Patient Preferences for Investigating Cancer-Related Symptoms in Australian General Practice: A Discrete Choice Experiment

BACKGROUND

Striking the right balance between early cancer diagnosis and the risk of excessive testing for low-risk symptoms is of paramount importance. Patient-centred care must also consider patient preferences for testing.

AIM

To investigate diagnostic testing preferences of the Australian public for symptoms associated with oesophagogastric (OG), bowel, or lung cancer.

DESIGN AND SETTING

One of three discrete choice experiments (DCEs) related to either OG, bowel, or lung cancer were administered to a nationally representative sample of Australians aged 40 and above.

METHODS

Each DCE comprised three scenarios with symptom positive predictive values (PPVs) for undiagnosed cancer ranging from 1% to 3%. The numerical risk was concealed from participants. DCE attributes encompassed the testing strategy, GP familiarity, test and result waiting times, travel duration, and test cost. Preferences were estimated using conditional and mixed logit models.

RESULTS

A total of 3013 individuals participated in one of three DCEs: OG (n=1004), Bowel (n=1006), and Lung (n=1003). Preferences were chiefly driven by waiting time, test cost followed by the test type. There was preference for more invasive tests. When confronted with symptoms carrying an extremely low risk (symptom PPV of 1% or less), participants were more inclined to abstain from testing.

CONCLUSIONS

Access-related factors, particularly waiting times and testing costs, emerged as the most pivotal elements influencing preferences, underscoring the substantial impact of these systemic factors on patient choices regarding investigations.

Cancer inequalities experienced by people with disability: a systematic review protocol

INTRODUCTION

Cancer is a leading cause of death and has a significant impact on individuals, families and society. Emerging evidence shows that people with disability face challenges in accessing services which could assist in early cancer diagnosis and optimal treatment, like cancer screening. Consequently, cancer patients with disabilities may present with later-stage disease, have reduced treatment options and experience lower survival rates compared with people without disability.This systematic review aims to summarise and evaluate the existing evidence on (a) inequalities in cancer survival and mortality between people with and without disability, (b) the inequalities in cancer screening and (c) stage at diagnosis that may contribute to the survival/mortality gap.

METHODS AND ANALYSIS

A literature search will be performed on MEDLINE, Embase, PsycInfo and Scopus up to May 2023. The review will include quantitative studies that reported inequalities in cancer survival and mortality, screening and stage at diagnosis between adults with and without disability. A summary of the characteristics and findings of the included studies will be provided. We will assess the quality of each study using the Risk Of Bias In Non-randomised Studies-of Exposure tool. Depending on the heterogeneity of studies, we will assess whether meta-analysis is appropriate.

ETHICS AND DISSEMINATION

Ethics approval is not applicable for this study since no original data will be collected. The results will be disseminated through peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42023427288.

Factors affecting patient decisions to undergo testing for cancer symptoms: an exploratory qualitative study in Australian general practice

BACKGROUND

Patients presenting to their GP are often concerned their symptoms may be due to cancer. However, there is a lack of evidence on the factors that influence patient decisions to undergo investigation for suspected cancer in the general practice setting.

AIM

To identify the factors influencing patient decisions to undertake investigations for suspected cancer in general practice.

DESIGN & SETTING

An exploratory qualitative, semi-structured interview study of patients attending rural and metropolitan general practices in Victoria, Australia.

METHOD

A purposive sample of 15 general practice patients aged ≥40 years participated. Thematic analysis of transcripts drew on interpretative description methodology and shared decision-making (SDM) theory.

RESULTS

Cancer-related concerns such as 'cancer worry' prompt patients to seek investigations from their GP. Participants prefer that their symptoms are investigated regardless of cancer risk. The perceived 'best test' provides the most reassurance. Trust and SDM enhance dialogue between patients and GPs about diagnostic testing strategies. Deterrents to testing included out-of-pocket costs, waiting time, travel time, and competing work and family demands.

CONCLUSION

There may be a mismatch between efforts to rationalise investigation use and patient preferences for investigation. SDM that incorporates patient concerns, facilitators, and barriers to testing may ensure appropriate and timely investigation of cancer symptoms.

Diagnostic pathways for breast cancer in 10 International Cancer Benchmarking Partnership (ICBP) jurisdictions: an international comparative cohort study based on questionnaire and registry data

OBJECTIVES

A growing body of evidence suggests longer time between symptom onset and start of treatment affects breast cancer prognosis. To explore this association, the International Cancer Benchmarking Partnership Module 4 examined differences in breast cancer diagnostic pathways in 10 jurisdictions across Australia, Canada, Denmark, Norway, Sweden and the UK.

