The presenting symptom signatures of incident cancer: evidence from the English 2018 National Cancer Diagnosis Audit

BACKGROUND

Understanding relationships between presenting symptoms and subsequently diagnosed cancers can inform symptom awareness campaigns and investigation strategies.

METHODS

We used English National Cancer Diagnosis Audit 2018 data for 55,122 newly diagnosed patients, and examined the relative frequency of presenting symptoms by cancer site, and of cancer sites by presenting symptom.

RESULTS

Among 38 cancer sites (16 cancer groups), three classes were apparent: cancers with a dominant single presenting symptom (e.g. melanoma); cancers with diverse presenting symptoms (e.g. pancreatic); and cancers that are often asymptomatically detected (e.g. chronic lymphocytic leukaemia). Among 83 symptoms (13 symptom groups), two classes were apparent: symptoms chiefly relating to cancers of the same body system (e.g. certain respiratory symptoms mostly relating to respiratory cancers); and symptoms with a diverse cancer site case-mix (e.g. fatigue). The cancer site case-mix of certain symptoms varied by sex.

CONCLUSION

We detailed associations between presenting symptoms and cancer sites in a large, representative population-based sample of cancer patients. The findings can guide choice of symptoms for inclusion in awareness campaigns, and diagnostic investigation strategies post-presentation when cancer is suspected. They can inform the updating of clinical practice recommendations for specialist referral encompassing a broader range of cancer sites per symptom.

National Cancer Diagnosis Audits for England 2018 versus 2014: a comparative analysis

BACKGROUND

Timely diagnosis of cancer in patients who present with symptoms in primary care is a quality-improvement priority.

AIM

To examine possible changes to aspects of the diagnostic process, and its timeliness, before and after publication of the National Institute for Health and Care Excellence's (2015) guidance on the referral of suspected cancer in primary care.

DESIGN AND SETTING

Comparison of findings from population-based clinical audits of cancer diagnosis in general practices in England for patients diagnosed in 2018 or 2014.

METHOD

GPs in 1878 (2018) and 439 (2014) practices collected primary care information on the diagnostic pathway of cancer patients. Key measures including patient characteristics, place of presentation, number of pre-referral consultations, use of primary care investigations, and referral type were compared between the two audits by descriptive analysis and regression models.

RESULTS

Among 64 489 (2018) and 17 042 (2014) records of a new cancer diagnosis, the percentage of patients with same-day referral (denoted by a primary care interval of 0 days) was higher in 2018 (42.7% versus 37.7%) than in 2014, with similar improvements in median diagnostic interval (36 days versus 40 days). Compared with 2014, in 2018: fewer patients had ≥3 pre-referral consultations (18.8% versus 26.2%); use of primary care investigations increased (47.9% versus 45.4%); urgent cancer referrals increased (54.8% versus 51.8%); emergency referrals decreased (13.4% versus 16.5%); and recorded use of safety netting decreased (40.0% versus 44.4%).

CONCLUSION

In the 5-year period, including the year when national guidelines were updated (that is, 2015), there were substantial improvements to the diagnostic process of patients who present to general practice in England with symptoms of a subsequently diagnosed cancer.

Predictors of the experience of a Cytosponge test: analysis of patient survey data from the BEST3 trial

BACKGROUND

The Cytosponge is a cell-collection device, which, coupled with a test for trefoil factor 3 (TFF3), can be used to diagnose Barrett's oesophagus, a precursor condition to oesophageal adenocarcinoma. BEST3, a large pragmatic, randomised, controlled trial, investigated whether offering the Cytosponge-TFF3 test would increase detection of Barrett's. Overall, participants reported mostly positive experiences. This study reports the factors associated with the least positive experience.

METHODS

Patient experience was assessed using the Inventory to Assess Patient Satisfaction (IAPS), a 22-item questionnaire, completed 7-14 days after the Cytosponge test.

STUDY COHORT

All BEST3 participants who answered ≥ 15 items of the IAPS (N = 1458).

STATISTICAL ANALYSIS

A mean IAPS score between 1 and 5 (5 indicates most negative experience) was calculated for each individual. 'Least positive' experience was defined according to the 90th percentile. 167 (11.4%) individuals with a mean IAPS score of ≥ 2.32 were included in the 'least positive' category and compared with the rest of the cohort. Eleven patient characteristics and one procedure-specific factor were assessed as potential predictors of the least positive experience. Multivariable logistic regression analysis using backwards selection was conducted to identify factors independently associated with the least positive experience and with failed swallow at first attempt, one of the strongest predictors of least positive experience.

RESULTS

The majority of responders had a positive experience, with an overall median IAPS score of 1.7 (IQR 1.5-2.1). High (OR = 3.01, 95% CI 2.03-4.46, p < 0.001) or very high (OR = 4.56, 95% CI 2.71-7.66, p < 0.001) anxiety (relative to low/normal anxiety) and a failed swallow at the first attempt (OR = 3.37, 95% CI 2.14-5.30, p < 0.001) were highly significant predictors of the least positive patient experience in multivariable analyses. Additionally, sex (p = 0.036), height (p = 0.032), alcohol intake (p = 0.011) and education level (p = 0.036) were identified as statistically significant predictors.

CONCLUSION

We have identified factors which predict patient experience. Identifying anxiety ahead of the procedure and discussing particular concerns with patients or giving them tips to help with swallowing the capsule might help improve their experience. Trial registration ISRCTN68382401.

An audit of clinically triaged women at low risk for breast cancer presenting to the Helen Joseph Mammography Unit

BACKGROUND

The Helen Joseph Hospital (HJH) breast clinic utilises a clinical triage system to stratify patients based on their risk of breast cancer into high-, medium-, or low-risk profiles. This allows for timeous imaging and subsequent management of those patients at increased risk for breast cancer. The primary objective was to determine the cancer detection rate (CDR). The secondary objective was to correlate biopsy results with the Breast Imaging-Reporting and Data System (BI-RADS) risk assessment.

METHODS

A retrospective audit of the patients at low risk for breast cancer who were referred to the breast imaging unit (BIU) in 2019 at HJH. Patients were clinically assessed as low risk based on a triage form and were identified using the imaging files stored in the BIU. Results were recorded on Microsoft Excel and calculated as per the American College of Radiology guidelines.

RESULTS

The total population sample consisted of 398 patients. Two patients were characterised as BI-RADS 4 and underwent breast biopsies. One patient was diagnosed with histologically proven breast cancer. The CDR was 2.51%. The most representative groups were the age group of 60-69 years, BI-RADS breast density B and BI-RADS risk assessment 2.

CONCLUSION

Amongst the low-risk population, both the CDR and spectrum of disease was comparable to that of a screening population. This may be due to the use of a triage system prior to imaging, as well as an increase in clinical awareness of breast cancer within a tertiary institution.

The evolution and co-evolution of a primary care cancer research network: From academic social connection to research collaboration

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

Patient-reported experiences and views on the Cytosponge test: a mixed-methods analysis from the BEST3 trial

OBJECTIVES

The BEST3 trial demonstrated the efficacy and safety of the Cytosponge-trefoil factor 3, a cell collection device coupled with the biomarker trefoil factor 3, as a tool for detecting Barrett's oesophagus, a precursor of oesophageal adenocarcinoma (OAC), in primary care. In this nested study, our aim was to understand patient experiences.

DESIGN

Mixed-methods using questionnaires (including Inventory to Assess Patient Satisfaction, Spielberger State-Trait Anxiety Inventory-6 and two-item perceived risk) and interviews.

OUTCOME MEASURES

Participant satisfaction, anxiety and perceived risk of developing OAC.

SETTING

General practices in England.

PARTICIPANTS

Patients with acid reflux enrolled in the intervention arm of the BEST3 trial and attending the Cytosponge appointment (N=1750).

RESULTS

1488 patients successfully swallowing the Cytosponge completed the follow-up questionnaires, while 30 were interviewed, including some with an unsuccessful swallow.Overall, participants were satisfied with the Cytosponge test. Several items showed positive ratings, in particular convenience and accessibility, staff's interpersonal skills and perceived technical competence. The most discomfort was reported during the Cytosponge removal, with more than 60% of participants experiencing gagging. Nevertheless, about 80% were willing to have the procedure again or to recommend it to friends; this was true even for participants experiencing discomfort, as confirmed in the interviews.Median anxiety scores were below the predefined level of clinically significant anxiety and slightly decreased between baseline and follow-up (p < 0.001). Interviews revealed concerns around the ability to swallow, participating in a clinical trial, and waiting for test results.The perceived risk of OAC increased following the Cytosponge appointment (p<0.001). Moreover, interviews suggested that some participants had trouble conceptualising risk and did not understand the relationships between test results, gastro-oesophageal reflux and risk of Barrett's oesophagus and OAC.

