Diagnosing cancer in primary care: results from the National Cancer Diagnosis Audit

BACKGROUND: Continual improvements in diagnostic processes are needed to minimise the proportion of patients with cancer who experience diagnostic delays. Clinical audit is a means of achieving this. AIM: To characterise key aspects of the diagnostic process for cancer and to generate baseline measures for future re-audit. DESIGN AND SETTING: Clinical audit of cancer diagnosis in general practices in England. METHOD: Information on patient and tumour characteristics held in the English National Cancer Registry was supplemented by information from GPs in participating practices. Data items included diagnostic timepoints, patient characteristics, and clinical management. RESULTS: Data were collected on 17 042 patients with a new diagnosis of cancer during 2014 from 439 practices. Participating practices were similar to non-participating ones, particularly regarding population age, urban/rural location, and practice-based patient experience measures. The median diagnostic interval for all patients was 40 days (interquartile range [IQR] 15-86 days). Most patients were referred promptly (median primary care interval 5 days [IQR 0-27 days]). Where GPs deemed diagnostic delays to have occurred (22% of cases), patient, clinician, or system factors were responsible in 26%, 28%, and 34% of instances, respectively. Safety netting was recorded for 44% of patients. At least one primary care-led investigation was carried out for 45% of patients. Most patients (76%) had at least one existing comorbid condition; 21% had three or more. CONCLUSION: The findings identify avenues for quality improvement activity and provide a baseline for future audit of the impact of 2015 National Institute for Health and Care Excellence guidance on management and referral of suspected cancer

A randomised control crossover trial of a theory based intervention to improve sun-safe and healthy behaviours in construction workers:Study protocol

Abstract Background Exposure to sunlight can have both positive and negative health impacts. Excessive exposure to ultra-violet (UV) radiation from the sun can cause skin cancer, however insufficient exposure to sunlight has a detrimental effect on production of Vitamin D. In the construction industry there are onsite proactive behaviours for safety, but sun-safety remains a low priority. There is limited research on understanding the barriers to adopting sun-safe behaviours and the association this may have with Vitamin D production. This paper reports a protocol for an intervention study, using text messaging in combination with a supportive smartphone App. The intervention aims to both reduce UV exposure during months with higher UV levels and promote appropriate dietary changes to boost Vitamin D levels during months with low UV levels. Method/design Approximately 60 construction workers will be recruited across the United Kingdom. A randomised control crossover trial (RCCT) will be used to test the intervention, with randomisation at site level – i.e. participants will receive both the control (no text messages or supportive App support) and intervention (daily text messages and supportive App). Using the Theory of Planned Behaviour (TPB) the intervention focuses on supporting sun-safety and healthy dietary decisions in relation to Vitamin D intake. The intervention emphasises cultivating the perception of normative support in the workplace, increasing awareness of control and self-efficacy in taking sun-protective behaviours, making healthier eating choices to boost Vitamin D, and tackling stigmas attached to image and group norms. Each study epoch will last 21 days with intervention text messages delivered on workdays only. The supportive App will provide supplementary information about sun protective behaviours and healthy dietary choices. The primary outcome measure is 25-hydroxy-Vitamin D [25(OH)D] level (obtained using blood spot sampling), which will be taken pre and post control and intervention periods. Secondary outcome measures are two-fold, (1) using the TPB to detect changes in behaviour, and (2) quantifying UV exposure during the UK peak radiation season (April–September) using body-mounted UV sensors. Discussion This study will provide important information about the effectiveness of a technology-based intervention to promote sun-safety and healthy behaviours in outdoor construction workers. Trial registration ISRCTN15888934 retrospectively registered 15.01.2018

Sunbed use in children aged 11-17 in England: face to face quota sampling surveys in the National Prevalence Study and Six Cities Study

Objectives To quantify the use of sunbeds in young people across England, identify geographical variation, and explore patterns of use, including supervision

Assessing awareness of colorectal cancer symptoms: Measure development and results from a population survey in the UK

Background: This paper describes the development of a Cancer Awareness Measure for colorectal (CRC) cancer (Bowel/Colorectal CAM(a)) (study 1) and presents key results from a population-representative survey using the measure (study 2).MethodsStudy 1: Items were taken from the literature and reviewed by expert groups. A series of three validation studies assessed reliability and validity of the measure. To establish test-retest reliability, 49 people over 50 years of age completed the Bowel/Colorectal CAM on two occasions (range 9-14 days, mean 13.5 days). Construct validity was assessed by comparing responses from bowel cancer experts (n = 16) and the lay public (n = 35). Lastly, a brief intervention study tested sensitivity to change with participants (n = 70) randomly allocated to be given a control leaflet or an intervention leaflet and their responses were compared. Study 2: 1520 respondents completed the Bowel/Colorectal CAM in a population survey carried out by TNS-British Market Research Bureau International (TNS-BMRB) in March 2010.ResultsStudy 1: Internal reliability (Cronbach's alpha = 0.84) was high. Test-retest reliability was over r = 0.7 for warning signs, risk factors and age people are first invited for screening, but lower (between 0.6 and 0.7) for other items (lifetime risk, awareness of bowel cancer screening, age at risk). Bowel cancer experts achieved higher scores than equally educated controls (54.7 [4.3] vs. 42.9 [5.7]; P < 0.001) demonstrating the measure has construct validity and intervention participants showed higher knowledge than controls (51.4 [5.9] vs. 42.9 [5.7]; P < 0.001) suggesting the measure is sensitive to change. Study 2: Respondents recalled on average, one CRC sign and one risk factor. There was particularly low prompted awareness of the signs 'lump in the abdomen' (64%) and 'tiredness' (50%) and several lifestyle risk factors for CRC, e. g. exercise (37%). Respondents from more affluent groups had consistently higher knowledge of signs and risk factors compared to those from more deprived groups.Conclusions: The Bowel/Colorectal CAM meets accepted psychometric criteria for reliability and construct validity and should therefore provide a useful tool for assessment of CRC awareness. The population survey revealed low awareness of several CRC signs and risk factors and emphasises the importance of continuing public education, particularly about the link between lifestyle behaviours and CRC

