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Down L, Barlow M, Bailey SER, Mounce LTA, Merriel SWD, Watson J, Martins T. Association between patient ethnicity and prostate cancer diagnosis following a prostate-specific antigen test: a cohort study of 730,000 men in primary care in the UK. BMC Med 2024; 22:82. [PMID: 38424555 PMCID: PMC10905783 DOI: 10.1186/s12916-024-03283-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 01/25/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Black men have higher prostate-specific antigen (PSA) levels and higher prostate cancer incidence and mortality than White men, while Asian men tend to have lower prostate cancer incidence and mortality than White men. Much of the evidence comes from the USA, and information from UK populations is limited. METHODS This retrospective cohort study used data on patients registered at general practices in England contributing to the Clinical Practice Research Datalink (CPRD) Aurum dataset. Those eligible were men aged 40 and over with a record of ethnicity and a PSA test result recorded between 2010 and 2017 with no prior cancer diagnosis. The aim was to assess the incidence of prostate cancer following a raised PSA test result in men from different ethnic groups. Additionally, incidence of advanced prostate cancer was investigated. Cancer incidence was estimated from multi-level logistic regression models adjusting for potential confounding factors. RESULTS 730,515 men with a PSA test were included (88.9% White). Black men and men with mixed ethnicity had higher PSA values, particularly for those aged above 60 years. In the year following a raised PSA result (using age-specific thresholds), Black men had the highest prostate cancer incidence at 24.7% (95% CI 23.3%, 26.2%); Asian men had the lowest at 13.4% (12.2%, 14.7%); incidence for White men was 19.8% (19.4%, 20.2%). The peak incidence of prostate cancer for all groups was in men aged 70-79. Incidence of prostate cancer diagnosed at an advanced stage was similar between Black and White men. CONCLUSIONS More prostate cancer was diagnosed in Black men with a raised PSA result, but rates of advanced prostate cancer were not higher in this group. In this large primary care-based cohort, the incidence of prostate cancer in men with elevated PSA levels increases with increasing age, even when using age-adjusted thresholds, with Black men significantly more likely to be diagnosed compared to White or Asian men. The incidence of advanced stage prostate cancer at diagnosis was similar for Black and White men with a raised PSA result, but lower for Asian men.
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Affiliation(s)
- Liz Down
- Department of Health and Community Sciences, University of Exeter, St Lukes Campus, Heavitree Road, Exeter, EX1 2LU, UK.
| | - Melissa Barlow
- Department of Health and Community Sciences, University of Exeter, St Lukes Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Sarah E R Bailey
- Department of Health and Community Sciences, University of Exeter, St Lukes Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Luke T A Mounce
- Department of Health and Community Sciences, University of Exeter, St Lukes Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Samuel W D Merriel
- Centre for Primary Care & Health Services Research, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Jessica Watson
- Centre for Academic Primary Care (CAPC), Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Tanimola Martins
- Department of Health and Community Sciences, University of Exeter, St Lukes Campus, Heavitree Road, Exeter, EX1 2LU, UK
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Martins T, Abel G, Ukoumunne OC, Price S, Lyratzopoulos G, Chinegwundoh F, Hamilton W. Assessing Ethnic Inequalities in Diagnostic Interval of Common Cancers: A Population-Based UK Cohort Study. Cancers (Basel) 2022; 14:3085. [PMID: 35804858 PMCID: PMC9264889 DOI: 10.3390/cancers14133085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This study investigated ethnic differences in diagnostic interval (DI)-the period between initial primary care presentation and diagnosis. METHODS We analysed the primary care-linked data of patients who reported features of seven cancers (breast, lung, prostate, colorectal, oesophagogastric, myeloma, and ovarian) one year before diagnosis. Accelerated failure time (AFT) models investigated the association between DI and ethnicity, adjusting for age, sex, deprivation, and morbidity. RESULTS Of 126,627 eligible participants, 92.1% were White, 1.99% Black, 1.71% Asian, 1.83% Mixed, and 2.36% were of Other ethnic backgrounds. Considering all cancer sites combined, the median (interquartile range) DI was 55 (20-175) days, longest in lung [127, (42-265) days], and shortest in breast cancer [13 (13, 8-18) days]. DI for the Black and Asian groups was 10% (AFT ratio, 95%CI 1.10, 1.05-1.14) and 16% (1.16, 1.10-1.22), respectively, longer than for the White group. Site-specific analyses revealed evidence of longer DI in Asian and Black patients with prostate, colorectal, and oesophagogastric cancer, plus Black patients with breast cancer and myeloma, and the Mixed group with lung cancer compared with White patients. DI was shorter for the Other group with lung, prostate, myeloma, and oesophagogastric cancer than the White group. CONCLUSION We found limited and inconsistent evidence of ethnic differences in DI among patients who reported cancer features in primary care before diagnosis. Our findings suggest that inequalities in diagnostic intervals, where present, are unlikely to be the sole explanation for ethnic variations in cancer outcomes.