CONCLUSIONS

When delivered during a trial in primary care, the Cytosponge is well accepted and causes little anxiety.

TRIAL REGISTRATION NUMBER

ISRCTN68382401.

Factors determining development of researchers within a research network on cancer diagnosis in primary care (CanTest): an interview study

OBJECTIVES

Developing connections with other researchers in a network, learning informally through these connections and using them to reach goals, is expected to increase research capacity and strengthen performance. So far, this has not been empirically demonstrated. We assessed what and how network collaboration adds to development of researchers.

DESIGN

Exploratory qualitative study using semistructured online interviews, analysed by inductive and deductive methods. For the deductive analysis, an existing value creation framework to study informal learning in networks was used and adjusted to our context.

SETTING

The CanTest Collaborative-an international team of primary care cancer researchers working on early detection and diagnosis of cancer.

PARTICIPANTS

Sixteen primary care cancer researchers.

RESULTS

Connections with other researchers in an international network created diverse value cycles, where most outcomes were in the potential value cycle, acquiring knowledge, skills, social capital, resources and ideas. Not all potential value will be applied but many interviewees described realised as well as transformational value. In our context, the transformational value from the framework appeared to be related to other perspectives on the research process. Advancement of the network depends on opportunities, timing, role models and connections between different perspectives.

CONCLUSIONS

Focus on the factors that are relevant for network advancement will support researchers in early detection and diagnosis of cancer research patients who participate in an international network and bring sustainable change in this domain. When, subsequently, researchers in the CanTest network bring about more realised and transformational learning outcomes, this will contribute to capacity development.

An audit of patients clinically deemed as high risk for malignant breast pathology at the Helen Joseph Hospital Breast Clinic

BACKGROUND

The Helen Joseph Hospital Breast Clinic has implemented a clinical triage system for patients presenting with a variety of breast concerns. The goal of this system is to expedite the process from initial presentation to radiological assessment of patients with suspected breast malignancy or breast abscess in a resource limited setting. The objective was to assess the clinical, imaging and histological diagnoses of breast disease in these patients with malignancy and sepsis.

METHODS

A retrospective audit of patients clinically deemed high risk for malignant breast pathology referred to the breast imaging unit (BIU) in 2018. Patients were triaged based on strict clinical criteria: presence of a breast mass with or without lymph nodes or a breast abscess. Patients that were subsequently referred for mammography/ultrasound were identified using the patient files in the BIU. Results were recorded on Microsoft Excel and analysed using SAS version 9.2.

RESULTS

Three hundred and twenty-five patients were included in this study. Eighty-seven (26.8%) were diagnosed with breast cancer and 236 (72.6%) with benign disease. The most common presenting complaint was a palpable mass (n = 227; 69.9%). Ninety-five per cent of patients characterised as BI-RADS 5 had malignant disease. 55.8% of malignancies diagnosed on ultrasound had locally advanced disease. The most common histological diagnosis of malignancy was invasive ductal carcinoma (n = 67, 77%). The most commonly diagnosed benign disease was breast abscess (n = 42, 17.8%).

CONCLUSION

BI-RADS findings correspond to similar studies, however, a large number of benign breast disease was diagnosed. This may indicate heightened clinical awareness of breast cancer diagnosis and early detection. A significant percentage of malignancies presented as locally advanced. Except for a lower number of invasive lobular carcinoma, the histological spectrum of malignant disease is similar to comparative studies.

An audit of patients presenting with clinically benign breast disease to the Helen Joseph Hospital Breast Imaging Unit

BACKGROUND

Benign breast pathology is a common presenting complaint, and its assessment is important to characterise not to miss malignant pathology. At Helen Joseph Hospital (HJH), patients are triaged at the breast clinic according to the clinical suspicion of benign versus malignant disease. The patients are assigned a colour label based on their clinical presentation. This triage system affects waiting times between clinical examination and mammography appointments. This study aims to assess the association between clinical examination and the radiological and pathological findings of disorders deemed clinically benign, and to ascertain the spectrum of benign breast disorders encountered at HJH.

METHOD

A retrospective study of imaging results of patients at HJH presenting as clinically benign breast disorders from January to June 2018 was conducted. Assessed Breast Imaging-Reporting and Data System (BI-RADS) score was noted and if core biopsies were performed, their results and patient demographics were documented.

RESULTS

Of the 1 263 clinically benign patients presenting from January to June 2018, the radiological assessment was: BI-RADS 1: 158 (12.5%), BI-RADS 2: 685 (54.2%), BI-RADS 3: 292 (23.1%), BI-RADS 4a: 54 (4.3%), BI-RADS 4b: 29 (2.3 %), BI-RADS 4c: 21 (1.7%), BI-RADS 5: 24 (1.9%). There were 133 biopsies (including eight BI-RADS 3 patients), with 46 (3.6%) confirmed malignancies. The combined specificity of mammography and ultrasound was 65.52% (54.56-75.39%) and combined sensitivity 91.30% (79.21-97.58%).

CONCLUSION

There is a vast spectrum of benign conditions presenting in this population group with only 3.6% confirmed malignancies, confirming an accurate triage system utilised at the breast clinic. Radiological imaging is highly sensitive but less specific, emphasising the triad of clinical, radiological and histological assessment as the gold standard with regard to diagnosis of breast disease.

Measuring patient experience of diagnostic care and acceptability of testing

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

Electronic clinical decision support tool for assessing stomach symptoms in primary care (ECASS): a feasibility study

OBJECTIVE

To determine the feasibility of a definitive trial in primary care of electronic clinical decision support (eCDS) for possible oesophago-gastric (O-G) cancer.

DESIGN AND SETTING

Feasibility study in 42 general practices in two regions of England, cluster randomised controlled trial design without blinding, nested qualitative and health economic evaluation.

PARTICIPANTS

Patients aged 55 years or older, presenting to their general practitioner (GP) with symptoms associated with O-G cancer. 530 patients (mean age 68 years, 58% female) participated.

INTERVENTION

Practices randomised 1:1 to usual care (control) or to receive a previously piloted eCDS tool for suspected cancer (intervention), for use at the discretion of the GPs, supported by a theory-based implementation package and ongoing support. We conducted semistructured interviews with GPs in intervention practices. Recruitment lasted 22 months.

OUTCOMES

Patient participation rate, use of eCDS, referrals and route to diagnosis, O-G cancer diagnoses; acceptability to GPs; cost-effectiveness. Participants followed up 6 months after index encounter.

RESULTS

From control and intervention practices, we screened 3841 and 1303 patients, respectively; 1189 and 434 were eligible, 392 and 138 consented to participate. Ten patients (1.9%) had O-G cancer. eCDS was used eight times in total by five unique users. GPs experienced interoperability problems between the eCDS tool and their clinical system and also found it did not fit with their workflow. Unexpected restrictions on software installation caused major problems with implementation.

CONCLUSIONS

The conduct of this study was hampered by technical limitations not evident during an earlier pilot of the eCDS tool, and by regulatory controls on software installation introduced by primary care trusts early in the study. This eCDS tool needed to integrate better with clinical workflow; even then, its use for suspected cancer may be infrequent. Any definitive trial of eCDS for cancer diagnosis should only proceed after addressing these constraints.

TRIAL REGISTRATION NUMBER

ISRCTN125595588.

An audit of patients clinically deemed as high risk for malignant breast pathology at the Helen Joseph Hospital Breast Clinic

ABSTRACT BACKGROUND: The Helen Joseph Hospital Breast Clinic has implemented a clinical triage system for patients presenting with a variety of breast concerns. The goal of this system is to expedite the process from initial presentation to radiological assessment of patients with suspected breast malignancy or breast abscess in a resource limited setting. The objective was to assess the clinical, imaging and histological diagnoses of breast disease in these patients with malignancy and sepsis METHODS: A retrospective audit of patients clinically deemed high risk for malignant breast pathology referred to the breast imaging unit (BIU) in 2018. Patients were triaged based on strict clinical criteria: presence of a breast mass with or without lymph nodes or a breast abscess. Patients that were subsequently referred for mammography/ultrasound were identified using the patient files in the BIU. Results were recorded on Microsoft Excel and analysed using SAS version 9.2 RESULTS: Three hundred and twenty-five patients were included in this study. Eighty-seven (26.8%) were diagnosed with breast cancer and 236 (72.6%) with benign disease. The most common presenting complaint was a palpable mass (n = 227; 69.9%). Ninety-five per cent of patients characterised as BI-RADS 5 had malignant disease. 55.8% of malignancies diagnosed on ultrasound had locally advanced disease. The most common histological diagnosis of malignancy was invasive ductal carcinoma (n = 67, 77%). The most commonly diagnosed benign disease was breast abscess (n = 42, 17.8% CONCLUSION: BI-RADS findings correspond to similar studies, however, a large number of benign breast disease was diagnosed. This may indicate heightened clinical awareness of breast cancer diagnosis and early detection. A significant percentage of malignancies presented as locally advanced. Except for a lower number of invasive lobular carcinoma, the histological spectrum of malignant disease is similar to comparative studies Keywords: malignant breast pathology, high risk patient, Helen Joseph Hospital Breast Clinic

