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.     

Reducing the time before consulting with symptoms of lung cancer: a randomised controlled trial in primary care

Background

Most individuals with lung cancer have symptoms for several months before presenting to their GP. Earlier consulting may improve survival.

Aim

To evaluate whether a theory-based primary care intervention increased timely consulting of individuals with symptoms of lung cancer.

Design and setting

Open randomised controlled trial comparing intervention with usual care in two general practices in north-east Scotland.

Method

Smokers and ex-smokers aged ≥55 years were randomised to receive a behavioural intervention or usual care. The intervention comprised a single nurse consultation at participants’ general practice and a self-help manual. The main outcomes were consultations within target times for individuals with new chest symptoms (≤3 days haemoptysis, ≤3 weeks other symptoms) in the year after the intervention commenced, and intentions about consulting with chest symptoms at 1 and 6 months.

Results

Two hundred and twelve participants were randomised and 206 completed the trial. The consultation rate for new chest symptoms in the intervention group was 1.19 (95% confidence interval [CI] = 0.92 to 1.53; P = 0.18) times higher than in the usual-care group and the proportion of consultations within the target time was 1.11 (95% CI = 0.41 to 3.03; P = 0.83) times higher. One month after the intervention commenced, the intervention group reported intending to consult with chest symptoms 31 days (95% CI = 7 to 54; P = 0.012) earlier than the usual care group, and at 6 months this was 25 days (95% CI = 1.5 to 48; P = 0.037) earlier.

Conclusion

Behavioural intervention in primary care shortened the time individuals at high risk of lung disease intended to take before consulting with new chest symptoms (the secondary outcome of the study), but increases in consultation rates and the proportions of consultations within target times were not statistically significant.     

Breast self-examination practices and attitudes of women with and without a history of breast cancer

Breast self-examination (BSE) practices and attitudes of three groups of women were compared using a mailed survey. Subjects were 59 women with previous breast cancer, 33 women with previously treated benign breast lump(s), and 80 general-population women with no history of breast disease. Groups were compared on frequency, proficiency, and knowledge of BSE. Determinants of practice were examined using attitudinal variables from the Health Belief Model. Results indicated that the breast cancer group had significantly higher rates of BSE frequency, proficiency, and knowledge than did the general-population group. The breast cancer group perceived cancer to be significantly less threatening than did the other two groups, although the general-population group reported significantly less susceptibility to breast cancer. Within-group analyses revealed that barriers to BSE practice accounted for the greatest amount of variance in BSE frequency in all three groups. These results are discussed.This research was supported in part by Grant CA26363 from the National Cancer Institute and is part of a doctoral dissertation by the first author.     

International variation in adherence to referral guidelines for suspected cancer: a secondary analysis of survey data

Background

Variation in cancer survival persists between comparable nations and appears to be due, in part, to primary care practitioners (PCPs) having different thresholds for acting definitively in response to cancer-related symptoms.

Aim

To explore whether cancer guidelines, and adherence to them, differ between jurisdictions and impacts on PCPs’ propensity to take definitive action on cancer-related symptoms.

Design and setting

A secondary analysis of survey data from six countries (10 jurisdictions) participating in the International Cancer Benchmarking Partnership.

Method

PCPs’ responses to five clinical vignettes presenting symptoms and signs of lung (n = 2), colorectal (n = 2), and ovarian cancer (n = 1) were compared with investigation and referral recommendations in cancer guidelines.

Results

Nine jurisdictions had guidelines covering the two colorectal vignettes. For the lung vignettes, although eight jurisdictions had guidelines for the first, the second was covered by a Swedish guideline alone. Only the UK and Denmark had an ovarian cancer guideline. Survey responses of 2795 PCPs (crude response rate: 12%) were analysed. Guideline adherence ranged from 20–82%. UK adherence was lower than other jurisdictions for the lung vignette covered by the guidance (47% versus 58%; P <0.01) but similar (45% versus 46%) or higher (67% versus 38%; P <0.01) for the two colorectal vignettes. PCPs took definitive action least often when a guideline recommended a non-definitive action or made no recommendation. UK PCPs adhered to recommendations for definitive action less than their counterparts (P <0.01). There wasno association between jurisdictional guideline adherence and 1-year survival.

