Discovery publications 2015
Discovery publications - 2015
The role of emotions in time to presentation for symptoms suggestive of cancer: A systematic literature review of quantitative studies.
Balasooriya-Smeekens C, Walter FM, Scott S Psychooncology. 2015 May 18. doi: 10.1002/pon.3833. [Epub ahead of print]
Emotions may be important in patients' decisions to seek medical help for symptoms suggestive of cancer.
The aim of this systematic literature review was to examine quantitative literature on the influence of emotion on patients' help-seeking for symptoms suggestive of cancer. The objectives were to identify the following: (a) which types of emotions influence help-seeking behaviour, (b) whether these form a barrier or trigger for seeking medical help and (c) how the role of emotions varies between different cancers and populations.
We searched four electronic databases and conducted a narrative synthesis. Inclusion criteria were studies that reported primary, quantitative research that examined any emotion specific to symptom appraisal or help-seeking for symptoms suggestive of cancer.
Thirty-three papers were included. The studies were heterogeneous in their methods and quality, and very few had emotion as the main focus of the research. Studies reported a limited range of emotions, mainly related to fear and worry. The impact of emotions appears mixed, sometimes acting as a barrier to consultation whilst at other times being a trigger or being unrelated to time to presentation. It is plausible that different emotions play different roles at different times prior to presentation.
This systematic review provides some quantitative evidence for the role of emotions in help-seeking behaviour. However, it also highlighted widespread methodological, definition and design issues among the existing literature. The conflicting results around the role of emotions on time to presentation may be due to the lack of definition of each specific emotion.
Quantifying the risk of non-Hodgkin lymphoma in symptomatic primary care patients aged ≥40 years: a large case-control study using electronic records.
Elizabeth A Shephard, Richard D Neal, Peter W Rose, Fiona M Walter, William T Hamilton. The British Journal of General Practice 2015 May; 65 (634): e281-e288
Non-Hodgkin lymphoma (NHL) is the sixth most common cancer in the UK; approximately 35 people are diagnosed and 13 die from the disease daily.
To identify the primary care clinical features of NHL and quantify their risk in symptomatic patients.
Design and setting
Matched case-control study using Clinical Practice Research Datalink patient records.
Putative clinical features of NHL were identified in the year before diagnosis. Results were analysed using conditional logistic regression and positive predictive values (PPVs).
A total of 4362 patients aged ≥40 years, diagnosed with NHL between 2000 and 2009, and 19 468 age, sex, and general practice-matched controls were studied. Twenty features were independently associated with NHL. The five highest risk symptoms were lymphadenopathy, odds ratio (OR) 263 (95% CI = 133 to 519), head and neck mass not described as lymphadenopathy OR 49 (95% CI = 32 to 74), other mass OR 12 (95% CI = 10 to 16), weight loss OR 3.2 (95% CI = 2.3 to 4.4), and abdominal pain OR 2.5 (95% CI = 2.1 to 2.9). Lymphadenopathy has a PPV of 13% for NHL in patients ≥60 years. Weight loss in conjunction with repeated back pain or raised gamma globulin had PPVs >2%.
Conclusion Unexplained lymphadenopathy in patients aged ≥60 years produces a very high risk of NHL in primary care. These patients warrant urgent investigation, potentially sooner than 6 weeks from initial presentation where the GP is particularly concerned.
Quantifying the risk of Hodgkin lymphoma in symptomatic primary care patients aged ≥40 years: a case-control study using electronic records
Elizabeth A Shephard, Richard D Neal, Peter W Rose, Fiona M Walter, William T Hamilton. The British Journal of General Practice 2015 May; 65 (634): e289-e294
In the UK, approximately five people are diagnosed with Hodgkin lymphoma (HL) daily. One-tenth of diagnoses are in those aged >75 years.
To establish a symptom profile of HL and quantify their risk in primary care patients aged ≥40 years.
Design and setting
Matched case-control study using Clinical Practice Research Datalink patient records.
Putative clinical features of HL were identified in the year before diagnosis. Results were analysed using conditional logistic regression and positive predictive values (PPVs) calculated for the consulting population.
