Clinical features of bladder cancer in primary care

Background

Bladder cancer accounts for over 150 000 deaths worldwide. No screening is available, so diagnosis depends on investigations of symptoms. Of these, only visible haematuria has been studied in primary care.

Aim

To identify and quantify the features of bladder cancer in primary care.

Design and setting

Case-control study, using electronic medical records from UK primary care.

Method

Participants were 4915 patients aged ≥40 years, diagnosed with bladder cancer January 2000 to December 2009, and 21 718 age, sex, and practice-matched controls, were selected from the General Practice Research Database, UK. All clinical features independently associated with bladder cancer using conditional logistic regression were identified, and their positive predictive values for bladder cancer, singly and in combination, were estimated.

Results

Cases consulted their GP more frequently than controls before diagnosis: median 15 consultations (interquartile range 9–22) versus 8 (4–15): P<0.001. Seven features were independently associated with bladder cancer: visible haematuria, odds ratio 34 (95% confidence interval [CI] = 29 to 41), dysuria 4.1 (95% CI = 3.4 to 5.0), urinary tract infection 2.2 (95% CI = 2.0 to 2.5), raised white blood cell count 2.1 (95% CI = 1.6 to 2.8), abdominal pain 2.0 (95% CI = 1.6 to 2.4), constipation 1.5 (95% CI = 1.2 to 1.9), raised inflammatory markers 1.5 (95% CI = 1.2 to 1.9), and raised creatinine 1.3 (95% CI = 1.2 to 1.4). The positive predictive value for visible haematuria in patients aged ≥60 years was PPV of 3.9% (95% CI = 2.2 to 3.2).

Conclusion

Visible haematuria is the commonest and most powerful predictor of bladder cancer in primary care, and warrants investigation. Most other previously reported features of bladder cancer were associated with the disease, but with low predictive values. There is a need for improved diagnostic methods, for those patients whose bladder cancer presents without visible haematuria.     

The diagnostic value of symptoms for colorectal cancer in primary care: a systematic review

Background

Over 37 000 new colorectal cancers are diagnosed in the UK each year. Most present symptomatically to primary care.

Aim

To conduct a systematic review of the diagnostic value of symptoms associated with colorectal cancer.

Design

Systematic review.

Method

MEDLINE, Embase, Cochrane Library, and CINAHL were searched to February 2010, for diagnostic studies of symptomatic adult patients in primary care. Studies of asymptomatic patients, screening, referred populations, or patients with colorectal cancer recurrences, or with fewer than 100 participants were excluded. The target condition was colorectal cancer. Data were extracted to estimate the diagnostic performance of each symptom or pair of symptoms. Data were pooled in a meta-analysis. The quality of studies was assessed with the QUADAS tool.

Results

Twenty-three studies were included. Positive predictive values (PPVs) for rectal bleeding from 13 papers ranged from 2.2% to 16%, with a pooled estimate of 8.1% (95% confidence interval [CI] = 6.0% to 11%) in those aged ≥50 years. Pooled PPV estimates for other symptoms were: abdominal pain (three studies) 3.3% (95% CI = 0.7% to 16%); and anaemia (four studies) 9.7% (95% CI = 3.5% to 27%). For rectal bleeding accompanied by weight loss or change in bowel habit, pooled positive likelihood ratios (PLRs) were 1.9 (95% CI = 1.3 to 2.8) and 1.8 (95% CI = 1.3 to 2.5) respectively, suggesting higher risk when both symptoms were present. Conversely, the PLR was one or less for abdominal pain, diarrhoea, or constipation accompanying rectal bleeding.

Conclusion

The findings suggest that investigation of rectal bleeding or anaemia in primary care patients is warranted, irrespective of whether other symptoms are present. The risks from other single symptoms are lower, though multiple symptoms also warrant investigation.     

Non-visible versus visible haematuria and bladder cancer risk: a study of electronic records in primary care

Background

Diagnosis of bladder cancer relies on investigation of symptoms presented to primary care, notably visible haematuria. The importance of non-visible haematuria has never been estimated.