NHS-Galleri trial: Enriched enrolment approaches and sociodemographic characteristics of enrolled participants.

BACKGROUND/AIMS: Certain sociodemographic groups are routinely underrepresented in clinical trials, limiting generalisability. Here, we describe the extent to which enriched enrolment approaches yielded a diverse trial population enriched for older age in a randomised controlled trial of a blood-based multi-cancer early detection test (NCT05611632). METHODS: Participants aged 50-77 years were recruited from eight Cancer Alliance regions in England. Most were identified and invited from centralised health service lists; a dynamic invitation algorithm was used to target those in older and more deprived groups. Others were invited by their general practice surgery (GP-based Participant Identification Centres in selected regions); towards the end of recruitment, specifically Asian and Black individuals were invited via this route, as part of a concerted effort to encourage enrolment among these individuals. Some participants self-referred, often following engagement activities involving community organisations. Enrolment took place in 11 mobile clinics at 151 locations that were generally more socioeconomically deprived and ethnically diverse than the England average. We reduced logistical barriers to trial participation by offering language interpretation and translation and disabled access measures. After enrolment, we examined (1) sociodemographic distribution of participants versus England and Cancer Alliance populations, and (2) number needed to invite (NNI; the number of invitations sent to enrol one participant) by age, sex, index of multiple deprivation (IMD) and ethnicity, and GP surgery-level bowel screening participation. RESULTS: Approximately 1.5 million individuals were invited and 142,924 enrolled (98% via centralised health service lists/invitation algorithm) in 10.5 months. The enrolled population was older and more deprived than the England population aged 50-77 years (73.3% vs 56.8% aged 60-77 years; 42.3% vs 35.3% in IMD groups 1-2). Ethnic diversity was lower in the trial than the England population (1.4% vs 2.8% Black; 3.3% vs 5.3% Asian). NNI was highest in Black (32.8), Asian (28.2) and most-deprived (21.5) groups, and lowest in mixed ethnicity (8.1) and least-deprived (4.6) groups. CONCLUSIONS: Enrolment approaches used in the NHS-Galleri trial enabled recruitment of an older, socioeconomically diverse participant population relatively rapidly. Compared with the England and Cancer Alliance populations, the enrolled population was enriched for those in older age and more deprived groups. Better ethnicity data availability in central health service records could enable better invitation targeting to further enhance ethnically diverse recruitment. Future research should evaluate approaches used to facilitate recruitment from underrepresented groups in clinical trials

Ethnic disparities in knowledge of cancer screening programmes in the UK

Objective The aim of the study was to examine awareness of the three National Cancer Screening Programmes (breast, cervical, bowel) among white and ethnic minority groups in the UK.Setting Data were from two surveys in which the screening questions were added: (i) the Office of National Statistics (ONS) Opinions Survey, carried out in September and October 2008; and (ii) the Ethnibus (TM) survey of the main ethnic minority groups in England, conducted in October and November 2008.Methods The ONS sample consisted of 2216 adults selected using stratified probability sampling to obtain a population-representative sample. The Ethnibus (TM) sample was obtained by quota sampling and included 1500 adults from the six largest ethnic minority groups in England (Indian, Pakistani, Bangladeshi, Caribbean, African and Chinese). Participants completed questions on awareness of cancer screening programmes as part of the wider Cancer Awareness Measure (CAM) in home-based, face-to-face interviews.Results Awareness of breast and cervical cancer screening was high in the white ONS participants (89% breast and 84% cervical), lower in the ONS ethnic minority sample (74% for both breast and cervical) and lowest in the Ethnibus (TM) sample (69% breast and 66% cervical). Ethnic disparities persisted after controlling for age, gender and occupational group. In both groups, knowledge of breast and cervical screening was lower among men and more socioeconomically deprived groups. Awareness of the new bowel cancer screening programme was less than 30% in both white and ethnic minority groups.Conclusions Ethnic disparities in knowledge of breast and cervical cancer screening should be addressed. Strategies to engage ethnic minority and socioeconomically deprived groups in bowel cancer screening should be instigated to avoid the emergence of disparities

