Elizabeth Mitchell

Risk factors for delayed presentation and referral of symptomatic cancer: evidence for common cancers.

Background:It has been suggested that the known poorer survival from cancer in the United Kingdom, compared with other European countries, can be attributed to more advanced cancer stage at presentation. There is, therefore, a need to understand the diagnostic process, and to ascertain the risk factors for increased time to presentation.Methods:We report the results from two worldwide systematic reviews of the literature on patient-mediated and practitioner-mediated delays, identifying the factors that may influence these.Results:Across cancer sites, non-recognition of symptom seriousness is the main patient-mediated factor resulting in increased time to presentation. There is strong evidence of an association between older age and patient delay for breast cancer, between lower socio-economic status and delay for upper gastrointestinal and urological cancers and between lower education level and delay for breast and colorectal cancers. Fear of cancer is a contributor to delayed presentation, while sanctioning of help seeking by others can be a powerful mediator of reduced time to presentation. For practitioner delay, ‘misdiagnosis’ occurring either through treating patients symptomatically or relating symptoms to a health problem other than cancer, was an important theme across cancer sites. For some cancers, this could also be linked to inadequate patient examination, use of inappropriate tests or failing to follow-up negative or inconclusive test results.Conclusion:Having sought help for potential cancer symptoms, it is therefore important that practitioners recognise these symptoms, and examine, investigate and refer appropriately.

Has general practitioner computing made a difference to patient care? A systematic review of published reports

Abstract Objective: To review findings from studies of the influence of desktop computers on primary care consultations. Design: Systematic review of world reports from 1984 to 1994. Setting: The computerised catalogues of Medline, BIDS, and GPlit were searched, as well as conference proceedings, books, bibliographies, and references in books and journal articles. Subjects: 30 papers met the inclusion criteria and were included for detailed review. Interventions: A validated scheme for assessing methodological adequacy was used to score each paper. Main outcome measures: Papers were rated on sample formation, baseline differences, unit of allocation, outcome measures, and follow up. Differences in outcomes were also recorded. Results: Four of the six papers dealing with the consultation process showed that consultations took longer. Doctor initiated and “medical” content of consultations increased at the expense of a reduction in patient initiated and “social” content. Each of the 21 studies which looked at clinician performance showed an improvement when a computer was used (from 8% to 50%, with better results for single preventive measures). Only one of the three studies looking at patient outcomes showed an improvement (diastolic blood pressure control 5 mm Hg better after one year, with fewer doctor-patient consultations). Conclusions: Using a computer in the consultation may help improve clinician performance but may increase the length of the consultation. More studies are needed to assess the effects on patient outcomes of using a computer in consultations.

Systematic review of factors influencing patient and practitioner delay in diagnosis of upper gastrointestinal cancer

As knowledge on the causation of cancers advances and new treatments are developed, early recognition and accurate diagnosis becomes increasingly important. This review focused on identifying factors influencing patient and primary care practitioner delay for upper gastrointestinal cancer. A systematic methodology was applied, including extensive searches of the literature published from 1970 to 2003, systematic data extraction, quality assessment and narrative data synthesis. Included studies were those evaluating factors associated with the time interval between a patient first noticing a cancer symptom and presenting to primary care, between a patient first presenting to primary care and being referred to secondary care, or describing an intervention designed to reduce those intervals. Twenty-five studies were included in the review. Studies reporting delay intervals demonstrated that the patient phase of delay was greater than the practitioner phase, whilst patient-related research suggests that recognition of symptom seriousness is more important than recognition of the presence of the symptom. The main factors related to practitioner delay were misdiagnosis, application and interpretation of tests, and the confounding effect of existing disease. Greater understanding of patient factors is required, along with evaluation of interventions to ensure appropriate diagnosis, examination and investigation.