Aim

To estimate the risk of bladder cancer with non-visible haematuria.

Design and setting

A case–control study using UK electronic primary care medical records, including uncoded data to supplement coded records.

Method

A total of 4915 patients (aged ≥40 years) diagnosed with bladder cancer between January 2000 and December 2009 were selected from the Clinical Practice Research Datalink and matched to 21 718 controls for age, sex, and practice. Variables for visible and non-visible haematuria were derived from coded and uncoded data. Analyses used multivariable conditional logistic regression, followed by estimation of positive predictive values (PPVs) for bladder cancer using Bayes’ theorem.

Results

Non-visible haematuria (coded/uncoded data) was independently associated with bladder cancer: odds ratio (OR) 20 (95% confidence interval [CI] =12 to 33). The PPV of non-visible haematuria was 1.6% (95% CI = 1.2 to 2.1) in those aged ≥60 years and 0.8% (95% CI = 0.1 to 5.6) in 40–59-year-olds. The PPV of visible haematuria was 2.8% (95% CI = 2.5 to 3.1) and 1.2% (95% CI = 0.6 to 2.3) for the same age groups respectively, lower than those calculated using coded data alone. The proportion of records of visible haematuria in coded, rather than uncoded, format was higher in cases than in controls (P<0.002, χ² test). There was no evidence for such differential recording of non-visible haematuria by case/control status (P = 0.78), although, overall, the uncoded format was preferred (P<0.001).

Conclusion

Both non-visible and visible haematuria are associated with bladder cancer, although the visible form confers nearly twice the risk of cancer compared with the non-visible form. GPs’ style of record keeping varies by symptom and possible diagnosis.     

Identifying patients with suspected renal tract cancer in primary care: derivation and validation of an algorithm

Background

Earlier diagnosis of renal tract cancer could help improve survival so better tools are needed to help this.

Aim

To derive and validate an algorithm to estimate the absolute risk of renal tract cancer in patients with and without symptoms in primary care.

Design

Cohort study using data from 375 UK QResearch® general practices for development and 189 for validation.

Method

Included patients were aged 30–84 years free at baseline of a diagnosis of renal tract cancer (bladder, kidney, ureter, or urethra) and without haematuria, abdominal pain, appetite loss, or weight loss in previous 12 months. The primary outcome was incident diagnosis of renal tract cancer recorded in the next 2 years. Risk factors examined were age, body mass index, smoking, alcohol, deprivation, treated hypertension, renal stones, structural kidney problems, diabetes, previous diagnosis of cancer apart from renal tract cancer, haematuria, abdominal pain, appetite loss, weight loss, diarrhoea, constipation, tiredness, and anaemia. Cox proportional hazards models were used to develop separate risk equations in males and females. Measures of calibration and discrimination assessed performance in the validation cohort.

Results

There were 2878 incident cases of renal tract cancer from 4.1 million person-years in the derivation cohort. Independent predictors in both males and females were age, smoking status, haematuria, abdominal pain, weight loss, and anaemia. A history of prior cancer other than renal tract cancer, and appetite loss were predictors for females only. On validation, the algorithms explained 75% of the variation in females and 76% in males. The receiver operating curve statistics were 0.91 (females) and 0.95 (males). The D statistic was 3.53 (females) and 3.60 (males). The 10% of patients with the highest predicted risks contained 87% of all renal tract cancers diagnosed over the next 2 years.

Conclusion

The algorithm has good discrimination and calibration and could potentially be used to identify those at highest risk of renal tract cancer, to facilitate more timely referral and investigation.     

Interventions to reduce primary care delay in cancer referral: a systematic review

Background

Reducing delay in the primary care part of the cancer care pathway is likely to improve cancer survival. Identifying effective interventions in primary care would allow action by primary healthcare professionals and local commissioners to reduce delay.

Aim

To identify interventions that reduce primary care delay in the referral of patients with cancer to secondary care.

Design and setting

Systematic review in primary care.

