Symptoms and signs of urogenital cancer in primary care.

BACKGROUND: Urogenital cancers are common, accounting for approximately 20% of cancer incidence globally. Cancers belonging to the same organ system often present with similar symptoms, making initial management challenging. In this study, 511 cases of cancer were recorded after the date of consultation among 61,802 randomly selected patients presenting in primary care in six European countries: a subgroup analysis of urogenital cancers was carried out in order to study variation in symptom presentation. METHODS: Initial data capture was by completion of standardised forms containing closed questions about symptoms recorded during the consultation. The general practitioner (GP) provided follow-up data after diagnosis, based on medical record data made after the consultation. GPs also provided free text comments about the diagnostic procedure for individual patients. RESULTS: The most common symptoms were mainly associated with one or two specific types of cancer: 'Macroscopic haematuria' with bladder or renal cancer (combined sensitivity 28.3%), 'Increased urinary frequency' with bladder (sensitivity 13.3%) or prostatic (sensitivity 32.1%) cancer, or to uterine body (sensitivity 14.3%) cancer, 'Unexpected genital bleeding' with uterine cancer (cervix, sensitivity 20.0%, uterine body, sensitivity 71.4%). 'Distended abdomen, bloating' had sensitivity 62.5% (based on eight cases of ovarian cancer). In ovarian cancer, increased abdominal circumference and a palpable tumour also were important diagnostic elements. Specificity for 'Macroscopic haematuria' was 99.8% (99.7-99.8). PPV > 3% was noted for 'Macroscopic haematuria' and bladder or renal cancer combined, for bladder cancer in male patients. In males aged 55-74, PPV = 7.1% for 'Macroscopic haematuria' and bladder cancer. Abdominal pain was an infrequent symptom in urogenital cancers. CONCLUSIONS: Most types of urogenital cancer present with rather specific symptoms. If the GP considers ovarian cancer, increased abdominal circumference should be actively determined. Several cases were clarified through the GP's clinical examination, or laboratory investigations.

Symptoms and signs of colorectal cancer, with differences between proximal and distal colon cancer: a prospective cohort study of diagnostic accuracy in primary care.

BACKGROUND: In an abdominal symptom study in primary care in six European countries, 511 cases of cancer were recorded prospectively among 61,802 patients 16 years and older in Norway, Denmark, Sweden, Netherlands, Belgium and Scotland. Colorectal cancer is one of the main types of cancer associated with abdominal symptoms; hence, an in-depth subgroup analysis of the 94 colorectal cancers was carried out in order to study variation in symptom presentation among cancers in different anatomical locations. METHOD: Initial data capture was by completion of standardised forms containing closed questions about symptoms recorded during the consultation. Follow-up data were provided by the GP after diagnosis, based on medical record data made after the consultation. GPs also provided free text comments about the diagnostic procedure for individual patients. Fisher's exact test was used to analyse differences between groups. RESULTS: Almost all symptoms recorded could indicate colorectal cancer. 'Rectal bleeding' had a specificity of 99.4% and a PPV of 4.0%. Faecal occult blood in stool (FOBT) or anaemia may indicate gastrointestinal bleeding: when these symptoms and signs were combined, sensitivity reached 57.5%, with 69.2% for cancer in the distal colon. For proximal colon cancers, none of 18 patients had 'Rectal bleeding' at the initial consultation, but three of the 18 did so at a later consultation. 'Abdominal pain, lower part', 'Constipation' and 'Distended abdomen, bloating' were less specific and also less sensitive than 'Rectal bleeding', and with PPV between 0.7% and 1.9%. CONCLUSIONS: Apart from rectal bleeding, single symptoms did not reach the PPV 3% NICE threshold. However, supplementary information such as a positive FOBT or persistent symptoms may revise the PPV upwards. If a colorectal cancer is suspected by the GP despite few symptoms, the total clinical picture may still reach the NICE PPV threshold of 3% and justify a specific referral.

