Publications by year
In Press
Ukoumunne OC, Moore H, Nixon C, Tariq A, Hamilton W, Hoare Z, Kershenbaum A, Neal RD, Usher-Smith J, Walter FM, et al (In Press). Evaluating a computer aid for assessing stomach symptoms (ECASS): study protocol for a multi-site phase II exploratory cluster randomised controlled trial.
TrialsAbstract:
Evaluating a computer aid for assessing stomach symptoms (ECASS): study protocol for a multi-site phase II exploratory cluster randomised controlled trial
Background
For most cancers, only a minority of patients have symptoms meeting the National Institute for Health and Clinical Excellence guidance for urgent referral. For gastro-oesophageal cancers, the ‘alarm’ symptoms of dysphagia and weight loss are reported by only 32% and 8% of patients respectively and their presence correlates with advanced stage disease. Electronic clinical decision support tools which integrate with clinical computer systems have been developed for general practice, although there is uncertainty about their effectiveness. The objectives of this trial are to optimise the intervention and establish acceptability of both the intervention and randomisation; confirm the suitability and selection of outcome measures; finalise design for the phase III definitive trial; and obtain preliminary estimates of the intervention effect.
Methods/Design
This is a two-arm, multi-centre, cluster randomised controlled phase II trial design, over a 16-month period, across 60 general practices within the North East & North Cumbria and Eastern Local Clinical Research Network areas. Practices will be randomised to receive either the intervention (electronic clinical decision support tool) or to act as control (usual care). From these practices, we will recruit 3000 adults who meet the trial eligibility criteria and present to their GP with symptoms potentially of gastro-oesophageal cancer. The main measures are process data, to include practitioner outcomes, service outcomes, diagnostic intervals, health economic outcomes and patient outcomes. 1:1 interviews in a sub-sample of 30 patient-GP dyads, will be undertaken to understand the impact of the use or non-use of the electronic clinical decision support tool in the consultation. A further 10-15 GPs will be interviewed to identify and gain an understanding of the facilitators and constraints influencing implementation of the electronic clinical decision support tool in practice.
Discussion
We aim to generate new knowledge on the process measures regarding use of electronic clinical decision support tools in primary care in general and to inform a subsequent definitive phase III trial. Preliminary data on the impact on resource utilisation and health care costs of the support tool will also be collected.
Abstract.
Walter F, Thompson MJ, Wellwood I, Abel G, Hamilton W, Johnson M, Lyratzopoulos G, Messenger M, Neal R, Greg R, et al (In Press). Evaluating diagnostic strategies for early detection of cancer: the CanTest Framework. BMC Cancer
2023
Muller D, Wilding S, Goss V, Walters J, Cazaly A, Ball D, Eckert C, Nutall J, Roberts C, Heinson A, et al (2023). 159 Research on the road: taking lung cancer research to the patient. Lung Cancer, 178, s69-s70.
Smith L, Carmichael J, Cook G, Shinkins B, Neal RD (2023). Development and Internal Validation of a Risk Prediction Model to Identify Myeloma Based on Routine Blood Tests: a Case-Control Study.
Cancers (Basel),
15(3).
Abstract:
Development and Internal Validation of a Risk Prediction Model to Identify Myeloma Based on Routine Blood Tests: a Case-Control Study.
Myeloma is one of the hardest cancers to diagnose in primary care due to its rarity and non-specific symptoms. A rate-limiting step in diagnosing myeloma is the clinician considering myeloma and initiating appropriate investigations. We developed and internally validated a risk prediction model to identify those with a high risk of having undiagnosed myeloma based on results from routine blood tests taken for other reasons. A case-control study, based on 367 myeloma cases and 1488 age- and sex-matched controls, was used to develop a risk prediction model including results from 15 blood tests. The model had excellent discrimination (C-statistic 0.85 (95%CI 0.83, 0.89)) and good calibration (calibration slope 0.87 (95%CI 0.75, 0.90)). At a prevalence of 15 per 100,000 population and a probability threshold of 0.4, approximately 600 patients would need additional reflex testing to detect one case. We showed that it is possible to combine signals and abnormalities from several routine blood test parameters to identify individuals at high-risk of having undiagnosed myeloma who may benefit from additional reflex testing. Further work is needed to explore the full potential of such a strategy, including whether it is clinically useful and cost-effective and how to make it ethically acceptable.
Abstract.
Author URL.
Anthony BF, Disbeschl S, Goulden N, Hendry A, Hiscock J, Hoare Z, Roberts J, Rose J, Surgey A, Williams NH, et al (2023). Earlier cancer diagnosis in primary care: a feasibility economic analysis of ThinkCancer!.
BJGP Open,
7(1).
Abstract:
Earlier cancer diagnosis in primary care: a feasibility economic analysis of ThinkCancer!
BACKGROUND: UK cancer survival rates are much lower compared with other high-income countries. In primary care, there are opportunities for GPs and other healthcare professionals to act more quickly in response to presented symptoms that might represent cancer. ThinkCancer! is a complex behaviour change intervention aimed at primary care practice teams to improve the timely diagnosis of cancer. AIM: to explore the costs of delivering the ThinkCancer! intervention to expedite cancer diagnosis in primary care. DESIGN & SETTING: Feasibility economic analysis using a micro-costing approach, which was undertaken in 19 general practices in Wales, UK. METHOD: from an NHS perspective, micro-costing methodology was used to determine whether it was feasible to gather sufficient economic data to cost the ThinkCancer! INTERVENTION: Owing to the COVID-19 pandemic, ThinkCancer! was mainly delivered remotely online in a digital format. Budget impact analysis (BIA) and sensitivity analysis were conducted to explore the costs of face-to-face delivery of the ThinkCancer! intervention as intended pre-COVID-19. RESULTS: the total costs of delivering the ThinkCancer! intervention across 19 general practices in Wales was £25 030, with an average cost per practice of £1317 (standard deviation [SD]: 578.2). Findings from the BIA indicated a total cost of £34 630 for face-to-face delivery. CONCLUSION: Data collection methods were successful in gathering sufficient health economics data to cost the ThinkCancer! INTERVENTION: Results of this feasibility study will be used to inform a future definitive economic evaluation alongside a pragmatic randomised controlled trial (RCT).
Abstract.
Author URL.
Jones DJ, Ali O, Honey S, Surr C, Scott S, de Wit N, Neal R (2023). Patient’s views on the decision to investigate cancer symptoms in older adults: a qualitative interview study. British Journal of General Practice
2022
Smith S, Ellison R, Hall L, Clark J, Hartley S, Mason E, Wilkes H, Metherell J, Olivier C, Napp V, et al (2022). Acceptance and Commitment Therapy to support medication decision-making and quality of life in women with breast cancer: protocol for a pilot randomised controlled trial.
Author URL.
Smith AF, Frempong SN, Sharma N, Neal RD, Hick L, Shinkins B (2022). An exploratory assessment of the impact of a novel risk assessment test on breast cancer clinic waiting times and workflow: a discrete event simulation model.
Konya J, Neal RD, Clark C, Bearman D, Campbell J (2022). Can early cancer detection be improved in deprived areas by involving community pharmacists?.
Br J Gen Pract,
72(717), 153-154.
Author URL.
Ashley L, Surr C, Kelley R, Price M, Griffiths AW, Fowler NR, Giza DE, Neal RD, Martin C, Hopkinson JB, et al (2022). Cancer care for people with dementia: Literature overview and recommendations for practice and research.
CA-A CANCER JOURNAL FOR CLINICIANS Author URL.
Neal RD, Johnson P, Clarke CA, Hamilton SA, Zhang N, Kumar H, Swanton C, Sasieni P (2022). Cell-Free DNA-Based Multi-Cancer Early Detection Test in an Asymptomatic Screening Population (NHS-Galleri): Design of a Pragmatic, Prospective Randomised Controlled Trial.
CANCERS,
14(19).
Author URL.
Savage R, Messenger M, Neal RD, Ferguson R, Johnston C, Lloyd KL, Neal MD, Sansom N, Selby P, Sharma N, et al (2022). Development and validation of multivariable machine learning algorithms to predict risk of cancer in symptomatic patients referred urgently from primary care: a diagnostic accuracy study.
BMJ Open,
12(4).
Abstract:
Development and validation of multivariable machine learning algorithms to predict risk of cancer in symptomatic patients referred urgently from primary care: a diagnostic accuracy study.
OBJECTIVES: to develop and validate tests to assess the risk of any cancer for patients referred to the NHS Urgent Suspected Cancer (2-week wait, 2WW) clinical pathways. SETTING: Primary and secondary care, one participating regional centre. PARTICIPANTS: Retrospective analysis of data from 371 799 consecutive 2WW referrals in the Leeds region from 2011 to 2019. The development cohort was composed of 224 669 consecutive patients with an urgent suspected cancer referral in Leeds between January 2011 and December 2016. The diagnostic algorithms developed were then externally validated on a similar consecutive sample of 147 130 patients (between January 2017 and December 2019). All such patients over the age of 18 with a minimum set of blood counts and biochemistry measurements available were included in the cohort. PRIMARY AND SECONDARY OUTCOME MEASURES: sensitivity, specificity, negative predictive value, positive predictive value, Receiver Operating Characteristic (ROC) curve Area Under Curve (AUC), calibration curves RESULTS: We present results for two clinical use-cases. In use-case 1, the algorithms identify 20% of patients who do not have cancer and may not need an urgent 2WW referral. In use-case 2, they identify 90% of cancer cases with a high probability of cancer that could be prioritised for review. CONCLUSIONS: Combining a panel of widely available blood markers produces effective blood tests for cancer for NHS 2WW patients. The tests are affordable, and can be deployed rapidly to any NHS pathology laboratory with no additional hardware requirements.
Abstract.
Author URL.
Smith L, Carmichael J, Cook G, Shinkins B, Neal RD (2022). Diagnosing myeloma in general practice: how might earlier diagnosis be achieved?. British Journal of General Practice, 72(723), 462-463.
Menon U, Weller D, Falborg AZ, Jensen H, Butler J, Barisic A, Knudsen AK, Bergin RJ, Brewster DH, Cairnduff V, et al (2022). Diagnostic Routes and Time Intervals for Ovarian Cancer in Nine International Jurisdictions; Findings from the International Cancer Benchmarking Partnership (ICBP). Obstetrical & Gynecological Survey, 77(12), 739-740.
Vedsted P, Weller D, Zalounina Falborg A, Jensen H, Kalsi J, Brewster D, Lin Y, Gavin A, Barisic A, Grunfeld E, et al (2022). Diagnostic pathways for breast cancer in 10 International Cancer Benchmarking Partnership (ICBP) jurisdictions: an international comparative cohort study based on questionnaire and registry data.
BMJ Open,
12(12).
Abstract:
Diagnostic pathways for breast cancer in 10 International Cancer Benchmarking Partnership (ICBP) jurisdictions: an international comparative cohort study based on questionnaire and registry data.
OBJECTIVES: a growing body of evidence suggests longer time between symptom onset and start of treatment affects breast cancer prognosis. To explore this association, the International Cancer Benchmarking Partnership Module 4 examined differences in breast cancer diagnostic pathways in 10 jurisdictions across Australia, Canada, Denmark, Norway, Sweden and the UK. SETTING: Primary care in 10 jurisdictions. PARTICIPANT: Data were collated from 3471 women aged >40 diagnosed for the first time with breast cancer and surveyed between 2013 and 2015. Data were supplemented by feedback from their primary care physicians (PCPs), cancer treatment specialists and available registry data. PRIMARY AND SECONDARY OUTCOME MEASURES: Patient, primary care, diagnostic and treatment intervals. RESULTS: Overall, 56% of women reported symptoms to primary care, with 66% first noticing lumps or breast changes. PCPs reported 77% presented with symptoms, of whom 81% were urgently referred with suspicion of cancer (ranging from 62% to 92%; Norway and Victoria). Ranges for median patient, primary care and diagnostic intervals (days) for symptomatic patients were 3-29 (Denmark and Sweden), 0-20 (seven jurisdictions and Ontario) and 8-29 (Denmark and Wales). Ranges for median treatment and total intervals (days) for all patients were 15-39 (Norway, Victoria and Manitoba) and 4-78 days (Sweden, Victoria and Ontario). The 10% longest waits ranged between 101 and 209 days (Sweden and Ontario). CONCLUSIONS: Large international differences in breast cancer diagnostic pathways exist, suggesting some jurisdictions develop more effective strategies to optimise pathways and reduce time intervals. Targeted awareness interventions could also facilitate more timely diagnosis of breast cancer.
Abstract.
Author URL.
Menon U, Weller D, Falborg AZ, Jensen H, Butler J, Barisic A, Knudsen AK, Bergin RJ, Brewster DH, Cairnduff V, et al (2022). Diagnostic routes and time intervals for ovarian cancer in nine international jurisdictions; findings from the International Cancer Benchmarking Partnership (ICBP). British Journal of Cancer, 127(5), 844-854.
Frempong SN, Shinkins B, Howdon D, Messenger M, Neal RD, Sagoo GS (2022). Early economic evaluation of an intervention to improve uptake of the NHS England Diabetes Prevention Programme.
Expert Review of Pharmacoeconomics and Outcomes Research,
22(3), 417-427.
