BACKGROUND:
Minimising diagnostic delays in cancer may help improve survival. Ethnic minorities have worse outcomes in some cancer types when compared to the majority; this may relate in part to differences during the diagnostic phase. Only a few British studies have specifically explored this relationship, and no synthesis of these exists. The present study aimed to systematically review evidence on ethnic inequalities in cancer diagnosis, focussing on patient and primary care intervals of diagnosis.
METHODS:
Six electronic databases were searched. Included studies were those conducted in the UK or elsewhere (where access to healthcare is comparable to the NHS) and those that described a time element during diagnosis. Study quality was evaluated using the Critical Appraisal Skills Programme (CASP) checklist for cohort studies and synthesis method was narrative.
RESULTS:
Seven of 8,520 studies retrieved by our search met the review criteria; six conducted in the UK, and one in New Zealand. Five (including one covering several sites) focused on breast cancer, one on prostate, and one on oesophagogastric cancer. The studies employed different methods of ascertainment and definition of ethnic groups and defined diagnostic delay in a non-standardised way; therefore, narrative synthesis was performed. In breast cancer, three studies reported longer diagnostic intervals among ethnic minorities and two found no evidence of differences by ethnicity. There was some evidence of longer diagnostic and referral intervals among ethnic minorities in oesophagogastric and colorectal cancers, but no evidence of this in prostate, non-Hodgkin's lymphoma, lung, and ovarian cancers. None of the studies identified shorter patient or primary care intervals in ethnic minorities.
CONCLUSIONS:
Existing studies provide insufficient evidence to confirm or refute ethnic inequalities in diagnostic intervals of cancer. Further studies are necessary to examine common cancer types including those frequently found in ethnic minorities (in addition to those covered here) and using current definitions of intervals in cancer diagnosis.

Diagnostic delay is deemed to account for an estimated 5000 to 10 000 extra cancer deaths each year in the UK. Many cancer patients do not have symptoms meeting national referral criteria for rapid investigation. Risk assessment tools (RATs) have been developed to assist GPs in selecting patient for cancer investigation.
To assess the usability and acceptability of lung and colorectal RATs, as well as subsequent resource use and cancer diagnoses.
Cohort study with nested qualitative study with 614 GPs from 165 practices in seven English cancer networks were provided with RATs applicable to patients aged ≥40 years with bowel or respiratory symptoms. In-depth interviews were conducted with 34 individuals (11 project managers and 23 GPs).
The study measured the number of RATs used, and subsequent cancer investigations and diagnoses, over a 6-month period and compared these with the previous 6 months.
A total of 2593 RATs (1160 lung, 1433 colorectal) were completed. Compared with the preceding 6 months, there were 292 more chest X-rays, 104 extra 2-week chest clinic appointments, and 47 additional diagnoses of lung cancer. For suspected colorectal cancer, there were 304 more 2-week referrals, 270 more colonoscopies, and 10 more cancers identified. RATs appeared to help GPs in their selection of patients for cancer investigation. Users reported that RATs helped to confirm a need for investigation as well as allowing reassurance when investigation was not needed.
Use of RATs in primary care was accompanied by increased diagnostic activity and additional cancer diagnoses.

Background. The UK has an estimated 5–10000 extra cancer deaths each year when compared to other European countries and diagnostic delays are thought to make a significant contribution to this. One of the initiatives in England intended to support primary care professionals has been the development of cancer risk assessment tools (RATs). These tools assist in identifying and quantifying the risk of cancer in symptomatic primary care patients.Objective. To explore GPs’ experiences of incorporating the RATs for lung and bowel cancers into their clinical practice and in so doing, identify constraints and facilitators to the wider dissemination of the tools in primary care.Methods. We conducted semi-structured interviews over the telephone with 11 project managers who implemented the study and 23 GPs who used the tool. The interviews were digitally recorded, professionally transcribed verbatim and analysed through the construction of a ‘thematic framework’.Results. The training and support package was fundamental to the successful integration of the RATs into GPs’ daily routines. Ongoing support from cancer networks alongside acknowledgement of the clinical expertize of the GPs by those implementing the study enhanced GPs’ uptake of the tool in practice.Conclusion. Findings suggest that the embedding of clinical decision support tools into clinical practice is more likely to be achieved when they are perceived to support but not supersede the clinical judgement of their users. This element of our findings is a focal point of this article.