Method

Eight electronic databases were searched using terms for primary care, cancer, and delay. Exclusion criteria included screening and the 2-week-wait referral system. Reference lists of relevant papers were hand searched. The quality of each paper was assessed using predefined criteria, and checked by a second reviewer.

Results

Searches identified 1798 references, of which 22 papers were found to meet the criteria. Interventions concerning education, audit and feedback, decision support software and guideline use, diagnostic tools, and other specific skills training were identified. Most studies reported a positive effect on their specified outcomes, although no study measured a direct effect on reducing delay.

Conclusion

There was no evidence that any intervention directly reduced primary care delay in the diagnosis of cancer. Limited evidence suggests that complex interventions, including audit and feedback and specific skills training, have the potential to do so.     

Clinical features of kidney cancer in primary care: a case-control study using primary care records

Background

Kidney cancer accounts for over 4000 UK deaths annually, and is one of the cancer sites with a poor mortality record compared with Europe.

Aim

To identify and quantify all clinical features of kidney cancer in primary care.

Design

Case-control study, using General Practice Research Database records.

Method

A total of 3149 patients aged ≥40 years, diagnosed with kidney cancer between 2000 and 2009, and 14 091 age, sex and practice-matched controls, were selected. Clinical features associated with kidney cancer were identified, and analysed using conditional logistic regression. Positive predictive values for features of kidney cancer were estimated.

Results

Cases consulted more frequently than controls in the year before diagnosis: median 16 consultations (interquartile range 10–25) versus 8 (4–15): P<0.001. Fifteen features were independently associated with kidney cancer: visible haematuria, odds ratio 37 (95% confidence interval [CI] = 28 to 49), abdominal pain 2.8 (95% CI = 2.4 to 3.4), microcytosis 2.6 (95% CI = 1.9 to 3.4), raised inflammatory markers 2.4 (95% CI = 2.1 to 2.8), thrombocytosis 2.2 (95% CI = 1.7 to 2.7), low haemoglobin 1.9 (95% CI = 1.6 to 2.2), urinary tract infection 1.8 (95% CI = 1.5 to 2.1), nausea 1.8 (95% CI = 1.4 to 2.3), raised creatinine 1.7 (95% CI = 1.5 to 2.0), leukocytosis 1.5 (95% CI = 1.2 to 1.9), fatigue 1.5 (95% CI = 1.2 to 1.9), constipation 1.4 (95% CI = 1.1 to 1.7), back pain 1.4 (95% CI = 1.2 to 1.7), abnormal liver function 1.3 (95% CI = 1.2 to 1.5), and raised blood sugar 1.2 (95% CI = 1.1 to 1.4). The positive predictive value for visible haematuria in patients aged ≥60 years was 1.0% (95% CI = 0.8 to 1.3).

Conclusion

Visible haematuria is the commonest and most powerful single predictor of kidney cancer, and the risk rises when additional symptoms are present. When considered alongside the risk of bladder cancer, the overall risk of urinary tract cancer from haematuria warrants referral.     

Diagnostic value of symptoms of oesophagogastric cancers in primary care: a systematic review and meta-analysis

Background

Selection of primary care patients for investigation of potential oesophagogastric cancer is difficult, as the symptoms may represent benign conditions, which are also more common.

Aim

To review systematically the presenting features of oesophagogastric cancers in primary care, including open-access endoscopy clinics.

Design and setting

Systematic review and meta-analysis.

Method

MEDLINE^®, Embase, the Cochrane Library, and CINAHL were searched for studies of adults who were symptomatic and presented in primary care or open-access endoscopy clinics. Exclusions were being asymptomatic, screening, or recurrent cancers. Data were extracted to estimate the diagnostic performance of features of oesophagogastric cancers and summarised in a meta-analysis.