An audit of patients presenting with clinically benign breast disease to the Helen Joseph Hospital Breast Imaging Unit

ABSTRACT BACKGROUND: Benign breast pathology is a common presenting complaint, and its assessment is important to characterise not to miss malignant pathology. At Helen Joseph Hospital (HJH), patients are triaged at the breast clinic according to the clinical suspicion of benign versus malignant disease. The patients are assigned a colour label based on their clinical presentation. This triage system affects waiting times between clinical examination and mammography appointments. This study aims to assess the association between clinical examination and the radiological and pathological findings of disorders deemed clinically benign, and to ascertain the spectrum of benign breast disorders encountered at HJH METHOD: A retrospective study of imaging results of patients at HJH presenting as clinically benign breast disorders from January to June 2018 was conducted. Assessed Breast Imaging-Reporting and Data System (BI-RADS) score was noted and if core biopsies were performed, their results and patient demographics were documented RESULTS: Of the 1 263 clinically benign patients presenting from January to June 2018, the radiological assessment was: BI-RADS 1: 158 (12.5%), BI-RADS 2: 685 (54.2%), BI-RADS 3: 292 (23.1%), BI-RADS 4a: 54 (4.3%), BI-RADS 4b: 29 (2.3 %), BI-RADS 4c: 21 (1.7%), BI-RADS 5: 24 (1.9%). There were 133 biopsies (including eight BI-RADS 3 patients), with 46 (3.6%) confirmed malignancies. The combined specificity of mammography and ultrasound was 65.52% (54.56-75.39%) and combined sensitivity 91.30% (79.21-97.58% CONCLUSION: There is a vast spectrum of benign conditions presenting in this population group with only 3.6% confirmed malignancies, confirming an accurate triage system utilised at the breast clinic. Radiological imaging is highly sensitive but less specific, emphasising the triad of clinical, radiological and histological assessment as the gold standard with regard to diagnosis of breast disease Keywords: clinically benign breast disease, breast imaging unit, Helen Joseph Hospital

Usefulness of prophylactic antibiotics in preventing infection after internal fixation of closed hand fractures

Prophylactic antibiotics (PA) have been shown to be ineffective in reducing the incidence of surgical site infection (SSI) in clean wounds associated with elective surgery of the hand. Routine administration of PA for internal fixation of hand fractures is a subject that has been scarcely studied. We hypothesized that PA do not reduce SSI incidence in fixation of closed hand fractures. We did a retrospective comparative study in patients who underwent open or closed reduction and internal fixation of a hand and carpus fracture. Patient demographics, past medical history, fracture characteristics and the type of internal fixation used were extracted from our electronic archives. Follow-up period lasted for 1 year, during which any form of clinically evident SSI, such as pus formation, wound dehiscence and positive bacterial culture was documented. A total of 107 patients met the inclusion criteria, 63 in the control group and 44 in the test group. The overall infection rate was 6.5%. All infections (3 in the control group and 4 in the test group) were pin-tract infections that resolved completely after pin extraction. Our study did not find significant differences between groups (P = 0.442). No specific fracture pattern was associated with increased total infection rate (p = 0.898). In this study, we found no support for routine administration of PA prior to internal fixation of closed fractures of the hand and carpus. PA should still be administered in selected patients, such as those with decreased immunity or open fractures. Further large-scale research is needed to establish proper guidelines, to reduce the adverse effects of antibiotic treatment.

Cytosponge-trefoil factor 3 versus usual care to identify Barrett's oesophagus in a primary care setting: a multicentre, pragmatic, randomised controlled trial

BACKGROUND

Treatment of dysplastic Barrett's oesophagus prevents progression to adenocarcinoma; however, the optimal diagnostic strategy for Barrett's oesophagus is unclear. The Cytosponge-trefoil factor 3 (TFF3) is a non-endoscopic test for Barrett's oesophagus. The aim of this study was to investigate whether offering this test to patients on medication for gastro-oesophageal reflux would increase the detection of Barrett's oesophagus compared with standard management.

METHODS

This multicentre, pragmatic, randomised controlled trial was done in 109 socio-demographically diverse general practice clinics in England. Randomisation was done both at the general practice clinic level (cluster randomisation) and at the individual patient level, and the results for each type of randomisation were analysed separately before being combined. Patients were eligible if they were aged 50 years or older, had been taking acid-suppressants for symptoms of gastro-oesophageal reflux for more than 6 months, and had not undergone an endoscopy procedure within the past 5 years. General practice clinics were selected by the local clinical research network and invited to participate in the trial. For cluster randomisation, clinics were randomly assigned (1:1) by the trial statistician using a computer-generated randomisation sequence; for individual patient-level randomisation, patients were randomly assigned (1:1) by the general practice clinics using a centrally prepared computer-generated randomisation sequence. After randomisation, participants received either standard management of gastro-oesophageal reflux (usual care group), in which participants only received an endoscopy if required by their general practitioner, or usual care plus an offer of the Cytosponge-TFF3 procedure, with a subsequent endoscopy if the procedure identified TFF3-positive cells (intervention group). The primary outcome was the diagnosis of Barrett's oesophagus at 12 months after enrolment, expressed as a rate per 1000 person-years, in all participants in the intervention group (regardless of whether they had accepted the offer of the Cytosponge-TFF3 procedure) compared with all participants in the usual care group. Analyses were intention-to-treat. The trial is registered with the ISRCTN registry, ISRCTN68382401, and is completed.

FINDINGS

Between March 20, 2017, and March 21, 2019, 113 general practice clinics were enrolled, but four clinics dropped out shortly after randomisation. Using an automated search of the electronic prescribing records of the remaining 109 clinics, we identified 13 657 eligible patients who were sent an introductory letter with 14 days to opt out. 13 514 of these patients were randomly assigned (per practice or at the individual patient level) to the usual care group (n=6531) or the intervention group (n=6983). Following randomisation, 149 (2%) of 6983 participants in the intervention group and 143 (2%) of 6531 participants in the usual care group, on further scrutiny, did not meet all eligibility criteria or withdrew from the study. Of the remaining 6834 participants in the intervention group, 2679 (39%) expressed an interest in undergoing the Cytosponge-TFF3 procedure. Of these, 1750 (65%) met all of the eligibility criteria on telephone screening and underwent the procedure. Most of these participants (1654 [95%]; median age 69 years) swallowed the Cytosponge successfully and produced a sample. 231 (3%) of 6834 participants had a positive Cytosponge-TFF3 result and were referred for an endoscopy. Patients who declined the offer of the Cytosponge-TFF3 procedure and all participants in the usual care group only had an endoscopy if deemed necessary by their general practitioner. During an average of 12 months of follow-up, 140 (2%) of 6834 participants in the intervention group and 13 (<1%) of 6388 participants in the usual care group were diagnosed with Barrett's oesophagus (absolute difference 18·3 per 1000 person-years [95% CI 14·8-21·8]; rate ratio adjusted for cluster randomisation 10·6 [95% CI 6·0-18·8], p<0·0001). Nine (<1%) of 6834 participants were diagnosed with dysplastic Barrett's oesophagus (n=4) or stage I oesophago-gastric cancer (n=5) in the intervention group, whereas no participants were diagnosed with dysplastic Barrett's oesophagus or stage I gastro-oesophageal junction cancer in the usual care group. Among 1654 participants in the intervention group who swallowed the Cytosponge device successfully, 221 (13%) underwent endoscopy after testing positive for TFF3 and 131 (8%, corresponding to 59% of those having an endoscopy) were diagnosed with Barrett's oesophagus or cancer. One patient had a detachment of the Cytosponge from the thread requiring endoscopic removal, and the most common side-effect was a sore throat in 63 (4%) of 1654 participants.

INTERPRETATION

In patients with gastro-oesophageal reflux, the offer of Cytosponge-TFF3 testing results in improved detection of Barrett's oesophagus. Cytosponge-TFF3 testing could also lead to the diagnosis of treatable dysplasia and early cancer. This strategy will lead to additional endoscopies with some false positive results.

FUNDING

Cancer Research UK, National Institute for Health Research, the UK National Health Service, Medtronic, and the Medical Research Council.

