A manifesto for improving cancer detection: four key considerations when implementing innovations across the interface of primary and secondary care.

Improving cancer outcomes through innovative cancer detection initiatives in primary care is an international policy priority. There are unique implementation challenges to the roll-out and scale-up of different innovations, requiring synchronisation between national policy levers and local implementation strategies. We draw on implementation science to highlight key considerations when seeking to sustainably embed cancer detection initiatives within health systems and clinical practice. Points of action include considering the implications of change on the current configuration of responsibility for detecting cancer; investing in understanding how to adapt systems to support innovations; developing strategies to address inequity when planning innovation implementation; and anticipating and making efforts to mitigate the unintended consequences of innovation. We draw on examples of contemporary cancer detection issues to illustrate how to apply these recommendations to practice.

The Association between Blood Test Trends and Undiagnosed Cancer: A Systematic Review and Critical Appraisal.

Clinical guidelines include monitoring blood test abnormalities to identify patients at increased risk of undiagnosed cancer. Noting blood test changes over time may improve cancer risk stratification by considering a patient's individual baseline and important changes within the normal range. We aimed to review the published literature to understand the association between blood test trends and undiagnosed cancer. MEDLINE and EMBASE were searched until 15 May 2023 for studies assessing the association between blood test trends and undiagnosed cancer. We used descriptive summaries and narratively synthesised studies. We included 29 articles. Common blood tests were haemoglobin (24%, n = 7), C-reactive protein (17%, n = 5), and fasting blood glucose (17%, n = 5), and common cancers were pancreatic (29%, n = 8) and colorectal (17%, n = 5). Of the 30 blood tests studied, an increasing trend in eight (27%) was associated with eight cancer types, and a decreasing trend in 17 (57%) with 10 cancer types. No association was reported between trends in 11 (37%) tests and breast, bile duct, glioma, haematological combined, liver, prostate, or thyroid cancers. Our review highlights trends in blood tests that could facilitate the identification of individuals at increased risk of undiagnosed cancer. For most possible combinations of tests and cancers, there was limited or no evidence.

Electronic safety-netting tool features considered important by UK general practice staff: an interview and Delphi consensus study.

BACKGROUND: The potential of the electronic health record to support safety netting has been recognised and a number of electronic safety-netting (E-SN) tools developed. AIM: To establish the most important features of E-SN tools. DESIGN & SETTING: User-experience interviews followed by a Delphi study in a primary care setting in the UK. METHOD: The user-experience interviews were carried out remotely with primary care staff who had trialled the EMIS E-SN toolkit for suspected cancer. An electronic modified Delphi approach was used, with primary care staff involved in safety netting in any capacity, to measure consensus on tool features. RESULTS: Thirteen user-experience interviews were carried out and features of E-SN tools seen as important formed the majority of the features included in the Delphi study. Three rounds of Delphi survey were administered. Sixteen responders (64%) completed all three rounds, and 28 out of 44 (64%) features reached consensus. Primary care staff preferred tools that were general in scope. CONCLUSION: Primary care staff indicated that tools that were not specific to cancer or any other disease, and had features that promoted their flexible, efficient, and integrated use, were important. However, when the important features were discussed with the patient and public involvement (PPI) group, they expressed disappointment that features they believed would make E-SN tools robust and provide a safety net that is difficult to fall through did not reach consensus. The successful adoption of E-SN tools will rely on an evidence base of their effectiveness. Efforts should be made to assess the impact of these tools on patient outcomes.

Serious disease risk among patients with unexpected weight loss: a matched cohort of over 70 000 primary care presentations.

BACKGROUND: Unexpected weight loss (UWL) in patients consulting in primary care presents dilemmas for management because of the broad differential diagnoses associated with UWL. Research on the risks of serious disease among patients with UWL to date has largely taken place in secondary care, limiting generalizability to primary care patients. In this study, we use a large matched cohort study to estimate the risks of 12 serious diseases among patients presenting to primary care with UWL where this was recorded, stratified by age and sex, in order to inform a rational clinical approach to patients presenting with UWL. METHODS: This was a retrospective matched cohort study using electronic health records (EHRs) from the UK Clinical Practice Research Datalink (CPRD). Each patient with UWL (ascertained from EHR coding) was matched to five patients without UWL and followed until the earliest of a diagnosis of the serious disease, date of death, exit from the CPRD database, or end of the study. Observed absolute risks of the 12 serious diseases were estimated as probabilities, and hazard ratios (HRs) were estimated with Cox proportional hazards models. RESULTS: Between 2000 and 2012, 70 193 patients in CPRD had at least one record of UWL and were matched with 295 579 patients without UWL. Patients with UWL had significantly higher risk of nearly all serious diseases examined compared with patients without. HRs ranged from 1.43 for congestive heart failure [95% confidence interval (CI): 1.27-1.62] to 9.70 for malabsorption (95% CI: 6.81-13.82). The absolute risks of any given serious disease were relatively low (<6% after 1 year). The magnitude and rank order of absolute risks varied by age and sex. Depression was the most common diagnosis among women aged <80 with UWL (3.74% of women aged <60 and 2.46% of women aged 60-79), whereas diabetes was the most common in men <60 with UWL (2.96%) and cancer was the most common in men aged 60 and over with UWL (3.79% of men aged 60-70 and 5.28% of men aged ≥80). CONCLUSIONS: This analysis provides new evidence to patients and clinicians about the risks of serious disease among patients presenting with UWL in primary care. Depending on age and sex, the results suggest that workup for UWL should include screening for diabetes, thyroid dysfunction, depression, and dementia. If performed in a timely manner, this workup could be used to triage patients eligible for cancer pathway referral.

