"Notification! You May Have Cancer." Could Smartphones and Wearables Help Detect Cancer Early?

This viewpoint paper considers the authors' perspectives on the potential role of smartphones, wearables, and other technologies in the diagnosis of cancer. We believe that these technologies could be valuable additions in the pursuit of early cancer diagnosis, as they offer solutions to the timely detection of signals or symptoms and monitoring of subtle changes in behavior that may otherwise be missed. In addition to signal detection, technologies could assist symptom interpretation and guide and facilitate access to health care. This paper aims to provide an overview of the scientific rationale as to why these technologies could be valuable for early cancer detection, as well as outline the next steps for research and development to drive investigation into the potential for smartphones and wearables in this context and optimize implementation. We draw attention to potential barriers to successful implementation, including the difficulty of the development of signals and sensors with sufficient utility and accuracy through robust research with the target group. There are regulatory challenges; the potential for innovations to exacerbate inequalities; and questions surrounding acceptability, uptake, and correct use by the intended target group and health care practitioners. Finally, there is potential for unintended consequences on individuals and health care services including unnecessary anxiety, increased symptom burden, overinvestigation, and inappropriate use of health care resources.

Understanding GPs' referral decisions for younger patients with symptoms of cancer: a qualitative interview study

BACKGROUND

Cancer incidence increases with age, so some clinical guidelines include patient age as one of the criteria used to decide whether a patient should be referred through the urgent suspected cancer (USC) pathway. Little is known about how strictly GPs adhere to these age criteria and what factors might influence their referral decisions for younger patients.

AIM

To understand GPs' clinical decision making for younger patients with concerning symptoms who do not meet the age criteria for USC referral.

DESIGN AND SETTING

Qualitative study using in-depth, semi-structured interviews with GPs working in surgeries across England.

METHOD

Participants (n = 23) were asked to recall consultations with younger patients with cancer symptoms, describe factors influencing their clinical decisions, and discuss their overall attitude to age thresholds in cancer referral guidelines. A thematic analysis guided by the Framework approach was used to identify recurring themes.

RESULTS

GPs' decision making regarding younger patients was influenced by several factors, including personal experiences, patients' views and behaviour, level of clinical concern, and ability to bypass system constraints. GPs weighted potential benefits and harms of a referral outside guidelines both on the patient and the health system. If clinical concern was high, GPs used their knowledge of local systems to ensure patients were investigated promptly even when not meeting the age criteria.

CONCLUSION

While most GPs interpret age criteria flexibly and follow their own judgement and experience when making clinical decisions regarding younger patients, system constraints may be a barrier to timely investigation.

Future cancer risk after urgent suspected cancer referral in England when cancer is not found: a national cohort study

BACKGROUND

Following referral for investigation of urgent suspected cancer within the English National Health Service referral system, 7% of referred individuals are diagnosed with cancer. This study aimed to investigate the risk of cancer occurrence within 1-5 years of finding no cancer following an urgent suspected cancer referral.

METHODS

This national cohort study used urgent suspected cancer referral data for England from the Cancer Waiting Times dataset and linked it with cancer diagnosis data from the National Cancer Registration dataset. Data were extracted for the eight most commonly referred to urgent suspected cancer referral pathways (breast, gynaecological, head and neck, lower and upper gastrointestinal, lung, skin, and urological) for the period April 1, 2013, to March 31, 2014, with 5-year follow-up for individuals with no cancer diagnosis within 1 year of referral. The primary objective was to investigate the occurrence and type of subsequent cancer in years 1-5 following an urgent suspected cancer referral when no cancer was initially found, both overall and for each of the eight referral pathways. The numbers of subsequent cancers were compared with expected cancer incidence in years 1-5 following referral, using standardised incidence ratios (SIRs) based on matched age-gender distributions of expected cancer incidence in England for the same time period. The analysis was repeated, stratifying by referral group, and by calculating the absolute and expected rate of all cancers and of the same individual cancer as the initial referral.

FINDINGS

Among 1·18 million referrals without a cancer diagnosis in years 0-1, there were 63 112 subsequent cancers diagnosed 1-5 years post-referral, giving an absolute rate of 1338 (95% CI 1327-1348) cancers per 100 000 referrals per year (1038 [1027-1050] in females, 1888 [1867-1909] in males), compared with an expected rate of 1054 (1045-1064) cancers per 100 000 referrals per year (SIR 1·27 [95% CI 1·26-1·28]). The absolute rate of any subsequent cancer diagnosis 1-5 years after referral was lowest following suspected breast cancer referral (746 [728-763] cancers per 100 000 referrals per year) and highest following suspected urological (2110 [2070-2150]) or lung cancer (1835 [1767-1906]) referral. For diagnosis of the same cancer as the initial referral pathway, the highest absolute rates were for the urological and lung pathways (1011 [984-1039] and 638 [598-680] cancers per 100 000 referrals per year, respectively). The highest relative risks of subsequent diagnosis of the same cancer as the initial referral pathway were for the head and neck pathway (SIR 3·49 [95% CI 3·22-3·78]) and lung pathway (3·00 [2·82-3·20]).

INTERPRETATION

Cancer risk was higher than expected in the 5 years following an urgent suspected cancer referral. The potential for targeted interventions, such as proactive monitoring, safety-netting, and cancer awareness or risk reduction initiatives should be investigated.

FUNDING

Cancer Research UK.

Talking about cancer: Patient responses to raising awareness of oral cancer in primary dental care

OBJECTIVES

Dentists and other members of the dental team could raise awareness by talking about oral cancer during routine dental check-ups. A communication guide has been developed to facilitate this. However, it has been suggested that discussions about oral cancer may raise patients' anxiety and this has been documented by dentists as a barrier to having these conversations. The current research aimed to investigate implementation of the communication guide and its impact on the dental patient.