Conclusion

Cancer guideline content is variable between similarly developed nations and poor guideline adherence does not explain differential survival. Guidelines that fail to cover high-risk presentations or that recommend non-definitive action may reduce definitive diagnostic action.     

The study of sirtuins in breast cancer patients before and after radiotherapy

Background/aimTargeting the new and unique proteins is an important medical strategy for treating breast cancer. It is quite important to find out proteins that have a role in the development of cancer. Sirtuins (SIRT) are well related in different physiological activities and connected with cancer. We aimed to determine the effect of radiotherapy on SIRT1 and SIRT2, which have not been yet been clarified as a tumor suppressor or promoter.Materials and methodsTwenty-two women with nonmetastatic breast cancer enrolled in the study. Blood samples were taken before and after radiotherapy, soluble SIRT1 and SIRT2 levels were determined with ELISA kits.ResultsThere was no difference in SIRT1 levels before and after radiotherapy (p = 0.548). SIRT2 levels were significantly found to be decreased after radiotherapy (p = 0.042). There was a strong and positive correlation before radiotherapy (p < 0.001), and a moderate and positive correlation after radiotherapy (p = 0.007) between SIRT1 and SIRT2.ConclusionThese results suggest that SIRT2 may provide a new strategy for follow-up of breast cancer treatment. Additionally, by emphasizing the importance of SIRT2 in breast cancer, it opens ways to provide grounds for the development of the next generation of SIRT2-specific radiotracers. Finally, the most important thing, in fact, the positive correlation between SIRT1 and SIRT2 both before and after radiotherapy, appears to be clear evidence suggesting more oncogenic roles of sirtuins.     

Older patients and their GPs: shared decision making in enhancing trust

Background

Older patients differ from younger patients in their perceptions of trust in doctors; their sense of shared decision making is particularly associated with their trust in the GP. Enhancing trust and improving shared decision making are thought to have positive health outcomes. Older patients are sometimes reported as being less frequently involved in decisions about their health care, however, and in having more unmet healthcare needs than younger patients.

Aim

This study explored older patients’ trust in their GPs and their perceptions of shared decision making.

Design and setting

Qualitative methods were used. Systematic sampling identified 20 participants, aged ≥65 years, from three GP surgeries in Devon, UK.

Method

A constant comparative approach was applied to thematic analysis of transcribed interviews.

Results

All participants valued feeling involved in decisions but differed regarding how they felt involved. Trust influenced preferences for shared decision making: a trusted GP ‘ally’, to competently manage participants’ increasing health-information requirements throughout the vulnerable ageing process, was important. Trust was affected by factors contributing to the facilitation of involvement. GP characteristics, communication skills, consultation duration, and continuity of care were common themes.

Conclusion

Although limited geographically and subsequently by ethnic group, the present sample allows for reasonable transferability of the study to other UK populations. A range of factors are highlighted for consideration when planning primary healthcare delivery: to facilitate the optimal involvement of older patients in decisions about their health care, while enhancing their trust in the GP; to help minimise potential health inequalities for this patient group.     

Asylum seekers' expectations of and trust in general practice: a qualitative study

Background

The UK has substantial minority populations of short-term and long-term migrants from countries with various types of healthcare systems.

Aim

This study explored how migrants'' previous knowledge and experience of health care influences their current expectations of health care in a system relying on clinical generalists performing a gatekeeping role.

Design of study

Two qualitative methods.

Setting

Glasgow, UK.