'Getting through' not 'going under': A qualitative study of gender and spousal support after diagnosis with colorectal cancer

Many studies have found that people with cancer value family support. Feminist work suggests that women carry most responsibility for practical and emotional support in families, but few qualitative cancer studies explicitly incorporate a gender perspective. We undertook secondary analysis of in-depth interviews with 33 married or cohabiting respondents with colorectal cancer in the UK to compare men and womens accounts of ‘spousal’ support. Both men and women described the vital role that their partners played in providing emotional and practical support. Mutual support and reciprocity were also key features of narratives; both men and women reported controlling their emotions to protect spouses and preserve ‘normal’ household routines. Traditional gender roles had some influence; some women organised ‘cover’ for domestic work and childcare when they were ill, while some men focused on making sure that their families were financially secure and partners were ‘protected’ from the effects of their stomas. Our findings illustrate the complexity of gendered constructions and performances of ‘care’ and contribute to debates about gender and emotional labour.

Modifiable and fixed factors predicting quality of life in people with colorectal cancer

Background:People with colorectal cancer have impaired quality of life (QoL). We investigated what factors were most highly associated with it.Methods:Four hundred and ninety-six people with colorectal cancer completed questionnaires about QoL, functioning, symptoms, co-morbidity, cognitions and personal and social factors. Disease, treatment and co-morbidity data were abstracted from case notes. Multiple linear regression identified modifiable and unmodifiable factors independently predictive of global quality of life (EORTC-QLQ-C30).Results:Of unmodifiable factors, female sex (P<0.001), more self-reported co-morbidities (P=0.006) and metastases at diagnosis (P=0.036) significantly predicted poorer QoL, but explained little of the variability in the model (R2=0.064). Adding modifiable factors, poorer role (P<0.001) and social functioning (P=0.003), fatigue (P=0.001), dyspnoea (P=0.001), anorexia (P<0.001), depression (P<0.001) and worse perceived consequences (P=0.013) improved the model fit considerably (R2=0.574). Omitting functioning subscales resulted in recent diagnosis (P=0.002), lower perceived personal control (P=0.020) and travel difficulties (P<0.001) becoming significant predictors.Conclusion:Most factors affecting QoL are modifiable, especially symptoms (fatigue, anorexia, dyspnoea) and depression. Beliefs about illness are also important. Unmodifiable factors, including metastatic (or unstaged) disease at diagnosis, have less impact. There appears to be potential for interventions to improve QoL in patients with colorectal cancer.

Understanding diagnosis of lung cancer in primary care: qualitative synthesis of significant event audit reports

BACKGROUNDnMost lung cancers present symptomatically, but the pathway to diagnosis in primary care can be complex and is poorly understood. Significant event audit (SEA) is a quality improvement technique widely used in UK general practice.nnnAIMnTo gain insights into the diagnostic process for lung cancer, drawn from analysis of SEA documents.nnnDESIGN AND SETTINGnQualitative analysis of SEAs from 92 general practices in the North of England Cancer Network.nnnMETHODnParticipating practices were provided with a standardised electronic template and asked to undertake a significant event audit related to the most recent diagnosis of lung cancer in the practice, even if that patient had since died. Reported accounts for 132 diagnoses were analysed using a modified framework approach.nnnRESULTSnMost SEAs demonstrated timely recognition and referral. Where this had taken longer, there were often reasonable explanations, including: chest X-rays reported as normal or with benign findings; patient-mediated factors, such as delay in re-presenting or declining earlier referral; and presentation complicated by comorbidity. Some opportunities for earlier referral were also found. Lessons drawn from these events included limitations of chest X-ray as a diagnostic tool, the need for vigilance in patients with existing morbidity, and the importance of safety-netting.nnnCONCLUSIONnQualitative synthesis of SEAs offered considerable value in understanding circumstances surrounding the diagnostic process for lung cancer in primary care. The most common presentation was with cough or other symptoms indicative of infection, and it is by understanding more about these patients in particular that most can be gained.

