rate was 35% (n = 1724). Over half the respondents (915/1724; 53%) had experienced an ‘alarm’ symptom, and 20 (2%) cited cancer as a possible cause. Cancer attributions were highest for ‘unexplained lump’; 7% (6/87). Cancer attributions were lowest for ‘unexplained weight loss’ (0/47). A higher proportion (375/1638; 23%) were concerned their symptom might be ‘serious’, ranging from 12% (13/112) for change in a mole to 41% (100/247) for unexplained pain. Just over half had contacted their doctor about their symptom (59%), although this varied by symptom. Alarm symptoms were appraised as more serious than non-alarm symptoms, and were more likely to trigger help-seeking. Conclusions Consistent with retrospective reports from cancer patients, ‘alarm’ symptoms experienced in daily life were rarely attributed to cancer. These results have implications for understanding how people appraise and act on symptoms that could be early warning signs of cancer.
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23
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Balasubramaniam K, Ravn P, Larsen PV, Søndergaard J, Jarbøl DE. Specific and unspecific gynecological alarm symptoms - prevalence estimates in different age groups: a population-based study. Acta Obstet Gynecol Scand 2014; 94:191-7. [DOI: 10.1111/aogs.12538] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 11/06/2014] [Indexed: 12/15/2022]
Affiliation(s)
- Kirubakaran Balasubramaniam
- Research Unit of General Practice; Institute of Public Health; University of Southern Denmark; Odense Denmark
| | - Pernille Ravn
- Department of Gynecology and Obstetrics; Odense University Hospital; Odense Denmark
| | - Pia V. Larsen
- Research Unit of General Practice; Institute of Public Health; University of Southern Denmark; Odense Denmark
| | - Jens Søndergaard
- Research Unit of General Practice; Institute of Public Health; University of Southern Denmark; Odense Denmark
| | - Dorte E. Jarbøl
- Research Unit of General Practice; Institute of Public Health; University of Southern Denmark; Odense Denmark
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24
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Jensen H, Tørring ML, Olesen F, Overgaard J, Vedsted P. Cancer suspicion in general practice, urgent referral and time to diagnosis: a population-based GP survey and registry study. BMC Cancer 2014; 14:636. [PMID: 25175155 PMCID: PMC4164756 DOI: 10.1186/1471-2407-14-636] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 08/26/2014] [Indexed: 01/17/2023] Open
Abstract
Background Many countries have implemented standardised cancer patient pathways (CPPs) to ensure fast diagnosis of patients suspected of having cancer. Yet, studies are sparse on the impact of such CPPs, and few have distinguished between referral routes. For incident cancer patients, we aimed to determine how often GPs suspected cancer at the time of first presentation of symptoms in general practice and to describe the routes of referral for further investigation. In addition, we aimed to analyse if the GP’s suspicion of cancer could predict the choice of referral to a CPP. Finally, we aimed to analyse associations between not only cancer suspicion and time to cancer diagnosis, but also between choice of referral route and time to cancer diagnosis. Methods We conducted a population-based, cross-sectional study of incident cancer patients in Denmark who had attended general practice prior to their diagnosis of cancer. Data were collected from GP questionnaires and national registers. We estimated the patients’ chance of being referred to a CPP (prevalence ratio (PR)) using Poisson regression. Associations between the GP’s symptom interpretation, use of CPP and time to diagnosis were estimated using quantile regression. Results 5,581 questionnaires were returned (response rate: 73.8%). A GP was involved in diagnosing the cancer in 4,101 (73.5%) cases (3,823 cases analysed). In 48.2% of these cases, the GP interpreted the patient’s symptoms as ‘alarm’ symptoms suggestive of cancer. The GP used CPPs in 1,426 (37.3%) cases. Patients, who had symptoms interpreted as ‘vague’ had a lower chance of being referred to a CPP than when interpreted as ‘alarm’ symptoms (PR = 0.53 (95%CI: 0.48;0.60)). Patients with ‘vague’ symptoms had a 34 (95% CI: 28;41) days longer median time to diagnosis than patients with ‘alarm’ symptoms. Conclusions GPs suspect cancer more often than they initiate a CPP, and patients were less likely to be referred to a CPP when their symptoms were not interpreted as alarm symptoms of cancer. The GP’s choice of referral route was a strong predictor of the duration of the diagnostic interval, but the GP’s symptom interpretation was approximately twice as strong an indicator of a longer diagnostic interval.