Abstract:
Early economic evaluation of an intervention to improve uptake of the NHS England Diabetes Prevention Programme
Background: Despite reported increases in referral numbers, a large proportion of those with prediabetes still decline participation in the NHS England Diabetes Prevention Programme (NDPP). The aim of this study was to explore whether investment in interventions to improve uptake of the programme has the potential to be cost-effective. Methods: an early cost-utility analysis was conducted using a Markov model parameterized based on secondary data sources. We explored different uptake scenarios and the impact that this had on the maximum allowable intervention price based on cost-effectiveness at the UK NICE willingness to pay threshold of £20,000 (US$ 25,913). Value of information analyses were conducted to explore the potential value of further research to resolve uncertainty at each uptake level. Results: As uptake levels increase, the maximum allowable intervention price and overall expected value of removing decision uncertainty increases. For 5 percentage and 50 percentage points increase in uptake levels, the maximum allowable intervention price is £41.86 (US$ 54.23) and £418.59 (US$ 542.34) per person, and the overall expected value of removing decision uncertainty are £361,818,839 (US$ 468,786,625) and £1,468,712,316 (US$ 1,902,921,063) respectively. Conclusion: There is headroom for investment in interventions that improve uptake to the NDPP, thereby allowing the programme itself to be delivered in a manner that remains cost-effective.
Abstract.
Jones D, Di Martino E, Bradley SH, Essang B, Hemphill S, Wright JM, Renzi C, Surr C, Clegg A, De Wit N, et al (2022). Factors affecting the decision to investigate older adults with potential cancer symptoms: a systematic review.
Br J Gen Pract,
72(714), e1-e10.
Abstract:
Factors affecting the decision to investigate older adults with potential cancer symptoms: a systematic review.
BACKGROUND: Older age and frailty increase the risk of morbidity and mortality from cancer surgery and intolerance of chemotherapy and radiotherapy. The effect of old age on diagnostic intervals is unknown; however, older adults need a balanced approach to the diagnosis and management of cancer symptoms, considering the benefits of early diagnosis, patient preferences, and the likely prognosis of a cancer. AIM: to examine the association between older age and diagnostic processes for cancer, and the specific factors that affect diagnosis. DESIGN AND SETTING: a systematic literature review. METHOD: Electronic databases were searched for studies of patients aged >65 years presenting with cancer symptoms to primary care considering diagnostic decisions. Studies were analysed using thematic synthesis and according to the Synthesis Without Meta-analysis guidelines. RESULTS: Data from 54 studies with 230 729 participants were included. The majority of studies suggested an association between increasing age and prolonged diagnostic interval or deferral of a decision to investigate cancer symptoms. Thematic synthesis highlighted three important factors that resulted in uncertainty in decisions involving older adults: presence of frailty, comorbidities, and cognitive impairment. Data suggested patients wished to be involved in decision making, but the presence of cognitive impairment and the need for additional time within a consultation were significant barriers. CONCLUSION: This systematic review has highlighted uncertainty in the management of older adults with cancer symptoms. Patients and their family wished to be involved in these decisions. Given the uncertainty regarding optimum management of this group of patients, a shared decision-making approach is important.
Abstract.
Author URL.
Jones D, Di Martino E, Bradley SH, Essang B, Hemphill S, Wright JM, Renzi C, Surr C, Clegg A, Neal R, et al (2022). Factors influencing symptom appraisal and help-seeking of older adults with possible cancer: a mixed-methods systematic review.
British Journal of General Practice,
72(723), e702-e712.
Abstract:
Factors influencing symptom appraisal and help-seeking of older adults with possible cancer: a mixed-methods systematic review
BackgroundThe cancer burden falls predominantly on older (≥65 years) adults. Prompt presentation to primary care with cancer symptoms could result in earlier diagnosis. However, patient symptom appraisal and help-seeking decisions involving cancer symptoms are complex and may be further complicated in older adults.AimTo explore the effect of older age on patients’ appraisal of possible cancer symptoms and their decision to seek help for these symptoms.Design and settingMixed-methods systematic review.MethodMEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library, Web of Science Core Collection, ASSIA, the ISRCTN registry, and the National Institute for Health and Care Excellence were searched for studies on symptom appraisal and help-seeking decisions for cancer symptoms by adults aged ≥65 years. Studies were analysed using thematic synthesis and according to the Synthesis Without Meta-Analysis guidelines.ResultsEighty studies were included with a total of 32 995 participants. Studies suggested a possible association between increasing age and prolonged symptom appraisal interval. Reduced knowledge of cancer symptoms and differences in symptom interpretation may contribute to this prolonged interval. In contrast, in the current study a possible association was found between increasing age and prompt help-seeking. Themes affecting help-seeking in older adults included the influence of family and carers, competing priorities, fear, embarrassment, fatalism, comorbidities, a desire to avoid doctors, a perceived need to not waste doctors’ time, and patient self-management of symptoms.ConclusionThis review suggests that increasing age is associated with delayed cancer symptom appraisal. When symptoms are recognised as potentially serious, increasing age was associated with prompt help-seeking although other factors could prolong this. Policymakers, charities, and GPs should aim to ensure older adults are able to recognise potential symptoms of cancer and seek help promptly.
Abstract.
Zigman Suchsland M, Kowalski L, Burkhardt HA, Prado MG, Kessler LG, Yetisgen M, Au MA, Stephens KA, Farjah F, Schleyer AM, et al (2022). How Timely is Diagnosis of Lung Cancer? Cohort Study of Individuals with Lung Cancer Presenting in Ambulatory Care in the United States.
Cancers,
14(23), 5756-5756.
Abstract:
How Timely is Diagnosis of Lung Cancer? Cohort Study of Individuals with Lung Cancer Presenting in Ambulatory Care in the United States
The diagnosis of lung cancer in ambulatory settings is often challenging due to non-specific clinical presentation, but there are currently no clinical quality measures (CQMs) in the United States used to identify areas for practice improvement in diagnosis. We describe the pre-diagnostic time intervals among a retrospective cohort of 711 patients identified with primary lung cancer from 2012–2019 from ambulatory care clinics in Seattle, Washington USA. Electronic health record data were extracted for two years prior to diagnosis, and Natural Language Processing (NLP) applied to identify symptoms/signs from free text clinical fields. Time points were defined for initial symptomatic presentation, chest imaging, specialist consultation, diagnostic confirmation, and treatment initiation. Median and interquartile ranges (IQR) were calculated for intervals spanning these time points. The mean age of the cohort was 67.3 years, 54.1% had Stage III or IV disease and the majority were diagnosed after clinical presentation (94.5%) rather than screening (5.5%). Median intervals from first recorded symptoms/signs to diagnosis was 570 days (IQR 273–691), from chest CT or chest X-ray imaging to diagnosis 43 days (IQR 11–240), specialist consultation to diagnosis 72 days (IQR 13–456), and from diagnosis to treatment initiation 7 days (IQR 0–36). Symptoms/signs associated with lung cancer can be identified over a year prior to diagnosis using NLP, highlighting the need for CQMs to improve timeliness of diagnosis.
Abstract.
Anthony BF, Disbeschl S, Goulden N, Hendry A, Hiscock J, Hoare Z, Lewis R, Roberts J, Rose J, Surgey A, et al (2022). Improving the diagnosis of cancer in primary care: a feasibility economic analysis of the ThinkCancer! study. International Journal for Population Data Science, 7(2).
di Martino E, Smith L, Bradley SH, Hemphill S, Wright J, Renzi C, Bergin R, Emery J, Neal RD (2022). Incidence trends for twelve cancers in younger adults-a rapid review.
BRITISH JOURNAL OF CANCER,
126(10), 1374-1386.
Author URL.
Prout H, Tod A, Neal R, Nelson A (2022). Maximising recruitment of research participants into a general practice based randomised controlled trial concerning lung diagnosis-staff insights from an embedded qualitative study.
Trials,
23(1).
Abstract:
Maximising recruitment of research participants into a general practice based randomised controlled trial concerning lung diagnosis-staff insights from an embedded qualitative study.
BACKGROUND: the ELCID Trial was a feasibility randomised controlled trial examining the effect on lung cancer diagnosis of lowering the threshold for referral for urgent chest X-ray for smokers and recent ex-smokers, aged over 60 with new chest symptoms. The qualitative component aimed to explore the feasibility of individually randomising patients to an urgent chest X-ray or not and to investigate any barriers to patient recruitment and participation. This would inform the design of any future definitive trial. This paper explores general practice staff insights into participating in and recruiting to diagnostic trials for possible/suspected lung cancer. METHODS: Qualitative interviews were conducted with 11 general practice staff which included general practitioners, a nurse practitioner, research nurses and practice managers. Interviews were analysed using a framework approach. RESULTS: Findings highlight general practice staff motivators to participate in the trial as recruiters, practice staff interactions with patients recruited onto the study, methods of organisation staff used to undertake the trial, the general impact of the trial on practice staff, how the trial research team supported the practices and lastly practice staff suggestions for trial delivery improvement. CONCLUSIONS: the integration of a qualitative component focused on staff experiences participating in a lung diagnostic trial has demonstrated the feasibility to recruit for similar future studies within general practice. Although recruitment into trials can be difficult, results from our study offer suggestions on maximising patient recruitment not just to trials in general but also specifically for a lung diagnosis study. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01344005. Registered on 27 April 2011.
Abstract.
Author URL.
Swanton C, Neal RD, Johnson PWM, Dur CC, Hamilton SA, Zhang N, Kumar H, Sasieni P (2022). NHS-Galleri Trial Design: Equitable study recruitment tactics for targeted population-level screening with a multi-cancer early detection (MCED) test. Journal of Clinical Oncology, 40(16_suppl), tps6606-tps6606.
Murray R, Brain K, Britton J, Lewis S, Thorley R, Baldwin D, Quaife S, Chalitsios C, Alexandris P, Crosbie P, et al (2022). PL03.03 Personalised Smoking Cessation Support in a Lung Cancer Screening Programme: the Yorkshire Enhanced Stop Smoking Study (YESS). Journal of Thoracic Oncology, 17(9).
Crosbie PAJ, Gabe R, Simmonds I, Hancock N, Alexandris P, Kennedy M, Rogerson S, Baldwin D, Booton R, Bradley C, et al (2022). Participation in community-based lung cancer screening: the Yorkshire Lung Screening Trial. European Respiratory Journal, 60(5).
Hall LH, King NV, Graham CD, Green SMC, Barber A, Neal RD, Foy R, Clark J, Lloyd KE, Smith SG, et al (2022). Strategies to self-manage side-effects of adjuvant endocrine therapy among breast cancer survivors: an umbrella review of empirical evidence and clinical guidelines.
Journal of Cancer Survivorship,
16(6), 1296-1338.
Abstract:
Strategies to self-manage side-effects of adjuvant endocrine therapy among breast cancer survivors: an umbrella review of empirical evidence and clinical guidelines
Purpose: Side-effects of adjuvant endocrine therapy (AET) are common in breast cancer survivors, and can affect adherence to treatment. We synthesised the evidence for strategies to self-manage these side-effects. Methods: We searched for systematic reviews and clinical guidelines on self-management strategies for AET side-effects (arthralgia, fatigue, hot flashes, gastrointestinal discomfort, nausea, vulvovaginal symptoms, and sleep disturbance). We searched oncology organisation’s websites and eight databases (Inception-November 2020). Screening, data extraction and quality assessment were completed independently in duplicate. PROSPERO: 2019CRD4201914001. Results: We identified 33 systematic reviews and 18 clinical guidelines. 21% of reviews were high quality, and the average quality score for guidelines was 44%. Evidence for most strategies was absent or weak. There was consensus from a low-quality review and multiple guidelines to recommend moisturisers, gels and lubricants for vulvovaginal symptoms. Evidence was weak for physical activity for self-managing most symptoms, although two high-quality reviews indicated yoga and aerobic exercise could reduce fatigue. Primary research was often biased by weak and underpowered study designs. Eleven reviews did not report information on adverse events. Conclusions: Most self-management strategies for breast cancer survivors experiencing side-effects from AET lack evidence. Primary research is needed using high-quality well-powered designs focusing on implementable strategies. Implications for Cancer Survivors: Patients and clinicians should be aware that although the risk of harm is low for these self-management strategies, the likelihood of benefit is often unclear. Women should consider moisturisers, gels or lubricants for self-managing vulvovaginal symptoms, and yoga or aerobic exercise for alleviating fatigue.
Abstract.
Prado MG, Kessler LG, Au MA, Burkhardt HA, Suchsland MZ, Kowalski L, Stephens KA, Yetisgen M, Walter FM, Neal RD, et al (2022). Symptoms and signs of lung cancer prior to diagnosis: Comparative study using electronic health records.
Summerfield C, Smith L, Todd O, Renzi C, Lyratzopoulos G, Neal RD, Jones D (2022). The Effect of Older Age and Frailty on the Time to Diagnosis of Cancer: a Connected Bradford Electronic Health Records Study.
Cancers,
14(22), 5666-5666.
Abstract:
The Effect of Older Age and Frailty on the Time to Diagnosis of Cancer: a Connected Bradford Electronic Health Records Study
Over 60% of cancer diagnoses in the UK are in patients aged 65 and over. Cancer diagnosis and treatment in older adults is complicated by the presence of frailty, which is associated with lower survival rates and poorer quality of life. This population-based cohort study used a longitudinal database to calculate the time between presentation to primary care with a symptom suspicious of cancer and a confirmed cancer diagnosis for 7460 patients in the Bradford District. Individual frailty scores were calculated using the electronic frailty index (eFI) and categorised by severity. The median time from symptomatic presentation to cancer diagnosis for all patients was 48 days (IQR 21–142). 23% of the cohort had some degree of frailty. After adjustment for potential confounders, mild frailty added 7 days (95% CI 3–11), moderate frailty 23 days (95% CI 4–42) and severe frailty 11 days (95% CI −27–48) to the median time to diagnosis compared to not frail patients. Our findings support use of the eFI in primary care to identify and address patient, healthcare and system factors that may contribute to diagnostic delay. We recommend further research to explore patient and clinician factors when investigating cancer in frail patients.
Abstract.