SETTING

Primary care in 10 jurisdictions.

PARTICIPANT

Data were collated from 3471 women aged >40 diagnosed for the first time with breast cancer and surveyed between 2013 and 2015. Data were supplemented by feedback from their primary care physicians (PCPs), cancer treatment specialists and available registry data.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patient, primary care, diagnostic and treatment intervals.

RESULTS

Overall, 56% of women reported symptoms to primary care, with 66% first noticing lumps or breast changes. PCPs reported 77% presented with symptoms, of whom 81% were urgently referred with suspicion of cancer (ranging from 62% to 92%; Norway and Victoria). Ranges for median patient, primary care and diagnostic intervals (days) for symptomatic patients were 3-29 (Denmark and Sweden), 0-20 (seven jurisdictions and Ontario) and 8-29 (Denmark and Wales). Ranges for median treatment and total intervals (days) for all patients were 15-39 (Norway, Victoria and Manitoba) and 4-78 days (Sweden, Victoria and Ontario). The 10% longest waits ranged between 101 and 209 days (Sweden and Ontario).

CONCLUSIONS

Large international differences in breast cancer diagnostic pathways exist, suggesting some jurisdictions develop more effective strategies to optimise pathways and reduce time intervals. Targeted awareness interventions could also facilitate more timely diagnosis of breast cancer.

Differential adherence to peer and nurse components of a supportive care package-The appeal of peer support may be related to women's health and psychological status

OBJECTIVE

Knowledge of factors associated with intervention non-adherence may provide insights into the clinical utility of non-pharmacologic interventions.

METHODS

This study compared complete and incomplete adherers to two separate components of a novel intervention package for women undergoing curative intent radiotherapy for gynaecological cancer on socio-demographic, clinical and pre-radiotherapy patient-reported outcomes data.

RESULTS

Adherence to the tailored specialist nurse consultations was satisfactory (71% participated in all available sessions, 19% participated in all but one). Adherence to the telephone peer support sessions was less satisfactory (47% participated in all available sessions, 24% participated in all but one session). Complete adherers to the peer sessions reported significantly lower levels of psychological distress and significantly higher levels of physical, emotional and functional wellbeing before radiotherapy. No other statistically significant differences were observed between complete and incomplete adherers to the nurse- or peer-led sessions.

CONCLUSION

Women's ability or motivation to engage with peer support may be influenced by their health and psychological status. Further, the extent of intervention non-adherence to the peer-led component may have compromised the assessment of its efficacy.

PRACTICE IMPLICATIONS

Peer support may be less acceptable or appropriate for women with more complex care needs. Such women may prefer specialised care from trained professionals.

797Understanding bias in recruitment through population-based cancer registries

Focus of Presentation

Participant recruitment through registries can provide population-based samples, but there are methodological challenges. We examine challenges and solutions in two studies recruiting participants through the Victorian Cancer Registry. Cross-sectional surveys of patients with colorectal, lung or ovarian cancer conducted in 2013-14 (study 1) and repeated in an ongoing study (study 2). The registry managed fast-track recruitment of eligible patients ( > =40yrs, confirmed diagnosis, approached within 6-months of diagnosis)

Findings

In study 1, registry rules for confirmed diagnosis required surgical histopathology. For cancers primarily treated non-surgically (e.g. lung), selection bias was common. In study 2, confirmation rules were extended to include biopsies with subsequent hospital notification.

The registry does not receive imaging notifications and pathology labs/hospital reports can be delayed (>60days). Study eligibility criteria meant cases with advanced disease, common in lung cancer, or without a confirmed diagnosis within the study timeframe were excluded. However, colorectal and ovarian cases in study 1 were largely representative of the eligible population.

In study 2, a different fast-track recruitment approach meant a longer time from diagnosis to response compared to study 1 (median 7 vs 5 months). Recruitment procedures are being improved through engagement between researchers and registry.

Conclusions/Implications

Local registry-based rules for recruitment and available data, study eligibility criteria and cancer type (particularly cancers without histopathological confirmation), may introduce bias. Researchers need to work closely with registry colleagues to understand and optimise recruitment.

Key messages

Registry-based recruitment can be biased. Early and ongoing communication between researchers and registry is strongly recommended.