Few data on obesity exist on Sub-Sahara population in Africa. This study investigated the prevalence of obesity and Body Mass Index (BMI) percentile and quartiles in accordance with sex and age in adult residents of the historic ancient semi-urban community of Ile-Ife, South-West, Nigeria.
2097 adults aged 21 years and above were recruited into the door-to-door survey through a multistage cluster sampling technique. The World Health Organization (WHO) criteria based on BMI was used in the definition of overweight and obesity. Height and weight were measured using standardized procedures.
The mean age and BMI of the participants were 44.2 years and 24.2 Kg/m2 respectively. Although age-matched; the females had higher BMI values compared to males (23.8 vs. 24.5 Kg/m2). The overall crude prevalence of overweight (25.0-29.9 Kg/m2) and obesity (>30 Kg/m2) were 20.3% and 12.5% respectively. The rates of overweight (17.9 vs. 22.1 Kg/m2) and obesity (9.7 vs. 14.5 Kg/m2) were both higher in women than men. Obesity increased across age gradient from young to old adults; peaking in the 60-69-year age group. The first to fourth BMI quartiles were = 20.4 Kg/m2, 20.5-24.1 Kg/m2, 24.2-25.2 Kg/m2, = 25.3 Kg/mr respectively in the study population. At all ages; more females (32.4%) than males (24.7%) were placed within fourth BMI quartile. The 95th percentile BMI in the study population was 33.4 Kg/m2.
Overweight and obesity are common in Nigerians, particular among females and elderly. The prevalence estimates of overweight and obesity in Nigerians is comparable with prevalence among Blacks in other populations.

BACKGROUND:

Hypertension has been reported to be a major problem of the blacks. There is a paucity of studies, however, on community-based surveys on the prevalence and pattern of hypertension in Nigeria in the recent time. This study sought to investigate the prevalence and pattern of hypertension in the adult population living in the ancient semiurban community of Ile-Ife, southwest Nigeria.

DESIGN AND METHODS:

Two thousand and ninety-seven adults of above 20 years of age were recruited into the door-to-door survey through a multistage cluster sampling technique. Diagnosis of hypertension was based on blood pressure (BP) threshold of 160/95 mmHg and the World Health Organization /International Society of Hypertension guidelines (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines) definitions. Resting blood pressure was taken using electronic sphygmomanometer.

RESULTS:

The mean age and BP of the participants were aged 44.2 +/- 11.6 years and 127/77 mmHg, respectively. The participants (36.6%) had a BP of greater than or equal to 140/90 mmHg whereas 13.3% had BP of greater than or equal to 160/95 mmHg. 22.1% had isolated systolic hypertension whereas 14.5% had isolated diastolic hypertension using the BP of greater than or equal to 140/90 mmHg cut off-point. Using the BP of greater than or equal to 160/95 mmHg, isolated systolic hypertension and isolated diastolic hypertension were 6.63%, respectively. A male-to-female ratio of 1.7 : 1 and 1 : 5 was observed for BP greater than or equal to 140/90 mmHg and BP greater than or equal to 160/95 mmHg, respectively. Hypertension prevalence increased across age gradient from young to old adults.

CONCLUSION:

The prevalence estimates of hypertension obtained in this study was higher than those found in most earlier studies from Nigeria, other West Africa nations and for African-Americans.

ABSTRACTObjectiveTo assess the effectiveness of a targeted postal promotion for improving cancer symptom awareness and increasing help-seeking in general practice, on subsequent general practitioner (GP) consultation rates in a population which has made infrequent use of consultations at their local practice.Setting23 general practices in England.DesignRandomised controlled trial comparing a mailed leaflet providing information on six key cancer symptoms plus a covering letter signed by their general practitioner designed to reduce barriers to primary care help-seeking (intervention arm), with usual care (control arm).Participants1,513 adults aged 50-84 years (783 individually randomised to the intervention arm and 730 individually randomised to the control arm) who had not consulted their GP in the last 12 months and had at least two other risk factors for late presentation with cancer, identified by practice staff between November 2016 and May 2017. 749 individuals in the intervention arm and 705 in the control arm were included in the intention to treat analyses.Outcome measureThe primary outcome was number of GP consultations in the six months subsequent to mailing of the intervention.ResultsThere was a significantly higher rate of consultation in the intervention arm: 436 consultations compared to 335 in the control arm (RR = 1.40, 95% CI 1.11-1.77, p=0.004). However, there was no difference in the numbers of persons consulting their GP, with 165 in each group.ConclusionsTargeted interventions of this nature can change behaviour. This intervention stimulated a greater number of consultations but not a greater number of patients consulting. There is a need to develop interventions which can be more effective on the broader less engaged population.Trial registrationThe trial was registered prospectively on the International Standard Randomised Controlled Trial Number (ISRCTN) registry (ISRCTN95610478).FundingThis research is funded by the National Institute for Health Research (NIHR) Policy Research Programme, conducted through the Policy Research Unit in Cancer Awareness, Screening and Early Diagnosis, 106/0001. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Additional support, including NHS service support costs, were provided by the National Institute for Health Research Clinical Research Network (NIHR CRN) (UKCRN ID 31163).