Usher-Smith JA, Godoy A, Burge SW, Burbidge S, Cartledge J, Crosbie PAJ, Eckert C, Farquhar F, Hammond D, Hancock N, et al (2022). The Yorkshire Kidney Screening Trial (YKST): protocol for a feasibility study of adding non-contrast abdominal CT scanning to screen for kidney cancer and other abdominal pathology within a trial of community-based CT screening for lung cancer.
BMJ Open,
12(9).
Abstract:
The Yorkshire Kidney Screening Trial (YKST): protocol for a feasibility study of adding non-contrast abdominal CT scanning to screen for kidney cancer and other abdominal pathology within a trial of community-based CT screening for lung cancer.
INTRODUCTION: Kidney cancer (renal cell cancer (RCC)) is the seventh most common cancer in the UK. As RCC is largely curable if detected at an early stage and most patients have no symptoms, there is international interest in evaluating a screening programme for RCC. The Yorkshire Kidney Screening Trial (YKST) will assess the feasibility of adding non-contrast abdominal CT scanning to screen for RCC and other abdominal pathology within the Yorkshire Lung Screening Trial (YLST), a randomised trial of community-based CT screening for lung cancer. METHODS AND ANALYSIS: in YLST, ever-smokers aged 55-80 years registered with a general practice in Leeds have been randomised to a Lung Health Check assessment, including a thoracic low-dose CT (LDCT) for those at high risk of lung cancer, or routine care. YLST participants randomised to the Lung Health Check arm who attend for the second round of screening at 2 years without a history of RCC or abdominal CT scan within the previous 6 months will be invited to take part in YKST. We anticipate inviting 4700 participants. Those who consent will have an abdominal CT immediately following their YLST thoracic LDCT. A subset of participants and the healthcare workers involved will be invited to take part in a qualitative interview. Primary objectives are to quantify the uptake of the abdominal CT, assess the acceptability of the combined screening approach and pilot the majority of procedures for a subsequent randomised controlled trial of RCC screening within lung cancer screening. ETHICS AND DISSEMINATION: YKST was approved by the North West-Preston Research Ethics Committee (21/NW/0021), and the Health Research Authority on 3 February 2021. Trial results will be disseminated at clinical meetings, in peer-reviewed journals and to policy-makers. Findings will be made available to participants via the study website (www.YKST.org). TRIAL REGISTRATION NUMBERS: NCT05005195 and ISRCTN18055040.
Abstract.
Author URL.
Smith L, Sansom N, Hemphill S, Bradley SH, Shinkins B, Wheatstone P, Hamilton W, Neal RD (2022). Trends and variation in urgent referrals for suspected cancer 2009/2010-2019/2020.
Br J Gen Pract,
72(714), 34-37.
Author URL.
2021
Bhartia BSK, Hatton NLF, Aslam R, Bradley SH, Darby M, Hamilton WT, Hurst E, Kennedy MPT, Mounce LTA, Neal RD, et al (2021). A prospective cohort evaluation of the sensitivity and specificity of the chest X-ray for the detection of lung cancer in symptomatic adults.
European Journal of Radiology,
144Abstract:
A prospective cohort evaluation of the sensitivity and specificity of the chest X-ray for the detection of lung cancer in symptomatic adults
Background: the accuracy of the chest x-ray (CXR) in the identification of lung cancer amongst symptomatic individuals is uncertain. Purpose: to determine the diagnostic accuracy of the CXR for the detection of non-small cell carcinomas (NSCLC) and all primary intrathoracic malignancies. Methods: a prospective cohort study of consecutive CXR reports obtained within a primary care open access initiative. Eligibility criteria were symptoms specified by National Institute for Clinical Excellence as indicative of possible lung cancer and age over 50-yrs. A positive test was a CXR which led directly or indirectly to investigation with CT. The reference standards were malignancies observed within a one- or two-year post-test period. Results: 8,948 CXR outcomes were evaluated. 496 positive studies led to a diagnosis of 101 patients with primary intrathoracic malignancy including 80 with NSCLC. Within two-years, a cumulative total of 168 patients with primary intrathoracic malignancies including 133 NSCLC were observed. The sensitivity and specificity for NSCLC were 76% (95 %CI 68–84) and 95% (95 %CI 95–96) within 1-year and 60% (95 %CI 52–69) and 95% (95 %CI 95–96) within 2-years. The 2-yr positive and negative likelihood ratios were 12.8 and 0.4. The results did not differ for NSCLC compared to all primary malignancies. Within this symptomatic population a negative test reduced the 2-year risk of lung cancer to 0.8%. Conclusions: a positive test strongly increases the probability of malignancy whereas a negative test does not conclusively exclude the disease. The findings allow the risk of malignancy following a negative test to be estimated.
Abstract.
Smith SG, Ellison R, Hall L, Clark J, Hartley S, Mason E, Metherell J, Olivier C, Napp V, Naik J, et al (2021). Acceptance and Commitment Therapy to Support Medication Decision-making and Quality of Life in Women with Breast Cancer: Protocol for a Pilot Randomised Controlled Trial.
Bradley SH, Barclay M, Cornwell B, Abel GA, Callister ME, Gomez-Cano M, Round T, Shinkins B, Neal RD (2021). Associations between general practice characteristics and chest x-ray rate: an observational study. British Journal of General Practice, 72(714).
Bradley SH, Bhartia BS, Callister ME, Hamilton WT, Hatton NLF, Kennedy MP, Mounce LT, Shinkins B, Wheatstone P, Neal RD, et al (2021). Chest X-ray sensitivity and lung cancer outcomes: a retrospective observational study.
Br J Gen Pract,
71(712), e862-e868.
Abstract:
Chest X-ray sensitivity and lung cancer outcomes: a retrospective observational study.
BACKGROUND: Chest X-ray (CXR) is the first-line investigation for lung cancer in many healthcare systems. An understanding of the consequences of false-negative CXRs on time to diagnosis, stage, and survival is limited. AIM: to determine the sensitivity of CXR for lung cancer and to compare stage at diagnosis, time to diagnosis, and survival between those with CXR that detected, or did not detect, lung cancer. DESIGN AND SETTING: Retrospective observational study using routinely collected healthcare data. METHOD: all patients diagnosed with lung cancer in Leeds Teaching Hospitals NHS Trust during 2008-2015 who had a GP-requested CXR in the year before diagnosis were categorised based on the result of the earliest CXR performed in that period. The sensitivity of CXR was calculated and analyses were performed with respect to time to diagnosis, survival, and stage at diagnosis. RESULTS: CXR was negative for 17.7% of patients (n = 376/2129). Median time from initial CXR to diagnosis was 43 days for those with a positive CXR and 204 days for those with a negative CXR. of those with a positive CXR, 29.8% (95% confidence interval [CI] = 27.9% to 31.8%) were diagnosed at stage I or II, compared with 33.5% (95% CI = 28.8% to 38.6%) with a negative CXR. CONCLUSION: GPs should consider lung cancer in patients with persistent symptoms even when CXR is negative. Despite longer duration to diagnosis for those with false-negative CXRs, there was no evidence of an adverse impact on stage at diagnosis or survival; however, this comparison is likely to be affected by confounding variables.
Abstract.
Author URL.
Atkin C, Iqbal G, Planche T, Pratt G, Yong K, Wood J, Raynes K, Low E, Higgins H, Neal RD, et al (2021). Diagnostic pathways in multiple myeloma and their relationship to end organ damage: an analysis from the Tackling Early Morbidity and Mortality in Myeloma (TEAMM) trial.
BRITISH JOURNAL OF HAEMATOLOGY,
192(6), 997-1005.
Author URL.
Tonge J, Bonner R, King N, Bekker H, Neal R (2021). Does lung cancer screening information support informed decision-making? a systematic environmental scan review.
Author URL.
Rubin G, Walter FM, Emery J, Hamilton W, Hoare Z, Howse J, Nixon C, Srivastava T, Thomas C, Ukoumunne OC, et al (2021). Electronic clinical decision support tool for assessing stomach symptoms in primary care (ECASS): a feasibility study.
BMJ Open,
11(3), e041795-e041795.
Abstract:
Electronic clinical decision support tool for assessing stomach symptoms in primary care (ECASS): a feasibility study
ObjectiveTo determine the feasibility of a definitive trial in primary care of electronic clinical decision support (eCDS) for possible oesophago-gastric (O-G) cancer.Design and settingFeasibility study in 42 general practices in two regions of England, cluster randomised controlled trial design without blinding, nested qualitative and health economic evaluation.ParticipantsPatients aged 55 years or older, presenting to their general practitioner (GP) with symptoms associated with O-G cancer. 530 patients (mean age 68 years, 58% female) participated.InterventionPractices randomised 1:1 to usual care (control) or to receive a previously piloted eCDS tool for suspected cancer (intervention), for use at the discretion of the GPs, supported by a theory-based implementation package and ongoing support. We conducted semistructured interviews with GPs in intervention practices. Recruitment lasted 22 months.OutcomesPatient participation rate, use of eCDS, referrals and route to diagnosis, O-G cancer diagnoses; acceptability to GPs; cost-effectiveness. Participants followed up 6 months after index encounter.ResultsFrom control and intervention practices, we screened 3841 and 1303 patients, respectively; 1189 and 434 were eligible, 392 and 138 consented to participate. Ten patients (1.9%) had O-G cancer. eCDS was used eight times in total by five unique users. GPs experienced interoperability problems between the eCDS tool and their clinical system and also found it did not fit with their workflow. Unexpected restrictions on software installation caused major problems with implementation.ConclusionsThe conduct of this study was hampered by technical limitations not evident during an earlier pilot of the eCDS tool, and by regulatory controls on software installation introduced by primary care trusts early in the study. This eCDS tool needed to integrate better with clinical workflow; even then, its use for suspected cancer may be infrequent. Any definitive trial of eCDS for cancer diagnosis should only proceed after addressing these constraints.Trial registration numberISRCTN125595588.
Abstract.
Bradley SH, Hatton NLF, Aslam R, Bhartia B, Callister ME, Kennedy MP, Mounce LT, Shinkins B, Hamilton WT, Neal RD, et al (2021). Estimating lung cancer risk from chest X-ray and symptoms: a prospective cohort study.
Br J Gen Pract,
71(705), e280-e286.
Abstract:
Estimating lung cancer risk from chest X-ray and symptoms: a prospective cohort study.
BACKGROUND: Chest X-ray (CXR) is the first-line investigation for lung cancer in many countries but previous research has suggested that the disease is not detected by CXR in approximately 20% of patients. The risk of lung cancer, with particular symptoms, following a negative CXR is not known. AIM: to establish the sensitivity and specificity of CXR requested by patients who are symptomatic; determine the positive predictive values (PPVs) of each presenting symptom of lung cancer following a negative CXR; and determine whether symptoms associated with lung cancer are different in those who had a positive CXR result compared with those who had a negative CXR result. DESIGN AND SETTING: a prospective cohort study was conducted in Leeds, UK, based on routinely collected data from a service that allowed patients with symptoms of lung cancer to request CXR. METHOD: Symptom data were combined with a diagnostic category (positive or negative) for each CXR, and the sensitivity and specificity of CXR for lung cancer were calculated. The PPV of lung cancer associated with each symptom or combination of symptoms was estimated for those patients with a negative CXR. RESULTS: in total, 114 (1.3%) of 8996 patients who requested a CXR were diagnosed with lung cancer within 1 year. Sensitivity was 75.4% and specificity was 90.2%. The PPV of all symptoms for a diagnosis of lung cancer within 1 year of CXR was
Abstract.
Author URL.
Al Achkar M, Suchsland MZ, Walter FM, Neal RD, Goulart BHL, Thompson MJ (2021). Experiences along the diagnostic pathway for patients with advanced lung cancer in the USA: a qualitative study.
BMJ OPEN,
11(4).
Author URL.
Bradley PT, Hall N, Maniatopoulos G, Neal RD, Paleri V, Wilkes S (2021). Factors shaping the implementation and use of Clinical Cancer Decision Tools by GPs in primary care: a qualitative framework synthesis.
BMJ OPEN,
11(2).
Author URL.
Tonge J, Bonner R, King N, Bekker H, Neal R (2021). How easy is it to read participant information about lung cancer screening?.
Author URL.
Archer S, Calanzani N, Honey S, Johnson M, Neal R, Scott SE, Walter FM (2021). Impact of the COVID-19 pandemic on cancer assessment in primary care: a qualitative study of GP views.
BJGP Open,
5(4).
Abstract:
Impact of the COVID-19 pandemic on cancer assessment in primary care: a qualitative study of GP views.
BACKGROUND: Early diagnosis is key to improve cancer outcomes, and most cancers are diagnosed in primary care after initial symptomatic presentation. Emerging evidence suggests an increase in avoidable cancer deaths owing to the COVID-19 pandemic. AIM: to understand GPs' views on the impact of the COVID-19 pandemic on the clinical assessment of possible cancer. DESIGN & SETTING: a qualitative semi-structured interview study with GPs from the East of England. METHOD: GPs were purposively sampled based on age, sex, and years of experience. Interviews were conducted via Zoom or Microsoft Teams in August and September 2020. Transcribed recordings were analysed inductively using thematic analysis. The Model of Pathways to Treatment guided the analysis. RESULTS: Three themes were identified across 23 interviews on GP views on the impact of: (1) changes in patient help-seeking behaviour on symptoms at presentation; (2) remote consultations on managing patients with possible cancer symptoms; and (3) the COVID-19 pandemic on triaging and referring patients with possible cancer. There were positive changes to practice, but concerns were raised about the adequacy of remote consultations for assessing symptoms. Some GPs reported delayed cancer diagnoses, and uncertainty about how backlog in referrals would be managed. CONCLUSION: This study provides new evidence on the impact of the COVID-19 pandemic on assessing symptomatic patients. Recommendations are made to inform safe and effective primary care clinical practice. Urgent action is needed to mitigate the impact of the COVID-19 pandemic, and ensure appropriate symptomatic assessment now and in the future.