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Affiliation(s)
- Henry Jensen
- Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000 Aarhus C, Denmark.
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Rasmussen S, Søndergaard J, Larsen PV, Balasubramaniam K, Elnegaard S, Svendsen RP, Andersen RS, Pedersen AF, Vedsted P, Jarbøl DE. The Danish Symptom Cohort: Questionnaire and Feasibility in the Nationwide Study on Symptom Experience and Healthcare-Seeking among 100 000 Individuals. INTERNATIONAL JOURNAL OF FAMILY MEDICINE 2014; 2014:187280. [PMID: 25147736 PMCID: PMC4132324 DOI: 10.1155/2014/187280] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 05/14/2014] [Accepted: 07/08/2014] [Indexed: 06/03/2023]
Abstract
Introduction. In order to develop strategies to prevent delay in diagnosis, it is important to gain knowledge of symptoms and healthcare-seeking processes in the population. This paper describes a combined survey and register-based study with (1) focus on development of a questionnaire concerning experience of symptoms and subsequent consequences and (2) feasibility of the study. Methods. The study is a nationwide cohort study of 100 000 individuals randomly selected from the Danish general population. A comprehensive questionnaire concerning experience of symptoms and subsequent consequences was developed. The methodological framework for the development included defining the domains to be measured, identification of previous items, scales and questionnaires in the literature, and pilot and field testing. Results. A total of five domains and 16 subdomains were defined covering the area of symptom experience, symptom characteristics, reaction in response to symptom experience, external factors, and personality characteristics with potential influence on the symptom experience. In total, 49 706 questionnaires were completed, yielding a response rate of 52.2%. Conclusion. We developed a comprehensive questionnaire used in a large combined survey and register-based study concerning experience of symptoms and subsequent consequences of symptom experiences. We succeeded in conducting a large survey providing the groundwork for The Danish Symptom Cohort.
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Affiliation(s)
- Sanne Rasmussen
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000 Odense C, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000 Odense C, Denmark
| | - Pia Veldt Larsen
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000 Odense C, Denmark
| | - Kirubakaran Balasubramaniam
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000 Odense C, Denmark
| | - Sandra Elnegaard
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000 Odense C, Denmark
| | - Rikke Pilsgaard Svendsen
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000 Odense C, Denmark
| | - Rikke Sand Andersen
- The Research Unit for General Practice, Danish Research Centre for Cancer Diagnosis in Primary Care (CaP), Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark
| | - Anette Fischer Pedersen
- The Research Unit for General Practice, Danish Research Centre for Cancer Diagnosis in Primary Care (CaP), Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark
| | - Peter Vedsted
- The Research Unit for General Practice, Danish Research Centre for Cancer Diagnosis in Primary Care (CaP), Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark
| | - Dorte Ejg Jarbøl
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000 Odense C, Denmark
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Jarlbaek L, Christensen L, Bruera E, Gilså Hansen D. The epidemiology of long- and short-term cancer survivors. A population-based cohort study exploring denominators for rehabilitation and palliative care programs. Acta Oncol 2014; 53:493-501. [PMID: 24050517 DOI: 10.3109/0284186x.2013.831471] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION In this study, we present data from a population-based cohort of incident cancer patients separated in long- and short-term survivors. Our aim was to procure denominators for use in the planning of rehabilitation and palliative care programs. MATERIAL AND METHODS A registry-linkage cohort study. All cancer patients, diagnosed from 1993 to 2003 from a 470 000 large population, were followed individually from diagnosis to death or until 31 December 2008. Long-term survivors lived five years or more after the time of the cancer diagnosis (TOCD). Short-term survivors died less than five years after TOCD. RESULTS The cohort comprised 24 162 incident cancer patients with 41% long-term survivors (N = 9813). Seventy percent of the cohort was 60 + years at TOCD. The 14 349 short-term survivors' median survival was 0.6 year, and 78% died less than two years after TOCD. A 12 years' difference in age at TOCD was seen between long- and short-term survivors, with median ages of 60 versus 72 years, respectively. Females comprised 64% of long-term, and 46% of short-term survivors. The proportion of breast and lung cancers differed between the groups: Long-term survivors: 31% breast cancer, 2.4% lung cancer. Short-term survivors: 21% lung cancer, 7.2% breast cancer. Chemotherapy was provided to 15% of all patients, and to 10% of the 60 + year olds. DISCUSSION The epidemiology of long- and short-term survivors shows significant differences with regard to age at TOCD, cancer types and sex. Two-year crude cancer survival seems as a clinically relevant cut point for characterizing potential "denominators" for rehabilitation or palliative care programs. From this cohort of incident cancer patients, and using two-year survival as a cut point, it could be estimated that 54% would candidate to a "care trajectory" focusing on rehabilitation and 46% a "care trajectory" focusing on palliative care at TOCD.