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Affiliation(s)
- Tanimola Martins
- College House St Luke’s Campus, College of Medicine and Health, University of Exeter, Magdalen Road, Exeter EX1 2LU, UK; (S.P.); (W.H.)
| | - Gary Abel
- National Institute for Health and Care Research (NIHR), Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter, Exeter EX1 2LU, UK; (G.A.); (O.C.U.)
| | - Obioha C. Ukoumunne
- National Institute for Health and Care Research (NIHR), Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter, Exeter EX1 2LU, UK; (G.A.); (O.C.U.)
| | - Sarah Price
- College House St Luke’s Campus, College of Medicine and Health, University of Exeter, Magdalen Road, Exeter EX1 2LU, UK; (S.P.); (W.H.)
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, University College London, 1–19 Torrington Place, London WC1E 7HB, UK;
| | - Frank Chinegwundoh
- Barts Health NHS Trust & Department of Health Sciences, University of London, London WC1E 7HB, UK;
| | - William Hamilton
- College House St Luke’s Campus, College of Medicine and Health, University of Exeter, Magdalen Road, Exeter EX1 2LU, UK; (S.P.); (W.H.)
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Jones D, Di Martino E, Bradley SH, Essang B, Hemphill S, Wright JM, Renzi C, Surr C, Clegg A, De Wit N, Neal R. Factors affecting the decision to investigate older adults with potential cancer symptoms: a systematic review. Br J Gen Pract 2022; 72:e1-e10. [PMID: 34782315 DOI: 10.3399/BJGP.2021.0257] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/27/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Older age and frailty increase the risk of morbidity and mortality from cancer surgery and intolerance of chemotherapy and radiotherapy. The effect of old age on diagnostic intervals is unknown; however, older adults need a balanced approach to the diagnosis and management of cancer symptoms, considering the benefits of early diagnosis, patient preferences, and the likely prognosis of a cancer. AIM To examine the association between older age and diagnostic processes for cancer, and the specific factors that affect diagnosis. DESIGN AND SETTING A systematic literature review. METHOD Electronic databases were searched for studies of patients aged >65 years presenting with cancer symptoms to primary care considering diagnostic decisions. Studies were analysed using thematic synthesis and according to the Synthesis Without Meta-analysis guidelines. RESULTS Data from 54 studies with 230 729 participants were included. The majority of studies suggested an association between increasing age and prolonged diagnostic interval or deferral of a decision to investigate cancer symptoms. Thematic synthesis highlighted three important factors that resulted in uncertainty in decisions involving older adults: presence of frailty, comorbidities, and cognitive impairment. Data suggested patients wished to be involved in decision making, but the presence of cognitive impairment and the need for additional time within a consultation were significant barriers. CONCLUSION This systematic review has highlighted uncertainty in the management of older adults with cancer symptoms. Patients and their family wished to be involved in these decisions. Given the uncertainty regarding optimum management of this group of patients, a shared decision-making approach is important.