Results

Fourteen studies were identified. The strongest summary sensitivity and specificity estimates were for: dyspepsia 0.42 (95% confidence interval [CI] 0.29 to 0.56) and 0.48 (95% CI = 0.31 to 0.65); pain 0.41 (95% CI = 0.24 to 0.62) and 0.75 (95% CI = 0.51 to 0.89); and dysphagia 0.32 (95% CI = 0.17 to 0.52) and 0.92 (95% CI = 0.81 to 0.97). Summary positive likelihood ratios (LR+) and diagnostic odds ratios were: dyspepsia 0.79 (95% CI = 0.55 to 1.15) and 0.65 (95% CI = 0.32 to 1.33); pain 1.64 (95% CI = 1.20 to 2.24) and 2.09 (95% CI = 1.57 to 2.77); and dysphagia 4.32 (95% CI = 2.46 to 7.58) and 5.91 (95% CI = 3.56 to 9.82). Corresponding LR+ were: anaemia 4.32 (95% CI = 2.64 to 7.08); nausea/vomiting/bloating 1.07 (95% CI = 0.52 to 2.19); reflux 0.78 (95% CI = 0.47 to 1.78) and; weight loss 5.46 (95% CI = 3.47 to 8.60).

Conclusion

Dysphagia, weight loss, and anaemia show the strongest association but with relatively low sensitivity and high specificity. The findings support the value of investigation of these symptoms, but also suggest that, in a population of patients who are low risk but not no-risk, investigation is not currently recommended.     

Follow-up of cancer in primary care versus secondary care: systematic review

Background

Cancer follow-up has traditionally been undertaken in secondary care, but there are increasing calls to deliver it in primary care.

Aim

To compare the effectiveness and cost-effectiveness of primary versus secondary care follow-up of cancer patients, determine the effectiveness of the integration of primary care in routine hospital follow-up, and evaluate the impact of patient-initiated follow-up on primary care.

Design of study

Systematic review.

Setting

Primary and secondary care settings.

Method

A search was carried out of 19 electronic databases, online trial registries, conference proceedings, and bibliographies of included studies. The review included comparative studies or economic evaluations of primary versus secondary care follow-up, hospital follow-up with formal primary care involvement versus conventional hospital follow-up, and hospital follow-up versus patient-initiated or minimal follow-up if the study reported the impact on primary care.

Results

There was no statistically significant difference for patient wellbeing, recurrence rate, survival, recurrence-related serious clinical events, diagnostic delay, or patient satisfaction. GP-led breast cancer follow-up was cheaper than hospital follow-up. Intensified primary health care resulted in increased home-care nurse contact, and improved discharge summary led to increased GP contact. Evaluation of patient-initiated or minimal follow-up found no statistically significant impact on the number of GP consultations or cancer-related referrals.

Conclusion

Weak evidence suggests that breast cancer follow-up in primary care is effective. Interventions improving communication between primary and secondary care could lead to greater GP involvement. Discontinuation of formal follow-up may not increase GP workload. However, the quality of the data in general was poor, and no firm conclusions can be reached.     

Risk of childhood cancer with symptoms in primary care: a population-based case-control study

Background

Guidelines describing symptoms in children that should alert GPs to consider cancer have been developed, but without any supporting primary-care research.

Aim

To identify symptoms and signs in primary care that strongly increase the likelihood of childhood cancer, to assist GPs in selection of children for investigation.

Design and setting

A population-based case-control study in UK general practice.

Method

Using electronic primary care records from the UK General Practice Research Database, 1267 children aged 0–14 years diagnosed with childhood cancer were matched to 15 318 controls. Clinical features associated with subsequent diagnosis of cancer were identified using conditional logistic regression, and likelihood ratios and positive predictive values (PPVs) were estimated for each.

Results

Twelve symptoms were associated with PPVs of ≥0.04%, which represents a greater than tenfold increase in prior probability. The six symptoms with the highest PPVs were pallor (odds ratio, OR = 84; PPV = 0.41% (95% confidence interval [CI] = 0.12% to 1.34%), head and neck masses (OR = 17; PPV = 0.30%; 95% CI = 0.10% to 0.84%), masses elsewhere (OR = 22; PPV = 0.11%; 95% CI = 0.06% to 0.20%), lymphadenopathy (OR = 10; PPV = 0.09%; 95% CI = 0.06% to 0.13%), symptoms/signs of abnormal movement (OR = 16; PPV = 0.08%; 95% CI = 0.04% to 0.14%), and bruising (OR = 12; PPV = 0·08%; 95% CI = 0.05% to 0.13%). When each of these 12 symptoms was combined singly with at least three consultations in a 3-month period, the probability of cancer was between 11 and 76 in 10 000.