Molten metal high pressure injection injury of the hand

The second case of high temperature molten metal, high-pressure injection injury of the hand is reported here. Like in the previous case, there was an innocent-looking entry point with deep thermal injury to the flexor tendons and the digital nerves that appeared a few days after the injury and lead to finger amputation. LEVEL OF EVIDENCE: 5.

Imaging and clinical features of breast tuberculosis: a review series of 62 cases

AIM

To outline the disease burden of breast tuberculosis (TB) as a quantitative analysis amongst three tertiary hospitals in South Africa, with correlation to their clinical, demographic, and imaging features.

MATERIALS AND METHODS

A retrospective analysis was undertaken over an 18-month period (01/01/2017-30/06/2018) of all patients undergoing laboratory investigations for breast disease at the mammography departments of these three tertiary centres.

RESULTS

The prevalence of breast TB was 2.5% (n=62) of 2,516 patients. The median age of presentation was 38.5 years (interquartile range [IQR] 33-45). HIV status was known in 45 patients, of whom 36 were HIV infected (80%, 95% CI: 0.65-0.90, p<0.0001). Based on the ultrasound and/or mammogram findings, the patients were classified into five categories: TB breast abscess (40.3%), inflammatory/disseminated (24.2%), isolated TB lymphadenitis (22.6%), nodular (11.3%), and sclerosing form (1.6%). Histology demonstrated necrotising granulomatous inflammation in 57 cases (92%). Acid-fast bacilli (AFB) were positive in 8.1% (n=5) of the cytology and 16.1% (n=10) of the histology specimens. Culture for Mycobacterium tuberculosis was positive in 27% (17 cases), and in 12.9% (n=8). AFB were detected histologically using polymerase chain reaction (PCR) testing.

CONCLUSION

Knowledge of the varied clinical and radiological features is necessary to maintain a high degree of suspicion to prevent misdiagnoses, inappropriate management, and complications. Ultrasound-guided core biopsy rather than fine-needle aspiration (FNA) is advocated as the first-line intervention in diagnosing or excluding this disease, as it yields a better tissue sample and more often a positive diagnosis.

The frequency, nature and impact of GP-assessed avoidable delays in a population-based cohort of cancer patients

BACKGROUND

There is a growing emphasis on the speed of diagnosis as an aspect of cancer prognosis. While epidemiological data in the last decade have quantified diagnostic timeliness and its variation, whether and how often prolonged diagnostic intervals can be considered avoidable is unknown.

METHODS

We used data from the English National Cancer Diagnosis Audit (NCDA) on 17,042 patients diagnosed with cancer in 2014. Participating primary care physicians were asked to identify delays in diagnosis that they deemed avoidable, together with the 'setting' of the avoidable delay and key attributable factors. We used descriptive analysis and regression frameworks to assess validity and examine variation in the frequency and nature of avoidable delays.

RESULTS

Among 14,259 patients, 24% were deemed to have had an avoidable delay to their diagnosis. Patients with a reported avoidable delay had a longer median diagnostic interval (92 days) than those without (30 days). Of all avoidable delays, 13% were deemed to have occurred pre-consultation, 49% within primary care, and 38% within secondary care. Avoidable delays were mostly attributed to the test request/performance phase (25%). Multimorbidity was associated with greater odds of avoidable delay (OR for 3+ vs no comorbidity: 1.43 (95% CI 1.25-1.63)), with heterogeneous associations with cancer site.

CONCLUSION

We have shown that GP-identified instances of avoidable delay have construct validity. Whilst the causes of avoidable diagnostic delays are multi-factorial and occur in different settings and phases of the diagnostic process, their analysis can guide improvement initiatives and enable the examination of any prognostic implications.

Cross-sectional study using primary care and cancer registration data to investigate patients with cancer presenting with non-specific symptoms

INTRODUCTION

Patients presenting to primary care with site-specific alarm symptoms can be referred onto urgent suspected cancer pathways, whereas those with non-specific symptoms currently have no dedicated referral routes leading to delays in cancer diagnosis and poorer outcomes. Pilot Multidisciplinary Diagnostic Centres (MDCs) provide a referral route for such patients in England.

OBJECTIVES

This work aimed to use linked primary care and cancer registration data to describe diagnostic pathways for patients similar to those being referred into MDCs and compare them to patients presenting with more specific symptoms.

METHODS

This cross-sectional study linked primary care data from the National Cancer Diagnosis Audit (NCDA) to national cancer registration and Route to Diagnosis records. Patient symptoms recorded in the NCDA were used to allocate patients to one of two groups - those presenting with symptoms mirroring referral criteria of MDCs (non-specific but concerning symptoms (NSCS)) and those with at least one site-specific alarm symptom (non-NSCS). Descriptive analyses compared the two groups and regression analysis by group investigated associations with long primary care intervals (PCIs).

RESULTS

Patients with NSCS were more likely to be diagnosed at later stage (32% stage 4, compared with 21% in non-NSCS) and via an emergency presentation (34% vs 16%). These patients also had more multiple pre-referral general practitioner consultations (59% vs 43%) and primary care-led diagnostics (blood tests: 57% vs 35%). Patients with NSCS had higher odds of having longer PCIs (adjusted OR: 1.24 (1.11 to 1.36)). Patients with lung and urological cancers also had higher odds of longer PCIs overall and in both groups.

CONCLUSIONS

Differences in the diagnostic pathway show that patients with symptoms mirroring the MDC referral criteria could benefit from a new referral pathway.

Comorbid chronic diseases and cancer diagnosis: disease-specific effects and underlying mechanisms

An earlier diagnosis is a key strategy for improving the outcomes of patients with cancer. However, achieving this goal can be challenging, particularly for the growing number of people with one or more chronic conditions (comorbidity/multimorbidity) at the time of diagnosis. Pre-existing chronic diseases might affect patient participation in cancer screening, help-seeking for new and/or changing symptoms and clinicians' decision-making on the use of diagnostic investigations. Evidence suggests, for example, that pre-existing pulmonary, cardiovascular, neurological and psychiatric conditions are all associated with a more advanced stage of cancer at diagnosis. By contrast, hypertension and certain gastrointestinal and musculoskeletal conditions might be associated with a more timely diagnosis. In this Review, we propose a comprehensive framework that encompasses the effects of disease-specific, patient-related and health-care-related factors on the diagnosis of cancer in individuals with pre-existing chronic illnesses. Several previously postulated aetiological mechanisms (including alternative explanations, competing demands and surveillance effects) are integrated with newly identified mechanisms, such as false reassurances, or patient concerns about appearing to be a hypochondriac. By considering specific effects of chronic diseases on diagnostic processes and outcomes, tailored early diagnosis initiatives can be developed to improve the outcomes of the large proportion of patients with cancer who have pre-existing chronic conditions.

Associations between general practice characteristics with use of urgent referrals for suspected cancer and endoscopies: a cross-sectional ecological study

BACKGROUND

Large variation in measures of diagnostic activity has been described previously between English general practices, but related predictors remain understudied.

OBJECTIVE

To examine associations between general practice population and characteristics, with the use of urgent referrals for suspected cancer, and use of endoscopy.

METHODS

Cross-sectional observational study of English general practices. We examined practice-level use (/1000 patients/year) of urgent referrals for suspected cancer, gastroscopy, flexible sigmoidoscopy and colonoscopy. We used mixed-effects Poisson regression to examine associations with the sociodemographic profile of practice populations and other practice attributes, including the average age, sex and country of qualification of practice doctors.

RESULTS

The sociodemographic characteristics of registered patients explained much of the between-practice variance in use of urgent referrals (32%) and endoscopic investigations (18-25%), all being higher in practices with older and more socioeconomically deprived patients. Practice-level attributes explained a substantial amount of between-practice variance in urgent referral (19%) but little of the variance in endoscopy (3%-4%). Adjusted urgent referral rates were higher in training practices and those with younger GPs. Practices with mean doctor ages of 41 and 57 years (at the 10th/90th centiles of the national distribution) would have urgent referral rates of 24.1 and 19.1/1000 registered patients, P < 0.001.

CONCLUSION

Most between-practice variation in use of urgent referrals and endoscopies seems to reflect health need. Some practice characteristics, such as the mean age of GPs, are associated with appreciable variation in use of urgent referrals, though these associations do not seem strong enough to justify targeted interventions.

Incidentally diagnosed cancer and commonly preceding clinical scenarios: a cross-sectional descriptive analysis of English audit data

OBJECTIVES

Cancer can be diagnosed in the absence of tumour-related symptoms, but little is known about the frequency and circumstances preceding such diagnoses which occur outside participation in screening programmes. We aimed to examine incidentally diagnosed cancer among a cohort of cancer patients diagnosed in England.

DESIGN

Cross-sectional study of national primary care audit data on an incident cancer patient population.