METHODS

A consecutive-case sample of adult dental patients attending primary dental care for a routine NHS check-up at one dental practice were invited to take part in the study via letter prior to their appointment. Consultations of participating patients (n = 77) were audio-recorded. Before and after their appointment, patients were asked to rate their current anxiety via the six-item version of Spielberger's State-Trait Anxiety Inventory. Audio recordings of each consultation were reviewed by two raters to determine the extent to which the dentist covered the topics recommended in the communication guide.

RESULTS

The dentist informed all patients that they were being checked for oral cancer, spoke about signs and symptoms, and discussed risk factors. However, they rarely recommended where help should be sought or addressed barriers to seeking help. Discussions took an average of 95 s. The extent to which oral cancer was discussed did not correlate with patients' post-appointment anxiety. Patients made positive or neutral responses to the discussions. The few questions that were asked were easily addressed.

CONCLUSIONS

As findings are based on one dentist working at one practice, generalization of these results should be cautious. The study indicated that using an evidence-based guide to talk about oral cancer did not appear to raise patients' anxiety in this practice population. This could help to increase awareness of oral cancer in the endeavour to facilitate early cancer diagnosis.

Should we? Could we? Feasibility of interventions to support prevention or early diagnosis of future cancer following urgent referral: A qualitative study

OBJECTIVE

This study investigated perspectives of healthcare professionals (HCPs) on the feasibility of giving additional support to patients after cancer is not found following urgent referral. We sought to understand key facilitators or barriers to offering such support.

METHODS

A convenience sample of primary and secondary care healthcare professionals (n = 36) participated in semi-structured interviews. Interviews were transcribed verbatim and analysed using Framework Analysis, inductively and deductively, guided by the Theoretical Domains Framework.

RESULTS

HCPs indicated that support should be offered if proven to be efficacious. It needs to avoid potential negative consequences such as patient anxiety and information overload. HCPs were more hesitant about whether support could feasibly be offered, due to resource restrictions and perceived remit of the urgent pathway for suspected cancer.

CONCLUSION

HCP support after discharge from urgent cancer referral pathways needs to be resource efficient, developed in collaboration with patients and should have proven efficacy. Development of brief interventions for delivery by a range of staff, and use of technology could mitigate barriers to implementation.

PRACTICE IMPLICATIONS

Changes to discharge procedures to provide information, endorsement or direction to services could offer much needed support. Additional support would need to overcome logistical challenges and address limited capacity.

Dentists' perspectives on denture provision after radiotherapy for head and neck cancer: an exploratory study using the theoretical domains framework

Introduction Patients are often keen to replace their missing teeth after radiotherapy for head and neck cancer (HNC), yet such replacement does not always take place.Aims This study aimed to investigate the influences on dentists' provision of dentures for patients treated with radiotherapy for HNC, including whether risk of osteoradionecrosis (ORN) is a factor influencing intention to provide dentures.Methods An online cross-sectional survey including a case scenario, self-reported behaviour and measures of factors (selected using the theoretical domains framework) that may affect dentists' decisions was completed by general dental practitioners (n = 150) and HNC multidisciplinary team dentists (n = 25) in England.Results Dentists' reluctance to provide dentures for HNC patients post-radiotherapy was often due to concerns about dry mouth and radiation caries rather than risk of ORN. Knowledge of guidelines and beliefs about consequences were independently associated with dentists' intention to replace missing teeth with dentures.Conclusion The likelihood of replacing missing teeth with dentures increased with awareness of clinical guidance on the use of dentures in HNC and that denture provision would have positive consequences that outweigh the costs.

"Whilst you are here…" Acceptability of providing advice about screening and early detection of other cancers as part of the breast cancer screening programme

Objectives

This research aimed to assess women's willingness to receive advice about cervical and bowel cancer screening participation and advice on cancer symptom awareness when attending breast cancer screening.

Methods

Women (n = 322) aged 60–64 years, living in the United Kingdom, who had previously taken part in breast cancer screening were recruited via a market research panel. They completed an online survey assessing willingness to receive advice, the potential impact of advice on breast screening participation, prospective acceptability and preferences for mode and timing of advice.

Results

Most women would be willing to receive information about cervical (86%) and bowel cancer screening (90%) and early symptoms of other cancers (92%) at a breast cancer screening appointment. Those who were not up to date with cervical cancer screening were less willing. Prospective acceptability was high for all three forms of advice and was associated with willingness to receive advice. Women would prefer to receive advice through a leaflet (41%) or discussion with the mammographer (30%) either before the appointment (27%), at the appointment (44%) or with their results (22%).

Conclusions

While there is high willingness and high acceptability towards using breast cancer screening as a teachable moment for advice about prevention and early detection of other cancers, some women find it unacceptable and this may reduce their likelihood of attending a breast screening appointment.

Patient or Public Contribution

This study focused on gaining women's insights into potential future initiatives to encourage screening and early diagnosis of cancer. Members of the public were also involved in piloting the questionnaire.

Knowledge of cervical cancer risk factors and symptoms among women in a refugee settlement: a cross-sectional study in northern Uganda

BACKGROUND

There are limited data on awareness of cervical cancer risk factors and symptoms among refugee populations living in Uganda. In this study, we sought to determine the awareness and knowledge of cervical cancer risk factors and symptoms among women in Palabek refugee settlement, northern Uganda.

METHODS

We conducted a cross-sectional study. 815 women (aged 18-60 years) were randomly selected using multistage sampling in Palabek refugee settlement. Data were collected using pre-tested, structured questionnaires. Logistic regression models were used to determine magnitudes of association between socio-demographic and health system factors, and knowledge on cervical cancer risk factors and symptoms.