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Affiliation(s)
- Lene Jarlbaek
- Danish Knowledge Center for Palliative Care (PAVI), University of Southern Denmark,
Odense, Denmark
- National Research Centre for Cancer Rehabilitation, Research Unit of General Practice, Institute of Public Health, University of Southern Denmark,
Odense, Denmark
- Department of Oncology, University Hospital of Southern Denmark,
Odense, Denmark
| | - Linda Christensen
- Department of Oncology, University Hospital of Southern Denmark,
Odense, Denmark
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center,
Houston, Texas
| | - Dorte Gilså Hansen
- National Research Centre for Cancer Rehabilitation, Research Unit of General Practice, Institute of Public Health, University of Southern Denmark,
Odense, Denmark
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Högberg C, Karling P, Rutegård J, Lilja M, Ljung T. Immunochemical faecal occult blood tests in primary care and the risk of delay in the diagnosis of colorectal cancer. Scand J Prim Health Care 2013; 31:209-14. [PMID: 24191847 PMCID: PMC3860297 DOI: 10.3109/02813432.2013.850205] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To evaluate the value, risks, and shortcomings of immunochemical faecal occult blood tests (iFOBTs) in the diagnosis of colorectal cancer (CRC) and adenomas with high-grade dysplasia (HGD) in patients initially presenting to primary care. DESIGN A retrospective population-based study. SETTING AND SUBJECTS All 495 cases of CRC and adenomas with HGD diagnosed in the county of Jämtland, Sweden from 2005 to 2009. RESULTS Of 495 patients 323 (65%) initially presented to primary care. IFOBTs were performed in 215 of 323 (67%) patients. The sensitivity of iFOBT for CRC and adenomas with HGD was 88% (83% when patients with a history of rectal bleeding were excluded). Of 34 patients with anaemia found en passant, 10 had negative iFOBTs. Time to diagnosis was longer for patients with negative iFOBTs (p < 0.0005). CONCLUSION IFOBT might be helpful in selecting which patients to refer for colonoscopy. However, iFOBT has a limited sensitivity as a diagnostic test for CRC and adenomas with HGD. Relying only on iFOBT for colonoscopy referral could delay diagnosis, especially for patients with anaemia found en passant.
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Affiliation(s)
- Cecilia Högberg
- Department of Public Health and Clinical Medicine, Unit of Clinical Research Centre - Östersund, Umeå University, Sweden
| | - Pontus Karling
- Department of Public Health and Clinical Medicine, Medicine/Gastroenterology, Umeå University, Sweden
| | - Jörgen Rutegård
- Department of Surgical and Perioperative Sciences, Umeå University, Sweden
| | - Mikael Lilja
- Department of Public Health and Clinical Medicine, Unit of Clinical Research Centre - Östersund, Umeå University, Sweden
| | - Thomas Ljung
- Department of Health Sciences, Mid Sweden University, Sweden
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Svendsen RP, Jarbol DE, Larsen PV, Støvring H, Hansen BL, Soendergaard J. Associations between health care seeking and socioeconomic and demographic determinants among people reporting alarm symptoms of cancer: a population-based cross-sectional study. Fam Pract 2013; 30:655-65. [PMID: 23864364 DOI: 10.1093/fampra/cmt036] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Late diagnosis of cancer may partly be explained by the fact that some patients do not seek health care promptly when experiencing an alarm symptom. Socioeconomic and demographic differences exist concerning knowledge and awareness of cancer alarm symptoms in the general population and socioeconomic differences are found in cancer incidence and survival. We therefore hypothesise that socioeconomic and demographic differences in health care-seeking behaviour are present among people with alarm symptoms. OBJECTIVES To analyse associations between health care seeking and socioeconomic and demographic factors among people reporting cancer alarm symptoms. METHODS A questionnaire survey comprising 20000 people aged >20 from the Danish population. The questionnaire concerned alarm symptoms of common cancers and subsequent health care seeking. Data on socioeconomic factors were obtained from Statistics Denmark. MAIN OUTCOMES health care seeking and patient interval. RESULTS A total of 26.1% of all subjects reported that they did not seek health care when having experienced an alarm symptom. Women-subjects aged >40, subjects living with a partner and subjects having a cancer diagnosis-were more likely to seek health care, whereas medium educational level was negatively associated with health care seeking. Further, women were more likely to seek health care within 1 month, whereas subjects out of the workforce were less likely to do so. CONCLUSIONS Approximately three out of four subjects sought health care when having experienced an alarm symptom but 50% waited for at least 1 month. Some demographic factors were found to be associated with health care-seeking behaviour and the patient interval, whereas no consistent associations were found with regard to socioeconomics.