Abstract.
Author URL.
Disbeschl S, Surgey A, Roberts JL, Hendry A, Lewis R, Goulden N, Hoare Z, Williams N, Anthony BF, Edwards RT, et al (2021). Protocol for a feasibility study incorporating a randomised pilot trial with an embedded process evaluation and feasibility economic analysis of ThinkCancer!: a primary care intervention to expedite cancer diagnosis in Wales.
Pilot and Feasibility Studies,
7(1).
Abstract:
Protocol for a feasibility study incorporating a randomised pilot trial with an embedded process evaluation and feasibility economic analysis of ThinkCancer!: a primary care intervention to expedite cancer diagnosis in Wales
Background: Compared to the rest of Europe, the UK has relatively poor cancer outcomes, with late diagnosis and a slow referral process being major contributors. General practitioners (GPs) are often faced with patients presenting with a multitude of non-specific symptoms that could be cancer. Safety netting can be used to manage diagnostic uncertainty by ensuring patients with vague symptoms are appropriately monitored, which is now even more crucial due to the ongoing COVID-19 pandemic and its major impact on cancer referrals. The ThinkCancer! workshop is an educational behaviour change intervention aimed at the whole general practice team, designed to improve primary care approaches to ensure timely diagnosis of cancer. The workshop will consist of teaching and awareness sessions, the appointment of a Safety Netting Champion and the development of a bespoke Safety Netting Plan and has been adapted so it can be delivered remotely. This study aims to assess the feasibility of the ThinkCancer! intervention for a future definitive randomised controlled trial. Methods: the ThinkCancer! study is a randomised, multisite feasibility trial, with an embedded process evaluation and feasibility economic analysis. Twenty-three to 30 general practices will be recruited across Wales, randomised in a ratio of 2:1 of intervention versus control who will follow usual care. The workshop will be delivered by a GP educator and will be adapted iteratively throughout the trial period. Baseline practice characteristics will be collected via questionnaire. We will also collect primary care intervals (PCI), 2-week wait (2WW) referral rates, conversion rates and detection rates at baseline and 6 months post-randomisation. Participant feedback, researcher reflections and economic costings will be collected following each workshop. A process evaluation will assess implementation using an adapted Normalisation Measure Development (NoMAD) questionnaire and qualitative interviews. An economic feasibility analysis will inform a future economic evaluation. Discussion: This study will allow us to test and further develop a novel evidenced-based complex intervention aimed at general practice teams to expedite the diagnosis of cancer in primary care. The results from this study will inform the future design of a full-scale definitive phase III trial. Trial registration: ClinicalTrials.gov NCT04823559.
Abstract.
Moriarty Y, Lau M, Sewell B, Trubey R, Quinn-Scoggins H, Owen S, Padgett L, Kolovou V, Hepburn J, Buckle P, et al (2021). Randomised controlled trial and economic evaluation of a targeted cancer awareness intervention for adults living in deprived areas of the UK.
BRITISH JOURNAL OF CANCER,
125(8), 1100-1110.
Author URL.
Neal RD, Smith L (2021). Urgent cancer referrals: how well are they working and can they be improved?.
Br J Gen Pract,
71(710), 390-391.
Author URL.
2020
Khan N, Jones D, Grice A, Alderson S, Bradley S, Carder P, Drinkwater J, Edwards H, Essang B, Richards S, et al (2020). A brave new world: the new normal for general practice after the COVID-19 pandemic. BJGP Open, 4(3).
Martino E, AyazâShah A, Shinkins B, Jain S, Neal RD (2020). A urine test for bladder cancer: available soon in primary care?. Trends in Urology & Men's Health, 11(4), 18-21.
Falborg AZ, Vedsted P, Menon U, Weller D, Neal RD, Reguilon I, Harrison S, Jensen H, Grp ICBPM4W (2020). Agreement between questionnaires and registry data on routes to diagnosis and milestone dates of the cancer diagnostic pathway.
CANCER EPIDEMIOLOGY,
65 Author URL.
Neal RD, Nekhlyudov L, Wheatstone P, Koczwara B (2020). Cancer care during and after the pandemic from ordeal to opportunity through innovation and cooperation.
BMJ-BRITISH MEDICAL JOURNAL,
370 Author URL.
Medina-Lara A, Grigore B, Lewis R, Peters J, Price S, Landa P, Robinson S, Neal R, Hamilton W, Spencer AE, et al (2020). Cancer diagnostic tools to aid decision-making in primary care: mixed-methods systematic reviews and cost-effectiveness analysis.
Health Technology Assessment,
24(66), 1-332.
Abstract:
Cancer diagnostic tools to aid decision-making in primary care: mixed-methods systematic reviews and cost-effectiveness analysis
. Background
. Tools based on diagnostic prediction models are available to help general practitioners diagnose cancer. It is unclear whether or not tools expedite diagnosis or affect patient quality of life and/or survival.
.
.
. Objectives
. The objectives were to evaluate the evidence on the validation, clinical effectiveness, cost-effectiveness, and availability and use of cancer diagnostic tools in primary care.
.
.
. Methods
. Two systematic reviews were conducted to examine the clinical effectiveness (review 1) and the development, validation and accuracy (review 2) of diagnostic prediction models for aiding general practitioners in cancer diagnosis. Bibliographic searches were conducted on MEDLINE, MEDLINE In-Process, EMBASE, Cochrane Library and Web of Science) in May 2017, with updated searches conducted in November 2018. A decision-analytic model explored the tools’ clinical effectiveness and cost-effectiveness in colorectal cancer. The model compared patient outcomes and costs between strategies that included the use of the tools and those that did not, using the NHS perspective. We surveyed 4600 general practitioners in randomly selected UK practices to determine the proportions of general practices and general practitioners with access to, and using, cancer decision support tools. Association between access to these tools and practice-level cancer diagnostic indicators was explored.
.
.
. Results
. Systematic review 1 – five studies, of different design and quality, reporting on three diagnostic tools, were included. We found no evidence that using the tools was associated with better outcomes. Systematic review 2 – 43 studies were included, reporting on prediction models, in various stages of development, for 14 cancer sites (including multiple cancers). Most studies relate to QCancer® (ClinRisk Ltd, Leeds, UK) and risk assessment tools.
.
.
. Decision model
. In the absence of studies reporting their clinical outcomes, QCancer and risk assessment tools were evaluated against faecal immunochemical testing. A linked data approach was used, which translates diagnostic accuracy into time to diagnosis and treatment, and stage at diagnosis. Given the current lack of evidence, the model showed that the cost-effectiveness of diagnostic tools in colorectal cancer relies on demonstrating patient survival benefits. Sensitivity of faecal immunochemical testing and specificity of QCancer and risk assessment tools in a low-risk population were the key uncertain parameters.
.
.
. Survey
. Practitioner- and practice-level response rates were 10.3% (476/4600) and 23.3% (227/975), respectively. Cancer decision support tools were available in 83 out of 227 practices (36.6%, 95% confidence interval 30.3% to 43.1%), and were likely to be used in 38 out of 227 practices (16.7%, 95% confidence interval 12.1% to 22.2%). The mean 2-week-wait referral rate did not differ between practices that do and practices that do not have access to QCancer or risk assessment tools (mean difference of 1.8 referrals per 100,000 referrals, 95% confidence interval –6.7 to 10.3 referrals per 100,000 referrals).
.
.
. Limitations
. There is little good-quality evidence on the clinical effectiveness and cost-effectiveness of diagnostic tools. Many diagnostic prediction models are limited by a lack of external validation. There are limited data on current UK practice and clinical outcomes of diagnostic strategies, and there is no evidence on the quality-of-life outcomes of diagnostic results. The survey was limited by low response rates.
.
.
. Conclusion
. The evidence base on the tools is limited. Research on how general practitioners interact with the tools may help to identify barriers to implementation and uptake, and the potential for clinical effectiveness.
.
.
. Future work
. Continued model validation is recommended, especially for risk assessment tools. Assessment of the tools’ impact on time to diagnosis and treatment, stage at diagnosis, and health outcomes is also recommended, as is further work to understand how tools are used in general practitioner consultations.
.
.
. Study registration
. This study is registered as PROSPERO CRD42017068373 and CRD42017068375.
.
.
. Funding
. This project was funded by the National Institute for Health Research (NIHR) Health Technology programme and will be published in full in Health Technology Assessment; Vol. 24, No. 66. See the NIHR Journals Library website for further project information.
.
Abstract.
Helsper CW, Campbell C, Emery J, Neal RD, Li L, Rubin G, van Weert H, Vedsted P, Walter FM, Weller D, et al (2020). Cancer has not gone away: a primary care perspective to support a balanced approach for timely cancer diagnosis during COVID-19.
Eur J Cancer Care (Engl),
29(5).
Author URL.
Savage RS, Messenger M, Neal RD, Ferguson R, Johnston C, Lloyd KL, Neal MD, Sansom N, Selby P, Sharma N, et al (2020). Development and validation of multivariable machine learning algorithms to predict risk of cancer in symptomatic patients referred urgently from primary care.
Pottle J, Hiscock J, Neal RD, Poolman M (2020). Dying at home of cancer: whose needs are being met? the experience of family carers and healthcare professionals (a multiperspective qualitative study).
BMJ SUPPORTIVE & PALLIATIVE CARE,
10(1).
Author URL.
Lai AG, Pasea L, Banerjee A, Hall G, Denaxas S, Chang WH, Katsoulis M, Williams B, Pillay D, Noursadeghi M, et al (2020). Estimated impact of the COVID-19 pandemic on cancer services and excess 1-year mortality in people with cancer and multimorbidity: near real-time data on cancer care, cancer deaths and a population-based cohort study.
BMJ OPEN,
10(11).
Author URL.
Jones D, Neal RD, Duffy SRG, Scott SE, Whitaker KL, Brain K (2020). Impact of the COVID-19 pandemic on the symptomatic diagnosis of cancer: the view from primary care.
LANCET ONCOLOGY,
21(6), 748-750.
Author URL.
Jones D, di Martino E, Hatton NL, Surr C, de Wit N, Neal RD (2020). Investigating cancer symptoms in older people: what are the issues and where is the evidence?.
BRITISH JOURNAL OF GENERAL PRACTICE,
70(696), 321-322.
Author URL.
di Martino E, Andersen CA, Mengel-Jorgensen T, Jensen MB, Bradley S, Neal RD (2020). Is there a place for point-of-care ultrasound in UK primary care?.
BRITISH JOURNAL OF GENERAL PRACTICE,
70(696), 323-324.
Author URL.
Okunade K, Akinsete AM, Salako O, Afolabi BB, Neal RD (2020). Oral etoposide for treatment and/or maintenance treatment of recurrent epithelial ovarian cancer.
Cochrane Database of Systematic Reviews,
2020(2).
Abstract:
Oral etoposide for treatment and/or maintenance treatment of recurrent epithelial ovarian cancer
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:. To assess the clinical therapeutic efficacy and adverse effects of oral etoposide as treatment and/or maintenance treatment in women with recurrent epithelial ovarian cancer.
Abstract.
Disbeschl S, Surgey A, Roberts JL, Hendry A, Lewis R, Goulden N, Hoare Z, Williams N, Anthony BF, Edwards RT, et al (2020). Protocol for a Feasibility study incorporating a Randomised Pilot Trial with an Embedded Process Evaluation and Feasibility Economic Analysis of ThinkCancer!: a primary care intervention to expedite cancer diagnosis in Wales.
Bradley SH, Kennedy MPT, Neal RD (2020). Recognising Lung Cancer in Primary Care (vol 36, pg 19, 2019).
ADVANCES IN THERAPY,
37(4), 1701-1701.
Author URL.
Kolovou V, Moriarty Y, Gilbert S, Quinn-Scoggins H, Townson J, Padgett L, Owen S, Buckle P, Edwards A, Hepburn J, et al (2020). Recruitment and Retention of Participants from Socioeconomically Deprived Communities: Lessons from the Awareness and Beliefs About Cancer (ABACus3) Randomised Controlled Trial.
Kolovou V, Moriarty Y, Gilbert S, Quinn-Scoggins H, Townson J, Padgett L, Owen S, Buckle P, Edwards A, Hepburn J, et al (2020). Recruitment and Retention of Participants from Socioeconomically Deprived Communities: Lessons from the Awareness and Beliefs About Cancer (ABACus3) Randomised Controlled Trial.
Kolovou V, Moriarty Y, Gilbert S, Quinn-Scoggins H, Townson J, Padgett L, Owen S, Buckle P, Edwards A, Hepburn J, et al (2020). Recruitment and retention of participants from socioeconomically deprived communities: lessons from the Awareness and Beliefs About Cancer (ABACus3) Randomised Controlled Trial.
BMC MEDICAL RESEARCH METHODOLOGY,
20(1).
Author URL.
Hall LH, King N, Graham CD, Neal RD, Velikova GI, Foy R, Lloyd KE, Clark J, Smith S (2020). SELF-MANAGEMENT OF SIDE-EFFECTS AMONG WOMEN WITH BREAST CANCER USING ADJUVANT HORMONAL THERAPY: a SYSTEMATIC REVIEW OF REVIEWS.
Author URL.
Wallis CJD, Catto JWF, Finelli A, Glaser AW, Gore JL, Loeb S, Morgan TM, Morgans AK, Mottet N, Neal R, et al (2020). The Impact of the COVID-19 Pandemic on Genitourinary Cancer Care: Re-envisioning the Future.