RESULTS

The majority of participants (53%, n = 433) were young (18-29 years), married (68%, n = 553), and did not have formal employment (93%, n = 759). Less than half (40%, n = 325) had heard of cervical cancer. Of those who had heard, most recognized multiple male sexual partners, early onset of sexual intercourse and HPV infections as risk factors for cervical cancer (93%, n = 295; 89%, n = 283; and 86%, n = 271 respectively). Median knowledge score for risk factor recognition = 7 (IQR: 3-9). Median knowledge score for symptoms recognition = 7 (IQR: 1-10). Half of women (50%, n = 409) correctly recognized 7 to 11 symptoms of cervical cancer, with vaginal bleeding between menstrual periods, pelvic pain, and vaginal bleeding during/after sexual intercourse recognized by 58, 52 and 54% respectively. Single women (OR = 0.59 (95%CI: 0.38-0.94), and women that lived farther than 1 kilo meter from nearest health facility in South Sudan (OR = 0.36-0.49 (95%CI: 0.26-0.84) were less likely to be knowledgeable of symptoms of cervical cancer.

CONCLUSION

A significant proportion of women in Palabek refugee settlement had not heard about cervical cancer. Refugee health services providers could increase awareness of cervical cancer risk factors and symptoms through health education in order to promote risk reduction behaviours and guide women during symptoms appraisal. Single women and those who lived more than one kilo metre from nearest health facility in home country could be a priority group for awareness intervention in the settlement.

Women's appraisal, interpretation and help-seeking for possible symptoms of breast and cervical cancer in South Africa: a qualitative study

BACKGROUND

In South Africa, breast cancer is the most commonly diagnosed cancer and cervical cancer the leading cause of cancer mortality. Most cancers are diagnosed at a late-stage and following symptomatic presentation. The overall purpose of the study was to inform interventions aimed at improving timely diagnosis of breast and cervical cancer.

METHODS

In-depth interviews were conducted with women with potential breast or cervical cancer symptoms from urban and rural South Africa. Participants were recruited from a community-based cross-sectional study on breast and cervical cancer awareness. Data were analysed using a thematic analysis approach.

RESULTS

Eighteen women were interviewed (10 urban, 8 rural): the median age was 34.5 years (range 22-58). Most were unemployed, and five were HIV positive. Themes included impact and attribution of bodily changes; influence of social networks and health messaging in help-seeking; management of symptoms and help-seeking barriers. Breast changes were often attributed to manual activities or possible cancer. Women were often unsure how to interpret vaginal symptoms, attributing them to HIV, hormonal contraceptives, or partner infidelity. Concerns about cancer were based on health information from the radio, social networks, or from primary care providers. Prompt care seeking was triggered by impact of symptoms on personal lives. Rural women, especially with possible symptoms of cervical cancer, experienced challenges during help-seeking including judgmental attitudes of clinic staff. Most participants were skeptical of traditional medicine.

CONCLUSIONS

This is the first study exploring interpretation of possible breast and cervical cancer symptoms at a community level in South Africa. The process of interpreting bodily changes, symptom attribution and help-seeking is complex and influenced by women's everyday life experiences. Timely diagnosis interventions should not only include cancer symptom awareness but also address individual, structural and health systems related barriers to care.

Use of dentures, receipt of information, quality of life, and oral function following radiotherapy for head and neck cancer

BACKGROUND

Teeth with a poor prognosis are often extracted prior to radiotherapy for head and neck cancer (HNC) in order to help prevent the need for dental treatment after radiotherapy that might in turn lead to the development of osteoradionecrosis. However, the details and impact of replacing missing teeth after radiotherapy for HNC have received little attention, especially from the patients' perspective.

AIMS

This study aimed to assess the use, satisfaction, and impact of denture use following radiotherapy for HNC. The study also sought to determine patients' satisfaction with information about replacing their missing teeth postradiotherapy. Finally, this study also aimed to assess interest in replacing missing teeth for those who had not done so.

METHODS

A structured, validated, and reliable questionnaire was sent to HNC patients who had received radiotherapy and had missing teeth at the time of discharge. In addition to demographic details and self-reported oral hygiene, the questionnaire included questions on use of (or interest in) dentures, satisfaction with dentures, satisfaction with information about replacing missing teeth, QoL as measured by two questions from the short version of WHOQoL-BREF, and oral functioning as measured by BCSQ-H&N. Demographic details and clinical details were extracted from the hospital records.

RESULTS

N = 80 (24%) returned a completed questionnaire. Participants had an average of 12 missing teeth (SD = 8.05). Most (n = 60, 75%) had not replaced their missing teeth. Of these, 35 (58%) were very or extremely interested in doing so. For HNC survivors who wore dentures, there was variable satisfaction and a number of side-effects of wearing dentures. Satisfaction with information about replacing missing teeth was low. There was no statistical difference in QoL or oral functioning between participants who wore dentures and participants who did not wear dentures. However, those with dentures reported fewer problems with carrying out daily routines as measured by the oral functioning tool.

CONCLUSIONS

QoL and oral functioning were similar regardless of denture use, highlighting reduced oral function in both those with and without dentures. In those who had not replaced their missing teeth, there was substantial interest in doing so and thus may be an unmet need. The dental team could offer HNC survivors more support after radiotherapy and following denture provision to improve information about denture use and increase satisfaction with dentures.

Tracking cancer occurrence in the 5 years after referral for suspected head and neck cancer

OBJECTIVES

Very little is known about those who receive a negative (benign) result after referral for suspected cancer, including their risk for future cancer. This service evaluation aimed to track the occurrence of cancer (of any type) in the 5 years after an appointment for suspected head and neck cancer (HNC) and compare to those referred to hospital for routine ear nose and throat reasons.

MATERIALS & METHODS

Patient identifiers of referrals to one hospital Trust with either a) suspected HNC cancer on a two week wait (TWW) pathway, or b) routine ear, nose & throat problems, were linked with the National Cancer Registry data to determine the occurrence, site and stage of subsequent cancer.