General practitioners' participation in cancer treatment in Norway.

INTRODUCTION: General practitioners (GPs) participate in a patient's cancer care to different extents at different times, from prevention and diagnosis to treatment and end-of-life care. Traditionally, the GP has had a minor role in cancer treatment. However, oncological and surgical services frequently delegate limited cancer treatment tasks to GPs, especially in rural areas far from hospitals. The aim of this study was to explore the extent of GPs' participation in cancer treatment in Norway. METHODS: This study was an observational questionnaire study. In 2007, the chief municipal medical officer in all 93 municipalities in North Norway and a 25% random sample (85 municipalities) in South Norway was asked to identify up to five GPs who had recently participated in local treatment of cancer patients, and to forward a patient questionnaire to them. RESULTS: Seventy-eight GPs in 49 municipalities returned completed questionnaires for 118 patients, most of them with progressive disease and living in rural areas. All the GPs reported substantial participation in therapeutic tasks for this select group of patients. Not counting palliative treatment, 64% of the GPs participated in cancer treatment either directly, or indirectly through referrals. Twenty patients received chemotherapy; they belonged to no particular diagnostic category. Eighty-eight percent of the GPs prescribed some kind of palliative medicine, such as analgesic, antiemetic, anxiolytic or antidepressant. Morphine was prescribed equally often by GPs and hospitals. Eighty-one percent of GPs reported having had a thorough conversation with the patient about the patient's condition and circumstances. CONCLUSION: In this group of GPs, participation rates were high for most of the therapeutic and communicative tasks suggested in the questionnaire. GP participation is feasible not only in palliative care, but also in some aspects of oncological treatment and in clinical follow-up. Communication with both patient and hospital seemed good in this local setting. GPs are important helpers for some cancer patients.

Abdominal symptoms and cancer in the abdomen: prospective cohort study in European primary care.

BACKGROUND: Different abdominal symptoms may signal cancer, but their role is unclear. AIM: To examine associations between abdominal symptoms and subsequent cancer diagnosed in the abdominal region. DESIGN AND SETTING: Prospective cohort study comprising 493 GPs from surgeries in Norway, Denmark, Sweden, Scotland, Belgium, and the Netherlands. METHOD: Over a 10-day period, the GPs recorded consecutive consultations and noted: patients who presented with abdominal symptoms pre-specified on the registration form; additional data on non-specific symptoms; and features of the consultation. Eight months later, data on all cancer diagnoses among all study patients in the participating general practices were requested from the GPs. RESULTS: Consultations with 61 802 patients were recorded and abdominal symptoms were documented in 6264 (10.1%) patients. Malignancy, both abdominal and non-abdominal, was subsequently diagnosed in 511 patients (0.8%). Among patients with a new cancer in the abdomen (n = 251), 175 (69.7%) were diagnosed within 180 days after consultation. In a multivariate model, the highest sex- and age-adjusted hazard ratio (HR) was for the single symptom of rectal bleeding (HR 19.1, 95% confidence interval = 8.7 to 41.7). Positive predictive values of >3% were found for macroscopic haematuria, rectal bleeding, and involuntary weight loss, with variations according to age and sex. The three symptoms relating to irregular bleeding had particularly high specificity in terms of colorectal, uterine, and bladder cancer. CONCLUSIONS: A patient with undiagnosed cancer may present with symptoms or no symptoms. Irregular bleeding must always be explained. Abdominal pain occurs with all types of abdominal cancer and several symptoms may signal colorectal cancer. The findings are important as they influence how GPs think and act, and how they can contribute to an earlier diagnosis of cancer.

Abdominal symptoms in general practice: Frequency, cancer suspicions raised, and actions taken by GPs in six European countries. Cohort study with prospective registration of cancer.