Method

Focus groups or semi-structured interviews were conducted with 52 asylum seekers. Analyses identified several areas where previous experience affected current expectations. An overview of health systems in each country of origin was established by combining responders'' accounts with World Health Organization statistics.

Results

Asylum seekers had previous experience of a diverse range of healthcare systems, most of which were characterised by a lack of GPs and direct access to hospital-based specialists. For some responders, war or internal conflict resulted in a complete breakdown of healthcare systems. Responders'' accounts also highlighted the difficulties that marginalised groups had in accessing health care. Although asylum seekers were generally pleased with the care they received from the NHS, there were areas where they experienced difficulties: confidence in their GP and access to hospital-based specialists and medication. These difficulties encountered might be explained by previous experience.

Conclusion

GPs and other healthcare professionals need to be aware that experience of different systems of care can have an impact on individuals'' expectations in a GPled system. If these are not acknowledged and addressed, a lack of confidence and trust in the GP may undermine the effectiveness of the clinical consultation.     

宫颈癌放疗前后免疫功能改变及其临床意义

目的 :探讨放疗对宫颈癌患者免疫功能的影响。方法 :用流式细胞技术检测 2 2例宫颈癌患者放疗前后细胞免疫表型的改变 ,并与对照组进行比较。结果 :宫颈癌放疗前CD3 、CD4 、CD8 、CD3 CD4 均较对照组低 ,NK值较对照组高 ,但无显著性差异 ;放疗后CD3 、CD4 逐渐降低 ,CD8 和NK升高 ,CD3 CD4 逐渐降低 ,最后比例倒置 ,有显著性差异。结论 :宫颈癌患者免疫功能无明显抑制 ,放疗可损伤其免疫功能 ,提示放疗期间应辅以免疫治疗。     

Exercise beliefs of breast cancer survivors before and after participation in a randomized controlled trial

The purpose of this study was to examine the exercise beliefs of breast cancer survivors before and after participation in a randomized trial. Prior to randomization, 52 breast cancer survivors completed exercise belief measures based on the theory of planned behavior. After the trial, participants assigned to the exercise group (n = 24) completed the belief measures again. Results show that there was significant variability in the expected benefits of exercise prerandomization, ranging from 40% for a reduced risk of breast cancer recurrence to 94% for an improved energy level. Moreover, attitudes toward exercise and perceptions of control were higher in the exercise group after the exercise program. The findings are discussed in terms of the veracity of the exercise beliefs held by breast cancer survivors as well as the aspects of the program that may have contributed to the positive changes in exercise beliefs.     

Eicosanoids in exhaled breath condensate and bronchoalveolar lavage fluid of patients with primary lung cancer

Although eicosanoids are involved in lung carcinogenesis they were poorly investigated in exhaled breath condensate (EBC) and bronchoalveolar lavage fluid (BALf) in patients with primary lung cancer. In this study 17 patients with diagnosed non-small cell lung cancer, 10 healthy smokers and 12 healthy nonsmokers were included. The levels of cys-LTs, 8-isoprostane, LTB4 and PGE2 were measured before any treatment in the EBC of all patients and in BALf of patients with lung cancer by enzyme linked immunosorbent assay. 8-isoprostane, LTB4, cys-LTs and PGE2 were detectable in the EBC and BALf. There were no significant differences between healthy smokers and nonsmokers in concentrations of all measured mediators. Compared with both healthy controls, patients with diagnosed lung cancer displayed higher concentrations of cys-LTs (p< 0.05) and LTB4 (p < 0.05) in EBC. In patients with lung cancer, the mean concentrations of all measured mediators were significantly higher in BALf compared with EBC and there was a significant, positive correlation between concentration of cys-LTs, LTB(4) and 8-isoprostane in BALf and their concentrations in the EBC (r=0.64, p < 0.05, r=0.59, p< 0.05, r=0.53, p< 0.05 respectively). Since cys-LT, LTB4 and 8-isoprostane concentrations in EBC from patients with lung cancer reflect their concentrations in BALf, they may serve as a possible non-invasive method to monitor the disease and to assess the effectiveness of therapy.     