RESULTS

10,314 patients were referred between 2009 and 2011. Cancer occurrence in the 5 years after their appointment for those who had initially received a negative diagnosis, was 4.0% for those referred via TWW and 2.1% for those routinely referred. Lung cancer was the most common subsequent cancer site in the TWW group. Those in higher age groups, those with previous cancer, and those referred via the TWW pathway were significantly more likely be diagnosed with subsequent cancer.

CONCLUSION

Given the increased risk of subsequent cancer, it could be beneficial to improve the service provision (e.g. advice on screening attendance, ways to reduce risk, advice on timely help-seeking for symptoms of cancer) at the point of a negative diagnosis on the TWW pathway, especially in older patients and those with a previous diagnosis of cancer.

Denture use and dental risk factors associated developing osteoradionecrosis after head and neck radiotherapy: A retrospective analysis of hospital records

OBJECTIVES

This study aimed to assess the association between denture use and occurrence of osteoradionecrosis (ORN) following radiotherapy for head and neck cancer (HNC).

MATERIALS AND METHODS

Medical records of 439 HNC patients treated with radiotherapy at Guy's & St Thomas' NHS Foundation Trust (London, UK) (2014-2019) who had missing teeth at the time of discharge were reviewed. Descriptive statistics were used to summarise the participant characteristics and outcome measures. Logistic regression analysis was used to identify factors associated with occurrence of ORN.

RESULTS

Patients had an average of 14 missing teeth and 39 % wore dentures. Twenty-two (5 %) developed ORN. Out of 22 who developed ORN, 11 (50 %) wore dentures. Of these, 5 patients developed ORN in areas contacted by dentures. Denture use was not significantly associated with the occurrence of ORN (OR = 1.94; 95%CI = 0.79-4.81; p-value = 0.150). Longer duration of radiotherapy (OR =1.03; 95%CI = 1.00-1.06; p-value= 0.048) and more missing teeth in the lower anterior area (OR = 1.11; 95%CI = 1.01-1.22; p-value = 0.024) were significantly associated with the development of ORN.

CONCLUSIONS

Within the limitations of this single-centre study in which few patients developed ORN, denture use may not be a risk factor for ORN following radiotherapy for HNC. This is likely to be the case if dentures are well-fitting and not causing sores or irritation.

CLINICAL SIGNIFICANCE

Replacement of the missing teeth with dentures in HNC patients post-radiotherapy may be a suitable choice for many HNC survivors. However, a powered study in a large cohort that includes clinical evaluation of dentures and the quality of fit alongside denture wearing experience would be useful to further assess the impact of denture use on the development of ORN.

Denture use and osteoradionecrosis following radiotherapy for head and neck cancer: A systematic review

BACKGROUND

It is strongly recommended to extract teeth with poor prognosis in head and neck cancer (HaNC) patients prior starting treatment with radiotherapy to avoid need for extraction post-radiotherapy and prevent development of osteoradionecrosis (ORN). Dental extraction means that patients are often left with insufficient teeth leading to psychological problems and reducing their quality of life post-radiotherapy. Some clinicians do not advocate the use of dentures in HaNC patients claiming that dentures might lead to soft tissue irritation followed by ORN when constructed on irradiated jaws.

AIMS

This systematic review aimed to investigate the existing evidence regarding the impact of denture use on the development of ORN in HaNC patients post-radiotherapy.

METHODS

This systematic review followed the Preferred Reporting Item for Systematic Review and Meta-analyses (PRISMA) guideline. Three database systems were used: Ovid Medline, EMBASE and PsycINFO. PROSPERO was searched for ongoing or recently completed systematic reviews. The https://ClinicalTrials.gov was searched for ongoing or recently completed trials. The Joanna Briggs Institute critical appraisal tools were used to assess quality of studies being reviewed.

RESULTS

Only three retrospective case-control studies were included. Numbers of participants included in the three studies are limited with incomparable types of mucosal dentures. None of the studies described the method of measurement of the exposure (denture use) in a standard, validated and reliable way.

CONCLUSION

The three included studies suggested no link between denture use and development of ORN. However, very little evidence exists and the robustness of the studies is questionable. Well-powered studies are needed.

'It was nothing that you would think was anything': Qualitative analysis of appraisal and help seeking preceding brain cancer diagnosis

Background

The patient’s interpretation of the events and decisions leading up to consultation with a healthcare professional for symptoms of brain cancer is under researched. The aim of this study was to document responses to noticing the changes preceding a diagnosis of brain cancer and living with them, focusing on appraisal of changes and the decision to seek (and re-seek) help, with attention to the psychological processes underpinning the appraisal and help-seeking intervals.

Method

In this qualitative study set in Eastern and NW England, in-depth interviews with adult patients recently diagnosed with primary brain cancer and their family members were analysed thematically, using the Model of Pathways to Treatment as a conceptual framework.

Results

39 adult patients were interviewed. Regarding the appraisal interval, cognitive heuristics were found to underpin explanations of changes/symptoms. The subtlety and normality of changes often suggested nothing serious was wrong. Common explanations included stress or being busy at work, or age and these did not seem to warrant a visit to a doctor. Explanations and the decision to seek help were made within the social context, with friends, family and work colleagues contributing to appraisal and help-seeking decisions.

Regarding the help-seeking interval, barriers to seeking help reflected components of Social Cognitive Theory, and included having other priorities, outcome expectations (e.g. ‘feeling silly’, not sure much can be done about it, not wanting to waste doctors’ time) and accessibility of a preferred healthcare professional.

Conclusion

Application of psychological theory facilitated understanding of the influences on cognition and behaviour. The study highlights implications for theory, awareness campaigns and potential opportunities promoting more timely help-seeking.

Do cognitive heuristics underpin symptom appraisal for symptoms of cancer?: A secondary qualitative analysis across seven cancers

OBJECTIVES

To explore the evidence for cognitive heuristics or "rules of thumb" used within patients' reports of symptom appraisal and decisions to seek help for symptoms of cancer.