BACKGROUND: Abdominal symptoms are diagnostically challenging to general practitioners (GPs): although common, they may indicate cancer. In a prospective cohort of patients, we examined abdominal symptom frequency, initial diagnostic suspicion, and actions of GPs in response to abdominal symptoms. METHODS: Over a 10-day period, 493 GPs in Norway, Denmark, Sweden, Belgium, the Netherlands, and Scotland, recorded consecutive consultations: sex, date of birth and any specified abdominal symptoms. For patients with abdominal symptoms, additional data on non-specific symptoms, GPs' diagnostic suspicion, and features of the consultation were noted. Data on all cancer diagnoses among all included patients were requested from the GPs eight months later. FINDINGS: Consultations with 61802 patients were recorded. Abdominal symptoms were recorded in 6264 (10.1%) patients. A subsequent malignancy was reported in 511 patients (0.8%): 441 (86.3%) had a new cancer, 70 (13.7%) a recurrent cancer. Abdominal symptoms were noted in 129 (25.2%) of cancer patients (P < 0.001), rising to 34.5% for the 89 patients with cancer located in the abdominal region. PPV for any cancer given any abdominal symptom was 2.1%. In symptomatic patients diagnosed with cancer, GPs noted a suspicion of cancer for 85 (65.9%) versus 1895 (30.9%) when there was no subsequent cancer (P < 0.001). No suspicion was noted in 32 (24.8%) cancer patients. The GP's intuitive cancer suspicion was independently associated with a subsequent new cancer diagnosis (OR 2.11, 95% CI 1.15-3.89). Laboratory tests were ordered for 45.4% of symptomatic patients, imaging for 10.4%, referral or hospitalization for 20.0%: all were more frequent in subsequent cancer patients (P < 0.001). INTERPRETATION: Abdominal symptoms pointed to abdominal cancers rather than to other cancers. However, the finding of abdominal symptoms in only one third of patients with an abdominal cancer, and the lack of cancer suspicion in a quarter of symptomatic cancer patients, provide challenges for GPs' diagnostic thinking and referral practices.

Symptoms, signs, and tests: The general practitioner's comprehensive approach towards a cancer diagnosis.

OBJECTIVE: To study the relative importance of different tools a GP can use during the diagnostic process towards cancer detection. DESIGN: Retrospective cohort study with prospective registration of cancer in general practice. SETTING AND SUBJECTS: One hundred and fifty-seven Norwegian general practitioners (GPs) reported 261 cancer patients. METHOD: During 10 consecutive days, GPs registered all patient consultations and recorded any presence of seven focal symptoms and three general symptoms, commonly considered as warning signs of cancer (WSC). Follow-up was done six to 11 months later. For each patient with new or recurrent cancer, the GP completed a questionnaire with medical-record-based information concerning the diagnostic procedure. RESULTS: In 78% of cancer cases, symptoms, signs, or tests helped diagnose cancer. In 90 cases, there were 131 consultation-recorded WSC that seemed related to the cancer. Further symptoms were reported for another 74 cases. Different clinical signs were noted in 41 patients, 16 of whom had no previous recording of symptoms. Supplementary tests added information in 59 cases; in 25 of these there were no recordings of symptoms or signs. Sensitivity of any cancer-relevant symptom or clinical finding ranged from 100% for patients with uterine body cancer to 57% for patients with renal cancer. CONCLUSION: WSC had a major role as initiator of a cancer diagnostic procedure. Low-risk-but-not-no-risk symptoms also played an important role, and in 7% of patients they were the only symptoms. Clinical findings and/or supplementary procedures were sometimes decisive for rapid referral.

Optimal starting point for antiretroviral HIV treatment in a town in Cameroon: a randomised controlled study.