Rural-Urban Variation in Time to Diagnosis and Treatment of Colorectal or Breast Cancer in Victoria, Australia

Background: Rural-urban disparities in cancer outcomes are found in many countries, though these vary by cancer type. In Victoria, Australia, survival is poorer for rural patients with colorectal cancer, but not breast cancer. Delayed diagnosis and treatment may contribute to disparities, but previous studies have not compared the timeliness of rural and urban pathways to treatment of these common cancers. Aim: We investigated whether time to diagnosis and treatment differed for rural and urban patients with colorectal or breast cancer in Victoria, Australia. Methods: Population-based, cross-sectional surveys examining events and dates on the pathway to treatment completed by patients aged ≥ 40 and approached within six months of diagnosis, their general practitioner (GP) and specialist. Data were collected from 2013 to 2014 as part of the International Cancer Benchmarking Partnership, Module 4. Six intervals were explored: patient (symptom to presentation), primary care (presentation to referral), diagnostic (presentation/screening to diagnosis), treatment (diagnosis to treatment), health system (presentation to treatment) and total intervals (symptom/screening to treatment). Rural-urban differences were examined for each cancer using quantile regression (50th, 75th and 90th percentiles) models including age, gender, health insurance and socioeconomic status. Results: 433 colorectal (48% rural) and 489 breast (42% rural) patients, 621 GPs and 370 specialists completed surveys. Compared with urban patients, symptomatic colorectal cancer patients from rural areas had a significantly longer total interval at all percentiles: 50th (18 days longer, 95% confidence interval (CI): 9-27), 75th (53, 95% CI: 47-59) 90th (44, 95% CI: 40-48). These patients also had longer health system intervals, ranging 7-85 days longer. This appeared mostly due to longer diagnostic intervals (range: 6-54 days longer). Results were similar when including screen-detected cases. In contrast, breast cancer intervals were similar for rural and urban patients, except the patient interval, which was shorter for rural patients. Conclusion: Consistent with variation in survival, we found longer total and diagnostic intervals for rural compared with urban patients with colorectal cancer, but not breast cancer. The lack of rural-urban differences observed for breast cancer suggest that inequities in the timeliness of colorectal cancer pathways can be ameliorated, and may improve clinical outcomes. Indeed, based on previous research, delays observed in this study could result in stage progression and hence reduced survival. From our results, interventions targeting the time from presentation to colorectal cancer diagnosis in rural populations should be pursued. Countries seeking to understand cancer disparities in their local context may also consider using a pathways approach to identify possible targets for policy intervention.

How rural and urban patients in Australia with colorectal or breast cancer experience choice of treatment provider: A qualitative study

Modern healthcare systems promote patient choice of cancer treatment provider, but little is known about how place of residence influences decision-making. This research explored how rural and urban patients with breast or colorectal cancer experience choice of cancer treatment provider in Victoria, Australia. Realist thematic analysis of 43 semi-structured telephone interviews identified little active participation in decision-making regardless of area of residence or cancer diagnosis. Perceptions of choice were impacted by urgency for treatment, insurance status and access to providers, a key issue for rural patients. All patients wanted high quality care, but needed to trust health professional's recommendations. Rural patients experienced more complex decision-making, balancing a range of social factors with perceptions about quality of accessible care. Further research into variation in quality of care and complex cancer pathways for rural and urban cancer patients is warranted to inform choices and enhance patient-centred care.

Nurse-led group consultation intervention reduces depressive symptoms in men with localised prostate cancer: a cluster randomised controlled trial

Background

Radiotherapy for localised prostate cancer has many known and distressing side effects. The efficacy of group interventions for reducing psychological morbidity is lacking. This study investigated the relative benefits of a group nurse-led intervention on psychological morbidity, unmet needs, treatment-related concerns and prostate cancer-specific quality of life in men receiving curative intent radiotherapy for prostate cancer.

Methods

This phase III, two-arm cluster randomised controlled trial included 331 men (consent rate: 72 %; attrition: 5 %) randomised to the intervention (n = 166) or usual care (n = 165). The intervention comprised four group and one individual consultation all delivered by specialist uro-oncology nurses. Primary outcomes were anxious and depressive symptoms as assessed by the Hospital Anxiety and Depression Scale. Unmet needs were assessed with the Supportive Care Needs Survey-SF34 Revised, treatment-related concerns with the Cancer Treatment Scale and quality of life with the Expanded Prostate Cancer Index −26. Assessments occurred before, at the end of and 6 months post-radiotherapy. Primary outcome analysis was by intention-to-treat and performed by fitting a linear mixed model to each outcome separately using all observed data.