METHODS

A secondary analysis of interviews from existing studies that explored symptom appraisal in patients who had sought help for potential symptoms of cancer. Transcripts from n = 50 in-depth interviews with patients referred with symptoms suspicious of cancer (pancreas, colorectal, oral, lung, melanoma, breast, and prostate) were re-analysed using a deductive thematic approach underpinned by the heuristics outlined in the Common Sense Model of Illness Self-regulation as set within the Model of Pathways to Treatment.

RESULTS

The most dominant heuristic in patient reports was the Rate of change rule (ie, symptoms that are worsening, increasing, or have a sudden onset [rather than improving, stable or decreasing in number] are more likely to indicate illness). There was also support for the Duration rule, Pattern rule, Chronology rule, Severity (of interference) rule, Age-illness rule, Novelty rule, Similarity rule, Location rule, and Optimistic bias rule. There was a lack of evidence for the Prevalence and Stress-illness rules.

CONCLUSIONS

People do appear to use heuristics to guide their appraisal of symptoms and their perceived need for healthcare. Heuristics may be an important aspect underlying symptom misinterpretation, thus making them key targets for interventions. For instance, campaigns could tackle cognitive biases rather than focusing on specific symptom awareness. Myth-busting messages could highlight that intermittent, mild symptoms, and symptoms that are not worsening can be signs of a serious health problem.

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.

Oral cancer awareness in young South-Asian communities in London

OBJECTIVES

First, to evaluate awareness of oral cancer amongst the young South-Asian community in London and identify any aspects of knowledge about oral cancer that are lacking; and, second, to determine whether demographic factors or health-related behaviours are associated with knowledge of oral cancer.

RESEARCH DESIGN

Cross-sectional questionnaire survey.

PARTICIPANTS

South Asians aged 18-44 years attending community centres or places of worship in London.

MAIN OUTCOME MEASURES

Oral cancer awareness; health-related behaviours.

RESULTS

Respondents (n = 201) were mainly male (61%), Indian (77%) and Hindu (35%). Over half (58%; n = 113) had one or more negative health-related behaviours and only 18% had attended a dentist in the previous two years. Chewing paan with betel nut (OR = 4.08, 95% CI = 1.58-10.59, p < 0.01), and time since last visit to a dentist (OR = 4.90, 95% CI = 2.13-11.28, p < 0.01) were independently associated with respondents level of knowledge of mouth cancer; the former positively and the latter negatively.

CONCLUSIONS

The results suggest that young adults in the South Asian Community are exposed to a number of risk factors for oral cancer yet have poor knowledge of the implications of these health-related behaviours, and ways in which oral cancer can be detected earlier. The survey highlighted specific issues for action.

Low cancer suspicion following experience of a cancer 'warning sign'

Aim

Lower socioeconomic status (SES) is associated with a higher risk of late-stage cancer diagnosis. A number of explanations have been advanced for this, but one which has attracted recent attention is lower patient knowledge of cancer warning signs, leading to delay in help-seeking. However, although there is psychometric evidence of SES differences in knowledge of cancer symptoms, no studies have examined differences in ‘cancer suspicion’ among people who are actually experiencing a classic warning sign.

Methods

A ‘health survey’ was mailed to 9771 adults (⩾50 years, no cancer diagnosis) with a symptom list including 10 cancer ‘warning signs’. Respondents were asked if they had experienced any of the symptoms in the past 3 months, and if so, were asked ‘what do you think caused it?’ Any mention of cancer was scored as ‘cancer suspicion’. SES was indexed by education.

Results

Nearly half the respondents (1732/3756) had experienced a ‘warning sign’, but only 63/1732 (3.6%) mentioned cancer as a possible cause. Lower education was associated with lower likelihood of cancer suspicion: 2.6% of respondents with school-only education versus 7.3% with university education suspected cancer as a possible cause. In multivariable analysis, low education was the only demographic variable independently associated with lower cancer suspicion (odds ratio (OR) = 0.34, confidence interval (CI): 0.20–0.59).

Conclusion

Levels of cancer suspicion were low overall in this community sample, and even lower in people from less educated backgrounds. This may hinder early symptomatic presentation and contribute to inequalities in stage at diagnosis.

Applying symptom appraisal models to understand sociodemographic differences in responses to possible cancer symptoms: a research agenda

BACKGROUND

Sociodemographic inequalities in the stage of diagnosis and cancer survival may be partly due to differences in the appraisal interval (time from noticing a bodily change to perceiving a reason to discuss symptoms with a health-care professional). A number of symptom appraisal models have been developed describing the psychological factors that underlie how people make sense of symptoms, although none explicitly focus on sociodemographic characteristics.

METHODS

We therefore conducted a conceptual review synthesising all symptom appraisal models, and focus on potential links with sociodemographics that could be the focus of future research.

RESULTS

Common psychological elements across nine symptom appraisal models included knowledge, attention, expectation and identity, all of which could be sensitive to sociodemographic factors. For example, lower socioeconomic status (SES), male sex and older age are associated with lower health literacy generally and lower cancer symptom knowledge. Limited attentional resources, lower expectations about health and lack of social support also hamper symptom interpretation, and would be likely to be more prevalent in those from lower SES backgrounds. Symptom heuristics ('rules of thumb') may lead to symptoms being normalised because they are common within the social network, potentially disadvantaging older populations.

CONCLUSIONS

A better understanding of the processes through which people interpret their symptoms, and the way these processes differ by sociodemographic factors, could help guide the development of interventions with the aim of reducing inequalities in cancer outcomes.

Patient drawings of their melanoma: a novel approach to understanding symptom perception and appraisal prior to health care

OBJECTIVE

This pilot study investigated the use of patient drawings to explore patient experiences of symptoms of melanoma prior to health care use.

DESIGN

Patients (n = 63) with melanoma were interviewed within 10 weeks of diagnosis. Participants were asked to draw what their melanoma had looked like when they first noticed it, and to make additional drawings to depict changes as it developed.