EUROPEAN UROLOGY,
78(5), 731-742.
Author URL.
Surgey A, Disbeschl S, Lewis R, Hiscock J, Nafees S, Law RJ, Roberts JL, Hendry A, Hoare Z, Goulden N, et al (2020). ThinkCancer! the multi-method development of a complex behaviour change intervention to improve the early diagnosis of cancer in primary care.
Murray RL, Brain K, Britton J, Quinn-Scoggins HD, Lewis S, McCutchan GM, Quaife SL, Wu Q, Ashurst A, Baldwin D, et al (2020). Yorkshire Enhanced Stop Smoking (YESS) study: a protocol for a randomised controlled trial to evaluate the effect of adding a personalised smoking cessation intervention to a lung cancer screening programme.
BMJ OPEN,
10(9).
Author URL.
Crosbie PAJ, Gabe R, Simmonds I, Kennedy M, Rogerson S, Ahmed N, Baldwin DR, Booton R, Cochrane A, Darby M, et al (2020). Yorkshire Lung Screening Trial (YLST): protocol for a randomised controlled trial to evaluate invitation to community-based low-dose CT screening for lung cancer versus usual care in a targeted population at risk.
BMJ OPEN,
10(9).
Author URL.
2019
Torring ML, Falborg AZ, Jensen H, Neal RD, Weller D, Reguilon I, Menon U, Vedsted P, Grp ICBPW (2019). Advanced-stage cancer and time to diagnosis: an International Cancer Benchmarking Partnership (ICBP) cross-sectional study.
EUROPEAN JOURNAL OF CANCER CARE,
28(5).
Author URL.
Renzi C, Kaushal A, Emery J, Hamilton W, Neal RD, Rachet B, Rubin G, Singh H, Walter FM, de Wit NJ, et al (2019). Comorbid chronic diseases and cancer diagnosis: disease-specific effects and underlying mechanisms.
Nat Rev Clin Oncol,
16(12), 746-761.
Abstract:
Comorbid chronic diseases and cancer diagnosis: disease-specific effects and underlying mechanisms.
An earlier diagnosis is a key strategy for improving the outcomes of patients with cancer. However, achieving this goal can be challenging, particularly for the growing number of people with one or more chronic conditions (comorbidity/multimorbidity) at the time of diagnosis. Pre-existing chronic diseases might affect patient participation in cancer screening, help-seeking for new and/or changing symptoms and clinicians' decision-making on the use of diagnostic investigations. Evidence suggests, for example, that pre-existing pulmonary, cardiovascular, neurological and psychiatric conditions are all associated with a more advanced stage of cancer at diagnosis. By contrast, hypertension and certain gastrointestinal and musculoskeletal conditions might be associated with a more timely diagnosis. In this Review, we propose a comprehensive framework that encompasses the effects of disease-specific, patient-related and health-care-related factors on the diagnosis of cancer in individuals with pre-existing chronic illnesses. Several previously postulated aetiological mechanisms (including alternative explanations, competing demands and surveillance effects) are integrated with newly identified mechanisms, such as false reassurances, or patient concerns about appearing to be a hypochondriac. By considering specific effects of chronic diseases on diagnostic processes and outcomes, tailored early diagnosis initiatives can be developed to improve the outcomes of the large proportion of patients with cancer who have pre-existing chronic conditions.
Abstract.
Author URL.
McCutchan G, Hiscock J, Hood K, Murchie P, Neal RD, Newton G, Thomas S, Thomas AM, Brain K (2019). Engaging high-risk groups in early lung cancer diagnosis: a qualitative study of symptom presentation and intervention preferences among the UK's most deprived communities.
BMJ OPEN,
9(5).
Author URL.
Moriarty Y, Townson J, Quinn-Scoggins H, Padgett L, Owen S, Smits S, Playle R, Dimitropoulou P, Sewell B, Kolovou V, et al (2019). Improving cancer symptom awareness and help-seeking among adults living in socioeconomically deprived communities in the UK using a facilitated health check: a protocol for the Awareness and Beliefs About Cancer (ABACus) Randomised Control Trial.
BMC PUBLIC HEALTH,
19 Author URL.
Neal RD, Sun F, Emery JD, Callister ME (2019). Lung cancer.
BMJ-BRITISH MEDICAL JOURNAL,
365 Author URL.
Lewis R, Hendry M, Din N, Stanciu MA, Nafees S, Hendry A, Teoh ZH, Lloyd T, Parsonage R, Neal RD, et al (2019). Pragmatic methods for reviewing exceptionally large bodies of evidence: systematic mapping review and overview of systematic reviews using lung cancer survival as an exemplar.
SYSTEMATIC REVIEWS,
8 Author URL.
Bradley SH, Kennedy MPT, Neal RD (2019). Recognising Lung Cancer in Primary Care.
ADVANCES IN THERAPY,
36(1), 19-30.
Author URL.
Krusche A, Bradbury K, Corbett T, Barnett J, Stuart B, Yao GL, Bacon R, Bohning D, Cheetham-Blake T, Eccles D, et al (2019). Renewed: Protocol for a randomised controlled trial of a digital intervention to support quality of life in cancer survivors.
BMJ OPEN,
9(3).
Author URL.
Bradley SH, Abraham S, Callister ME, Grice A, Hamilton WT, Lopez RR, Shinkins B, Neal RD (2019). Sensitivity of chest X-ray for detecting lung cancer in people presenting with symptoms: a systematic review.
Br J Gen Pract,
69(689), e827-e835.
Abstract:
Sensitivity of chest X-ray for detecting lung cancer in people presenting with symptoms: a systematic review.
BACKGROUND: Despite increasing use of computed tomography (CT), chest X-ray remains the first-line investigation for suspected lung cancer in primary care in the UK. No systematic review evidence exists as to the sensitivity of chest X-ray for detecting lung cancer in people presenting with symptoms. AIM: to estimate the sensitivity of chest X-ray for detecting lung cancer in symptomatic people. DESIGN AND SETTING: a systematic review was conducted to determine the sensitivity of chest X-ray for the detection of lung cancer. METHOD: Databases including MEDLINE, EMBASE, and the Cochrane Library were searched; a grey literature search was also performed. RESULTS: a total of 21 studies met the eligibility criteria. Almost all were of poor quality. Only one study had the diagnostic accuracy of chest X-ray as its primary objective. Most articles were case studies with a high risk of bias. Several were drawn from non-representative groups, for example, specific presentations, histological subtypes, or comorbidities. Only three studies had a low risk of bias. Two primary care studies reported sensitivities of 76.8% (95% confidence interval [CI] = 64.5 to 84.2%) and 79.3% (95% CI = 67.6 to 91.0%). One secondary care study reported a sensitivity of 79.7% (95% CI = 72.7 to 86.8%). CONCLUSION: Though there is a paucity of evidence, the highest-quality studies suggest that the sensitivity of chest X-ray for symptomatic lung cancer is only 77% to 80%. GPs should consider if further investigation is necessary in high-risk patients who have had a negative chest X-ray.
Abstract.
Author URL.
Menon U, Vedsted P, Falborg AZ, Jensen H, Harrison S, Reguilon I, Barisic A, Bergin RJ, Brewster DH, Butler J, et al (2019). Time intervals and routes to diagnosis for lung cancer in 10 jurisdictions: cross-sectional study findings from the International Cancer Benchmarking Partnership (ICBP).
BMJ OPEN,
9(11).
Author URL.
Stanciu MA, Morris C, Makin M, Watson E, Bulger J, Evans R, Hiscock J, Hoare Z, Edwards RT, Neal RD, et al (2019). Trial of personalised care after treatment—Prostate cancer: a randomised feasibility trial of a nurse-led psycho-educational intervention.
European Journal of Cancer Care,
28(2).
Abstract:
Trial of personalised care after treatmentâProstate cancer: a randomised feasibility trial of a nurse-led psycho-educational intervention
Objective: the present parallel randomised control trial evaluated the feasibility of a nurse-led psycho-educational intervention aimed at improving the self-management of prostate cancer survivors. Methods: We identified 305 eligible patients from a district general hospital, diagnosed 9–48 months previously, who completed radical treatment, or were monitored clinically (ineligible for treatment). Ninety-five patients were recruited by blinded selection and randomised to Intervention (N = 48) and Control (N = 47) groups. Participant allocation was revealed to patients and researchers after recruitment was completed. For 36 weeks, participants received augmented usual care (Control) or augmented usual care and additional nurse support (Intervention) provided in two community hospitals and a university clinic, or by telephone. Results: Data from 91 participants (Intervention, N = 45; Control, N = 46) were analysed. All feasibility metrics met predefined targets: recruitment rate (31.15%; 95% CI: 25.95%–36.35%), attrition rate (9.47%; 95% CI: 3.58%–15.36%) and outcome measures completion rates (77%–92%). Forty-five patients received the intervention, with no adverse events. The Extended Prostate Cancer Index Composite can inform the minimum sample size for a future effectiveness trial. The net intervention cost was £317 per patient. Conclusions: the results supported the feasibility and acceptability of the intervention, suggesting that it should be evaluated in a fully powered trial to assess its effectiveness and cost-effectiveness.
Abstract.
McCutchan G, Hiscock J, Murchie P, Hood K, Neal R, Thomas S, Thomas AM, Newton G, Brain K (2019). UNDERSTANDING THE INFLUENCES ON EARLY LUNG CANCER SYMPTOM PRESENTATION AND INTERVENTION PREFERENCES IN HIGH RISK GROUPS: a QUALITATIVE STUDY (vol 25, pg 1, 2018).
INTERNATIONAL JOURNAL OF BEHAVIORAL MEDICINE,
26(1), 109-110.
Author URL.
2018
Aslam R, Kennedy MPT, Bhartia B, Shinkins B, Neal RD, Callister MEJ (2018). ARE THERE ANY DIFFERENCES IN CANCER OUTCOMES ACCORDING TO TIME BETWEEN BASELINE CHEST X-RAY AND LUNG CANCER DIAGNOSIS?.
Author URL.
Stanciu MA, Law R-J, Nafees S, Hendry M, Yeo ST, Hiscock J, Lewis R, Edwards RT, Williams NH, Brain K, et al (2018). Development of an intervention to expedite cancer diagnosis through primary care: a protocol.
BJGP Open,
2(3).
Abstract:
Development of an intervention to expedite cancer diagnosis through primary care: a protocol.
BACKGROUND: GPs can play an important role in achieving earlier cancer diagnosis to improve patient outcomes, for example through prompt use of the urgent suspected cancer referral pathway. Barriers to early diagnosis include individual practitioner variation in knowledge, attitudes, beliefs, professional expectations, and norms. AIM: This programme of work (Wales Interventions and Cancer Knowledge about Early Diagnosis [WICKED]) will develop a behaviour change intervention to expedite diagnosis through primary care and contribute to improved cancer outcomes. DESIGN & SETTING: Non-experimental mixed-method study with GPs and primary care practice teams from Wales. METHOD: Four work packages will inform the development of the behaviour change intervention. Work package 1 will identify relevant evidence-based interventions (systematic review of reviews) and will determine why interventions do or do not work, for whom, and in what circumstances (realist review). Work package 2 will assess cancer knowledge, attitudes, and behaviour of GPs, as well as primary care teams' perspectives on cancer referral and investigation (GP survey, discrete choice experiment [DCE], interviews, and focus groups). Work package 3 will synthesise findings from earlier work packages using the behaviour change wheel as an overarching theoretical framework to guide intervention development. Work package 4 will test the feasibility and acceptability of the intervention, and determine methods for measuring costs and effects of subsequent behaviour change in a randomised feasibility trial. RESULTS: the findings will inform the design of a future effectiveness trial, with concurrent economic evaluation, aimed at earlier diagnosis. CONCLUSION: This comprehensive, evidence-based programme will develop a complex GP behaviour change intervention to expedite the diagnosis of symptomatic cancer, and may be applicable to countries with similar healthcare systems.
Abstract.
Author URL.
Weller D, Menon U, Falborg AZ, Jensen H, Barisic A, Knudsen AK, Bergin RJ, Brewster DH, Cairnduff V, Gavin AT, et al (2018). Diagnostic routes and time intervals for patients with colorectal cancer in 10 international jurisdictions; findings from a cross-sectional study from the International Cancer Benchmarking Partnership (ICBP).
BMJ OPEN,
8(11).
Author URL.
Mccutchan G, Hiscock J, Murchie P, Hood K, Neal R, Thomas S, Thomas AM, Newton G, Brain K (2018). Lung Cancer Symptom Perception and Intervention Preferences in the UK's Most Deprived Communities: a Qualitative Study.
Author URL.
Prout HC, Barham A, Bongard E, Tudor-Edwards R, Griffiths G, Hamilton W, Harrop E, Hood K, Hurt CN, Nelson R, et al (2018). Patient understanding and acceptability of an early lung cancer diagnosis trial: a qualitative study.
Trials,
19(1).
Abstract:
Patient understanding and acceptability of an early lung cancer diagnosis trial: a qualitative study.