BACKGROUND: Optimal starting point for antiretroviral treatment (ART) has been uncertain. METHODS: Parallel group, single blind, randomised controlled study of adult HIV positive patients consulting at the Protestant Hospital, Ngaoundere, Cameroon in 2007-8. Simple randomisation of patients in WHO clinical stage 1-2 to start of ART early or deferred, i.e. when CD4 counts dropped below 350 versus 250 cells/mm(3), or when they reached clinical stage 3-4. Clinical follow-up every three months were offered for all patients. Main outcomes were clinical stage, CD4 differences and mortality. Of 424 consulting patients, most were excluded, mainly because they were already in WHO stage 3-4. Forty-four patients were randomised. RESULTS: In the 'early' group two patients died and five were lost to follow-up. In the 'deferred' group, six patients died and nine were lost to follow-up (Hazard ratio for death by early compared to deferred treatment 0.26, 95% confidence interval 0.05-1.29). Of the patients lost to follow-up, three patients in the 'early' group and four patients in the 'deferred' group were known to be alive when the study ended. Fourteen patients in the early group and 11 in the deferred group started ART. Twenty-two patients were evaluated clinically six to seven months after the study period was terminated. Except for one patient with AIDS, these were all still in clinical stage 1-2. CONCLUSIONS: In our small sample, relative risk for death did not differ significantly, but deferred treatment seemed to carry no increased survival or other clinical advantage. During the study period, other studies made WHO change its guidelines to conform to our early treatment. The tendency in our study lends support to this policy. TRIAL REGISTRATION: ISRCTN22114173.

Cancer suspicion in general practice: the role of symptoms and patient characteristics, and their association with subsequent cancer.

BACKGROUND: Awareness of detail in ambiguous complaints may help GPs suspect cancer when a malignancy is present. AIM: To study the contribution of symptoms and patient characteristics to GPs' suspicions of cancer being present, and to what degree these suspicions were confirmed. DESIGN AND SETTING: Prospective cohort study of patients in 283 rural and urban general practices throughout Norway. METHOD: During patient consultations (over a period of 10 days) GPs registered whether there was a suspicion of cancer when a patient presented with at least one of seven focal symptoms and three general symptoms commonly considered to be warning signs of cancer. Follow-up questionnaires were sent to GPs 6-7 months later, requesting information on any subsequent diagnosis of cancer in these patients. RESULTS: Out of 51 073 patients, 6321 presented with warning signs of cancer; of these, 106 had a subsequent cancer diagnosis. Of the patients presenting with warning signs, 1515 (24%) patients were suspected of having cancer; this was correct for 3.8% of suspected cases. Of the 106 patients diagnosed with cancer who presented with warning signs, cancer was suspected in 58 (54.7%). GPs' correct cancer suspicions were six times more frequent than their erroneous lack of suspicion. Multiple symptoms, previous cancer, comorbidity, and multiple consultations increased the probability of cancer, but only multiple symptoms and previous cancer increased suspicion. Suspicion led to an increase in the number of diagnostic procedures undertaken. The proportion of cancer cases where GPs recorded a lack of suspicion was relatively small, but important. CONCLUSION: Selected symptoms appropriately resulted in GPs suspecting cancer. Comorbidity and multiple consultations were underestimated by GPs as factors associated with cancer. Cancer suspicion should rely on symptoms in combination with other relevant information.

Frequency of 'warning signs of cancer' in Norwegian general practice, with prospective recording of subsequent cancer.

BACKGROUND: Early diagnosis of cancer is an important challenge in general practice. Symptoms are the most common starting points. OBJECTIVE: To assess the association between symptoms presented and subsequent cancer. DESIGN: A cohort study of all patients seen consecutively by GPs. Prospective recording of cancer diagnosis, new cancer or new recurrence. SETTING: Two hundred and eighty-three general practice surgeries and 10 working days. METHOD: During patient consultations, GPs registered seven focal symptoms and three general symptoms, commonly considered as warning signs of cancer (WSC). Follow-up 6-11 months later with registration of any subsequent diagnosis of cancer was done. RESULTS: Of 51 073 patients, 6321 (12.4%) had recordings of 7704 WSC. During a median follow-up period of 8 months, 263 patients were diagnosed with cancer and 59 of them with recurrence of a previously diagnosed cancer. Of the cancer patients, 106 (40%) had presented one or more WSC during a preceding consultation. Examined symptoms had likelihood ratios for cancer from 1.5 to 8.2 and positive predictive values (PPVs) from 0.8% to 3.8%. Limited to older age groups, PPVs were a little higher. General symptoms were rarely associated with cancer unless a focal symptom had been recorded as well. Multiple symptoms increased the probability of cancer. CONCLUSION: 12.4% of GP patients presented with WSC. A general symptom may have cancer diagnostic value, but usually, only when it occurs along with a focal symptom. PPV of any single symptom is low, and decisions about referral require additional information.