MAIN OUTCOME MEASURE

The size and features of the drawings were compared between participants and with clinical data (thickness of the melanoma; histological diameter; clinical photographs).

RESULTS

Eighty-four percent of participants were able to produce at least one drawing. This facilitated discussion of their lesion and recall of events on the pathway to diagnosis. Common features of the drawings related to the view, presence of shading, inclusion of sections and the shape and border of the lesion. There was potential for disparity between the details in awareness resources and the perceptions of patients. The drawings resembled the clinical photographs and the size of the drawings was positively associated with the histological diameter, but did not differ according to tumour thickness.

CONCLUSION

Asking patients to make drawings of their melanoma appears to be an acceptable, inclusive, feasible and insightful methodological tool.

Patterns and predictors of disclosure of a diagnosis of cancer

BACKGROUND

The value of talking (i.e. disclosing ones innermost thoughts and feelings) has been recognised as playing an important role in helping people work through their difficulties. Although disclosing a diagnosis of cancer has been identified to be one of the hardest aspects of having the disease, relatively little is known about the extent to which people talk about their diagnosis of cancer. This study aimed to identify disclosure patterns among patients with cancer and to determine the factors associated with disclosure.

METHODS

Patients (n = 120) who had received a diagnosis of either lung, colorectal or skin cancer completed a questionnaire assessing potential psychosocial predictors of disclosure.

RESULTS

Results indicated that the majority of patients (95%) found it helpful to disclose information and did so to a variety of social targets, with the highest levels of disclosure being reported to medical personnel (38% talked 'very much'), followed by family members (24%) and then friends (12%). There were no differences in disclosure across cancer types, with the exception of patients with colorectal cancer who disclosed information more to nurses and other cancer patients. Men disclosed information more than women to some social targets. Dispositional openness (B = .233, p < 0.05) and treatment type (B = -.240, p < 0.01) were found to predict 13% of the variance in degree of disclosure.

CONCLUSIONS

The results suggest that individual differences and social and clinical factors impact on disclosure and that medical professionals play an important role in the disclosure process.

Patients' perceptions of oral cancer screening in dental practice: a cross-sectional study

Background

Oral cancer is increasing in incidence in the UK and indeed worldwide. Delay in diagnosis is common; up to half of patients are diagnosed with advanced lesions. Thus it is essential to develop methods to aid early detection. This study aimed to assess dental patients’ experiences and awareness of oral cancer and screening within general dental practice.

Methods

A cross-sectional questionnaire survey of 184 English-speaking adults, with no previous history of oral cancer was conducted. The questionnaire collected data on participant’s knowledge of oral cancer, experience of ‘screening’, attitudes and feelings towards having a screening, anticipated help-seeking behaviours, health-related behaviours (particularly risk factors) and sociodemographics.

Results

Twenty percent of respondents had never heard of oral cancer; 77% knew little or nothing about it and 72% did not know that their Dentist routinely screens for oral cancer. Overall, attitudes to screening were positive. Ninety two percent of respondents would like their Dentist to tell them if they were being screened for signs of oral cancer and 97% would like help from their Dentists to reduce their risk.

Conclusion

Patients seem generally unaware of oral cancer screening by their dentist but are happy to take part in screening, would like to be informed, and welcome the support of their Dentist to reduce their risk of developing oral cancer.

A randomised controlled trial of a pilot intervention to encourage early presentation of oral cancer in high risk groups

OBJECTIVE

Prognosis for oral cancer is substantially improved when diagnosed early. This research aimed to evaluate an intervention to promote early presentation of oral cancer.

METHODS

Participants were randomly assigned to a leaflet group (n = 42), a one-to-one group (n = 46) or a control group (n = 24). Participants in the leaflet group read a theory-based (Extended Self-Regulatory Model; Social Cognitive Theory) leaflet on how to spot oral cancer early. Those in the one-to-one group received a brief, interactional discussion on early presentation of oral cancer and were then asked to read the leaflet. Participants in the control group received no information about oral cancer.

RESULTS

The leaflet and the one-to-one instruction led to more accurate knowledge of oral cancer, decreased anticipated delay, and increased understanding, likelihood and confidence to perform self-examination. Neither intervention raised participants' anxiety. There were minimal differences between the two interventions, yet both were superior to the control group.

CONCLUSION

This piloting indicates the initial effectiveness of an brief intervention purposefully designed for people at risk of developing oral cancer.

PRACTICE IMPLICATION

A low cost intervention may be a useful tool to encourage early detection of oral cancer. This could be embedded into routine consultations or an early detection programme.

The model of pathways to treatment: conceptualization and integration with existing theory

BACKGROUND

Studying and understanding pathways to diagnosis and treatment is vital for the development of successful interventions to encourage early detection, presentation, and diagnosis. An existing framework posited to describe the decisional and behavioural processes that occur prior to treatment (Andersen et al.'s General Model of Total Patient Delay) does not appear to match the complex and dynamic nature of the pathways into and through the health care system or provide a clear framework for research. Therefore a revised descriptive framework, the Model of Pathways to Treatment, has been proposed.

PURPOSE

This paper presents the concepts and definitions of the Model of Pathways to Treatment and specifies how the model can encompass existing psychological theory, with particular focus on the Appraisal and Help-seeking intervals. The potential and direction for future work is also discussed.

STATEMENT OF CONTRIBUTION

WHAT IS ALREADY KNOWN ON THIS SUBJECT?: • The use of theory is often lacking in existing research into delays in presentation, diagnosis and treatment of illness. WHAT DOES THIS STUDY ADD?: • A detailed account of the concepts and definitions of a revised framework: the Model of Pathways to Treatment. • Specification of how the Model of Pathways to Treatment can encompass existing psychological theory such as the Common Sense Model of Illness Self-regulation and Social Cognitive Theory.