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Martins T, Walter FM, Penfold C, Abel G, Hamilton W. Primary care use by men with symptoms of possible prostate cancer: A multi-method study with an ethnically diverse sample in London. Eur J Cancer Care (Engl) 2021; 30:e13482. [PMID: 34152656 DOI: 10.1111/ecc.13482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/15/2021] [Accepted: 05/31/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of this study is to investigate primary care use by men with recent onset of lower urinary tract symptoms (LUTS) to identify differences in presentation and investigation that may explain ethnic inequality in prostate cancer outcomes. METHODS This is a multi-method study of men presenting LUTS to primary care. Two hundred seventy-four men completed a self-administered questionnaire, and 23 participated in face-to-face interviews. Regression analyses investigated ethnic differences in (a) the period between symptom onset and first primary care presentation (patient interval) and (b) the interval between first primary care presentation and investigation with prostate-specific antigen (PSA) and digital rectal examination (DRE). Interview data were analysed using thematic analysis. RESULTS Half (144, 53%) reported a solitary first symptom, although multiple first symptoms were also common, particularly in Asian and Black men. There was no difference between ethnicities in patient interval or time from presentation to investigation. However, Asian men were offered less PSA testing (odds ratio 0.39; 95% confidence interval 0.17-0.92; p = 0.03). Qualitative data revealed ethnic differences in general practitioners' offer of DRE and PSA testing and highlighted limitations in doctor-patient communication and safety netting. CONCLUSION Our study showed only small differences in primary care experiences, insufficient to explain ethnic inequalities in prostate cancer outcomes.
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Affiliation(s)
- Tanimola Martins
- College of Medicine and Health, University of Exeter-College House St Luke's Campus, Exeter, UK
| | - Fiona M Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Clarissa Penfold
- Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute of Palliative Care, London, UK
| | - Gary Abel
- College of Medicine and Health, University of Exeter-College House St Luke's Campus, Exeter, UK
| | - William Hamilton
- College of Medicine and Health, University of Exeter-College House St Luke's Campus, Exeter, UK
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Abstract
Prostate cancer is a complex disease which is more prevalent among men of black and minority ethnic (BME) background than their Caucasian counterparts, with men of African-Caribbean background experiencing higher levels of incidence and mortality than any other ethnic group. The reasons behind this health inequality are poorly understood and likely to be multifactorial. Several theories have been posited, including genetic disposition, poorer access to health care, a lack of understanding of the risks posed by prostate cancer and an unwillingness to access mainstream health care. There is, however, a notable disparity between the amount of literature focusing on prostate cancer as it affects those with a BME background and on prostate cancer in general. This further compounds the difficulties encountered by BME men, who rely on health professionals being aware of the greater risk they face. More knowledge and understanding is required by both the general population and medical practitioners to address this health inequality.
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Affiliation(s)
- Bría J McAllister
- Urology Nurse Practitioner, Department of Urology, Nottingham University Hospitals NHS Trust
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Piano M, Black G, Amelung D, Power E, Whitaker KL. Exploring public attitudes towards the new Faster Diagnosis Standard for cancer: a focus group study with the UK public. Br J Gen Pract 2019; 69:e413-21. [PMID: 30858334 DOI: 10.3399/bjgp19X702677] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 11/21/2018] [Indexed: 11/10/2022] Open
Abstract
Background The Faster Diagnosis Standard (FDS) is to be introduced in England in 2020. This standard is a new policy in which patients should have cancer ruled out or diagnosed within 28 days of referral. Aim To explore public attitudes towards the FDS within the context of their recent referral experiences. Design and setting Four 90-minute focus groups (two in Guildford, two in Bradford). Method Participants aged >50 years without a current cancer diagnosis (N = 29), who had completed certain diagnostic tests, for example, ultrasound, and received results within the last 6 months were recruited. Age, education, and sex were evenly distributed across groups through purposive sampling. Results The largest cause of concern was the waiting process for obtaining test results. Most had experienced swift referral, and it was difficult for participants to understand how the new standard could impact upon time progressing through the system. Responsibility for meeting the standard was also a concern: participants did not see their own behaviours as a form of involvement. The GP’s role was conceptualised by patients as communicating about their referral, establishing patients’ preferences for information, and continued involvement at each stage of the referral process. The standard legitimised chasing for test results, but 28 days was considered too long. Conclusion Patients should be asked what they would like to know about their referral. GPs should be more transparent about the referral process and the potential for a lack of clarity around next steps.