How does the thought of cancer arise in a general practice consultation? Interviews with GPs.

BACKGROUND: Only a few patients on a GP's list develop cancer each year. To find these cases in the jumble of presented problems is a challenge. OBJECTIVE: To explore how general practitioners (GPs) come to think of cancer in a clinical encounter. DESIGN: Qualitative interviews with Norwegian GPs, who were invited to think back on consultations during which the thought of cancer arose. The 11 GPs recounted and reflected on 70 such stories from their practices. A phenomenographic approach enabled the study of variation in GPs' ways of experiencing. RESULTS: Awareness of cancer could arise in several contexts of attention: (1) Practising basic knowledge: explicit rules and skills, such as alarm symptoms, epidemiology and clinical know-how; (2) Interpersonal awareness: being alert to changes in patients' appearance or behaviour and to cues in their choice of words, on a background of basic knowledge and experience; (3) Intuitive knowing: a tacit feeling of alarm which could be difficult to verbalize, but nevertheless was helpful. Intuition built on the earlier mentioned contexts: basic knowledge, experience, and interpersonal awareness; (4) Fear of cancer: the existential context of awareness could affect the thoughts of both doctor and patient. The challenge could be how not to think about cancer all the time and to find ways to live with insecurity without becoming over-precautious. CONCLUSION: The thought of cancer arose in the relationship between doctor and patient. The quality of their interaction and the doctor's accuracy in perceiving and interpreting cues were decisive.

'I deal with the small things': the doctor-patient relationship and professional identity in GPs' stories of cancer care.

An important part of GPs' work consists of attending to the everyday and existential conditions of human being. In these life world aspects, biomedicine is often not the relevant theory to guide the GP; nevertheless they are a part of GPs' professional domain. In cancer care, previous studies have shown that GPs with a biomedical perspective on medicine could feel subordinate to specialists, and that doctors with a curative focus could see disease progression as a personal failure. The aim of this study was to explore in depth the experiences of being a GP for people with advanced cancer. Fourteen Norwegian GPs were interviewed about accompanying patients through a cancer illness. Their stories were analysed using a narrative approach. The GPs expressed a strong commitment to these patients, a loyalty which in some cases could be weakened due to judgements of distant specialists. In view of the GPs' close knowledge of their patients' background and history this subordination was a paradox, mirroring a hierarchy of medical knowledge. The GPs had an ideal of honesty and openness about death, which they sometimes failed. To reach the ideal of honesty, clinicians would have to abandon the biomedical ideal of mastering human nature through interventions and acknowledge the fundamental uncertainty and finiteness of human life. GPs may learn from being with their patients that bodily and existential suffering are connected, and thus learn implicitly to overlook the body-mind dualism. This practical wisdom lacks a theoretical anchoring, which is a problem not only for general practice.

A doctor close at hand: How GPs view their role in cancer care.