红外热成像技术在乳腺癌检测中的应用进展

乳腺癌作为全球女性中最常见的恶性肿瘤, 近年来,发病率逐年增高。人们期待寻找新一代检查方法,能进一步提高乳腺癌检出率,早期控制疾病进程,从而提高乳腺癌患者的生存率。红外热成像技术是一种常见的物理技术,在军事、工业、医疗等多个领域均有应用,我国近十几年来才开始将该项技术应用到医学领域中。由于该技术具有操作简单、非接触、无辐射、无创伤等优点,在医学领域中有广泛的应用前景。本文主要对该物理技术在乳腺疾病检测中的应用及该技术的临床诊断价值做简要概述。     

Utilising out-of-hours primary care for assistance with cancer pain: a semi-structured interview study of patient and caregiver experiences

Background

Pain is the most frequent complication of cancer and an important reason for out-of-hours (OOH) primary care contacts by patients with established cancer. Existing quantitative data give little insight into the reason for these contacts. Exploring such encounters of care could highlight ways to improve anticipatory cancer care and communication between daytime and OOH primary care services.

Aim

To explore the experiences, views, and opinions of patients and their caregivers who have used OOH primary care for help with managing cancer pain.

Design and setting

A semi-structured interview study with patients and caregivers who have utilised an OOH primary care service in Grampian, Scotland, because of pain related to cancer.

Method

Semi-structured interviews with 11 patients and four caregivers (n = 15), transcribed verbatim and analysed using framework analysis and, to a lesser extent, inductive thematic analysis.

Results

Six key themes emerged: making sense of pain and predicting its likely course; beliefs about analgesics; priority daytime access; the importance of continuity of care and communication between all involved; barriers and facilitators to seeking help in the OOH period; and satisfaction/dissatisfaction with OOH care. Three prominent sub-themes were: patient knowledge; the influence of a caregiver on decision-making; and the benefits of having a palliative care summary.

Conclusion

Effective daytime and anticipatory care can positively influence OOH care. Interventions that aid patients in understanding cancer pain, communicating about pain, utilising analgesics effectively, and seeking appropriate and timely help may improve cancer pain management.     

Associations between home death and GP involvement in palliative cancer care

Background

Most cancer patients die at institutions despite their wish for home death. GP-related factors may be crucial in attaining home death.

Aim

To describe cancer patients in palliative care at home and examine associations between home death and GP involvement in the palliative pathway.

Design of study

Population-based, combined register and questionnaire study.

Setting

Aarhus County, Denmark.

Method

Patient-specific questionnaires were sent to GPs of 599 cancer patients who died during a 9-month period in 2006. The 333 cases that were included comprised information on sociodemography and GP-related issues; for example knowledge of the patient, unplanned home visits, GPs providing their private phone number, and contact with relatives. Register data were collected on patients'' age, sex, cancer diagnosis, place of death, and number of GP home visits. Associations with home death were analysed in a multivariable regression model with prevalence ratios (PR) as a measure of association.

Results

There was a strong association between facilitating home death and GPs making home visits (PR = 4.3, 95% confidence interval [CI] = 1.2 to 14.9) and involvement of community nurses (PR = 1.4, 95% CI = 1.0 to 1.9). No other GP-related variables were statistically significantly associated with home death.

Conclusion

Active involvement of GPs providing home visits and the use of home nurses were independently associated with a higher likelihood of facilitating home death for cancer patients. The primary care team may facilitate home death, accommodating patients'' wishes. Future research should examine the precise mechanisms of their involvement.     

Mortality and morbidity after initial diagnostic excision biopsy of cutaneous melanoma in primary versus secondary care

Background

Current UK melanoma guidelines do not support the initial diagnostic excision biopsy of pigmented lesions in primary care, although this is standard in other countries such as Australia. Previous research in Northeast Scotland found that initial diagnostic excision biopsies in primary care that prove to be melanoma were no more likely to be incomplete than those performed in secondary care, but data on longer-term outcomes were not available.