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Prabhu V, Rosenkrantz AB, Otazo R, Sodickson DK, Kang SK. Population net benefit of prostate MRI with high spatiotemporal resolution contrast-enhanced imaging: A decision curve analysis. J Magn Reson Imaging 2019; 49:1400-1408. [DOI: 10.1002/jmri.26318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/10/2018] [Accepted: 08/13/2018] [Indexed: 12/29/2022] Open
Affiliation(s)
- Vinay Prabhu
- Department of Radiology; NYU School of Medicine; New York New York USA
| | | | - Ricardo Otazo
- Department of Medical Physics; Memorial Sloan Kettering Cancer Center; New York USA
| | | | - Stella K. Kang
- Department of Radiology; NYU School of Medicine; New York New York USA
- Department of Population Health; NYU School of Medicine; New York New York USA
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Chiva Giurca B, Hamilton W, Martins T. The impact of health literacy on diagnosis and outcomes of symptomatic cancer by ethnicity: a systematic review protocol. Syst Rev 2018; 7:164. [PMID: 30326949 PMCID: PMC6192147 DOI: 10.1186/s13643-018-0831-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 10/01/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Ethnic minorities in multi-ethnic societies like the UK and USA have poorer outcomes for some cancer types when compared with the majority. The causes of ethnic inequalities in cancer outcomes are complex and not fully understood. In particular, the potential role of health literacy on symptomatic presentation and diagnostic interval (the period between first consultation within primary care and definitive diagnosis of cancer) by ethnicity is unknown. Given the increasing need for shared decision-making and patient involvement in the diagnostic process, understanding the potential impact of the differences in health literacy may help redress ethnic inequality in cancer outcomes. The present study aims to critically examine the evidence in this area. METHODS Seven electronic databases will be searched using keywords and controlled vocabulary related to ethnicity, health literacy, cancer diagnosis and cancer outcomes. Citations and bibliography searches of included studies will be performed to identify relevant studies that have cited eligible articles. Authors of included studies will be contacted to identify unpublished studies. Eligible studies will be restricted to primary cancers. Study quality will be evaluated in using the Critical Appraisal Skills Programme (CASP) checklists. A descriptive summary of selected studies will be presented, and the synthesis will follow a narrative framework. DISCUSSION This systematic review will summarise the evidence regarding ethnic inequality in health literacy and how this impacts on diagnosis and outcomes of cancer. The review will identify possible areas for future research, and inform clinical practice and interventions to reduce ethnic inequalities in cancer diagnosis and outcomes.
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Affiliation(s)
- Bogdan Chiva Giurca
- University of Exeter Medical School, Room G02 Medical School Building, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK.