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Affiliation(s)
- Rikke P Svendsen
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9A, DK-5000 Odense C and
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Larsen MB, Hansen RP, Sokolowski I, Vedsted P. Agreement between patient-reported and doctor-reported patient intervals and date of first symptom presentation in cancer diagnosis - a population-based questionnaire study. Cancer Epidemiol 2013; 38:100-5. [PMID: 24238619 DOI: 10.1016/j.canep.2013.10.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 10/15/2013] [Accepted: 10/17/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND The concept of delay in cancer diagnosis has been a scientific issue for decades, and there is still no standardised and validated way to measure the time intervals. One of the intervals that are difficult to measure is the patient interval (i.e. the period from the patient's first symptom until the first presentation to the health care system) because dates of symptom onset and first presentation are difficult to establish precisely. Further, since patients may have another experience of the diagnostic pathway than e.g. the general practitioner (GP), a reasonable question remains whether patients and GPs agree on these important milestones. The objective of this study was to analyse the agreement between patient-reported and GP-reported patient intervals and date of first presentation of cancer-related symptom(s) to the GP. METHODS On the basis of a cohort study, we included incident cancer patients from the former Aarhus County from 1 September, 2004 to 31 August, 2005. Both patients and GPs reported the length of the patient interval and the date of the first presentation to the GP with a cancer-related symptom measured by self-administered questionnaires. Agreement was measured using agreement-survival plots and Lin's concordance correlation coefficient (CCC). RESULTS There was full agreement between GP- and patient-reported patient intervals in 21.0% of all the cancer cases. In 50.1% of cases, patients and GPs agreed about the patient interval within a margin of one month. There was full agreement between GP- and patient-reported date of first presentation in 37.5% of the cancer cases and within one week in 52.0% of all the cancer cases. Overall, the agreement on the length of the patient interval was poor (CCC=0.513), but better for patients presenting with alarm symptoms. The agreement was moderate between GP- and patient-reported dates of first presentation (CCC=0.924). CONCLUSION We found that GPs systematically reported a longer patient interval than patients did. We found moderate agreement on reported date of first presentation of symptoms to the GP, meaning that the disagreement in reported patient interval is related to date of first symptom rather than date of first presentation to the GP.
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Affiliation(s)
- Mette Bach Larsen
- Research Unit for General Practice, Aarhus University, Department of Public Health, Bartholins Allé 2, DK-8000 Aarhus C, Denmark; Department of Public Health Programs, Randers Regional Hospital, Skovlyvej 1, DK-8930 Randers NØ, Denmark.