Conclusion

Twelve features of childhood cancers were identified, each of which increased the risk of cancer at least tenfold. These symptoms, particularly when combined with multiple consultations, warrant careful evaluation in general practice.     

Bereavement care in primary care: a systematic literature review and narrative synthesis

Background

Over half a million people die in Britain each year and, on average, a GP will have 20 patients die annually. Bereavement is associated with significant morbidity and mortality, but the research evidence on which GPs and district nurses can base their practice is limited.

Aim

To review the existing literature concerning how GPs and district nurses think they should care for patients who are bereaved and how they do care for them.

Design

Systematic literature review.

Method

Searches of AMED, BNI, CINAHL, EMBASE, Medline and PsychInfo databases were undertaken, with citation searches of key papers and hand searches of two journals. Inclusion criteria were studies containing empirical data relating to adult bereavement care provided by GPs and district nurses. Information from data extraction forms were analysed using NVivo software, with a narrative synthesis of emergent themes.

Results

Eleven papers relating to GPs and two relating to district nurses were included. Both groups viewed bereavement care as an important and satisfying part of their work, for which they had received little training. They were anxious not to ‘medicalise’ normal grief. Home visits, telephone consultations, and condolence letters were all used in their support of bereaved people.

Conclusion

A small number of studies were identified, most of which were >10 years old, from single GP practices, or small in size and of limited quality. Although GPs and district nurses stated a preference to care for those who were bereaved in a proactive fashion, little is known of the extent to which this takes place in current practice, or the content of such care.     

Multimorbidity in primary care: a systematic review of prospective cohort studies

Background

Primary care increasingly deals with patients with multimorbidity, but relevant evidence-based interventions are scarce. Knowledge about multimorbidity over time is required to inform the development of effective interventions.

Aim

This review identifies prospective cohort studies of multimorbidity in primary care to determine: their nature, scope and key findings; the methodologies used; and gaps in knowledge.

Design

Systematic review.

Method

Studies were identified by searching electronic databases, reviewing citations, and writing to authors. Searches were limited to adult populations with no restrictions on publication date or language. In total, 996 articles were identified and screened.

Results

Of the 996 articles, six detailing five completed prospective cohort studies were selected as appropriate. Three of the studies were undertaken in the US and two in The Netherlands; none was nationally representative. The main focus of the studies was: healthcare utilisation and/or costs (n = 3); patients'' physical functioning (n = 1); and risk factors for developing multimorbidity (n = 1). The conditions that were included varied widely. The findings of these studies showed that multimorbidity increased healthcare costs (n = 2), inpatient admission (n = 1), death rates (n = 1), and service use (n = 3), and reduced physical functioning (n = 1). One study identified psychosocial risk factors for multimorbidity. No study used random sampling, sample sizes were relatively small (414–3745 patients at baseline), and study duration was relatively short (1–4 years). No study focused on prevalence, treatment use, patient safety, service models, cultural or socioeconomic factors, and patient experience, and no study collected qualitative data.

Conclusion

Few longitudinal studies based in primary care have investigated multimorbidity. Further large, long-term prospective studies are required to inform healthcare commissioning, planning, and delivery.     

Association between point-of-care CRP testing and antibiotic prescribing in respiratory tract infections: a systematic review and meta-analysis of primary care studies

Background

Most patients with respiratory tract infections (RTIs) are prescribed antibiotics in general practice. However, there is little evidence that antibiotics bring any value to the treatment of most RTIs. Point-of-care C-reactive protein testing may reduce antibiotic prescribing.

Aim

To systematically review studies that have examined the association between point-of-care (POC) C-reactive protein testing and antibiotic prescribing for RTIs in general practice.