Results

Mixed models analysis indicated that group consultations had a significant beneficial effect on one of two primary endpoints, depressive symptoms (p = 0.009), and one of twelve secondary endpoints, procedural concerns related to cancer treatment (p = 0.049). Group consultations did not have a significant beneficial effect on generalised anxiety, unmet needs and prostate cancer-specific quality of life.

Conclusions

Compared with individual consultations offered as part of usual care, the intervention provides a means of delivering patient education and is associated with modest reductions in depressive symptoms and procedural concerns. Future work should seek to confirm the clinical feasibility and cost-effectiveness of group interventions.

Trial registration

Australian and New Zealand Clinical Trials Registry ANZCTRN012606000184572. 1 March 2006.

Toward structured peer support interventions in oncology: a qualitative insight into the experiences of gynaecological cancer survivors providing peer support

PURPOSE

Research into dyadic (one-to-one) peer support has predominantly focused on the recipients of peer support whilst neglecting the impact on the peer support providers (PSPs). Increasingly, structured/protocolised peer support interventions are employed. The aim of this qualitative study was to explore the experience of providing peer support within a protocolised intervention and how common key characteristics of such interventions (guidelines and checklists, rigorous training and partnerships with health professionals) may influence PSPs' experiences. This research was conducted within the context of an ongoing randomised controlled trial investigating a protocolised peer support intervention (the Peer and Nurse support Trial to Assist women in Gynaecological Oncology (PeNTAGOn) study).

METHODS

Eleven women (gynaecological cancer survivors) providing peer support within the PeNTAGOn study participated in semi-structured telephone interviews. Transcribed interviews were analysed using interpretative phenomenological analysis.

RESULTS

Five key themes were identified which described the overall experience of providing protocolised peer support: (i) fitting oneself to the protocolised PSP role, (ii) the impact of personal beliefs about the value of research, (iii) protocolisation as both blessing and curse, (iv) discussing taboo or sensitive topics and (v) the impact of interactions with study personnel.

CONCLUSIONS

These insights into the advantages and disadvantages of protocolised peer support can be used to inform future research and social support programs and maximise the effectiveness of such programs for patients, PSPs and the health-care system.

A nurse- and peer-led support program to assist women in gynaecological oncology receiving curative radiotherapy, the PeNTAGOn study (peer and nurse support trial to assist women in gynaecological oncology): study protocol for a randomised controlled trial

Background

Women who undergo radiotherapy for gynaecological cancer (GC) can experience distressing side effects which impact on psychosocial functioning and intimate relationships. Cancer-related distress may be ameliorated by comprehensive preparation for treatment and addressing women’s informational, physical, psychological and psychosexual needs. This paper describes the protocol for a multisite randomised controlled trial (RCT) testing a novel intervention package which combines tailored specialist nursing consultations and telephone peer support with the primary aim to reduce psychological distress. Secondary aims assess patient quality of life, symptom distress, unmet supportive care needs, preparation for treatment, psychosexual functioning and vaginal stenosis.

Methods/design

This multifaceted intervention comprises four nurse-led consultations coupled with four phone calls from a peer support volunteer (GC survivor). The evidence-based intervention will be delivered at critical points in the illness trajectory: pre-treatment, mid-treatment, treatment completion and post-treatment. Nurses and peers undergo 2-day intensive training workshops, are guided by comprehensive study intervention manuals and receive ongoing supervision and support. Eligible patients will have a diagnosis of GC, be scheduled to receive curative radiotherapy, be aged 18 years or over and speak English. Three-hundred and six participants will be randomized to receive usual care or usual care with the intervention package. Study outcome measures will be collected at baseline, day 1 of radiotherapy and 1, 6 and 12 months post radiotherapy. Clinical assessments of vaginal toxicity will occur at baseline, and 3, 6, and 12 months post radiotherapy.

Discussion

This timely research has the potential to substantially reduce the physical, psychosexual and supportive care needs of women with GC. Using a telephone peer support model, the intervention package ensures equitable access to support services for geographically isolated patients. The novel intervention engages peer volunteers who liaise with nurses to encourage adherence to professionally-delivered information and provide emotional support. It has been designed to be potentially transferable to a range of treatment settings and diseases. Based on pilot data, the proposed intervention was found to be useful and acceptable to patients and clinicians. If effective and feasible in the multisite RCT, the program could be widely disseminated.