Background: This study investigated ethnic differences in diagnostic interval (DI)—the period between initial primary care presentation and diagnosis. Methods: We analysed the primary care-linked data of patients who reported features of seven cancers (breast, lung, prostate, colorectal, oesophagogastric, myeloma, and ovarian) one year before diagnosis. Accelerated failure time (AFT) models investigated the association between DI and ethnicity, adjusting for age, sex, deprivation, and morbidity. Results: of 126,627 eligible participants, 92.1% were White, 1.99% Black, 1.71% Asian, 1.83% Mixed, and 2.36% were of Other ethnic backgrounds. Considering all cancer sites combined, the median (interquartile range) DI was 55 (20–175) days, longest in lung [127, (42–265) days], and shortest in breast cancer [13 (13, 8–18) days]. DI for the Black and Asian groups was 10% (AFT ratio, 95%CI 1.10, 1.05–1.14) and 16% (1.16, 1.10–1.22), respectively, longer than for the White group. Site-specific analyses revealed evidence of longer DI in Asian and Black patients with prostate, colorectal, and oesophagogastric cancer, plus Black patients with breast cancer and myeloma, and the Mixed group with lung cancer compared with White patients. DI was shorter for the Other group with lung, prostate, myeloma, and oesophagogastric cancer than the White group. Conclusion: We found limited and inconsistent evidence of ethnic differences in DI among patients who reported cancer features in primary care before diagnosis. Our findings suggest that inequalities in diagnostic intervals, where present, are unlikely to be the sole explanation for ethnic variations in cancer outcomes.

BACKGROUND: UK Asian and Black ethnic groups have poorer outcomes for some cancers and are less likely to report a positive care experience than their White counterparts. This study investigated ethnic differences in the route to diagnosis (RTD) to identify areas in patients' cancer journeys where inequalities lie, and targeted intervention might have optimum impact. METHODS: We analysed data of 243,825 patients with 10 cancers (2006-2016) from the RTD project linked to primary care data. Crude and adjusted proportions of patients diagnosed via six routes (emergency, elective GP referral, two-week wait (2WW), screen-detected, hospital, and Other routes) were calculated by ethnicity. Adjusted odds ratios (including two-way interactions between cancer and age, sex, IMD, and ethnicity) determined cancer-specific differences in RTD by ethnicity. RESULTS: Across the 10 cancers studied, most patients were diagnosed via 2WW (36.4%), elective GP referral (23.2%), emergency (18.2%), hospital routes (10.3%), and screening (8.61%). Patients of Other ethnic group had the highest proportion of diagnosis via the emergency route, followed by White patients. Asian and Black group were more likely to be GP-referred, with the Black and Mixed groups also more likely to follow the 2WW route. However, there were notable cancer-specific differences in the RTD by ethnicity. CONCLUSION: Our findings suggest that, where inequalities exist, the adverse cancer outcomes among Asian and Black patients are unlikely to be arising solely from a poorer diagnostic process.

OBJECTIVE: the objective of this study is to investigate primary care use by men with recent onset of lower urinary tract symptoms (LUTS) to identify differences in presentation and investigation that may explain ethnic inequality in prostate cancer outcomes. METHODS: This is a multi-method study of men presenting LUTS to primary care. Two hundred seventy-four men completed a self-administered questionnaire, and 23 participated in face-to-face interviews. Regression analyses investigated ethnic differences in (a) the period between symptom onset and first primary care presentation (patient interval) and (b) the interval between first primary care presentation and investigation with prostate-specific antigen (PSA) and digital rectal examination (DRE). Interview data were analysed using thematic analysis. RESULTS: Half (144, 53%) reported a solitary first symptom, although multiple first symptoms were also common, particularly in Asian and Black men. There was no difference between ethnicities in patient interval or time from presentation to investigation. However, Asian men were offered less PSA testing (odds ratio 0.39; 95% confidence interval 0.17-0.92; p = 0.03). Qualitative data revealed ethnic differences in general practitioners' offer of DRE and PSA testing and highlighted limitations in doctor-patient communication and safety netting. CONCLUSION: Our study showed only small differences in primary care experiences, insufficient to explain ethnic inequalities in prostate cancer outcomes.