Design and setting

Systematic review and meta-analysis of randomised controlled trials and observational studies.

Method

MEDLINE^® and Embase were systematically searched to identify relevant publications. All studies that examined the association between POC C-reactive protein testing and antibiotic prescribing for patients with RTIs were included. Two authors independently screened the search results and extracted data from eligible studies. Dichotomous measures of outcomes were combined using risk ratios (RRs) with 95% confidence intervals (CIs) either by fixed or random-effect models.

Results

Thirteen studies containing 10 005 patients met the inclusion criteria. POC C-reactive protein testing was associated with a significant reduction in antibiotic prescribing at the index consultation (RR 0.75, 95% CI = 0.67 to 0.83), but was not associated with antibiotic prescribing at any time during the 28-day follow-up period (RR 0.85, 95% CI = 0.70 to 1.01) or with patient satisfaction (RR 1.07, 95% CI = 0.98 to 1.17).

Conclusion

POC C-reactive protein testing significantly reduced antibiotic prescribing at the index consultation for patients with RTIs. Further studies are needed to analyse the confounders that lead to the heterogeneity.     

Screening for increased cardiometabolic risk in primary care: a systematic review

Background

Many programmes to detect and prevent cardiovascular disease (CVD) have been performed, but the optimal strategy is not yet clear.

Aim

To present a systematic review of cardiometabolic screening programmes performed among apparently healthy people (not yet known to have CVD, diabetes, or cardiometabolic risk factors) and mixed populations (apparently healthy people and people diagnosed with risk factor or disease) to define the optimal screening strategy.

Design and setting

Systematic review of studies performed in primary care in Western countries.

Method

MEDLINE, Embase, and CINAHL databases were searched for studies screening for increased cardiometabolic risk. Exclusion criteria were studies designed to assess prevalence of risk factors without follow-up or treatment; without involving a GP; when fewer than two risk factors were considered as the primary outcome; and studies constrained to ethnic minorities.

Results

The search strategy yielded 11 445 hits; 26 met the inclusion criteria. Five studies (1995–2012) were conducted in apparently healthy populations: three used a stepwise method. Response rates varied from 24% to 79%. Twenty-one studies (1967–2012) were performed in mixed populations; one used a stepwise method. Response rates varied from 50% to 75%. Prevalence rates could not be compared because of heterogeneity of used thresholds and eligible populations. Observed time trends were a shift from mixed to apparently healthy populations, increasing use of risk scores, and increasing use of stepwise screening methods.

Conclusion

The optimal screening strategy in primary care is likely stepwise, in apparently healthy people, with the use of risk scores. Increasing public awareness and actively involving GPs might facilitate screening efficiency and uptake.     

Identifying patients with suspected lung cancer in primary care: derivation and validation of an algorithm

BackgroundLung cancer has one of the lowest survival outcomes of any cancer because more then two-thirds of patients are diagnosed when curative treatment is not possible. The challenge is to help earlier diagnosis of lung cancer and hence improve prognosis.AimTo derive and validate an algorithm incorporating information on symptoms, to estimate the absolute risk of having lung cancerMethodSelected patients were aged 30-84 years and free of lung cancer at baseline and haemoptysis, loss of appetite, orweight loss in previous 12 months. Primary outcome was incident diagnosis of lung cancer recorded in the next 2 years. Risk factors examined were: haemoptysis, appetite loss, weight loss, cough, dyspnoea, tiredness, hoarseness, smoking, body mass index, deprivation score, family history of lung cancer, other cancers, asthma, chronic obstructive airways disease, pneumonia, asbestos exposure, and anaemia. Cox proportional hazards models with age as the underlying time variable were used to develop separate risk equations in males and females. Measures of calibration and discrimination assessed performance in the validation cohort.ResultsThere were 3785 incident cases of lung cancer arising from 4 289 282 person-years in the derivation cohort. Independent predictors were haemoptysis, appetite loss, weight loss, cough, body mass index, deprivation score, smoking status, chronic obstructive airways disease, anaemia, and prior cancer (females only). On validation, the algorithms explained 72% of the variation. The receiver operating characteristic (ROC) statistics were 0.92 for both females and males. The D statistic was 3.25 for females and 3.29 for males. The 10% of patients with the highest predicted risks included 77% of all lung cancers diagnosed over the subsequent 2 years.ConclusionThe algorithm has good discrimination and calibration and could potentially be used to identify those at highest risk of lung cancer, to facilitate early referral and investigation.     