SETTING

We analysed free-text information on the presenting features of cancer patients aged 15 or older included in the English National Audit of Cancer Diagnosis in Primary Care (2009-2010). Patients with screen-detected cancers or prostate cancer were excluded. We examined the odds of incidental cancer diagnosis by patient characteristics and cancer site using logistic regression, and described clinical scenarios leading to incidental diagnosis.

RESULTS

Among the studied cancer patient population (n=13 810), 520 (4%) patients were diagnosed incidentally. The odds of incidental cancer diagnosis increased with age (p<0.001), with no difference between men and women after adjustment. Incidental diagnosis was most common among patients with leukaemia (23%), renal (13%) and thyroid cancer (12%), and least common among patients with brain (0.9%), oesophageal (0.5%) and cervical cancer (no cases diagnosed incidentally). Variation in odds of incidental diagnosis by cancer site remained after adjusting for age group and sex.There was a range of clinical scenarios preceding incidental diagnoses in primary or secondary care. These included the monitoring or management of pre-existing conditions, routine testing before or after elective surgery, and the investigation of unrelated acute or new conditions.

CONCLUSIONS

One in 25 patients with cancer in our population-based cohort were diagnosed incidentally, through different mechanisms across primary and secondary care settings. The epidemiological, clinical, psychological and economic implications of this phenomenon merit further investigation.

High-pressure injection injuries of the fingers: Long-term follow-up in patients after extensive debridement

High-pressure injection injuries to the fingers resulting from the introduction of a foreign substance, such as oil or paint, through a minor puncture wound are rare but can have serious clinical consequences. The objective of this article was to examine the long-term outcomes after surgical debridement of these injuries. We present a retrospective case series of 8 adults who had a high-pressure injection injury to their hand and underwent surgical debridement in our facility. Data were extracted from our outpatient registry. Assessment included a full physical examination, grip strength, range of motion, two-point discrimination and Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. We followed 8 male patients for an average of 12.7 years. Their average age was 37 at time of injury and all had injured their right dominant hand. Seventy-five percent of the injuries were to the index finger. Seven out of the 8 patients returned to their pre-injury occupation, 4 out of 8 patients had reduced range of motion of the affected digit. Injury sequelae adversely affected activities of daily living (ADL) with an average QuickDASH score of 26. Grip strength in the injured hand was reduced by an average of 35% in 6 out of 8 patients compared with the uninjured hand. Sensation was also reduced in the affected digit in 7 out of 8 patients. All patients suffered from some level of neuropathic pain and/or cold intolerance. High pressure injection injury to the fingers is a serious event found amongst industrial laborers. In most patients, this injury will lead to long-term disability along with a negative impact on ADL. However, most patients eventually return to their pre-injury occupation. Extensive, single or repeat debridement of high-pressure injection injuries remains a valid treatment option with good long-term results.

Evaluating diagnostic strategies for early detection of cancer: the CanTest framework

BACKGROUND

Novel diagnostic triage and testing strategies to support early detection of cancer could improve clinical outcomes. Most apparently promising diagnostic tests ultimately fail because of inadequate performance in real-world, low prevalence populations such as primary care or general community populations. They should therefore be systematically evaluated before implementation to determine whether they lead to earlier detection, are cost-effective, and improve patient safety and quality of care, while minimising over-investigation and over-diagnosis.

METHODS

We performed a systematic scoping review of frameworks for the evaluation of tests and diagnostic approaches.

RESULTS

We identified 16 frameworks: none addressed the entire continuum from test development to impact on diagnosis and patient outcomes in the intended population, nor the way in which tests may be used for triage purposes as part of a wider diagnostic strategy. Informed by these findings, we developed a new framework, the 'CanTest Framework', which proposes five iterative research phases forming a clear translational pathway from new test development to health system implementation and evaluation.

CONCLUSION

This framework is suitable for testing in low prevalence populations, where tests are often applied for triage testing and incorporated into a wider diagnostic strategy. It has relevance for a wide range of stakeholders including patients, policymakers, purchasers, healthcare providers and industry.

The influence of health literacy on the timely diagnosis of symptomatic cancer: A systematic review

Low health literacy has been associated with poor cancer screening uptake, difficulty in making treatment choices and reduced quality of life following a cancer diagnosis, yet it is unclear whether and how health literacy influences the pathway to diagnosis for patients with cancer symptoms. This systematic review aimed to evaluate the influence of health literacy on the timely diagnosis of symptomatic cancer. Literature was searched between January 1990 and May 2017 using MEDLINE, Embase, Scopus, ASSIA, CINAHL and PsycINFO. Only three papers met the inclusion criteria. These reported two qualitative studies and one quantitative, with adult patients diagnosed with gastrointestinal (colon, rectum and pancreas), cervical and breast cancer. The definition and assessment of health literacy varied between the studies, as did the descriptions of the pathway to diagnosis. Due to the methodological weaknesses identified, the conclusions are limited; however, the studies did highlight important considerations in the definition and measurement of health literacy. Further research is required that clearly defines health literacy and follows the principles of the Aarhus Statement to assess the influence of health literacy on the pathway to cancer diagnosis. The protocol for this review was registered with PROSPERO (CRD42016048917).

Development of an intervention to expedite cancer diagnosis through primary care: a protocol

BACKGROUND

GPs can play an important role in achieving earlier cancer diagnosis to improve patient outcomes, for example through prompt use of the urgent suspected cancer referral pathway. Barriers to early diagnosis include individual practitioner variation in knowledge, attitudes, beliefs, professional expectations, and norms.

AIM

This programme of work (Wales Interventions and Cancer Knowledge about Early Diagnosis [WICKED]) will develop a behaviour change intervention to expedite diagnosis through primary care and contribute to improved cancer outcomes.

DESIGN & SETTING

Non-experimental mixed-method study with GPs and primary care practice teams from Wales.

METHOD

Four work packages will inform the development of the behaviour change intervention. Work package 1 will identify relevant evidence-based interventions (systematic review of reviews) and will determine why interventions do or do not work, for whom, and in what circumstances (realist review). Work package 2 will assess cancer knowledge, attitudes, and behaviour of GPs, as well as primary care teams' perspectives on cancer referral and investigation (GP survey, discrete choice experiment [DCE], interviews, and focus groups). Work package 3 will synthesise findings from earlier work packages using the behaviour change wheel as an overarching theoretical framework to guide intervention development. Work package 4 will test the feasibility and acceptability of the intervention, and determine methods for measuring costs and effects of subsequent behaviour change in a randomised feasibility trial.

RESULTS

The findings will inform the design of a future effectiveness trial, with concurrent economic evaluation, aimed at earlier diagnosis.

CONCLUSION

This comprehensive, evidence-based programme will develop a complex GP behaviour change intervention to expedite the diagnosis of symptomatic cancer, and may be applicable to countries with similar healthcare systems.

The Aarhus statement on cancer diagnostic research: turning recommendations into new survey instruments

BACKGROUND

Over recent years there has been a growth in cancer early diagnosis (ED) research, which requires valid measurement of routes to diagnosis and diagnostic intervals. The Aarhus Statement, published in 2012, provided methodological guidance to generate valid data on these key pre-diagnostic measures. However, there is still a wide variety of measuring instruments of varying quality in published research. In this paper we test comprehension of self-completion ED questionnaire items, based on Aarhus Statement guidance, and seek input from patients, GPs and ED researchers to refine these questions.

METHODS

We used personal interviews and consensus approaches to generate draft ED questionnaire items, then a combination of focus groups and telephone interviews to test comprehension and obtain feedback. A framework analysis approach was used, to identify themes and potential refinements to the items.

RESULTS

We found that many of the questionnaire items still prompted uncertainty in respondents, in both routes to diagnosis and diagnostic interval measurement. Uncertainty was greatest in the context of multiple or vague symptoms, and potentially ambiguous time-points (such as 'date of referral').

CONCLUSIONS

There are limits on the validity of self-completion questionnaire responses, and refinements to the wording of questions may not be able to completely overcome these limitations. It's important that ED researchers use the best identifiable measuring instruments, but accommodate inevitable uncertainty in the interpretation of their results. Every effort should be made to increase clarity of questions and responses, and use of two or more data sources should be considered.

Barrett's oESophagus trial 3 (BEST3): study protocol for a randomised controlled trial comparing the Cytosponge-TFF3 test with usual care to facilitate the diagnosis of oesophageal pre-cancer in primary care patients with chronic acid reflux

BACKGROUND

Early detection of oesophageal cancer improves outcomes; however, the optimal strategy for identifying patients at increased risk from the pre-cancerous lesion Barrett's oesophagus (BE) is not clear. The Cytosponge, a novel non-endoscopic sponge device, combined with the biomarker Trefoil Factor 3 (TFF3) has been tested in four clinical studies. It was found to be safe, accurate and acceptable to patients. The aim of the BEST3 trial is to evaluate if the offer of a Cytosponge-TFF3 test in primary care for patients on long term acid suppressants leads to an increase in the number of patients diagnosed with BE.