General practitioner referrals to one-stop clinics for symptoms that could be indicative of cancer: a systematic review of use and clinical outcomes.

BACKGROUND: One-stop clinics provide comprehensive diagnostic testing in one outpatient appointment. They could benefit patients with conditions, such as cancer, whose outcomes are improved by early diagnosis, and bring efficiency savings for health systems. OBJECTIVE: To assess the use and outcomes of one-stop clinics for symptoms where cancer is a possible diagnosis. DESIGN AND SETTING: Systematic review of studies reporting use and outcomes of one-stop clinics in primary care patients. METHOD: We searched MEDLINE, Embase, and Cochrane Library for studies assessing one-stop clinics for adults referred after presenting to primary care with any symptom that could be indicative of cancer. Study selection was carried out independently in duplicate with disagreements resolved through discussion. RESULTS: Twenty-nine studies were identified, most were conducted in the UK and observational in design. Few included a comparison arm. A pooled comparison of the cancer conversion rate of one-stop and multi-stop clinics was only possible for breast symptoms, and we found no significant difference. One-stop clinics were associated with significant reductions in the interval from referral to testing (15 versus 75 days) and more patients diagnosed on the same day (79% versus 25%) compared to multi-stop pathways. The majority of patients and GPs found one-stop clinics to be acceptable. CONCLUSION: This review found one-stop clinics were associated with reduced time from referral to testing, increased same day diagnoses, and were acceptable to patients and GPs. Our conclusions are limited by high levels of heterogeneity, scarcity of comparator groups, and the overwhelmingly observational nature of included studies.

The Suspected CANcer (SCAN) pathway: protocol for evaluating a new standard of care for patients with non-specific symptoms of cancer.

INTRODUCTION: Cancer survival in England lags behind most European countries, due partly to lower rates of early stage diagnosis. We report the protocol for the evaluation of a multidisciplinary diagnostic centre-based pathway for the investigation of 'low-risk but not no-risk' cancer symptoms called the Suspected CANcer (SCAN) pathway. SCAN is a new standard of care being implemented in Oxfordshire; one of a number of pathways implemented during the second wave of the Accelerate, Coordinate, Evaluate (ACE) programme, an initiative which aims to improve England's cancer survival rates through establishing effective routes to early diagnosis. METHODS AND ANALYSIS: To evaluate SCAN, we are collating a prospective database of patients referred onto the pathway by their general practitioner (GP). Patients aged over 40 years, with non-specific symptoms such as weight loss or fatigue, who do not meet urgent cancer referral criteria or for whom symptom causation remains unclear after investigation via other existing pathways, can be referred to SCAN. SCAN provides rapid CT scanning, laboratory testing and clinic review within 2 weeks. We will follow all patients in the primary and secondary care record for at least 2 years. The data will be used to understand the diagnostic yield of the SCAN pathway in the short term (28 days) and the long term (2 years). Routinely collected primary and secondary care data from patients not referred to SCAN but with similar symptoms will also be used to evaluate SCAN. We will map the routes to diagnosis for patients referred to SCAN to assess cost-effectiveness. Acceptability will be evaluated using patient and GP surveys. ETHICS AND DISSEMINATION: The Oxford Joint Research Office Study Classification Group has judged this to be a service evaluation and so outside of research governance. The results of this project will be disseminated by peer-reviewed publication and presentation at conferences.

Quantitative evaluation of an information leaflet to increase prompt help-seeking for gynaecological cancer symptoms.

BACKGROUND: Provision of written information may improve awareness of cancer symptoms and encourage timely presentation in primary care. This study assessed changes in symptom knowledge, perceived barriers to help-seeking, anxiety and intention to seek help, following exposure to a leaflet to raise awareness of gynaecological cancer symptoms. METHODS: Women (N = 484) completed questionnaires before and after reading the leaflet. The primary outcome was change in anticipated time to help-seeking for 12 symptoms. Changes in symptom knowledge, barriers and anxiety, and their association with prompt help-seeking were evaluated using Wilcoxon signed rank tests and logistic regression analyses. RESULTS: After reading the leaflet, symptom knowledge increased (p < 0.001), and perceived barriers (p < 0.001) and anxiety (p = 0.008) decreased. The number of symptoms for which women anticipated seeking help promptly increased (p < 0.001). Changes in knowledge (OR 4.21, 95 % CI 1.95-9.13) and perceived barriers (OR 4.60, 95 % CI 1.91-11.04) were independently associated with increased help-seeking. CONCLUSION: Increased symptom knowledge and lowered perceived barriers were related to increased prompt anticipated help-seeking. This occurred without an increase in anxiety. This intervention is effective in altering knowledge, beliefs and help-seeking intentions for gynaecological cancer symptoms, at least in the short-term, and should be trialled in primary care.