BACKGROUND: the ELCID (Early Lung Cancer Investigation and Diagnosis) trial was a feasibility randomised controlled trial examining the effect on lung cancer diagnosis of lowering the threshold for referral for urgent chest x-ray for smokers and recent ex-smokers, aged over 60 years with new chest symptoms. The qualitative component aimed to explore the feasibility of individually randomising patients to an urgent chest x-ray or not and to investigate any barriers to patient recruitment and participation. We integrated this within the feasibility trial to inform the design of any future definitive trial, particularly in view of the lack of research exploring symptomatic patients' experiences of participating in diagnostic trials for possible/suspected lung cancer. Although previous studies contributed valuable information concerning screening for lung cancer and patient participation in trials, this paper is the first to explore issues relating to this specific patient group. METHODS: Qualitative interviews were conducted with 21 patients, comprising 9 who had been randomised to receive an immediate chest x-ray, 10 who were randomised to receive the standard treatment according to the National Institute for Health and Care Excellence guidelines, and 2 who chose not to participate in the trial. Interviews were analysed using a framework approach. RESULTS: the findings of this analysis showed that altruism, personal benefit and the reassurance of not having lung cancer were important factors in patient participation. However, patients largely believed that being in the intervention arm was more beneficial, highlighting a lack of understanding of clinical equipoise. Disincentives to participation in the trial included the stigmatisation of patients who smoked (given the inclusion criteria). Although the majority of patients reported that they were happy with the trial design, there was evidence of poor understanding. Last, for several patients, placing trust in health professionals was preferred to understanding the trial processes. CONCLUSIONS: the integration of a qualitative study focusing on participant experience as a secondary outcome of a feasibility trial enabled exploration of patient response to participation and recruitment. The study demonstrated that although it is feasible to recruit patients to the ELCID trial, more work needs to be done to ensure an understanding of study principles and also of smoking stigmatisation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01344005. Registered on 27 April 2011.
Abstract.
Author URL.
Hubbard G, Kyle RG, Neal RD, Marmara V, Wang Z, Dombrowski SU (2018). Promoting sunscreen use and skin self-examination to improve early detection and prevent skin cancer: quasi-experimental trial of an adolescent psycho-educational intervention.
BMC PUBLIC HEALTH,
18 Author URL.
Bradley S, Bradley S, Abraham S, Grice A, Lopez RR, Wright J, Farragher T, Shinkins B, Neal RD (2018). Sensitivity of chest X-ray for lung cancer: systematic review. British Journal of General Practice, 68(suppl 1).
Watson EK, Shinkins B, Matheson L, Burns RM, Frith E, Neal D, Hamdy F, Walter FM, Weller D, Wilkinson C, et al (2018). Supporting prostate cancer survivors in primary care: Findings from a pilot trial of a nurse-led psycho-educational intervention (PROSPECTIV).
Eur J Oncol Nurs,
32, 73-81.
Abstract:
Supporting prostate cancer survivors in primary care: Findings from a pilot trial of a nurse-led psycho-educational intervention (PROSPECTIV).
PURPOSE: This study sought to test the acceptability and feasibility of a nurse-led psycho-educational intervention (NLPI) delivered in primary care to prostate cancer survivors, and to provide preliminary estimates of the effectiveness of the intervention. METHODS: Men who reported an ongoing problem with urinary, bowel, sexual or hormone-related functioning/vitality on a self-completion questionnaire were invited to participate. Participants were randomly assigned to the NLPI plus usual care, or to usual care alone. Recruitment and retention rates were assessed. Prostate-related quality of life, self-efficacy, unmet needs, and psychological morbidity were measured at baseline and 9 months. Health-care resource use data was also collected. An integrated qualitative study assessed experiences of the intervention. RESULTS: 61% eligible men (83/136) participated in the trial, with an 87% (72/83) completion rate. Interviews indicated that the intervention filled an important gap in care following treatment completion, helping men to self-manage, and improving their sense of well-being. However, only a small reduction in unmet needs and small improvement in self-efficacy was observed, and no difference in prostate-related quality of life or psychological morbidity. Patients receiving the NLPI recorded more primary care visits, while the usual care group recorded more secondary care visits. Most men (70%; (21/30)) felt the optimal time for the intervention was around the time of diagnosis/before the end of treatment. CONCLUSIONS: Findings suggest a nurse-led psycho-educational intervention in primary care is feasible, acceptable and potentially useful to prostate cancer survivors.
Abstract.
Author URL.
Aslam R, Kennedy MPT, Bhartia B, Shinkins B, Neal RD, Callister MEJ (2018). THE RADIOLOGICAL ROUTE TO DIAGNOSIS OF LUNG CANCER PATIENTS.
Author URL.
Coxon D, Campbell C, Walter FM, Scott SE, Neal RD, Vedsted P, Emery J, Rubin G, Hamilton W, Weller D, et al (2018). The Aarhus statement on cancer diagnostic research: turning recommendations into new survey instruments.
BMC Health Serv Res,
18(1).
Abstract:
The Aarhus statement on cancer diagnostic research: turning recommendations into new survey instruments.
BACKGROUND: over recent years there has been a growth in cancer early diagnosis (ED) research, which requires valid measurement of routes to diagnosis and diagnostic intervals. The Aarhus Statement, published in 2012, provided methodological guidance to generate valid data on these key pre-diagnostic measures. However, there is still a wide variety of measuring instruments of varying quality in published research. In this paper we test comprehension of self-completion ED questionnaire items, based on Aarhus Statement guidance, and seek input from patients, GPs and ED researchers to refine these questions. METHODS: We used personal interviews and consensus approaches to generate draft ED questionnaire items, then a combination of focus groups and telephone interviews to test comprehension and obtain feedback. A framework analysis approach was used, to identify themes and potential refinements to the items. RESULTS: We found that many of the questionnaire items still prompted uncertainty in respondents, in both routes to diagnosis and diagnostic interval measurement. Uncertainty was greatest in the context of multiple or vague symptoms, and potentially ambiguous time-points (such as 'date of referral'). CONCLUSIONS: There are limits on the validity of self-completion questionnaire responses, and refinements to the wording of questions may not be able to completely overcome these limitations. It's important that ED researchers use the best identifiable measuring instruments, but accommodate inevitable uncertainty in the interpretation of their results. Every effort should be made to increase clarity of questions and responses, and use of two or more data sources should be considered.
Abstract.
Author URL.
Morrison V, Spencer LH, Totton N, Pye K, Yeo ST, Butterworth C, Hall L, Whitaker R, Edwards RT, Timmis LJ, et al (2018). Trial of Optimal Personalised Care After Treatment-Gynaecological Cancer (TOPCAT-G) a Randomized Feasibility Trial.
INTERNATIONAL JOURNAL OF GYNECOLOGICAL CANCER,
28(2), 401-411.
Author URL.
McCutchan G, Hiscock J, Murchie P, Hood K, Neal R, Thomas S, Thomas AM, Newton G (2018). UNDERSTANDING THE INFLUENCES ON EARLY LUNG CANCER SYMPTOM PRESENTATION AND INTERVENTION PREFERENCES IN HIGH RISK GROUPS: a QUALITATIVE STUDY.
Author URL.
Aslam R, Kennedy MPT, Bhartia B, Shinkins B, Neal RD, Callister MEJ (2018). WHAT PROPORTION OF PATIENTS UNDERGOING CHEST X-RAY FOR NICE LUNG CANCER SYMPTOMS ARE DIAGNOSED WITH LUNG CANCER OVER a TWO YEAR FOLLOW-UP PERIOD?.
Author URL.
Nafees S, Law R-J, Hendry M, Hiscock J, Stanciu MA, Lewis R, Surgey A, Goulden N, Hoare Z, Brain K, et al (2018). Wales Interventions and Cancer Knowledge about Early Diagnosis (WICKED): findings of work package 2 of the WICKED research programme. British Journal of General Practice, 68(suppl 1).
2017
Usher-Smith JA, Kassianos AP, Emery JD, Abel GA, Teoh Z, Hall S, Neal RD, Murchie P, Walter FM (2017). Identifying people at higher risk of melanoma across the U.K.: a primary-care-based electronic survey.
Br J Dermatol,
176(4), 939-948.
Abstract:
Identifying people at higher risk of melanoma across the U.K.: a primary-care-based electronic survey.
BACKGROUND: Melanoma incidence is rising rapidly worldwide among white populations. Defining higher-risk populations using risk prediction models may help targeted screening and early detection approaches. OBJECTIVES: to assess the feasibility of identifying people at higher risk of melanoma using the Williams self-assessed clinical risk estimation model in U.K. primary care. METHODS: We recruited participants from the waiting rooms of 22 general practices covering a total population of > 240 000 in three U.K. regions: Eastern England, North East Scotland and North Wales. Participants completed an electronic questionnaire using tablet computers. The main outcome was the mean melanoma risk score using the Williams melanoma risk model. RESULTS: of 9004 people approached, 7742 (86%) completed the electronic questionnaire. The mean melanoma risk score for the 7566 eligible participants was 17·15 ± 8·51, with small regional differences [lower in England compared with Scotland (P = 0·001) and Wales (P < 0·001), mainly due to greater freckling and childhood sunburn among Scottish and Welsh participants]. After weighting to the age and sex distribution, different potential cut-offs would allow between 4% and 20% of the population to be identified as higher risk, and those groups would contain 30% and 60%, respectively of those likely to develop melanoma. CONCLUSIONS: Collecting data on the melanoma risk profile of the general population in U.K. primary care is both feasible and acceptable for patients in a general practice setting, and provides opportunities for new methods of real-time risk assessment and risk stratified cancer interventions.
Abstract.
Author URL.
Neal RD, Barham A, Bongard E, Edwards RT, Fitzgibbon J, Griffiths G, Hamilton W, Hood K, Nelson A, Parker D, et al (2017). Immediate chest X-ray for patients at risk of lung cancer presenting in primary care: randomised controlled feasibility trial.
Br J Cancer,
116(3), 293-302.
Abstract:
Immediate chest X-ray for patients at risk of lung cancer presenting in primary care: randomised controlled feasibility trial.
BACKGROUND: Achieving earlier stage diagnosis is one option for improving lung cancer outcomes in the United Kingdom. Patients with lung cancer typically present with symptoms to general practitioners several times before referral or investigation. METHODS: We undertook a mixed methods feasibility individually randomised controlled trial (the ELCID trial) to assess the feasibility and inform the design of a definitive, fully powered, UK-wide, Phase III trial of lowering the threshold for urgent investigation of suspected lung cancer. Patients over 60, with a smoking history, presenting with new chest symptoms to primary care, were eligible to be randomised to intervention (urgent chest X-ray) or usual care. RESULTS: the trial design and materials were acceptable to GPs and patients. We randomised 255 patients from 22 practices, although the proportion of eligible patients who participated was lower than expected. Survey responses (89%), and the fidelity of the intervention (82% patients X-rayed within 3 weeks) were good. There was slightly higher anxiety and depression in the control arm in participants aged >75. Three patients (1.2%) were diagnosed with lung cancer. CONCLUSIONS: We have demonstrated the feasibility of individually randomising patients at higher risk of lung cancer, to a trial offering urgent investigation or usual care.
Abstract.
Author URL.
Parsonage RK, Hiscock J, Law R-J, Neal RD (2017). Patient perspectives on delays in diagnosis and treatment of cancer: a qualitative analysis of free-text data.
BRITISH JOURNAL OF GENERAL PRACTICE,
67(654), E49-E56.
Author URL.
Hulbert-Williams NJ, Plumpton CO, Flowers P, McHugh R, Neal RD, Semlyen J, Storey L (2017). The cancer care experiences of gay, lesbian and bisexual patients: a secondary analysis of data from the UK Cancer Patient Experience Survey.
EUROPEAN JOURNAL OF CANCER CARE,
26(4).
Author URL.
2016
Baird R, Banks I, Cameron D, Chester J, Earl H, Flannagan M, Januszewski A, Kennedy R, Payne S, Samuel E, et al (2016). An Association of Cancer Physicians' strategy for improving services and outcomes for cancer patients.
Ecancermedicalscience,
10Abstract:
An Association of Cancer Physicians' strategy for improving services and outcomes for cancer patients.
The Association of Cancer Physicians in the United Kingdom has developed a strategy to improve outcomes for cancer patients and identified the goals and commitments of the Association and its members.
Abstract.
Author URL.
Weller D, Vedsted P, Anandan C, Zalounina A, Fourkala EO, Desai R, Liston W, Jensen H, Barisic A, Gavin A, et al (2016). An investigation of routes to cancer diagnosis in 10 international jurisdictions, as part of the International Cancer Benchmarking Partnership: survey development and implementation.
BMJ OPEN,
6(7).
Author URL.
Hamilton W, Walter FM, Rubin G, Neal RD (2016). Improving early diagnosis of symptomatic cancer.
Nature Reviews Clinical Oncology,
13(12), 740-749.
Abstract:
Improving early diagnosis of symptomatic cancer
Much time, effort and investment goes into the diagnosis of symptomatic cancer, with the expectation that this approach brings clinical benefits. This investment of resources has been particularly noticeable in the UK, which has, for several years, appeared near the bottom of international league tables for cancer survival in economically developed countries. In this Review, we examine expedited diagnosis of cancer from four perspectives. The first relates to the potential for clinical benefits of expedited diagnosis of symptomatic cancer. Limited evidence from clinical trials is available, but the considerable observational evidence suggests benefits can be obtained from this approach. The second perspective considers how expedited diagnosis can be achieved. We concentrate on data from the UK, where extensive awareness campaigns have been conducted, and initiatives in the primary-care setting, including clinical decision support, have all occurred during a period of considerable national policy change. The third section considers the most appropriate patients for cancer investigations, and the possible community settings for identification of such patients; UK national guidance for selection of patients for investigation is discussed. Finally, the health economics of expedited diagnosis are reviewed, although few studies provide definitive evidence on this topic.
Abstract.
Nicholson BD, Mant D, Neal RD, Hart N, Hamilton W, Shinkins B, Rubin G, Rose PW (2016). International variation in adherence to referral guidelines for suspected cancer: a secondary analysis of survey data.
Br J Gen Pract,
66(643), e106-e113.
Abstract:
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
Abstract.
Author URL.