BACKGROUND: for some common cancers, survival is lower in the UK than in comparable high-income countries. AIM: to assess the effectiveness of a targeted postal intervention (to promote awareness of cancer symptoms and earlier help seeking) on patient consultation rates. DESIGN AND SETTING: a two-arm randomised controlled trial was carried out on patients aged 50-84 years registered at 23 general practices in rural and urban areas of Greater London, Greater Manchester, and the North East of England. METHOD: Patients who had not had a consultation at their general practice in the previous 12 months and had at least two other risk factors for late presentation with cancer were randomised to intervention and control arms. The intervention consisted of a posted letter and leaflet. Primary outcome was the number of consultations at the practice with patients randomised to each arm in the 6 months subsequent to posting the intervention. All patients with outcome data were included in the intention-to-treat analyses. RESULTS: in total, 1513 patients were individually randomised to the intervention (n = 783) and control (n = 730) arms between Nov 2016 - May 2017; outcome data were available for 749 and 705 patients, respectively, with a statistically significantly higher rate of consultation in the intervention arm compared with the control arm: 436 versus 335 consultations (relative risk 1.40, 95% confidence interval = 1.11 to 1.77, P = 0.004). There was, however, no difference in the numbers of patients consulting. CONCLUSION: Targeted interventions of this nature can change behaviour; there is a need to develop interventions that can be more effective at engaging patients with primary care. This study demonstrates that targeted interventions promoting both awareness of possible cancer symptoms and earlier health seeking, can change behaviour. There is a need to develop and test interventions that can be more effective at engaging the most at-risk patients.

BackgroundMost cancers in sub-Saharan Africa (SSA) are diagnosed at advanced stages, with limited treatment options and poor outcomes. Part of this may be linked to various events occurring in patients’ journey to diagnosis. Using the model of pathways to treatment, we examined the evidence regarding the routes to cancer diagnosis in SSA.Design and settingsA systematic review of available literature was performed.MethodsThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Between 30 September and 30 November 2019, seven electronic databases were searched using terms relating to SSA countries, cancer and routes to diagnosis comprising the population, exposure and outcomes, respectively. Citation lists of included studies were manually searched to identify relevant studies. Furthermore, ProQuest Dissertations & Theses Global was searched to identify appropriate grey literature on the subject.Results18 of 5083 references identified met the inclusion criteria: eight focused on breast cancer; three focused on cervical cancer; two each focused on lymphoma, Kaposi’s sarcoma and childhood cancers; and one focused on colorectal cancer. With the exception of Kaposi’s sarcoma, definitive diagnoses were made in tertiary healthcare centres, including teaching and regional hospitals. The majority of participants initially consulted within primary care, although a considerable proportion first used complementary medicine before seeking conventional medical help. The quality of included studies was a major concern, but their findings provided important insight into the pathways to cancer diagnosis in the region.ConclusionThe proportion of patients who initially use complementary medicine in their cancer journey may explain a fraction of advanced-stage diagnosis and poor survival of cancer in SSA. However, further research would be necessary to fully understand the exact role (or activities) of primary care and alternative care providers in patient cancer journeys.