METHODS

The BEST3 trial is a pragmatic multi-site cluster-randomised controlled trial set in primary care in England. Approximately 120 practices will be randomised 1:1 to either the intervention arm, invitation to a Cytosponge-TFF3 test, or the control arm usual care. Inclusion criteria are men and women aged 50 or over with records of at least 6 months of prescriptions for acid-suppressants in the last year. Patients in the intervention arm will receive an invitation to have a Cytosponge-TFF3 test in their general practice. Patients with a positive TFF3 test will receive an invitation for an upper gastro-intestinal endoscopy at their local hospital-based endoscopy clinic to test for BE. The primary objective is to compare histologically confirmed BE diagnosis between the intervention and control arms to determine whether the offer of the Cytosponge-TFF3 test in primary care results in an increase in BE diagnosis within 12 months of study entry.

DISCUSSION

The BEST3 trial is a well-powered pragmatic trial testing the use of the Cytosponge-TFF3 test in the same population that we envisage it being used in clinical practice. The data generated from this trial will enable NICE and other clinical bodies to decide whether this test is suitable for routine clinical use.

TRIAL REGISTRATION

This trial was prospectively registered with the ISRCTN Registry on 19/01/2017, trial number ISRCTN68382401 .

Reimagining the diagnostic pathway for gastrointestinal cancer

A crisis is looming for the diagnosis of gastrointestinal cancers, one grounded only partly in the steady increase in their overall incidence. Public demand for diagnostic tests to be undertaken early and at lower levels of risk is reflected in early diagnosis being a widely held policy objective for reasons of both clinical outcome and patient experience. In the UK, urgent referrals for suspected lower gastrointestinal cancer have increased by 78% in the past 6 years, with parallel increases in endoscopy and imaging activity. Such growth in demand is unsustainable with current models of care. If gastrointestinal cancer diagnosis is to be affordable, the roles of professionals and their interactions with each other will need to be reframed while retaining public confidence in the process. In this Perspective, we consider how the relationship between medical specialists and generalists could be redefined to make better use of the skills of each while delivering optimal clinical outcomes and a good patient experience.

The role of social context in symptom appraisal and help-seeking among people with lung or colorectal symptoms: A qualitative interview study

Prolonged diagnostic intervals are associated with poorer outcomes, and the patient interval appears to be a substantial contributor to the overall length of the diagnostic interval. This study sought to understand how the broader context of people's lives influenced symptom appraisal and help-seeking, comparing experiences by length of the patient interval. Patients referred with a suspicion of lung or colorectal cancer were invited to complete a questionnaire about their symptoms, with 26 respondents purposively sampled to take part in a semi-structured interview about their patient intervals. Embodied experience, appraisal, help-seeking decision-making and consultation were identified as component stages of the patient interval, with the factors affecting movement between these stages located in one of four contextual domains: individual experience, interpersonal relationships, healthcare system interactions and social and temporal context. The length of the patient interval was related to the type of symptom(s) experienced, discussion of symptoms with others and the social responsibilities people held during symptomatic periods. A contextual model of the patient interval illustrates the stages and domains of this interval, as grounded in the data from this study. The model has potential application to future studies examining the patient interval for a range of symptoms.

Associations between diagnostic activity and measures of patient experience in primary care: a cross-sectional ecological study of English general practices

BACKGROUND

Lower use of endoscopies and urgent referrals for suspected cancer has been linked to poorer outcomes for patients with cancer; it is important to examine potential predictors of variable use.

AIM

To examine the associations between general practice measures of patient experience and practice use of endoscopies or urgent referrals for suspected cancer.

DESIGN AND SETTING

Cross-sectional ecological analysis in English general practices.

METHOD

Data were taken from the GP Patient Survey and the Cancer Services Public Health Profiles. After adjustment for practice population characteristics, practice-level associations were examined between the use of endoscopy and urgent referrals for suspected cancer, and the ability to book an appointment (used as proxy for ease of access), the ability to see a preferred doctor (used as proxy for relational continuity), and doctor/nurse communication skills.

RESULTS

Taking into account practice scores for the ability to book an appointment, practices rated higher for the proxy measure of relational continuity used urgent referrals and endoscopies less often (for example, 30% lower urgent referral and 15% lower gastroscopy rates between practices in the 90th/10th centiles, respectively). In contrast, practices rated higher for doctor communication skills used urgent referrals and endoscopies more often (for example, 26% higher urgent referral and 17% higher gastroscopy rates between practices in the 90th/10th centiles, respectively). Patients with cancer in practices that were rated higher for doctor communication skills were less likely to be diagnosed as emergencies (1.7% lower between practices in the 90th than in the 10th centile).

CONCLUSION

Practices where patients rated doctor communication highly were more likely to investigate and refer patients urgently but, in contrast, practices where patients could see their preferred doctor more readily were less likely to do so. This article discusses the possible implications of these findings for clinical practice.

Diagnosing cancer in primary care: results from the National Cancer Diagnosis Audit

BACKGROUND

Continual improvements in diagnostic processes are needed to minimise the proportion of patients with cancer who experience diagnostic delays. Clinical audit is a means of achieving this.

AIM

To characterise key aspects of the diagnostic process for cancer and to generate baseline measures for future re-audit.

DESIGN AND SETTING

Clinical audit of cancer diagnosis in general practices in England.

METHOD

Information on patient and tumour characteristics held in the English National Cancer Registry was supplemented by information from GPs in participating practices. Data items included diagnostic timepoints, patient characteristics, and clinical management.

RESULTS

Data were collected on 17 042 patients with a new diagnosis of cancer during 2014 from 439 practices. Participating practices were similar to non-participating ones, particularly regarding population age, urban/rural location, and practice-based patient experience measures. The median diagnostic interval for all patients was 40 days (interquartile range [IQR] 15-86 days). Most patients were referred promptly (median primary care interval 5 days [IQR 0-27 days]). Where GPs deemed diagnostic delays to have occurred (22% of cases), patient, clinician, or system factors were responsible in 26%, 28%, and 34% of instances, respectively. Safety netting was recorded for 44% of patients. At least one primary care-led investigation was carried out for 45% of patients. Most patients (76%) had at least one existing comorbid condition; 21% had three or more.

CONCLUSION

The findings identify avenues for quality improvement activity and provide a baseline for future audit of the impact of 2015 National Institute for Health and Care Excellence guidance on management and referral of suspected cancer.

Bromelain-based enzymatic debridement and minimal invasive modality (mim) care of deeply burned hands

The objective was to critically review the data and assess the implications of NexoBrid [NexoBrid-NXB formerly Debrase Gel Dressing-DGD]^a in the special field of deep hand burns. Detailed analysis of endpoints in the treatment of hand burn patients was conducted as part of a multi-center, open label, randomized, controlled two-arm study to evaluate the safety and efficacy of NXB enzymatic debridement, comparing it to the current standard of care (SOC). These results were compared to a large cohort of patients treated with NXB in a previous, single arm study. Thirty-one burned hands were treated with NXB and 41 hand burns were in the SOC group. In the NXB group, 4 out of 31 hand burns (12.9%) required some excisional debridement compared to 29 out of the 41 (70.7%) in the SOC group (p<0.0001). Mean percentage of burn wound area excised in the NXB group was 4.4 ± 13.1% compared to 52.0 ± 41.4% in the SOC group (p<0.0001). None of the NXB-treated hands required escharotomy compared to 4 out of the 41 (9.7%) in the SOC group. NXB enzymatic debridement demonstrated a statistically significant reduction in burn wound excision and auto-grafting compared to SOC, and seems to prevent the need for emergency escharotomy. ^a DGD is produced by MediWound and distributed under the name NexoBrid®.

Evidence of advanced stage colorectal cancer with longer diagnostic intervals: a pooled analysis of seven primary care cohorts comprising 11 720 patients in five countries

Background:

The benefits from expedited diagnosis of symptomatic cancer are uncertain. We aimed to analyse the relationship between stage of colorectal cancer (CRC) and the primary and specialist care components of the diagnostic interval.

Methods:

We identified seven independent data sets from population-based studies in Scotland, England, Canada, Denmark and Spain during 1997–2010 with a total of 11 720 newly diagnosed CRC patients, who had initially presented with symptoms to a primary care physician. Data were extracted from patient records, registries, audits and questionnaires, respectively. Data sets were required to hold information on dates in the diagnostic interval (defined as the time from the first presentation of symptoms in primary care until the date of diagnosis), symptoms at first presentation in primary care, route of referral, gender, age and histologically confirmed stage. We carried out reanalysis of all individual data sets and, using the same method, analysed a pooled individual patient data set.