Body dysmorphic disorder and aesthetic dentistry

This paper outlines the features and presentation of body dysmorphic disorder (BDD), a psychological syndrome which results in patients seeking treatment for an imagined defect in appearance. The assessment of patients with suspected body dysmorphic disorder is outlined, as well as management strategies.

CLINICAL RELEVANCE

Clinicians working in the field of aesthetic dentistry should be aware that some patients presenting for treatment may have body dysmorphic disorder. Aesthetic dental treatment for such patients is not beneficial and carries some risks. Advice for clinicians on assessment and management is outlined.

Pilot study to estimate the accuracy of mouth self-examination in an at-risk group

BACKGROUND

Mouth self-examination (MSE) is a possible method of detecting oral cancer early. This study aimed to determine whether those at risk of developing oral cancer are able to correctly detect potentially malignant oral lesions via MSE.

METHODS

Participants (53 smokers aged over 45 years) received an oral mucosal examination by the dentist and then performed MSE after education through a self-read leaflet. The dentist and participant both recorded the presence and absence of potentially malignant oral lesions.

RESULTS

The prevalence of potentially malignant oral lesions was 22%. The sensitivity of MSE was 33% and the specificity was 54%. MSE had a positive predictive value of 17% and a negative predictive value of 73%.

CONCLUSION

The at-risk group were poor at correctly identifying the presence or absence of potentially malignant oral lesions. A leaflet may be an ineffective training tool to aid self-identification of potentially malignant oral lesions.

The process of symptom appraisal: cognitive and emotional responses to detecting potentially malignant oral symptoms

OBJECTIVE

Following the self-discovery of symptoms of oral cancer, approximately 30% of patients wait for more than 3 months before seeking attention from a health care professional. Although symptom appraisal is known to be an important stage in the decision to seek help, little is known about the process of symptom appraisal. The aims of the current study were to produce a theory-guided investigation of the specific cognitive interpretations and emotional reactions to the self-discovery of potentially malignant oral symptoms and to gain understanding as to why these may change prior to help seeking.

METHODS

In-depth semi-structured interviews were conducted with 57 consecutive patients who had been referred with potentially malignant oral symptoms. Participants were asked about symptom detection, initial and subsequent beliefs about symptoms, and emotional responses prior to their first visit to a health care professional. The tape-recorded interviews were transcribed verbatim and analyzed using "framework analysis."

RESULTS

Patients often attributed the symptoms to transient, minor conditions such as mouth ulcers, physical trauma, or dental problems and, in turn were unconcerned about their presence. Patients infrequently attributed their symptoms to cancer. Origins of specific interpretations included previous experiences, specific symptomatology, logical associations with the perceived cause, and information from medical literature. Stimuli for reinterpretation included receipt of new information, symptom development, and persistence of symptoms.

CONCLUSION

This study has documented the process of symptom appraisal and indicates that an individual's interpretation of potentially malignant oral symptoms is often misguided.

Patient's delay in oral cancer: a systematic review

Detecting oral cancer at an early stage is the most effective means of improving survival and reducing morbidity from this disease, yet a significant proportion of patients delay seeking help after the self-discovery of symptoms of oral cancer. The literature on factors associated with patient delay was searched systematically to access relevant data published between 1975 and 2005. Eight studies met the inclusion criteria for the review. In these studies, most clinical/tumour factors, sociodemographic variables, and patient health-related behaviours were not related to the duration of patient delay. Healthcare factors and psychosocial factors may play a role but the research in this area is sparse, atheoretical and of poor quality. Patient delay is a problem in oral cancer and yet at present the reasons for such delays are poorly understood and under-researched. Systematic, high-quality and theory-driven research in this area is urgently required.

Patient delay in oral cancer: a qualitative study of patients' experiences

Up to 30% of patients delay seeking the advice of a healthcare professional after self-discovery of symptom(s) of oral cancer. Reasons for this patient delay are poorly understood. The aim of the present study was to explore patients' initial experiences and reactions to developing symptoms of oral cancer, and to identify factors influencing their decision to consult a health care professional. In-depth semi-structured interviews were conducted with 17 consecutive patients who had received a diagnosis of oral squamous cell carcinoma, but had yet to start treatment. Participants were asked about their beliefs about their symptoms over the course of the disease and their decision to seek help. The tape-recorded interviews were transcribed verbatim and analysed using 'Framework analysis'. Oral symptoms were rarely attributed to cancer and were frequently interpreted as minor oral conditions. As a result of these beliefs, patients tended to postpone seeking help or fail to be concerned over their symptoms. Prior to seeking help, patients responded to symptoms by using self-medication, changing the way they ate and disclosing their discovery of symptoms to friends or family. Problems with access to healthcare professionals and patients' social responsibilities acted as barriers to prompt help-seeking. This study has documented that an individual's interpretation of oral cancer symptoms may be misguided and this can adversely affect subsequent help-seeking behaviour.

The idiosyncratic relationship between diagnostic delay and stage of oral squamous cell carcinoma

Approximately half of patients with oral cancer present with advanced lesions when five-year survival rates are as low as 20%, however, diagnostic delay has repeatedly been found to be unrelated to the stage of oral cancer at diagnosis. The aim of this study was to investigate why diagnostic delay is frequently unrelated to the stage of oral cancer at diagnosis. The odds ratio (OR) of early versus advanced oral squamous cell carcinoma was calculated for 245 consecutive patients with untreated oral squamous cell carcinoma. Being female (OR=0.40; 0.19-0.80; p<0.05) and married (OR=0.27; 0.11-0.66; p<0.01) was predictive of early stage disease. Being non-white (OR=5.42; 1.66-17.67; p<0.01) was predictive of advanced stage disease. There is no evidence that these patient demographics are associated with faster growing tumours, yet it is possible that those who are male, unmarried and non-white may not notice an oral lesion until it is advanced in stage. It is concluded that differences in tumour biology are not a likely explanation for the absence of a delay-stage relationship but instead, a proportion of tumours may be silent until advanced in stage.