Hughes DL, Neal RD, Lyratzopoulos G, Rubin G (2016). Profiling for primary-care presentation, investigation and referral for liver cancers: evidence from a national audit.
EUROPEAN JOURNAL OF GASTROENTEROLOGY & HEPATOLOGY,
28(4), 428-432.
Author URL.
Hubbard G, Kyle R, Stoddart I, Forbat L, Neal R, O'Carroll R, Haw S (2016). RAISING ADOLESCENT CANCER AWARENESS AND CANCER COMMUNICATION IN FAMILIES.
Author URL.
Hubbard G, Kyle R, Stoddart I, Forbat L, Neal RD, O'Carroll R, Haw S (2016). RAISING ADOLESCENT CANCER AWARENESS AND CANCER COMMUNICATION IN FAMILIES.
Author URL.
Sundar S, Rick C, Dowling F, Au P, Snell K, Rai N, Champaneria R, Neal R, Davenport C, Mallet S, et al (2016). Refining Ovarian Cancer Test accuracy Scores (ROCkeTS) trial update.
Author URL.
Sundar S, Rick C, Dowling F, Au P, Snell K, Rai N, Champaneria R, Stobart H, Neal R, Davenport C, et al (2016). Refining Ovarian Cancer Test accuracy Scores (ROCkeTS): protocol for a prospective longitudinal test accuracy study to validate new risk scores in women with symptoms of suspected ovarian cancer.
BMJ OPEN,
6(8).
Author URL.
Hubbard G, Stoddart I, Forbat L, Neal RD, O'Carroll RE, Haw S, Rauchhaus P, Kyle RG (2016). School-based brief psycho-educational intervention to raise adolescent cancer awareness and address barriers to medical help-seeking about cancer: a cluster randomised controlled trial.
PSYCHO-ONCOLOGY,
25(7), 760-771.
Author URL.
Shephard EA, Neal RD, Rose PW, Walter FM, Hamilton W (2016). Symptoms of adult chronic and acute leukaemia before diagnosis: large primary care case-control studies using electronic records.
Br J Gen Pract,
66(644), e182-e188.
Abstract:
Symptoms of adult chronic and acute leukaemia before diagnosis: large primary care case-control studies using electronic records.
BACKGROUND: Leukaemia is the eleventh commonest UK cancer. The four main subtypes have different clinical profiles, particularly between chronic and acute types. AIM: to identify the symptom profiles of chronic and acute leukaemia in adults in primary care. DESIGN AND SETTING: Matched case-control studies using Clinical Practice Research Datalink records. METHOD: Putative symptoms of leukaemia were identified in the year before diagnosis. Conditional logistic regression was used for analysis, and positive predictive values (PPVs) were calculated to estimate risk. RESULTS: of cases diagnosed between 2000 and 2009, 4655 were aged ≥40 years (2877 chronic leukaemia (CL), 937 acute leukaemia (AL), 841 unreported subtype). Ten symptoms were independently associated with CL, the three strongest being: lymphadenopathy (odds ratio [OR] 22, 95% confidence interval [CI] = 13 to 36), weight loss (OR 3.0, 95% CI = 2.1 to 4.2), and bruising (OR 2.3, 95% CI = 1.6 to 3.2). Thirteen symptoms were independently associated with AL, the three strongest being: nosebleeds and/or bleeding gums (OR 5.7, 95% CI = 3.1 to 10), fever (OR 5.3, 95% CI = 2.7 to 10), and fatigue (OR 4.4, 95% CI = 3.3 to 6.0). No individual symptom or combination of symptoms had a PPV >1%. CONCLUSION: the symptom profiles of CL and AL have both overlapping and distinct features. This presents a dichotomy for GPs: diagnosis, by performing a full blood count, is easy; however, the symptoms of leukaemia are non-specific and of relatively low risk. This explains why many leukaemia diagnoses are unexpected findings.
Abstract.
Author URL.
Rai N, Davenport C, Champaneria R, Snell K, Bayliss S, Stevens S, Neal R, Balogun M, Mallet S, Kehoe S, et al (2016). Symptoms, ultrasound and biomarkers in combination for the diagnosis of ovarian cancer in women with suspicious symptoms: a systematic review and meta-analysis.
Author URL.
Watson E, Shinkins B, Frith E, Neal D, Hamdy F, Walter F, Weller D, Wilkinson C, Faithfull S, Wolstenholme J, et al (2016). Symptoms, unmet needs, psychological well-being and health status in survivors of prostate cancer: implications for redesigning follow-up.
BJU Int,
117(6B), E10-E19.
Abstract:
Symptoms, unmet needs, psychological well-being and health status in survivors of prostate cancer: implications for redesigning follow-up.
OBJECTIVE: to explore ongoing symptoms, unmet needs, psychological wellbeing, self-efficacy and overall health status in survivors of prostate cancer. PATIENTS AND METHODS: an invitation to participate in a postal questionnaire survey was sent to 546 men, diagnosed with prostate cancer 9-24 months previously at two UK cancer centres. The study group comprised men who had been subject to a range of treatments: surgery, radiotherapy, hormone therapy and active surveillance. The questionnaire included measures of prostate-related quality of life (Expanded Prostate cancer Index Composite 26-item version, EPIC-26); unmet needs (Supportive Care Needs Survey 34-item version, SCNS-SF34); anxiety and depression (Hospital Anxiety and Depression Scale, HADS), self-efficacy (modified Self-efficacy Scale), health status (EuroQol 5D, EQ-5D) and satisfaction with care (questions developed for this study). A single reminder was sent to non-responders after 3 weeks. Data were analysed by age, co-morbidities, and treatment group. RESULTS: in all, 316 men completed questionnaires (64.1% response rate). Overall satisfaction with follow-up care was high, but was lower for psychosocial than physical aspects of care. Urinary, bowel, and sexual functioning was reported as a moderate/big problem in the last month for 15.2% (n = 48), 5.1% (n = 16), and 36.5% (n = 105) men, respectively. The most commonly reported moderate/high unmet needs related to changes in sexual feelings/relationships, managing fear of recurrence/uncertainty, and concerns about the worries of significant others. It was found that 17% of men (51/307) reported potentially moderate-to-severe levels of anxiety and 10.2% (32/308) reported moderate-to-severe levels of depression. The presence of problematic side-effects was associated with higher psychological morbidity, poorer self-efficacy, greater unmet needs, and poorer overall health status. CONCLUSION: While some men report relatively few problems after prostate cancer treatment, this study highlights important physical and psycho-social issues for a significant minority of survivors of prostate cancer. Strategies for identifying those men with on-going problems, alongside new interventions and models of care, tailored to individual needs, are needed to improve quality of life.
Abstract.
Author URL.
Pye K, Totton N, Stuart N, Whitaker R, Morrison V, Edwards RT, Yeo ST, Timmis LJ, Butterworth C, Hall L, et al (2016). Trial of Optimal Personalised Care After Treatment for Gynaecological cancer (TOPCAT-G): a study protocol for a randomised feasibility trial.
Pilot and Feasibility Studies,
2(1).
Abstract:
Trial of Optimal Personalised Care After Treatment for Gynaecological cancer (TOPCAT-G): a study protocol for a randomised feasibility trial
Background: Gynaecological cancers are diagnosed in over 1000 women in Wales every year. We estimate that this is costing the National Health Service (NHS) in excess of £1 million per annum for routine follow-up appointments alone. Follow-up care is not evidence-based, and there are no definitive guidelines from the National Institute for Health and Care Excellence (NICE) for the type of follow-up that should be delivered. Standard care is to provide a regular medical review of the patient in a hospital-based outpatient clinic for a minimum of 5years. This study is to evaluate the feasibility of a proposed alternative where the patients are delivered a specialist nurse-led telephone intervention known as Optimal Personalised Care After Treatment for Gynaecological cancer (OPCAT-G), which comprised of a protocol-based patient education, patient empowerment and structured needs assessment. Methods: the study will recruit female patients who have completed treatment for cervical, endometrial, epithelial ovarian or vulval cancer within the previous 3months in Betsi Cadwaladr University Health Board (BCUHB) in North Wales. Following recruitment, participants will be randomised to one of two arms in the trial (standard care or OPCAT-G intervention). The primary outcomes for the trial are patient recruitment and attrition rates, and the secondary outcomes are quality of life, health status and capability, using the EORTC QLQ-C30, EQ-5D-3L and ICECAP-A measures. Additionally, a client service receipt inventory (CSRI) will be collected in order to pilot an economic evaluation. Discussion: the results from this feasibility study will be used to inform a fully powered randomised controlled trial to evaluate the difference between standard care and the OPCAT-G intervention.
Abstract.
2015
Neal RD, Team ELCIDT (2015). A feasibility randomised controlled trial looking at the effect on lung cancer diagnosis of giving a Chest X-Ray to smokers aged over 60 with new chest symptoms - feasibility and 2-month follow-up data (ELCID).
Author URL.
Stanciu MA, Morris C, Makin M, Watson E, Bulger J, Evans R, Hiscock J, Hoare Z, Edwards RT, Neal RD, et al (2015). A pilot randomised controlled trial of personalised care after treatment for prostate cancer (TOPCAT-P): nurse-led holistic-needs assessment and individualised psychoeducational intervention: study protocol.
BMJ Open,
5(6).
Abstract:
A pilot randomised controlled trial of personalised care after treatment for prostate cancer (TOPCAT-P): nurse-led holistic-needs assessment and individualised psychoeducational intervention: study protocol.
INTRODUCTION: Prostate cancer is common and the incidence is increasing, but more men are living longer after diagnosis, and die with their disease rather than of it. Nonetheless, specific and substantial physical, sexual, emotional and mental health problems often lead to a poor quality of life. Urology services increasingly struggle to cope with the demands of follow-up care, and primary care is likely to play the central role in long-term follow-up. The present phase II trial will evaluate the feasibility and acceptability of a nurse-led, person-centred psychoeducational intervention, delivered in community or primary care settings. METHODS AND ANALYSIS: Prostate cancer survivors diagnosed in the past 9-48 months and currently biochemically stable will be identified from hospital records by their treating clinician. Eligible men would have either completed radical treatment, or would be followed up with prostate specific antigen monitoring and symptom reporting. We will recruit 120 patients who will be randomised to receive either an augmented form of usual care, or an additional nurse-led intervention for a period of 36 weeks. Following the health policy in Wales, the intervention is offered by a key worker, is promoting prudent healthcare and is using a holistic needs assessment. Outcome measures will assess physical symptoms, psychological well-being, confidence in managing own health and quality of life. Healthcare service use will be measured over 36 weeks. Feedback interviews with patients and clinicians will further inform the acceptability of the intervention. Recruitment, attrition, questionnaire completion rates and outcome measures variability will be assessed, and results will inform the design of a future phase III trial and accompanying economic evaluation. ETHICS AND DISSEMINATION: Ethics approval was granted by Bangor University and North Wales REC (13/WA/0291). Results will be reported in peer-reviewed publications, at scientific conferences, and directly through national cancer and primary care networks. TRIAL REGISTRATION NUMBER: ISRCTN 34516019.
Abstract.
Author URL.
Din NU, Ukoumunne OC, Rubin G, Hamilton W, Carter B, Stapley S, Neal RD (2015). Age and Gender Variations in Cancer Diagnostic Intervals in 15 Cancers: Analysis of Data from the UK Clinical Practice Research Datalink.
PLoS One,
10(5).
Abstract:
Age and Gender Variations in Cancer Diagnostic Intervals in 15 Cancers: Analysis of Data from the UK Clinical Practice Research Datalink.
BACKGROUND: Time from symptomatic presentation to cancer diagnosis (diagnostic interval) is an important, and modifiable, part of the patient's cancer pathway, and can be affected by various factors such as age, gender and type of presenting symptoms. The aim of this study was to quantify the relationships of diagnostic interval with these variables in 15 cancers diagnosed between 2007 and 2010 using routinely collected data from the Clinical Practice Research Datalink (CPRD) in the UK. METHODS: Symptom lists for each cancer were prepared from the literature and by consensus amongst the clinician researchers, which were then categorised into either NICE qualifying (NICE) or not (non-NICE) based on NICE Urgent Referral Guidelines for Suspected Cancer criteria. Multivariable linear regression models were fitted to examine the relationship between diagnostic interval (outcome) and the predictors: age, gender and symptom type. RESULTS: 18,618 newly diagnosed cancer patients aged ≥40 who had a recorded symptom in the preceding year were included in the analysis. Mean diagnostic interval was greater for older patients in four disease sites (difference in days per 10 year increase in age; 95% CI): bladder (10.3; 5.5 to 15.1; P
Abstract.
Author URL.
Coxon D, Campbell C, Walter F, Scott S, Neal R, Vedsted P, Emery J, Rubin G, Hamilton W, Weller D, et al (2015). Development of the 'Aarhus Statement Tool for Researching Intervals in Diagnosis' (ASTRID): results from a pilot study with cancer patients and their GPs.
EUROPEAN JOURNAL OF CANCER CARE,
24, 16-16.
Author URL.
Sundar S, Neal RD, Kehoe S (2015). Diagnosis of ovarian cancer.
BMJ-BRITISH MEDICAL JOURNAL,
351 Author URL.
Astin MP, Martins T, Welton N, Neal RD, Rose PW, Hamilton W (2015). Diagnostic value of symptoms of oesophagogastric cancers in primary care: a systematic review and meta-analysis.
Br J Gen Pract,
65(639), e677-e691.
Abstract:
Diagnostic value of symptoms of oesophagogastric cancers in primary care: a systematic review and meta-analysis.
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.
Abstract.
Author URL.
Rose PW, Rubin G, Perera-Salazar R, Almberg SS, Barisic A, Dawes M, Grunfeld E, Hart N, Neal RD, Pirotta M, et al (2015). Explaining variation in cancer survival between 11 jurisdictions in the International Cancer Benchmarking Partnership: a primary care vignette survey.