Results:

The association between intervals and stage was similar in the individual and combined data set. There was a statistically significant convex (∩-shaped) association between primary care interval and diagnosis of advanced (i.e., distant or regional) rather than localised CRC (P=0.004), with odds beginning to increase from the first day on and peaking at 90 days. For specialist care, we saw an opposite and statistically significant concave (∪-shaped) association, with a trough at 60 days, between the interval and diagnosis of advanced CRC (P<0.001).

Conclusions:

This study provides evidence that longer diagnostic intervals are associated with more advanced CRC. Furthermore, the study cannot define a specific ‘safe’ waiting time as the length of the primary care interval appears to have negative impact from day one.

Improving early diagnosis of symptomatic cancer

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.

Concerns, perceived need and competing priorities: a qualitative exploration of decision-making and non-participation in a population-based flexible sigmoidoscopy screening programme to prevent colorectal cancer

OBJECTIVE

Optimising uptake of colorectal cancer (CRC) screening is important to achieve projected health outcomes. Population-based screening by flexible sigmoidoscopy (FS) was introduced in England in 2013 (NHS Bowel scope screening). Little is known about reactions to the invitation to participate in FS screening, as offered within the context of the Bowel scope programme. We aimed to investigate responses to the screening invitation to inform understanding of decision-making, particularly in relation to non-participation in screening.

DESIGN

Qualitative analysis of semistructured in-depth interviews and written accounts.

PARTICIPANTS AND SETTING

People from 31 general practices in the North East and East of England invited to attend FS screening as part of NHS Bowel scope screening programme were sent invitations to take part in the study. We purposively sampled interviewees to ensure a range of accounts in terms of beliefs, screening attendance, sex and geographical location.

RESULTS

20 screeners and 25 non-screeners were interviewed. Written responses describing reasons for, and circumstances surrounding, non-participation from a further 28 non-screeners were included in the analysis. Thematic analysis identified a range of reactions to the screening invitation, decision-making processes and barriers to participation. These include a perceived or actual lack of need; inability to attend; anxiety and fear about bowel preparation, procedures or hospital; inability or reluctance to self-administer an enema; beliefs about low susceptibility to bowel cancer or treatment and understanding of harm and benefits. The strength, rather than presence, of concerns about the test and perceived need for reassurance were important in the decision to participate for screeners and non-screeners. Decision-making occurs within the context of previous experiences and day-to-day life.

CONCLUSIONS

Understanding the reasons for non-participation in FS screening can help inform strategies to improve uptake and may be transferable to other screening programmes.

Socio-economic inequalities in stage at diagnosis, and in time intervals on the lung cancer pathway from first symptom to treatment: systematic review and meta-analysis

Cancer diagnosis at an early stage increases the chance of curative treatment and of survival. It has been suggested that delays on the pathway from first symptom to diagnosis and treatment may be socio-economically patterned, and contribute to socio-economic differences in receipt of treatment and in cancer survival. This review aimed to assess the published evidence for socio-economic inequalities in stage at diagnosis of lung cancer, and in the length of time spent on the lung cancer pathway. MEDLINE, EMBASE and CINAHL databases were searched to locate cohort studies of adults with a primary diagnosis of lung cancer, where the outcome was stage at diagnosis or the length of time spent within an interval on the care pathway, or a suitable proxy measure, analysed according to a measure of socio-economic position. Meta-analysis was undertaken when there were studies available with suitable data. Of the 461 records screened, 39 papers were included in the review (20 from the UK) and seven in a final meta-analysis for stage at diagnosis. There was no evidence of socio-economic inequalities in late stage at diagnosis in the most, compared with the least, deprived group (OR=1.04, 95% CI=0.92 to 1.19). No socio-economic inequalities in the patient interval or in time from diagnosis to treatment were found. Socio-economic inequalities in stage at diagnosis are thought to be an important explanatory factor for survival inequalities in cancer. However, socio-economic inequalities in stage at diagnosis were not found in a meta-analysis for lung cancer.

PROSPERO PROTOCOL REGISTRATION NUMBER

CRD42014007145.

A new bromelain-based enzyme for the release of Dupuytren's contracture: Dupuytren's enzymatic bromelain-based release

Objectives

Injectable Bromelain Solution (IBS) is a modified investigational derivate of the medical grade bromelain-debriding pharmaceutical agent (NexoBrid) studied and approved for a rapid (four-hour single application), eschar-specific, deep burn debridement. We conducted an ex vivo study to determine the ability of IBS to dissolve-disrupt (enzymatic fasciotomy) Dupuytren’s cords.

Materials and Methods

Specially prepared medical grade IBS was injected into fresh Dupuytren’s cords excised from patients undergoing surgical fasciectomy. These cords were tested by tension-loading them to failure with the Zwick 1445 (Zwick GmbH & Co. KG, Ulm, Germany) tension testing system.

Results

We completed a pilot concept-validation study that proved the efficacy of IBS to induce enzymatic fasciotomy in ten cords compared with control in ten cords. We then completed a dosing study with an additional 71 cords injected with IBS in descending doses from 150 mg/cc to 0.8 mg/cc. The dosing study demonstrated that the minimal effective dose of 0.5 cc of 6.25 mg/cc to 5 mg/cc could achieve cord rupture in more than 80% of cases.

Conclusions

These preliminary results indicate that IBS may be effective in enzymatic fasciotomy in Dupuytren’s contracture.

Cite this article: Dr G. Rubin. A new bromelain-based enzyme for the release of Dupuytren’s contracture: Dupuytren’s enzymatic bromelain-based release. Bone Joint Res 2016;5:175–177. DOI: 10.1302/2046-3758.55.BJR-2016-0072.

Evaluating a computer aid for assessing stomach symptoms (ECASS): study protocol for a randomised controlled trial

BACKGROUND

For most cancers, only a minority of patients have symptoms meeting the National Institute for Health and Clinical Excellence guidance for urgent referral. For gastro-oesophageal cancers, the 'alarm' symptoms of dysphagia and weight loss are reported by only 32 and 8 % of patients, respectively, and their presence correlates with advanced-stage disease. Electronic clinical decision-support tools that integrate with clinical computer systems have been developed for general practice, although uncertainty remains concerning their effectiveness. The objectives of this trial are to optimise the intervention and establish the acceptability of both the intervention and randomisation, confirm the suitability and selection of outcome measures, finalise the design for the phase III definitive trial, and obtain preliminary estimates of the intervention effect.

METHODS/DESIGN

This is a two-arm, multi-centre, cluster-randomised, controlled phase II trial design, which will extend over a 16-month period, across 60 general practices within the North East and North Cumbria and the Eastern Local Clinical Research Network areas. Practices will be randomised to receive either the intervention (the electronic clinical decision-support tool) or to act as a control (usual care). From these practices, we will recruit 3000 adults who meet the trial eligibility criteria and present to their GP with symptoms suggestive of gastro-oesophageal cancer. The main measures are the process data, which include the practitioner outcomes, service outcomes, diagnostic intervals, health economic outcomes, and patient outcomes. One-on-one interviews in a sub-sample of 30 patient-GP dyads will be undertaken to understand the impact of the use or non-use of the electronic clinical decision-support tool in the consultation. A further 10-15 GPs will be interviewed to identify and gain an understanding of the facilitators and constraints influencing implementation of the electronic clinical decision-support tool in practice.

DISCUSSION

We aim to generate new knowledge on the process measures regarding the use of electronic clinical decision-support tools in primary care in general and to inform a subsequent definitive phase III trial. Preliminary data on the impact of the support tool on resource utilisation and health care costs will also be collected.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN12595588 .

Profiling for primary-care presentation, investigation and referral for liver cancers: evidence from a national audit

BACKGROUND AND AIM

The incidence of liver cancer across Europe is increasing. There is a lack of evidence within the current literature on the identification and investigation of liver cancer within primary care. We aimed to profile liver cancer recognition and assessment as well as the timeliness of liver cancer diagnosis from within the primary-care setting in the UK.

METHODS

Data were obtained from the National Audit of Cancer Diagnosis in Primary Care 2009-2010 and analysed. We calculated the patient interval, the primary-care interval and the number of prereferral consultations for liver cancer. We then compared these data with prior data on the respective indicators for other common cancers.