Awareness of cancer symptoms and anticipated help seeking among ethnic minority groups in England

&lt;p&gt;Objective: Little is known about ethnic differences in awareness of cancer-warning signs or help-seeking behaviour in Britain. As part of the National Awareness and Early Diagnosis Initiative (NAEDI), this study aimed to explore these factors as possible contributors to delay in cancer diagnosis.&lt;/p&gt; &lt;p&gt;Methods: We used quota sampling to recruit 1500 men and women from the six largest minority ethnic groups in England (Indian, Pakistani, Bangladeshi, Caribbean, African and Chinese). In face-to-face interviews, participants completed the newly developed cancer awareness measure (CAM), which includes questions about warning signs for cancer, speed of consultation for possible cancer symptoms and barriers to help seeking.&lt;/p&gt; &lt;p&gt;Results: Awareness of warning signs was low across all ethnic groups, especially using the open-ended (recall) question format, with lowest awareness in the African group. Women identified more emotional barriers and men more practical barriers to help seeking, with considerable ethnic variation. Anticipated delay in help seeking was higher in individuals who identified fewer warning signs and more barriers.&lt;/p&gt; &lt;p&gt;Conclusions: The study suggests the need for culturally sensitive, community-based interventions to raise awareness and encourage early presentation.&lt;/p&gt

Development of a measurement tool to assess public awareness of cancer

Objective:We aimed to develop and validate a measurement tool to assess cancer awareness in the general population: the cancer awareness measure (CAM).Methods:Items assessing awareness of cancer warning signs, risk factors, incidence, screening programmes and attitudes towards help seeking were extracted from the literature or generated by expert groups. To determine reliability, the CAM was administered to a university participant panel (n=148), with a sub-sample (n=94) completing it again 2 weeks later. To establish construct validity, CAM scores of cancer experts (n=12) were compared with those of non-medical academics (n=21). Finally, university students (n=49) were randomly assigned to read either a cancer information leaflet or a leaflet with control information before completing the measure, to ensure the CAM was sensitive to change.Results:Cognitive interviewing indicated that the CAM was being interpreted as intended. Internal reliability (Cronbach's α=0.77) and test–retest reliability (r=0.81) were high. Scores for cancer experts were significantly higher than those for non-medical academics (t(31)=6.8,

Progress in cancer survival, mortality, and incidence in seven high-income countries 1995–2014 (ICBP SURVMARK-2): a population-based study

© 2019 World Health Organization Background: Population-based cancer survival estimates provide valuable insights into the effectiveness of cancer services and can reflect the prospects of cure. As part of the second phase of the International Cancer Benchmarking Partnership (ICBP), the Cancer Survival in High-Income Countries (SURVMARK-2) project aims to provide a comprehensive overview of cancer survival across seven high-income countries and a comparative assessment of corresponding incidence and mortality trends. Methods: In this longitudinal, population-based study, we collected patient-level data on 3·9 million patients with cancer from population-based cancer registries in 21 jurisdictions in seven countries (Australia, Canada, Denmark, Ireland, New Zealand, Norway, and the UK) for seven sites of cancer (oesophagus, stomach, colon, rectum, pancreas, lung, and ovary) diagnosed between 1995 and 2014, and followed up until Dec 31, 2015. We calculated age-standardised net survival at 1 year and 5 years after diagnosis by site, age group, and period of diagnosis. We mapped changes in incidence and mortality to changes in survival to assess progress in cancer control. Findings: In 19 eligible jurisdictions, 3 764 543 cases of cancer were eligible for inclusion in the study. In the 19 included jurisdictions, over 1995–2014, 1-year and 5-year net survival increased in each country across almost all cancer types, with, for example, 5-year rectal cancer survival increasing more than 13 percentage points in Denmark, Ireland, and the UK. For 2010–14, survival was generally higher in Australia, Canada, and Norway than in New Zealand, Denmark, Ireland, and the UK. Over the study period, larger survival improvements were observed for patients younger than 75 years at diagnosis than those aged 75 years and older, and notably for cancers with a poor prognosis (ie, oesophagus, stomach, pancreas, and lung). Progress in cancer control (ie, increased survival, decreased mortality and incidence) over the study period was evident for stomach, colon, lung (in males), and ovarian cancer. Interpretation: The joint evaluation of trends in incidence, mortality, and survival indicated progress in four of the seven studied cancers. Cancer survival continues to increase across high-income countries; however, international disparities persist. While truly valid comparisons require differences in registration practice, classification, and coding to be minimal, stage of disease at diagnosis, timely access to effective treatment, and the extent of comorbidity are likely the main determinants of patient outcomes. Future studies are needed to assess the impact of these factors to further our understanding of international disparities in cancer survival. Funding: Canadian Partnership Against Cancer; Cancer Council Victoria; Cancer Institute New South Wales; Cancer Research UK; Danish Cancer Society; National Cancer Registry Ireland; The Cancer Society of New Zealand; National Health Service England; Norwegian Cancer Society; Public Health Agency Northern Ireland, on behalf of the Northern Ireland Cancer Registry; The Scottish Government; Western Australia Department of Health; and Wales Cancer Network