Predictors of anxiety and depression in people with colorectal cancer

BackgroundPeople living with colorectal cancer are at risk of anxiety and depression. We investigated what factors were most highly associated with these.MethodsFour hundred and ninety-six people with colorectal cancer completed the Hospital Anxiety and Depression Scale (HADS). Data on functioning, symptoms, illness perceptions and social difficulties were collected by questionnaire. Case-note-identified disease, treatment and co-morbidity data were recorded. Multiple logistic regression identified factors independently predictive of anxiety and depression caseness.ResultsSelf-reported history of anxiety/depression predicted anxiety but not depression caseness. Depression caseness predicted anxiety caseness (pu2009=u20090.043), as did poorer self-reported cognitive functioning (pu2009=u20090.001), dyspnoea (pu2009=u20090.015) or diarrhoea (pu2009=u20090.021), reporting a high negative life and emotional impact (pu2009<u20090.001) and having difficulties with finance (pu2009=u20090.007). Having neo-adjuvant radiotherapy increased the odds of depression caseness (pu2009=u20090.007), as did poorer physical (pu2009=u20090.007), cognitive (pu2009<u20090.001) and social (pu2009<u20090.001) functioning, having constipation (pu2009=u20090.011), reporting a high negative life and emotional impact (pu2009<u20090.001), having difficulties with personal care (pu2009=u20090.022) and communicating with others (pu2009=u20090.014).ConclusionLevels of anxiety caseness were similar to those of non-clinical samples, but depression caseness was higher, particularly in those who had received neo-adjuvant radiotherapy. Most factors associated with possible or probable depression may be modified with appropriate intervention.

Patients' needs following colorectal cancer diagnosis: where does primary care fit in?

BACKGROUNDnColorectal cancer is the third most common cancer in the UK. Patients with colorectal cancer spend most of their time in the community, but the role of primary care in their management and follow-up is unclear.nnnAIMnTo explore colorectal cancer patients experiences of psychosocial problems and their management in primary and specialist care.nnnDESIGN AND SETTINGnLongitudinal qualitative study of participants recruited from three hospitals in the west of Scotland and interviewed in their own homes.nnnMETHODnIn-depth interviews with 24 participants with a new diagnosis of colorectal cancer, and then follow-up interviews 12 months later.nnnRESULTSnParticipants needs following a diagnosis for colorectal cancer included physical, psychological, and social issues. GPs played a key role in diagnosis, after which they were less involved. Participants valued GPs making unsolicited contact and offering support. Participants described being well supported by clinical nurse specialists who are expert in the illness, and who provide continuity of care and psychological support. A year after diagnosis, when there was less contact with GPs and clinical nurse specialists, participants still faced challenges associated with the ongoing impact of colorectal cancer.nnnCONCLUSIONnWhile some patients enjoyed straightforward recoveries from surgery, others experienced longer-term implications from their disease and treatment, particularly bowel-function issues, fatigue, anxiety, and sexual problems. The potential for primary care to contribute more to the ongoing care of colorectal cancer patients was identified.

The role of primary care in cancer diagnosis via emergency presentation : qualitative synthesis of significant event reports.

Background:Patients diagnosed with cancer in the context of an emergency presentation (EP) have poorer outcomes. It is often assumed that such patients present to the emergency department without consulting their general practitioner (GP). Little work has been done to identify primary care involvement before hospital attendance.Methods:Participating primary care practices completed a significant event audit (SEA) report for the last patient diagnosed with cancer as a result of an EP. Accounts were synthesised and a qualitative approach to analysis undertaken.Results:SEAs for 222 patients were analysed. A range of cancers were included, the most common being lung (32.4%) and upper gastrointestinal (19.8%). In most cases, patients had contact with their practice before diagnosis, primarily in the period immediately before admission. In only eight cases had there been no input from primary care. Accounts of protracted primary care contact generally demonstrated complexity, often related to comorbidity, patient-mediated factors or reassurance provided by negative investigations. Learning points identified by practices centred on the themes of presentation and diagnosis, consultation and safety-netting, communication and system issues, patient factors and referral guidelines.Conclusions:There is extensive primary care input into patients whose diagnosis results from EP, and for the most part potential ‘delay’ in referral can be reasonably explained by the complexity of the presentation or by coexisting patient factors.