RESULTS

The median patient interval was 9 days (interquartile range 0-31 days), and the median primary-care interval for liver cancer was 11 days (interquartile range 0-40 days). Of the 90 patients, 21 (23.3%) had three or more consultations with their general practitioner before specialist referral. For the three metrics (patient interval, primary-care interval and number of prereferral consultations), liver cancer has average or longer intervals when compared with other cancers. The most common symptomatic presentation of liver cancer within the primary-care setting was right upper quadrant pain (11%), followed by decompensated liver failure (9%). Of the patients, 12% were diagnosed with liver cancer on the basis of an incidental finding of an abnormal liver function test.

CONCLUSION

This study provides a detailed and thorough overview of the recognition of liver cancer and the promptness of liver cancer identification in an English context, and should inform strategies for improving the timeliness of diagnosis.

Minimally invasive burn care: a review of seven clinical studies of rapid and selective debridement using a bromelain-based debriding enzyme (Nexobrid®)

Current surgical and non-surgical eschar removal-debridement techniques are invasive or ineffective. A bromelainbased rapid and selective enzymatic debriding agent was developed to overcome these disadvantages and compared with the standard of care (SOC). The safety and efficacy of a novel Debriding Gel Dressing (DGD) was determined in patients with deep partial and full thickness burns covering up to 67% total body surface area (TBSA). This review summarizes data from seven studies, four of which were randomized clinical trials that included a SOC or control vehicle. DGD eschar debridement efficacy was >90% in all studies, comparable to the SOC and significantly greater than the control vehicle. The total area excised was less in patients treated with DGD compared with the control vehicle (22.9% vs. 73.2%, P<0.001) or the surgical/non-surgical SOC (50.5%, P=0.006). The incidence of surgical debridement in patients treated with DGD was lower than the SOC (40/163 [24.5%] vs. 119/170 [70.0%], P0.001). Less autografting was used in all studies. Long-term scar quality and function were similar in DGD- and SOCtreated. DGD is a safe and effective method of burn debridement that offers an alternative to surgical and non-surgical SOC.

For which cancers might patients benefit most from expedited symptomatic diagnosis? Construction of a ranking order by a modified Delphi technique

BACKGROUND

This study aimed to answer the question 'for which cancers, in a symptomatic patient, does expediting the diagnosis provide an improvement in mortality and/or morbidity?'

METHODS

An initial ranking was constructed from previous work identifying 'avoidable deaths' for 21 common cancers in the UK. In a two-round modified Delphi exercise, 22 experts, all experienced across multiple cancers, used an evidence pack summarising recent relevant publications and their own experience to adjust this ranking. Participants also answered on a Likert scale whether they anticipated mortality or morbidity benefits for each cancer from expedited diagnosis.

RESULTS

Substantial changes in ranking occurred in the Delphi exercise. Finally, expedited diagnosis was judged to provide the greatest mortality benefit in breast cancer, uterine cancer and melanoma, and least in brain and pancreatic cancers. Three cancers, prostate, brain and pancreas, attracted a median answer of 'disagree' to whether they expected mortality benefits from expedited diagnosis of symptomatic cancer.

CONCLUSIONS

Our results can guide future research, with emphasis given to studying interventions to improve symptomatic diagnosis of those cancers ranked highly. In contrast, research efforts for cancers with the lowest rankings could be re-directed towards alternative avenues more likely to yield benefit, such as screening or treatment.

Use of the English urgent referral pathway for suspected cancer and mortality in patients with cancer: cohort study

OBJECTIVE

To assess the overall effect of the English urgent referral pathway on cancer survival.

SETTING

8049 general practices in England.

DESIGN

Cohort study. Linked information from the national Cancer Waiting Times database, NHS Exeter database, and National Cancer Register was used to estimate mortality in patients in relation to the propensity of their general practice to use the urgent referral pathway.

PARTICIPANTS

215,284 patients with cancer, diagnosed or first treated in England in 2009 and followed up to 2013.

OUTCOME MEASURE

Hazard ratios for death from any cause, as estimated from a Cox proportional hazards regression.

RESULTS

During four years of follow-up, 91,620 deaths occurred, of which 51,606 (56%) occurred within the first year after diagnosis. Two measures of the propensity to use urgent referral, the standardised referral ratio and the detection rate, were associated with reduced mortality. The hazard ratio for the combination of high referral ratio and high detection rate was 0.96 (95% confidence interval 0.94 to 0.99), applying to 16% (n=34,758) of the study population. Patients with cancer who were registered with general practices with the lowest use of urgent referral had an excess mortality (hazard ratio 1.07 (95% confidence interval 1.05 to 1.08); 37% (n=79,416) of the study population). The comparator group for these two hazard ratios was the remaining 47% (n=101,110) of the study population. This result in mortality was consistent for different types of cancer (apart from breast cancer) and with other stratifications of the dataset, and was not sensitive to adjustment for potential confounders and other details of the statistical model.

CONCLUSIONS

Use of the urgent referral pathway could be efficacious. General practices that consistently have a low propensity to use urgent referrals could consider increasing the use of this pathway to improve the survival of their patients with cancer.

Risk of Ischaemic Heart Disease in Patients with Inflammatory Bowel Disease: Cohort Study Using the General Practice Research Database

Objective

Patients with inflammatory bowel disease (IBD) demonstrate an inflammatory response which bears some similarities to that seen in ischaemic heart disease (IHD). The nature of the association of IBD with IHD is uncertain. We aimed to define the extent and direction of that association.

Design

This retrospective cohort study examined records from patients aged ≥ 15 years with IBD from 1987–2009 (n = 19163) who were age and gender matched with patients without IBD (n = 75735) using the General Practice Research Database. The primary outcome was the hazard ratio for IHD.

Results

A higher proportion of IBD patients had a recorded diagnosis of IHD ever, 2220 (11.6%) compared with 6504 (8.6%) of controls. However, the majority (4494, 51.5%) developed IHD prior to IBD diagnosis (1404 (63.2%) of IBD cases and 3090 (47.5%) of controls). There was increased IHD incidence in the first year after IBD diagnosis. Mean age at IHD diagnosis was statistically similar across all IBD groups apart from for those with Ulcerative Colitis (UC) who were slightly younger at diagnosis of angina compared to controls (64.5y vs. 67.0y, p = 0.008) and coronary heart disease (65.7y vs.67.9y, p = 0.015). Of those developing IHD following IBD diagnosis, UC patients were at higher risk of IHD (unadjusted HR 1.3 (95% CI 1.1–1.5), p<0.001) or MI (unadjusted HR 1.4 (95% CI 1.1–1.6), p = 0.004).

Conclusion

Although IHD prevalence was higher in IBD patients, most IHD diagnoses predated the diagnosis of IBD. This implies a more complex relationship than previously proposed between the inflammatory responses associated with IHD and IBD, and alternative models should be considered.

The expanding role of primary care in cancer control

The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.

Free myocutaneous flap transfer to treat congenital Volkmann's contracture of the forearm

The purpose of this study is to report our experience with free functional muscle transfer procedures for the late sequelae of the rare condition of congenital Volkmann's ischaemic contracture of the forearm. Four children, with an average age of 9.5 years (range 1.5-17), were treated and were followed for a mean of 6 years (range 1-14). Two patients had dorsal forearm contractures, and two had both flexor and extensor forearm contractures. We carried out free functional muscle transfers to replace the flexor or extensor muscles. The functional result was assessed according to the classification system of Hovius and Ultee. All patients had wrist contractures and skeletal involvement with limb length discrepancy that influenced the outcome. All five transferred muscles survived and improved the function of the hand in three of the four patients. LEVEL OF EVIDENCE 4.

Irritable bowel syndrome: an integrated explanatory model for clinical practice

BACKGROUND

Although irritable bowel syndrome (IBS) is a symptom-based diagnosis, clinicians' management of and communication about the disorder is often hampered by an unclear conceptual understanding of the nature of the problem. We aimed to elucidate an integrated explanatory model (EM) for IBS from the existing literature for pragmatic use in the clinical setting.

METHODS

Systematic and exploratory literature searches were performed in PubMed to identify publications on IBS and EMs.

KEY RESULTS

The searches did not identify a single, integrated EM for IBS. However, three main hypotheses were elucidated that could provide components with which to develop an IBS EM: (i) altered peripheral regulation of gut function (including sensory and secretory mechanisms); (ii) altered brain-gut signaling (including visceral hypersensitivity); and (iii) psychological distress. Genetic polymorphisms and epigenetic changes may, to some degree, underlie the etiology and pathophysiology of IBS and could increase the susceptibility to developing the disorder. The three model components also fit into one integrated explanation for abdominal symptoms and changes in stool habit. Additionally, IBS may share a common pathophysiological mechanism with other associated functional syndromes.

CONCLUSIONS & INFERENCES

It was possible to elucidate an integrated, three-component EM as a basis for clinicians to conceptualize the nature of IBS, with the potential to contribute to better diagnosis and management, and dialog with sufferers.