Identifying patients with suspected colorectal cancer in primary care: derivation and validation of an algorithm

Background

Earlier diagnosis of colorectal cancer could help improve survival so better tools are needed to help this.

Aim

To derive and validate an algorithm to quantify the absolute risk of colorectal cancer in patients in primary care with and without symptoms.

Design and setting

Cohort study using data from 375 UK QResearch® general practices for development and 189 for validation.

Method

Included patients were aged 30–84 years, free at baseline from a diagnosis of colorectal cancer and without rectal bleeding, abdominal pain, appetite loss, or weight loss in the previous 12 months. The primary outcome was incident diagnosis of colorectal cancer recorded in the next 2 years. Risk factors examined were age, body mass index, smoking status, alcohol status, deprivation, diabetes, inflammatory bowel disease, family history of gastrointestinal cancer, gastrointestinal polyp, history of another cancer, rectal bleeding, abdominal pain, abdominal distension, appetite loss, weight loss, diarrhoea, constipation, change of bowel habit, tiredness, and anaemia. Cox proportional hazards models were used to develop separate risk equations in males and females. Measures of calibration and discrimination assessed performance in the validation cohort.

Results

There were 4798 incident cases of colorectal cancer from 4.1 million person-years in the derivation cohort. Independent predictors in males and females included family history of gastrointestinal cancer, anaemia, rectal bleeding, abdominal pain, appetite loss, and weight loss. Alcohol consumption and recent change in bowel habit were also predictors in males. On validation, the algorithms explained 65% of the variation in females and 67% in males. The receiver operating curve statistics were 0.89 (females) and 0.91 (males). The D statistic was 2.8 (females) and 2.9 (males). The 10% of patients with the highest predicted risks contained 71% of all colorectal cancers diagnosed over the next 2 years

Conclusion

The algorithm has good discrimination and calibration and could potentially be used to help identify those at highest risk of current colorectal cancer, to facilitate early referral and investigation.     

Identifying patients with suspected gastro-oesophageal cancer in primary care: derivation and validation of an algorithm

Background

Gastro-oesphageal is one of the most common cancers worldwide. Evidence suggested that increased awareness of symptoms and earlier diagnosis could help improve treatment options and improve survival.

Aim

To derive and validate an algorithm to estimate the absolute risk of having gastro-oesophageal cancer in patients in primary care with and without symptoms.

Design and setting

Cohort study of 375 UK QResearch® general practices for development, and 189 for validation.

Method

Included patients were aged 30-84 years, free at baseline of a diagnosis of gastro-oesophageal cancer, and without dysphagia, haematemesis, abdominal pain, appetite loss, orweight loss recorded in previous 12 months. The primary outcome was incident diagnosis of gastro-oesophageal cancer recorded in the next 2 years. Risk factors examined were age, body mass index, alcohol status, smoking status, deprivation, family history of gastrointestinal cancer, dysphagia, previous diagnosis of cancer apart from gastro-oesophageal cancer, haematemesis, abdominal pain, appetite loss, weight loss, tiredness, and anaemia. Cox proportional hazards models were used to develop risk equations. Measures of calibration and discrimination assessed performance in the validation cohort.

Results

There were 2527 incident cases of gastro-oesophageal cancer from 4.1 million person-years in the derivation cohort. Independent predictors were age, smoking, dysphagia, haematemesis, abdominal pain, appetite loss, weight loss, and anaemia. On validation, the algorithms explained 71% of the variation in females and 73% in males. The receiver operating curve statistics were 0.89 (females) and 0.92 (males). The D statistic was 3.2 (females) and 3.3 (males). The 10% of patients with the highest predicted risks included 77% of all gastro-oesophageal cancers diagnosed over the next 2 years.