Aim

To determine whether initial diagnostic excision biopsy of cutaneous melanoma in primary versus secondary care leads to poorer survival and increased morbidity.

Design and setting

Analysis of a linked dataset comprising pathological data from melanoma cases diagnosed in Northeast Scotland between 1991 and 2007, the General Registry Office (Scotland) death registry, and an NHS Scotland episode of care database.

Method

Patient data from three sources were matched using the Community Health Index (CHI) number. Cox proportional hazards regression, with robust standard error estimates, was used to examine the hazard ratio (95% confidence interval) of key mortality and morbidity outcomes based on excision in primary versus secondary care. Analysis was conducted before and after adjustment for operator and patient-level factors, using a multilevel approach.

Results

Patients receiving their initial diagnostic excision biopsy for melanoma in primary versus secondary care were no more likely to be dead, or to have died of metastatic malignant melanoma. Patients who had their initial diagnostic excision biopsy for melanoma in primary care had significantly fewer subsequent hospital admissions and spent fewer days in hospital.

Conclusion

These findings suggest that initial diagnostic excision biopsy of melanoma in primary care does not lead to poorer long-term outcomes.     

Diverse molecular pathways in ovarian cancer and their clinical significance

The origin of epithelial ovarian cancer remains unknown. It is believed to develop from ovarian surface epithelium, post-ovulatory inclusion cysts, endometriosis and more recently the fimbrial end of the fallopian tube. Molecular evidence suggests that ovarian cancer may progress both through a step-wise mutation process (low-grade pathway, type I), and a separate pathway with high genetic instability leading to rapid metastasis without an identifiable precursor lesion (high-grade pathway, type II). This sub-classification explains the clinical and biological heterogeneity of ovarian cancer and highlights the importance for developing novel diagnostics and therapeutics targeting two unique diseases—type I and type II ovarian carcinomas. This article summarises current knowledge of the aetiology and molecular basis of ovarian cancer and discusses recent clinical strategies for type I and type II disease.     

Sperm aneuploidy frequencies analysed before and after chemotherapy in testicular cancer and Hodgkin's lymphoma patients

BACKGROUND Multicolour fluorescent in situ hybridization was utilized to detect sperm aneuploidy for chromosomes 13, 21, X and Y in testicular cancer and Hodgkin's lymphoma chemotherapy patients. METHODS Aneuploidy was assessed before, and 6, 12 and/or 18-24 months after, the initiation of chemotherapy, and compared with age matched controls. 635 396 sperm were scored blindly with 5000 sperm/patient/chromosome/ time point, where sperm was available. (First two phrases have been reversed). RESULTS Comparing testicular cancer and Hodgkin's lymphoma patients to each other and with controls, cancer-specific differences were identified. Hodgkin's lymphoma patients, particularly, exhibited significantly increased aneuploidy frequencies for all chromosomes throughout treatment. At 6 months, all cancer patients showed significantly increased frequencies of XY disomy and nullisomy for chromosomes 13 and 21. In general, aneuploidy frequencies declined to pretreatment levels 18 months after treatment initiation, but increased aneuploidy frequencies persisted in some chromosomes for up to 24 months. CONCLUSIONS Because of elevated aneuploidy frequencies prior to and up to 24 months from the start of chemotherapy, patients should receive genetic counselling about the potentially increased risk of an aneuploid conceptus from sperm cryopreserved prior to chemotherapy, and for conceptions up to 2 years after the initiation of treatment.     