Low probability of chloroplast movement from oilseed rape (Brassica napus) into wild Brassica rapa

Pollen-mediated movement of transgenes from transplastomic oilseed rape (Brassica napus) into wild relatives will be avoided if chloroplasts are maternally transmitted. We assess the probability of chloroplast exchange between conventional oilseed rape and wild Brassica rapa to model the future behavior of transplastomic cultivars. Primers specific to cpDNA were used to demonstrate maternal inheritance of chloroplasts in 47 natural hybrids between cultivated B. napus and wild B. rapa. We conclude that there will be no or negligible pollen-mediated chloroplast dispersal from oilseed rape. Transgene introgression could still occur in mixed populations, however, if B. napus acted as the recurrent female parent. Rate of transfer would then depend on the abundance of mixed populations, their persistence as mixtures, and hybridization frequency within stands. A low incidence of sympatry (0.6-0.7%) between wild B. rapa and cultivated B. napus along the river Thames, UK, in 1997 and 1998, suggests mixed stands will form only rarely. Eighteen feral populations of B. napus also showed a strong tendency toward rapid decline in plant number, seed return, and ultimately, extinction within 3 years. Conversely, hybrid production is significant in mixed stands, and the absence of control practices means that oilseed rape will have slightly greater persistence. We infer that some introgression from transplastomic B. napus into B. rapa is inevitable in mixed populations even though such populations will occur infrequently and will tend to lose B. napus plants relatively quickly. Chloroplast exchange will be extremely rare and scattered.

Efficacy and safety of monophasic and biphasic waveform shocks using a braided endocardial defibrillation lead system

Endocardial lead systems for implantable cardioverter-defibrillators utilize large (12F) rigid catheters with spring defibrillation electrodes, and lead system failure has been observed during long-term implant. We evaluated a novel flexible 8F braided electrode catheter for pacing and defibrillation in canine experiments. Active fixation and pacing were accomplished using a screw-in distal electrode, and defibrillation pulses were delivered through a braided electrode. Two braided electrode catheters were positioned in the right ventricular apex (6 cm2) and in the superior vena cava-right atrial junction (5 cm2), respectively. An elliptical 13 cm2 surface area patch electrode was positioned along the left lateral cardiac border. Ventricular fibrillation (VF) was induced and monophasic and asymmetric biphasic shocks (leading voltages 260 to 1000 V) were delivered via dual and triple electrode configurations in each animal using a prospective randomized crossover study design. Mean right ventricular pacing threshold was 0.5 +/- 0.2 mA, with a mean electrogram amplitude of 11.1 +/- 2.8 mV during sinus rhythm prior to fibrillation and defibrillation. Two hundred seven VF inductions (mean 30 +/- 4 per animal) were analyzed. The mean defibrillation threshold could be reduced to 8.0 +/- 3.2 joules with biphasic shocks from 12.9 +/- 5.1 joules obtained for monophasic shocks using a dual electrode system (p less than 0.004). Mean shock leading voltage was correspondingly reduced to 488 +/- 100 V from 691 +/- 154 V (p less than 0.0006).(ABSTRACT TRUNCATED AT 250 WORDS)

Secondary tracheoesophageal puncture for voice rehabilitation after laryngectomy

Since the introduction of the tracheoesophageal puncture technique for restoration of voice in 1980, 125 secondary punctures have been performed in 117 patients at the Cleveland Clinic Foundation. Preoperative evaluation, pharyngeal preparation, and their relation to final speech results were reviewed retrospectively. Critical factors in the rehabilitation of these patients are discussed based on our experience and a review of the literature.

Assessment of quality of survival in children with medulloblastoma and cerebellar astrocytoma

To determine the quality of survival for children with posterior fossa tumors, comprehensive neuropsychological, behavioral, and academic assessment and physician ratings of functional status were obtained on 15 brain tumor patients (ages 6-19 years) at a median of 20 months post-diagnosis. More than 50% of the children (whether irradiated or not) experienced major problems in academic, motor, sensory, cognitive, and emotional function. All but two children were reported by teachers to be "slow workers," and four of 15 patients were able to maintain their school work in regular classes. Although 80% of the patients were rated by physicians as having "excellent" or "good" functional status, no relationship was found between these global ratings and psychometric measures. Although the affected site was the posterior fossa, deficits also involved higher cortical function. These findings indicate the need for further evaluation of treatment effects and the provision of intervention for survivors.

Chemotherapy side effects in pediatric oncology patients: drugs, age, and sex as risk factors

Nausea, vomiting, and the extent to which chemotherapy-bothered children were assessed by patient and parent ratings for 31 children (65 courses) receiving combination chemotherapy with either high-dose cyclophosphamide or doxorubicin/daunorubicin. Patients and parents both reported more severe vomiting with cyclophosphamide than with the anthracyclines. The use of antiemetics did not affect emesis for the former drug; for the anthracyclines, there was more severe emesis for courses with antiemetics than for those with none. Adolescents reported more severe nausea than children, and females reported both more nausea and bother than males. There were no significant age or sex findings for parent reports. The findings suggest that chemotherapy-related nausea and vomiting in children is a complex phenomenon not accounted for by drugs alone.

Effects of posture on limb blood flow in late pregnancy

Arm and leg blood flow was measured in 40 patients in late pregnancy in the supine and left lateral positions, and the changes were contrasted with changes found in 15 patients investigated in the early puerperium. A significant reduction in leg flow occurred in the pregnant subjects when the supine position was assumed. A further 30 patients in late pregnancy had leg flow measured in the following positions: left lateral, supine, right lateral, and the two mid-positions. Leg flow significantly increased on moving from the supine to all other positions except the right intermediate position, indicating that a leftward tilt is more effective in preventing caval compression.