| | - Rikke Pilegaard Hansen
- Research Unit for General Practice, Aarhus University, Department of Public Health, Bartholins Allé 2, DK-8000 Aarhus C, Denmark; Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Department of Public Health, Bartholins Allé 2, DK-8000 Aarhus C, Denmark
| | - Ineta Sokolowski
- Research Unit for General Practice, Aarhus University, Department of Public Health, Bartholins Allé 2, DK-8000 Aarhus C, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Aarhus University, Department of Public Health, Bartholins Allé 2, DK-8000 Aarhus C, Denmark; Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Department of Public Health, Bartholins Allé 2, DK-8000 Aarhus C, Denmark
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Rosendal M, Jarbøl DE, Pedersen AF, Andersen RS. Multiple perspectives on symptom interpretation in primary care research. BMC FAMILY PRACTICE 2013; 14:167. [PMID: 24188544 PMCID: PMC4228340 DOI: 10.1186/1471-2296-14-167] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 10/16/2013] [Indexed: 01/28/2023]
Abstract
BACKGROUND Assessment and management of symptoms is a main task in primary care. Symptoms may be defined as 'any subjective evidence of a health problem as perceived by the patient'. In other words, symptoms do not appear as such; symptoms are rather the result of an interpretation process. We aim to discuss different perspectives on symptom interpretation as presented in the disciplines of biomedicine, psychology and anthropology and the possible implications for our understanding of research on symptoms in relation to prevalence and diagnosis in the general population and in primary care. DISCUSSION Symptom experiences are embedded in a complex interplay between biological, psychological and cultural factors. From a biomedical perspective, symptoms are seen as possible indicators of disease and are characterized by parameters related to seriousness (e.g. appearance, severity, impact and temporal aspects). However, such symptom characteristics are rarely unambiguous, but merely indicate disease probability. In addition, the GP's interpretation of presenting symptoms will also be influenced by other factors. From a psychological perspective, factors affecting interpretation are in focus (e.g. internal frame of reference, attention to sensations, illness perception and susceptibility to suggestion). These individual factors cannot stand alone either, but are influenced by the surroundings. Anthropological research suggests that personal experiences and culture form a continuous feedback relationship which influence when and how sensations are understood as symptoms of disease and acted upon. SUMMARY The different approaches to symptom interpretation imply that we need to be cautious and conscious when interpreting survey findings that are based on symptom prevalence in the general population or in primary care. These findings will reflect a variety of interpretations of sensations, which are not equivalent to expressions of underlying disease. Furthermore, if diagnosis of disease is based exclusively on the presence of specific symptom characteristics, we may risk reinforcing a dualistic approach, including medicalisation of normal phenomena and devaluation of medically unexplained symptoms. Future research in primary care could gain from exploring symptoms as a generic phenomenon and raised awareness of symptom complexity.
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Affiliation(s)
- Marianne Rosendal
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Alle 2, DK-8000 Aarhus C, Denmark
| | - Dorte Ejg Jarbøl
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9 A, DK-5000 Odense, Denmark
| | - Anette Fischer Pedersen
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Alle 2, DK-8000 Aarhus C, Denmark
| | - Rikke Sand Andersen
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Alle 2, DK-8000 Aarhus C, Denmark
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Pedersen AF, Hansen RP, Vedsted P. Patient delay in colorectal cancer patients: associations with rectal bleeding and thoughts about cancer. PLoS One 2013; 8:e69700. [PMID: 23894527 PMCID: PMC3718764 DOI: 10.1371/journal.pone.0069700] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 06/14/2013] [Indexed: 11/18/2022] Open
Abstract
Rectal bleeding is considered to be an alarm symptom of colorectal cancer. However, the symptom is seldom reported to the general practitioner and it is often assumed that patients assign the rectal bleeding to benign conditions. The aims of this questionnaire study were to examine whether rectal bleeding was associated with longer patient delays in colorectal cancer patients and whether rectal bleeding was associated with cancer worries. All incident colorectal cancer patients during a 1-year period in the County of Aarhus, Denmark, received a questionnaire. 136 colorectal cancer patients returned the questionnaire (response rate: 42%). Patient delay was assessed as the interval from first symptom to help-seeking and was reported by the patient. Patients with rectal bleeding (N = 81) reported longer patient intervals than patients without rectal bleeding when adjusting for confounders including other symptoms such as pain and changes in bowel habits (HR = 0.43; p = 0.004). Thoughts about cancer were not associated with the patient interval (HR = 1.05; p = 0.887), but more patients with rectal bleeding reported to have been wondering if their symptom(s) could be due to cancer than patients without rectal bleeding (chi2 = 15.29; p<0.001). Conclusively, rectal bleeding was associated with long patient delays in colorectal cancer patients although more patients with rectal bleeding reported to have been wondering if their symptom(s) could be due to cancer than patients without rectal bleeding. This suggests that assignment of symptoms to benign conditions is not the only explanation of long patient delays in this patient group and that barriers for timely help-seeking should be examined.