食管癌患者手术前后机体免疫调节与反应性蛋白表达的分析

目的 研究淋巴细胞及其分泌的因子和几种时相蛋白在食管癌患者手术前后的变化及意义。方法 采用流式细胞术、酶联免疫吸附法及速率散射比浊法检测食管癌根治术患者手术前后的T细胞亚群和NK细胞,血清中IL-6和TNF-α,以及C反应蛋白（CRP）、前白蛋白（PAB）、转铁蛋白（TRF）的水平。结果 与健康对照组比较,食管癌患者组CD3^＋CD4^＋细胞明显增高（P〈0．05）,CD3^＋CD8^＋T细胞明显减少（P〈0．05）,二者比例增高（P〈0．05）,术后较术前更明显（P〈0．05）;术后NK细胞较术前明显减少（P〈0．05）;手术前后血清中IL-6和TNF-α水平与健康对照组比较显著增高（P〈0．05）;CRP水平显著增高（P〈0．05）,PAB和TRF平显著降低（P〈0．05）,术后较术前更明显（P〈0．05）。结论 食管癌患者T细胞亚群的平衡紊乱导致其细胞因子合成分泌紊乱,具有B细胞活化刺激和炎症活化刺激效应的IL-6和TNF-α因子在调节急性时相性反应蛋白的合成过程中起重要作用。当CRP持续升高,负性时相蛋白PAB、TRF水平持续性降低可提示患者预后不良。对恶性肿瘤患者检测血浆中IL-6和TNF-α可了解其细胞免疫功能状态,而CRP、PAB和TRF同样可作为肿瘤治疗监测和预后判断的参考指标。     

Prognostic value of Ki67 expression in HR-negative breast cancer before and after neoadjuvant chemotherapy

Background: Immunohistochemical (IHC) expression of Ki67 has been identified as a prognostic and predictive marker in hormone receptor (HR)-positive breast cancer, however, there is little evidence of the association of Ki67 with prognosis in HR-negative patients. We aimed to assess the benefit of Ki67 assessment in HR-negative breast cancers after neoadjuvant chemotherapy (NAC). Methods: In the present study, a total of 183 HR-negative breast cancer patients with Stage II to III that treated with anthracycline and/or taxane-based neoadjuvant chemotherapy between 2004 and 2011 were retrospectively analyzed. Endocrine therapy and trastuzumab was not administered to any patients in this study. Clinical and pathological features of the patients with breast cancer were retrieved from the hospital records. Predictive factors for NAC response and survival were analyzed. Results: Of the 183 patients, 122 (66.6%) were HR- HER2+, and 61 (33.3%) were triple-negative. The clinical response rates were similar across breast cancer subtype. Patients whose tumors contained high Ki67 expression effectively responded to NAC. Ki67 labeling index was a predictive marker for pathologic complete response (pCR). Ki67 expression showed a positive correlation with HER2 status, tumor size, lymph node status, lymphovascular invasion and tumor grade. Furthermore, high Ki67 expression in post-treatment tumors was strongly correlated with poor disease-free survival (DFS), but no correlation of Ki-67 expression with overall survival (OS) was observed. Conclusions: Our results suggest that Ki67 expression in HR-negative breast cancer may improve the assessment of pathological response after NAC, and Ki67 score in residual tumor was an independent prognosticator for DFS in the HR-negative breast cancer patients.     

无线智能手环在机器人胃癌患者术后下床活动中的应用及效果

目的:探讨无线智能手环在加速康复外科机器人胃癌患者术后下床活动中的应用及效果.方法:选取2014年12月至2015年12月行达芬奇机器人胃癌根治术的患者95例,随机分为试验组(45例)与对照组(40例).试验组佩戴无线智能手环(fitbit flex)监测术后患者的下床活动;对照组术后采用传统的护理方法.比较两组患者术后活动的依从性、活动的效果等.结果:试验组患者活动的依从性高于对照组;两组患者术后通气、通便时间等比较,差异均有统计学意义(P＜0.05).结论:无线智能手环在加速康复外科机器人胃癌患者术后下床活动中的应用客观有效,可促进患者的快速康复.