OBJECTIVE: To explore GPs' own views on their role in cancer care. DESIGN: Qualitative study based on semi-structured interviews. SETTING: Norwegian primary care. METHODS: The stories of 14 GPs concerning 18 patients were analyzed for core content and abstracted into general ideas, to create a broader sense of the experienced professional role. RESULTS: The GPs claimed to have an important role in cancer care. In our analysis, three main aspects of GPs' work emerged: first, as a flexible mediator, e.g. between the patient and the clinic, interpreting and translating; second, as an efficient "handyman", solving practical problems locally; and third, as a personal companion for the patient throughout the illness. CONCLUSION: The interviewed GPs see their place in cancer care as being close to their patients. In their many tasks we found three main aspects: the mediating, the practical, and the personal.

General practitioners' role in cancer care: a French-Norwegian study.

BACKGROUND: In cancer care, a GP's work is rarely defined clearly. Our aim was to assess GPs' work with cancer patients in France and in Norway, where the roles of the GP and the organization of the system are rather different. FINDINGS: A questionnaire with 40 closed-ended questions about GP involvement in diagnosis, treatment, follow-up and terminal care was constructed and mailed to samples of GPs. The patients had seen the doctor at least once over the past year. In France 1679 and in Norway 386 individual patient questionnaires were completed. GPs have a major role in the diagnosis of cancer, and this role varies according to cancer type. The GPs participated actively in different phases of follow-up after cancer treatment. Low response rates do not allow direct comparison between countries, but higher PSA screening rates in France seem to increase the percentage of patients diagnosed after screening rather than after a clinical suspicion. Interaction between GPs and specialists during cancer treatment and follow-up was important in both countries. CONCLUSION: Both in France and in Norway GPs participate actively in cancer care. Early clinical diagnosis is a challenge. More research is needed about how GPs can improve their early diagnostic work. Organisational issues may influence cancer responsibilities for the GP, and national health systems should be challenged to look at possible new roles for GPs in cancer care. Medical training, both pre- and post-graduate, should prepare doctors for collaboration between primary and secondary care, particularly important in cancer care.

Peace work: some lessons from medicine and biology.

Medical peace work, or peace through health, is a new discipline in some universities, offered to students in health sciences as well as social science and the humanities. This article deals with some comparisons between conflict handling in medicine/biology and possible violence-reducing approaches in politics and in social science thinking. In biology, conflict and repair is normal and carries a potential for growth and development. It is neither necessary nor possible to eliminate conflict to prevent violence. However, biological defence is grounded on much more than simple killing of living organisms with competing interests. The great variation of species in nature can be seen as the successful result of an evolutionary process that does not necessarily promote hegemony of one species. Health systems and political systems claim a common aim, the welfare of the people. When medicine fails, this is often linked to aggressive methods aimed at short-term gains and the same kind of flawed reasoning sometimes decides international affairs.

Research and practice combined--ideas for a life in general practice.

Abstract: The modern era of research in general practice is scarcely more than half a century old. The author has been fortunate enough to be part of this development for more than three decades, sharing his professional life between clinical practice and research. Here is the story. All clinical care should be supported and developed by research evidence, and some of it must be collected where the care is performed. Research may improve the theoretical understanding underlying practice. Some patients probably receive better care because their general practitioner has done research, or their GP has attended a meeting or read an article by a research-minded colleague.

Examination of final-year medical students in general practice.

With general practice recognized as one of three major subjects in the Tromsø medical school curriculum, a matching examination counterpart was needed. The aim was to develop and implement an examination in an authentic general practice setting for final-year medical students. In a general practice surgery, observed by two examiners and one fellow student, the student performs a consultation with a consenting patient who would otherwise have consulted his/her general practitioner (GP). An oral examination follows. It deals with the consultation process, the observed communication between "doctor" and patient, and with clinical problem-solving, taking today's patient as a starting point. The session is closed by discussion of a public-health-related question. Since 2004 the model has been evaluated through questionnaires to students, examiners, and patients, and through a series of review meetings among examiners and students. Examination in general practice using unselected, consenting patients mimics real life to a high degree. It constitutes one important element in a comprehensive assessment process. This is considered to be an acceptable and appropriate way of testing the students before graduation.