Two-hundred and eighty-three patients aged ≥40 years, diagnosed with HL between 2000 and 2009, and 1237 age, sex, and general practice-matched participants were studied. Six features were independently associated with HL: lymphadenopathy (OR 280, 95% confidence interval [CI] = 25 to 3100), head and neck mass not described as lymphadenopathy (OR 260, 95% CI = 21 to 3200), other mass (OR 12, 95% CI = 4.4 to 35), thrombocytosis (OR 6.0, 95% CI = 2.6 to 14), raised inflammatory markers (OR 5.2, 95% CI = 3.0 to 9.0), and low full blood count (OR 2.8, 95% CI = 1.6 to 4.8). Lymphadenopathy per se has a positive predictive value (PPV) of 5.6% for HL in patients aged ≥60 years.
Consistent with secondary care findings, lymphadenopathy is the clinical feature with the highest risk of HL in primary care and warrants urgent investigation.
Symptoms and other factors associated with time to diagnosis and stage of lung cancer: a prospective cohort study.
Walter FM, Rubin G, Bankhead C, Morris HC, Hall N, Mills K, Dobson C, Rintoul RC, Hamilton W, Emery J. Br J Cancer. 2015 Mar 3. doi: 10.1038/bjc.2015.30. [Epub ahead of print]
This prospective cohort study aimed to identify symptom and patient factors that influence time to lung cancer diagnosis and stage at diagnosis.
Data relating to symptoms were collected from patients upon referral with symptoms suspicious of lung cancer in two English regions; we also examined primary care and hospital records for diagnostic routes and diagnoses. Descriptive and regression analyses were used to investigate associations between symptoms and patient factors with diagnostic intervals and stage.
Among 963 participants, 15.9% were diagnosed with primary lung cancer, 5.9% with other thoracic malignancies and 78.2% with non-malignant conditions. Only half the cohort had an isolated first symptom (475, 49.3%); synchronous first symptoms were common. Haemoptysis, reported by 21.6% of cases, was the only initial symptom associated with cancer. Diagnostic intervals were shorter for cancer than non-cancer diagnoses (91 vs 124 days, P=0.037) and for late-stage than early-stage cancer (106 vs 168 days, P=0.02). Chest/shoulder pain was the only first symptom with a shorter diagnostic interval for cancer compared with non-cancer diagnoses (P=0.003).
Haemoptysis is the strongest symptom predictor of lung cancer but occurs in only a fifth of patients. Programmes for expediting earlier diagnosis need to focus on multiple symptoms and their evolution.
Ethnic differences in patients' preferences for prostate cancer investigation: a vignette-based survey in primary care.
Martin T, Ukoumunne OC, Banks J, Raine R, Hamilton W. Br J Gen Pract. 2015 Mar; DOI: 10.3399/bjgp15X683965
Minority ethnic groups in the UK have worse outcomes for some cancer types compared with the white majority. Black males have worse staging at diagnosis of prostate cancer and often present as emergencies, suggesting possible delays in the diagnostic pathway. Delay may arise from lower awareness of cancer symptoms, reluctance to report symptoms, reduced desire for investigation, or a combination of these. Reduced desire for investigation was examined in this study.
To investigate whether black males in the UK would choose to be tested for prostate cancer compared with the white majority.
Design and setting:
A vignette (hypothetical scenario)-based, electronic survey of male patients aged ≥40 years from four general practices in Bristol, UK.
The vignettes described possible prostate cancer symptoms (equating to risk levels of 2%, 5%, and 10%), investigative procedures, and possible outcomes. Participants indicated whether they would choose investigation in these scenarios. Analysis used logistic regression, with preference for investigation as the outcome variable and ethnicity as the main explanatory variable.
In total, 449 (81%) of 555 participants opted for investigation, regardless of risk levels; of these, the acceptance rate was 94% (251 out of 267) among white males and 70% (198 out of 285) among black males. In multivariable analyses, preference for investigation was lower in black males, even after controlling for relevant confounding factors including specific risk level (odds ratio 0.13; 95% confidence interval = 0.07 to 0.25; P<0.001).