Trial registration

Australian New Zealand Clinical Trial Registry ACTRN12611000744954

Development of human cells with RXFP1 knockdown using retroviral delivery of microRNA against human RXFP1

To study the specific actions of relaxin through RXFP1 in human cells, it would be advantageous to develop cell populations with permanent RXFP1 knockdown (KD). We have developed and assessed four microRNA against human RXFP1. One of the four designed microRNA displayed significant RXFP1 KD as assessed by reduced relaxin binding when co-transfected with human RXFP1 into HEK-293T cells. The selected microRNA sequence was subsequently retrovirally delivered into the human dermal fibroblast cell line BJ3 which natively expresses RXFP1. The RXFP1 KD BJ3 cells displayed diminished RXFP1 mRNA expression and complete loss of ability of relaxin treatment to reduce collagen deposition after TGF-beta1 stimulation. The retroviral expression of miRNA to successfully silence RXFP1 expression is an invaluable tool to investigate receptor specificity, signalling and possible off-target effects of newly developed relaxin analogs.

The use of a virtual patient case in an OSCE-based exam--a pilot study

BACKGROUND

This study focuses on a skills test based clinical assessment where 118 fourth-year medical students at the four teaching hospitals of Karolinska Institutet participated in the same 12-module OSCE. The goal of one of the twelve examination modules was to assess the students' skills and ability to solve a virtual patient (VP) case (the ISP system), which included medical history taking, lab tests, physical examinations and suggestion of a preliminary diagnosis.

AIMS

The primary aim of this study was to evaluate the potential of a VP as a possible tool for assessment of clinical reasoning and problem solving ability among medical students. The feeling of realism of the VP and its possible affective impact on the student's confidence were also investigated.

METHOD

We observed and analysed students' reactions, engagement and performance (activity log files) during their interactive sessions with the simulation. An individual human assistant was provided along with the computer simulation and the videotaped interaction student/assistant was then analysed in detail and related to the students' outcomes.

RESULTS

The results indicate possible advantages of using ISP-like systems for assessment. The VP was for instance able to reliably differentiate between students' performances but some weaknesses were also identified, like a confounding influence on students' outcomes by the assistants used. Significant differences, affecting the results, were found between the students in their degree of affective response towards the system as well as the perceived usefulness of assistance.

CONCLUSION

Students need to be trained beforehand in mastering the assessment tool. Rating compliance needs to be targeted before VP-based systems like ISP can be used in exams and if such systems would be used in high-stake exams, the use of human assistants should be limited and scoring rubrics validated (and preferably automated).

DNA as a basis for acquired long-term memory in neurons

After a short review of trends in the research on localization of memory, a hypothesis is presented in which DNA is the basis for acquired long-term memory in neurons. This is conceivable as neurons do not divide. As an example, the possible storage capacity in DNA is calculated using the coding of action potentials into DNA sequences. Such a record of a human lifetime of action potentials would not occupy more than a fraction of the available DNA in the cell nucleus.

Computerized cephalometrics

A method to analyse cephalometric radiographs with the help of a computer has been described. With the system a cephalometric radiograph can be analysed and the results compared to corresponding analyses of individuals with ideal occlusion. The results can also be visualized as schematic figures of the patients. The computer calculates means and standard deviations of groups of individuals and can visualize the results as mean figures. A program to train operators in pinpointing radiographic reference points has also been developed. A methodological study has shown that the errors of the computerized method are of little importance compared to the errors made in pinpointing radiographic reference points. A clinical test of the system has shown that inexperienced operators are able to use the system after about one hour's training. The method is about twenty minutes faster compared to an ordinary manual radiographic analysis. Some future aspects are also discussed.

Molecular characteristics of biogenic monoamines and their analogs

Until recently there has been very limited information concerning the molecular geometry and conformation of biogenic monoamines and this lack of knowledge has seriously hampered efforts to unravel the structure—function relationships at the molecular level. Nevertheless, several theories have been proposed regarding interaction between the monoamines and their receptor sites. This is especially true for the neurohumoral transmitters dopamine, noradrenaline (norepinephrine) and serotonin (5-hydroxytryptamine), the target areas of which seem to be specific not only in the sense of chemical structure but also from the steric point of view. The well-known differences in biological activity due to chiralty illustrate the importance of the three-dimensional architecture of the molecules and indicate also the presence of stereospecific receptor sites. A detailed knowledge of the conformation of the biogenic monoamines would not only elucidate the requirements upon a natural or synthetic monoamine for proper function but also give indirect information about the geometry of the receptor sites.