Conclusion

The algorithm has good performance and could potentially be used to help identify those at highest risk of gastro-oesophageal cancer, to facilitate early referral and investigation.     

Identifying patients with suspected pancreatic cancer in primary care: derivation and validation of an algorithm

Background

Pancreatic cancer has the worst survival for any cancer and is often diagnosed late when the cancer is advanced. Chances of survival are more likely if patients can be diagnosed earlier.

Aim

To derive and validate an algorithm to estimate absolute risk of having pancreatic cancer in patients with and without symptoms in primary care.

Design and setting

Cohort study using data from 375 UK QResearch® general practices for development and 189 for validation.

Method

Included patients were aged 30–84 years, free at baseline from a diagnosis of pancreatic cancer and had not had dysphagia, abdominal pain, abdominal distension, appetite loss, or weight loss recorded in the preceding 12 months. The primary outcome was incident diagnosis of pancreatic cancer recorded in the following 2 years. Risk factors examined included: age, body mass index, smoking status, alcohol, deprivation, diabetes, pancreatitis, previous diagnosis of cancer apart from pancreatic cancer, dysphagia, abdominal pain, abdominal distension, appetite loss, weight loss, diarrhoea, constipation, tiredness, itching, and anaemia. Cox proportional hazards models were used to develop separate risk equations in males and females. Measures of calibration and discrimination assessed performance in the validation cohort.

Results

There were a total of 1415 incident cases of pancreatic cancer from 4.1 million person-years in the derivation cohort. Independent predictors in both males and females were age, smoking, type 2 diabetes, chronic pancreatitis, abdominal pain, appetite loss, and weight loss. Abdominal distension was a predictor for females only; dysphagia and constipation were predictors for males only. On validation, the algorithms explained 59% of the variation in females and 62% in males. The receiver operating characteristic statistics were 0.84 (females) and 0.87 (males). The D statistic was 2.44 (females) and 2.61 (males). The 10% of patients with the highest predicted risks contained 62% of all pancreatic cancers diagnosed over the following 2 years.

Conclusion

The algorithm has good discrimination and calibration and could potentially be used to help identify those at highest risk of pancreatic cancer to facilitate early referral and investigation.     

Symptoms and risk factors to identify men with suspected cancer in primary care: derivation and validation of an algorithm

Background

Early diagnosis of cancer could improve survival so better tools are needed.

Aim

To derive an algorithm to estimate absolute risks of different types of cancer in men incorporating multiple symptoms and risk factors.

Design and setting

Cohort study using data from 452 UK QResearch® general practices for development and 224 for validation.

Method

Included patients were males aged 25–89 years. The primary outcome was incident diagnosis of cancer over the next 2 years (lung, colorectal, gastro-oesophageal, pancreatic, renal, blood, prostate, testicular, other cancer). Factors examined were: ‘red flag’ symptoms such as weight loss, abdominal distension, abdominal pain, indigestion, dysphagia, abnormal bleeding, lumps; general symptoms such as tiredness, constipation; and risk factors including age, family history, smoking, alcohol intake, deprivation score and medical conditions. Multinomial logistic regression was used to develop a risk equation to predict cancer type. Performance was tested on a separate validation cohort.

Results

There were 22 521 cancers from 1 263 071 males in the derivation cohort. The final model included risk factors (age, BMI, chronic pancreatitis, COPD, diabetes, family history, alcohol, smoking, deprivation); 22 symptoms, anaemia and venous thrombo-embolism. The model was well calibrated with good discrimination. The receiver operator curve statistics values were: lung (0.92), colorectal (0.92), gastro-oesophageal (0.93), pancreas (0.89), renal (0.94), prostate (0.90) blood (0.83, testis (0.82); other cancers (0.86). The 10% of males with the highest risks contained 59% of all cancers diagnosed over 2 years.

Conclusion

The algorithm has good discrimination and could be used to identify those at highest risk of cancer to facilitate more timely referral and investigation.