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Affiliation(s)
- Anette F Pedersen
- Research Unit for General Practice, The Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus University, Aarhus C, Denmark.
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Ingebrigtsen SG, Scheel BI, Hart B, Thorsen T, Holtedahl K. Frequency of 'warning signs of cancer' in Norwegian general practice, with prospective recording of subsequent cancer. Fam Pract 2013; 30:153-60. [PMID: 23097250 DOI: 10.1093/fampra/cms065] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Early diagnosis of cancer is an important challenge in general practice. Symptoms are the most common starting points. OBJECTIVE To assess the association between symptoms presented and subsequent cancer. DESIGN A cohort study of all patients seen consecutively by GPs. Prospective recording of cancer diagnosis, new cancer or new recurrence. SETTING Two hundred and eighty-three general practice surgeries and 10 working days. METHOD During patient consultations, GPs registered seven focal symptoms and three general symptoms, commonly considered as warning signs of cancer (WSC). Follow-up 6-11 months later with registration of any subsequent diagnosis of cancer was done. RESULTS Of 51 073 patients, 6321 (12.4%) had recordings of 7704 WSC. During a median follow-up period of 8 months, 263 patients were diagnosed with cancer and 59 of them with recurrence of a previously diagnosed cancer. Of the cancer patients, 106 (40%) had presented one or more WSC during a preceding consultation. Examined symptoms had likelihood ratios for cancer from 1.5 to 8.2 and positive predictive values (PPVs) from 0.8% to 3.8%. Limited to older age groups, PPVs were a little higher. General symptoms were rarely associated with cancer unless a focal symptom had been recorded as well. Multiple symptoms increased the probability of cancer. CONCLUSION 12.4% of GP patients presented with WSC. A general symptom may have cancer diagnostic value, but usually, only when it occurs along with a focal symptom. PPV of any single symptom is low, and decisions about referral require additional information.
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Affiliation(s)
- Susanne G Ingebrigtsen
- Department of Community Medicine, Faculty of Health Science, University of Tromsø, Tromsø, Norway
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Svendsen RP, Paulsen MS, Larsen PV, Hansen BL, Støvring H, Jarbøl DE, Søndergaard J. Associations between reporting of cancer alarm symptoms and socioeconomic and demographic determinants: a population-based, cross-sectional study. BMC Public Health 2012; 12:686. [PMID: 22914003 PMCID: PMC3560107 DOI: 10.1186/1471-2458-12-686] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 08/13/2012] [Indexed: 11/30/2022] Open
Abstract
Background Reporting of symptoms which may signal cancer is the first step in the diagnostic pathway of cancer diseases. Cancer alarm symptoms are common in the general population. Public awareness and knowledge of cancer symptoms are sparse, however, and many people do not seek medical help when having possible cancer symptoms. As social inequality is associated with cancer knowledge, cancer awareness, and information-seeking, our hypothesis is that social inequality may also exist in the general population with respect to reporting of cancer alarm symptoms. The aim of this study was to investigate possible associations between socioeconomic and demographic determinants and reporting of common cancer alarm symptoms. Methods A cross-sectional questionnaire survey was performed based on a stratified sample of the Danish general population. A total of 13 777 randomly selected persons aged 20 years and older participated. Our main outcome measures were weighted prevalence estimates of self-reporting one of the following cancer alarm symptoms during the preceding 12 months: a lump in the breast, coughing for more than 6 weeks, seen blood in urine, or seen blood in stool. Logistic regression models were used to calculate unadjusted and adjusted odds ratios with 95% confidence intervals for the associations between each covariate and reporting of cancer alarm symptoms. Results A total of 2 098 (15.7%) of the participants reported one or more cancer alarm symptoms within the preceding 12 months. Women, subjects out of the workforce, and subjects with a cancer diagnosis had statistically significantly higher odds of reporting one or more cancer alarm symptoms. Subjects with older age and subjects living with a partner had lower odds of reporting one or more cancer alarm symptoms. When analysing the four alarm symptoms of cancer separately most tendencies persisted. Conclusions Socioeconomic and demographic determinants are associated with self-reporting of common cancer alarm symptoms.
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Affiliation(s)
- Rikke Pilsgaard Svendsen
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, JB, Winsløwsvej 9A, DK-5000 Odense C, Denmark.
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