Black males are less likely to opt for investigation at any risk level of prostate cancer compared with white males. This may explain some of their late-stage presentation at diagnosis and subsequent poorer outcomes.
Quantifying the risk of multiple myeloma from symptoms reported in primary care patients: a large case-control study using electronic records.
Shephard EA, Neal RD, Rose P, Walter FM, Litt EJ, Hamilton WT.
Br J Gen Pract. 2015 Feb;65(631):e106-13. doi: 10.3399/bjgp15X683545.
Patients with myeloma experience the longest diagnostic delays compared with patients with other cancers in the UK; 37% are diagnosed through emergency presentations.
To identify and quantify the risk of myeloma from specific clinical features reported by primary care patients.
Design and setting:
Matched case-control study using General Practice Research Database primary care electronic records.
Putative clinical features of myeloma were identified and analysed using conditional logistic regression. Positive predictive values (PPVs) were calculated for the consulting population.
A total of 2703 patients aged =40 years, diagnosed with myeloma between 2000 and 2009, and 12 157 age, sex, and general practice-matched controls were identified. Sixteen features were independently associated with myeloma: hypercalcaemia, odds ratio 11.4 (95% confidence interval [CI] = 7.1 to 18), cytopenia 5.4 (95% CI = 4.6 to 6.4), raised inflammatory markers 4.9 (95% CI = 4.2 to 5.8), fracture 3.1 (95% CI = 2.3 to 4.2), raised mean corpuscular volume 3.1 (95% CI = 2.4 to 4.1), weight loss 3.0 (95% CI = 2.0 to 4.5), nosebleeds 3.0 (95% CI = 1.9 to 4.7), rib pain 2.5 (95% CI = 1.5 to 4.4), back pain 2.2 (95% CI = 2.0 to 2.4), other bone pain 2.1 (95% CI = 1.4 to 3.1), raised creatinine 1.8 (95% CI = 1.5 to 2.2), chest pain 1.6 (95% CI = 1.4 to 1.8), joint pain 1.6 (95% CI = 1.2 to 2.2), nausea 1.5 (95% CI = 1.1 to 2.1), chest infection 1.4 (95% CI = 1.2 to 1.6), and shortness of breath 1.3 (95% CI = 1.1 to 1.5). Individual symptom PPVs were generally <1%, although were >10% for some symptoms when combined with leucopenia or hypercalcaemia.
Individual symptoms of myeloma in primary care are generally low risk, probably explaining diagnostic delays. Once simple primary care blood tests are taken, risk estimates change. Hypercalcaemia and leucopenia are particularly important abnormalities, and coupled with symptoms, strongly suggest myeloma.
New Discovery Research publication
The SYMPTOM Study team's research into symptom appraisal for colorectal cancer has been published in BMJ Open. This is a unique piece of research which compares the appraisal and help seeking experiences of patients with colorectal cancer symptoms who go on to have cancer and those who turn out to have non-cancer conditions. The research did not identify any clear differences between the two groups but did identify important barriers to presentation around the ‘private nature’ of colorectal symptoms which will prove useful to policy makers and the design of awareness campaigns. To read more about the research paper see the results section here.
Discovery conference slides available & new research publications
The Discovery Programme held its research conference at the Royal College of General Practitioners on June 2nd 2015. The team presented their research findings and outlined the impact of the programme to a wide range of patient groups, clinicians, policy makers, researchers and journalists. The PowerPoint slides used during the presentation have been uploaded to this website and can be viewed here.
There are also 2 new research papers to report. Chantal Balasooriya-Smeekens has published the literature review of her PhD in Psycho-Oncology, "The role of emotions in time to presentation for symptoms suggestive of cancer: a systematic review of quantitative studies". Abstract and publication details are here and further papers from Chantal's PhD will be published soon.
Nafees Din has published a new paper under the Discovery related research umbrella. The paper uses Discovery data drawn from the CAPER (theme 2) studies and considers "Age and Gender Variations in Cancer Diagnostic Intervals in 15 Cancers". Full publication details and abstract can be found here.