BACKGROUND: Ethnic minorities in multi-ethnic societies like the UK and USA have poorer outcomes for some cancer types when compared with the majority. The causes of ethnic inequalities in cancer outcomes are complex and not fully understood. In particular, the potential role of health literacy on symptomatic presentation and diagnostic interval (the period between first consultation within primary care and definitive diagnosis of cancer) by ethnicity is unknown. Given the increasing need for shared decision-making and patient involvement in the diagnostic process, understanding the potential impact of the differences in health literacy may help redress ethnic inequality in cancer outcomes. The present study aims to critically examine the evidence in this area. METHODS: Seven electronic databases will be searched using keywords and controlled vocabulary related to ethnicity, health literacy, cancer diagnosis and cancer outcomes. Citations and bibliography searches of included studies will be performed to identify relevant studies that have cited eligible articles. Authors of included studies will be contacted to identify unpublished studies. Eligible studies will be restricted to primary cancers. Study quality will be evaluated in using the Critical Appraisal Skills Programme (CASP) checklists. A descriptive summary of selected studies will be presented, and the synthesis will follow a narrative framework. DISCUSSION: This systematic review will summarise the evidence regarding ethnic inequality in health literacy and how this impacts on diagnosis and outcomes of cancer. The review will identify possible areas for future research, and inform clinical practice and interventions to reduce ethnic inequalities in cancer diagnosis and outcomes.

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). Sensitivity was lower for: anaemia 0.12 [95% Cl = 0.08 to 0.19] with specificity 0.97 [95% Cl = 0.94 to 0.99]; nausea/vomiting/bloating 0.17 [95% Cl = 0.05 to 0.46] and 0.84 [95% Cl = 0.60 to 0.94] respectively; reflux 0.23 [95% Cl = 0.10 to 0.46] and 0.70 [95% Cl = 0.59 to 0.80]; weight loss 0.25 [95% Cl = 0.12 to 0.43] and 0.96 [95% Cl = 0.88 to 0.98]. [corrected]. 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.

Background: 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 Aim: 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. Method: 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. Results: 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

BACKGROUND: the UK has an estimated 5-10000 extra cancer deaths each year when compared to other European countries and diagnostic delays are thought to make a significant contribution to this. One of the initiatives in England intended to support primary care professionals has been the development of cancer risk assessment tools (RATs). These tools assist in identifying and quantifying the risk of cancer in symptomatic primary care patients. OBJECTIVE: to explore GPs' experiences of incorporating the RATs for lung and bowel cancers into their clinical practice and in so doing, identify constraints and facilitators to the wider dissemination of the tools in primary care. METHODS: We conducted semi-structured interviews over the telephone with 11 project managers who implemented the study and 23 GPs who used the tool. The interviews were digitally recorded, professionally transcribed verbatim and analysed through the construction of a 'thematic framework'. RESULTS: the training and support package was fundamental to the successful integration of the RATs into GPs' daily routines. Ongoing support from cancer networks alongside acknowledgement of the clinical expertize of the GPs by those implementing the study enhanced GPs' uptake of the tool in practice. CONCLUSION: Findings suggest that the embedding of clinical decision support tools into clinical practice is more likely to be achieved when they are perceived to support but not supersede the clinical judgement of their users. This element of our findings is a focal point of this article.

BACKGROUND: Minimising diagnostic delays in cancer may help improve survival. Ethnic minorities have worse outcomes in some cancer types when compared to the majority; this may relate in part to differences during the diagnostic phase. Only a few British studies have specifically explored this relationship, and no synthesis of these exists. The present study aimed to systematically review evidence on ethnic inequalities in cancer diagnosis, focussing on patient and primary care intervals of diagnosis. METHODS: Six electronic databases were searched. Included studies were those conducted in the UK or elsewhere (where access to healthcare is comparable to the NHS) and those that described a time element during diagnosis. Study quality was evaluated using the Critical Appraisal Skills Programme (CASP) checklist for cohort studies and synthesis method was narrative. RESULTS: Seven of 8,520 studies retrieved by our search met the review criteria; six conducted in the UK, and one in New Zealand. Five (including one covering several sites) focused on breast cancer, one on prostate, and one on oesophagogastric cancer. The studies employed different methods of ascertainment and definition of ethnic groups and defined diagnostic delay in a non-standardised way; therefore, narrative synthesis was performed. In breast cancer, three studies reported longer diagnostic intervals among ethnic minorities and two found no evidence of differences by ethnicity. There was some evidence of longer diagnostic and referral intervals among ethnic minorities in oesophagogastric and colorectal cancers, but no evidence of this in prostate, non-Hodgkin's lymphoma, lung, and ovarian cancers. None of the studies identified shorter patient or primary care intervals in ethnic minorities. CONCLUSIONS: Existing studies provide insufficient evidence to confirm or refute ethnic inequalities in diagnostic intervals of cancer. Further studies are necessary to examine common cancer types including those frequently found in ethnic minorities (in addition to those covered here) and using current definitions of intervals in cancer diagnosis.