| | - William Hamilton
- University of Exeter Medical School, Room G02 Medical School Building, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Tanimola Martins
- University of Exeter Medical School, Room G02 Medical School Building, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
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Usher-Smith J, Kassianos A, Emery J, Abel G, Teoh Z, Hall S, Neal R, Murchie P, Walter F. Identifying people at higher risk of melanoma across the U.K.: a primary-care-based electronic survey. Br J Dermatol 2016; 176:939-948. [DOI: 10.1111/bjd.15181] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2016] [Indexed: 12/11/2022]
Affiliation(s)
- J.A. Usher-Smith
- Primary Care Unit, Department of Public Health & Primary Care; University of Cambridge School of Clinical Medicine; Strangeways Research Laboratory; Cambridge CB1 8RN U.K
| | - A.P. Kassianos
- Department of Applied Health Research; University College London; London U.K
| | - J.D. Emery
- Department of General Practice; Melbourne Medical School Faculty of Medicine, Dentistry and Health Sciences; University of Melbourne; Carlton Victoria Australia
| | - G.A. Abel
- Primary Care Unit, Department of Public Health & Primary Care; University of Cambridge School of Clinical Medicine; Strangeways Research Laboratory; Cambridge CB1 8RN U.K
| | - Z. Teoh
- Betsi Cadwaladr University Health Board; Wrexham Maelor Hospital; Wrexham U.K
| | - S. Hall
- Centre of Academic Primary Care; Division of Applied Health Sciences; University of Aberdeen; Aberdeen U.K
| | - R.D. Neal
- North Wales Centre for Primary Care Research; Bangor University; Wrexham U.K
| | - P. Murchie
- Centre of Academic Primary Care; Division of Applied Health Sciences; University of Aberdeen; Aberdeen U.K
| | - F.M. Walter
- Primary Care Unit, Department of Public Health & Primary Care; University of Cambridge School of Clinical Medicine; Strangeways Research Laboratory; Cambridge CB1 8RN U.K
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Abstract
Much time, effort and investment goes into the diagnosis of symptomatic cancer, with the expectation that this approach brings clinical benefits. This investment of resources has been particularly noticeable in the UK, which has, for several years, appeared near the bottom of international league tables for cancer survival in economically developed countries. In this Review, we examine expedited diagnosis of cancer from four perspectives. The first relates to the potential for clinical benefits of expedited diagnosis of symptomatic cancer. Limited evidence from clinical trials is available, but the considerable observational evidence suggests benefits can be obtained from this approach. The second perspective considers how expedited diagnosis can be achieved. We concentrate on data from the UK, where extensive awareness campaigns have been conducted, and initiatives in the primary-care setting, including clinical decision support, have all occurred during a period of considerable national policy change. The third section considers the most appropriate patients for cancer investigations, and the possible community settings for identification of such patients; UK national guidance for selection of patients for investigation is discussed. Finally, the health economics of expedited diagnosis are reviewed, although few studies provide definitive evidence on this topic.
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Affiliation(s)
- Willie Hamilton
- University of Exeter, College House, St Luke's Campus, Exeter EX2 4TE, UK
| | - Fiona M Walter
- Department of Public Health &Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Greg Rubin
- School of Medicine, Pharmacy and Health, Wolfson Building, Queen's Campus, University of Durham, Stockton-on-Tees TS17 6BH, UK
| | - Richard D Neal
- North Wales Centre for Primary Care Research, Bangor University, Gwenfro Unit 5, Wrexham Technology Park, Wrexham LL13 7YP, UK
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Ilunga Tshiswaka D, Donley T, Okafor A, Memiah P, Mbizo J. Prostate and Colorectal Cancer Screening Uptake among US and Foreign-Born Males: Evidence from the 2015 NHIS Survey. J Community Health 2017; 42:612-23. [DOI: 10.1007/s10900-016-0296-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Affiliation(s)
- Tanimola Martins
- College House St Luke's Campus, University of Exeter Medical School, Magdalen Road, Exeter EX1 2LU, UK.
| | - William Hamilton
- College House St Luke's Campus, University of Exeter Medical School, Magdalen Road, Exeter EX1 2LU, UK
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Banks J, Hamilton W, Walter F. The Discovery Programme and its impact on cancer diagnostics. Br J Hosp Med (Lond) 2015; 76:558-9. [PMID: 26457934 DOI: 10.12968/hmed.2015.76.10.558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jon Banks
- Research Fellow and Programme Manager for the Discovery Programme Centre for Academic Primary Care School of Social and Community Medicine University of Bristol Bristol BS8 2PS
| | - Willie Hamilton
- Professor of Primary Care Diagnostics and Chief Investigator for the Discovery Programme University of Exeter Medical School St Luke's Campus Exeter
| | - Fiona Walter
- Clinical Principal Researcher and Deputy Chief Investigator for the Discovery Programme University of Cambridge Primary Care Unit Strangeways Research Laboratory Cambridge
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Muir KR, Lophatananon A, Gnanapragasam V, Rees J. The Future of Prostate Cancer Risk Prediction. CURR EPIDEMIOL REP 2015. [DOI: 10.1007/s40471-015-0056-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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