BMJ Open,
5(5).
Abstract:
Explaining variation in cancer survival between 11 jurisdictions in the International Cancer Benchmarking Partnership: a primary care vignette survey.
OBJECTIVES: the International Cancer Benchmarking Partnership (ICBP) is a collaboration between 6 countries and 12 jurisdictions with similar primary care-led health services. This study investigates primary care physician (PCP) behaviour and systems that may contribute to the timeliness of investigating for cancer and subsequently, international survival differences. DESIGN: a validated survey administered to PCPs via the internet set out in two parts: direct questions on primary care structure and practice relating to cancer diagnosis, and clinical vignettes, assessing management of scenarios relating to the diagnosis of lung, colorectal or ovarian cancer. PARTICIPANTS: 2795 PCPs in 11 jurisdictions: New South Wales and Victoria (Australia), British Columbia, Manitoba, Ontario (Canada), England, Northern Ireland, Wales (UK), Denmark, Norway and Sweden. PRIMARY AND SECONDARY OUTCOME MEASURES: Analysis compared the cumulative proportion of PCPs in each jurisdiction opting to investigate or refer at each phase for each vignette with 1-year survival, and conditional 5-year survival rates for the relevant cancer and jurisdiction. Logistic regression was used to explore whether PCP characteristics or system differences in each jurisdiction affected the readiness to investigate. RESULTS: 4 of 5 vignettes showed a statistically significant correlation (p
Abstract.
Author URL.
Hamilton W, Stapley S, Campbell C, Lyratzopoulos G, Rubin G, Neal RD (2015). For which cancers might patients benefit most from expedited symptomatic diagnosis? Construction of a ranking order by a modified Delphi technique.
BMC Cancer,
15Abstract:
For which cancers might patients benefit most from expedited symptomatic diagnosis? Construction of a ranking order by a modified Delphi technique.
BACKGROUND: This study aimed to answer the question 'for which cancers, in a symptomatic patient, does expediting the diagnosis provide an improvement in mortality and/or morbidity?' METHODS: an initial ranking was constructed from previous work identifying 'avoidable deaths' for 21 common cancers in the UK. In a two-round modified Delphi exercise, 22 experts, all experienced across multiple cancers, used an evidence pack summarising recent relevant publications and their own experience to adjust this ranking. Participants also answered on a Likert scale whether they anticipated mortality or morbidity benefits for each cancer from expedited diagnosis. RESULTS: Substantial changes in ranking occurred in the Delphi exercise. Finally, expedited diagnosis was judged to provide the greatest mortality benefit in breast cancer, uterine cancer and melanoma, and least in brain and pancreatic cancers. Three cancers, prostate, brain and pancreas, attracted a median answer of 'disagree' to whether they expected mortality benefits from expedited diagnosis of symptomatic cancer. CONCLUSIONS: Our results can guide future research, with emphasis given to studying interventions to improve symptomatic diagnosis of those cancers ranked highly. In contrast, research efforts for cancers with the lowest rankings could be re-directed towards alternative avenues more likely to yield benefit, such as screening or treatment.
Abstract.
Author URL.
Rubin GP, Saunders CL, Abel GA, McPhail S, Lyratzopoulos G, Neal RD (2015). Impact of investigations in general practice on timeliness of referral for patients subsequently diagnosed with cancer: analysis of national primary care audit data.
Br J Cancer,
112(4), 676-687.
Abstract:
Impact of investigations in general practice on timeliness of referral for patients subsequently diagnosed with cancer: analysis of national primary care audit data.
BACKGROUND: for patients with symptoms of possible cancer who do not fulfil the criteria for urgent referral, initial investigation in primary care has been advocated in the United Kingdom and supported by additional resources. The consequence of this strategy for the timeliness of diagnosis is unknown. METHODS: We analysed data from the English National Audit of Cancer Diagnosis in Primary Care on patients with lung (1494), colorectal (2111), stomach (246), oesophagus (513), pancreas (327), and ovarian (345) cancer relating to the ordering of investigations by the General Practitioner and their nature. Presenting symptoms were categorised according to National Institute for Health and Care Excellence (NICE) guidance on referral for suspected cancer. We used linear regression to estimate the mean difference in primary-care interval by cancer, after adjustment for age, gender, and the symptomatic presentation category. RESULTS: Primary-care investigations were undertaken in 3198/5036 (64%) of cases. The median primary-care interval was 16 days (IQR 5-45) for patients undergoing investigation and 0 days (IQR 0-10) for those not investigated. Among patients whose symptoms mandated urgent referral to secondary care according to NICE guidelines, between 37% (oesophagus) and 75% (pancreas) were first investigated in primary care. In multivariable linear regression analyses stratified by cancer site, adjustment for age, sex, and NICE referral category explained little of the observed prolongation associated with investigation. INTERPRETATION: for six specified cancers, investigation in primary care was associated with later referral for specialist assessment. This effect was independent of the nature of symptoms. Some patients for whom urgent referral is mandated by NICE guidance are nevertheless investigated before referral. Reducing the intervals between test order, test performance, and reporting can help reduce the prolongation of primary-care intervals associated with investigation use. Alternative models of assessment should be considered.
Abstract.
Neal RD, Tharmanathan P, France B, Din NU, Cotton S, Fallon-Ferguson J, Hamilton W, Hendry A, Hendry M, Lewis R, et al (2015). Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review.
Br J Cancer,
112 Suppl 1(Suppl 1), S92-107.
Abstract:
Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review.
BACKGROUND: it is unclear whether more timely cancer diagnosis brings favourable outcomes, with much of the previous evidence, in some cancers, being equivocal. We set out to determine whether there is an association between time to diagnosis, treatment and clinical outcomes, across all cancers for symptomatic presentations. METHODS: Systematic review of the literature and narrative synthesis. RESULTS: We included 177 articles reporting 209 studies. These studies varied in study design, the time intervals assessed and the outcomes reported. Study quality was variable, with a small number of higher-quality studies. Heterogeneity precluded definitive findings. The cancers with more reports of an association between shorter times to diagnosis and more favourable outcomes were breast, colorectal, head and neck, testicular and melanoma. CONCLUSIONS: This is the first review encompassing many cancer types, and we have demonstrated those cancers in which more evidence of an association between shorter times to diagnosis and more favourable outcomes exists, and where it is lacking. We believe that it is reasonable to assume that efforts to expedite the diagnosis of symptomatic cancer are likely to have benefits for patients in terms of improved survival, earlier-stage diagnosis and improved quality of life, although these benefits vary between cancers.
Abstract.
Author URL.
Shephard EA, Neal RD, Rose PW, Walter FM, Hamilton WT (2015). Quantifying the risk of Hodgkin lymphoma in symptomatic primary care patients aged ≥40 years: a case-control study using electronic records.
Br J Gen Pract,
65(634), e289-e294.
Abstract:
Quantifying the risk of Hodgkin lymphoma in symptomatic primary care patients aged â40 years: a case-control study using electronic records.
BACKGROUND: in the UK, approximately five people are diagnosed with Hodgkin lymphoma (HL) daily. One-tenth of diagnoses are in those aged >75 years. AIM: 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. METHOD: 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. RESULTS: 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. CONCLUSION: Consistent with secondary care findings, lymphadenopathy is the clinical feature with the highest risk of HL in primary care and warrants urgent investigation.
Abstract.
Author URL.
Shephard EA, Neal RD, Rose P, Walter FM, Litt EJ, Hamilton WT (2015). Quantifying the risk of multiple myeloma from symptoms reported in primary care patients: a large case-control study using electronic records.
Br J Gen Pract,
65(631), e106-e113.
Abstract:
Quantifying the risk of multiple myeloma from symptoms reported in primary care patients: a large case-control study using electronic records.
BACKGROUND: Patients with myeloma experience the longest diagnostic delays compared with patients with other cancers in the UK; 37% are diagnosed through emergency presentations. AIM: 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. METHOD: Putative clinical features of myeloma were identified and analysed using conditional logistic regression. Positive predictive values (PPVs) were calculated for the consulting population. RESULTS: 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 10% for some symptoms when combined with leucopenia or hypercalcaemia. CONCLUSION: 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.
Abstract.
Author URL.
Shephard EA, Neal RD, Rose PW, Walter FM, Hamilton WT (2015). Quantifying the risk of non-Hodgkin lymphoma in symptomatic primary care patients aged ≥40 years: a large case-control study using electronic records.
Br J Gen Pract,
65(634), e281-e288.
Abstract:
Quantifying the risk of non-Hodgkin lymphoma in symptomatic primary care patients aged â40 years: a large case-control study using electronic records.
BACKGROUND: 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. AIM: 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. METHOD: Putative clinical features of NHL were identified in the year before diagnosis. Results were analysed using conditional logistic regression and positive predictive values (PPVs). RESULTS: 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.
Abstract.
Author URL.
Campbell C, Weller D, Neal R, Consortium ABC-DEEP (2015). Recent research into symptomatic cancer diagnosis the UK and international landscape.
Author URL.
Campbell C, Weller D, Neal R, Consortium ABC-DEEP (2015). Recent research into symptomatic cancer diagnosis: the UK and international landscape.
Author URL.
Rogers TK, Hamilton W, Tod A, Neal R (2015). Response to: What characteristics of primary care and patients are associated with early death in patients with lung cancer in the UK?.
Thorax,
70(2).
Author URL.
Hubbard G, Kyle R, MacMillan I, Harding A, Neal R (2015). School-based Brief Psychoeducational Intervention to Raise Adolescent Cancer Awareness and Address Barriers to Seeking Medical Help about Cancer: Cluster Randomized Controlled Trial.
Author URL.
Rai N, Champaneria R, Snell K, Mallett S, Bayliss SE, Neal RD, Balogun M, Kehoe S, Deeks JJ, Sundar S, et al (2015). Symptoms, ultrasound imaging and biochemical markers alone or in combination for the diagnosis of ovarian cancer in women with symptoms suspicious of ovarian cancer.
Cochrane Database of Systematic Reviews,
2015(12).
Abstract:
Symptoms, ultrasound imaging and biochemical markers alone or in combination for the diagnosis of ovarian cancer in women with symptoms suspicious of ovarian cancer
This is the protocol for a review and there is no abstract. The objectives are as follows: to establish the accuracy of symptoms, ultrasound and biomarkers alone or in combination for the diagnosis of ovarian cancer in pre- and postmenopausal women. To compare the accuracy of different tests or test combinations. We will investigate the following sources of heterogeneity: Population: Clinical setting (generalist/primary care/community/family practice) versus specialist setting (cancer unit/cancer centre/gynaecological oncology) Menopausal status Index tests: Test positivity threshold Experience of the ultrasound test operator (general sonographers versus specialist interest) Target condition: Histological subtype Study quality: Case-control versus other study designs Study quality: for study participants not receiving surgery initially following a negative index test result: 12 months follow-up versus less than 12 months follow-up.
Abstract.
Neal RD, Robbe IJ, Lewis M, Williamson I, Hanson J (2015). The complexity and difficulty of diagnosing lung cancer: findings from a national primary-care study in Wales.
PRIMARY HEALTH CARE RESEARCH AND DEVELOPMENT,
16(5), 436-449.
Author URL.
Rubin G, Berendsen A, Crawford SM, Dommett R, Earle C, Emery J, Fahey T, Grassi L, Grunfeld E, Gupta S, et al (2015). The expanding role of primary care in cancer control.
Lancet Oncol,
16(12), 1231-1272.
Abstract:
The expanding role of primary care in cancer control.
The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.
Abstract.
Author URL.
Lyratzopoulos G, Saunders CL, Abel GA, McPhail S, Neal RD, Wardle J, Rubin GP (2015). The relative length of the patient and the primary care interval in patients with 28 common and rarer cancers.
Br J Cancer,
112 Suppl 1, S35-S40.
Abstract:
The relative length of the patient and the primary care interval in patients with 28 common and rarer cancers.
BACKGROUND: Appreciating variation in the length of pre- or post-presentation diagnostic intervals can help prioritise early diagnosis interventions with either a community or a primary care focus. METHODS: We analysed data from the first English National Audit of Cancer Diagnosis in Primary Care on 10 953 patients with any of 28 cancers. We calculated summary statistics for the length of the patient and the primary care interval and their ratio, by cancer site. RESULTS: Interval lengths varied greatly by cancer. Laryngeal and oropharyngeal cancers had the longest median patient intervals, whereas renal and bladder cancer had the shortest (34.5 and 30 compared with 3 and 2 days, respectively). Multiple myeloma and gallbladder cancer had the longest median primary care intervals, and melanoma and breast cancer had the shortest (20.5 and 20 compared with 0 and 0 days, respectively). Mean patient intervals were longer than primary care intervals for most (18 of 28) cancers, and notably so (two- to five-fold greater) for 10 cancers (breast, melanoma, testicular, vulval, cervical, endometrial, oropharyngeal, laryngeal, ovarian and thyroid). CONCLUSIONS: the findings support the continuing development and evaluation of public health interventions aimed at shortening patient intervals, particularly for cancers with long patient interval and/or high patient interval over primary care interval ratio.
Abstract.
Hulbert-Williams N, Plumpton C, McHugh R, Semlyen J, Flowers P, Storey L, Rearn E, Neal R (2015). What are the experiences of cancer care in gay, lesbian and bisexual patients, and how do these differ from heterosexual cancer patients?.
Author URL.
Bulger JK, Hiscock J, Neal RD, Stanciu A, Makin M, Wilkinson C (2015). ‘Carrying on the way we are is becoming shambolic’ – an interview study with prostate cancer specialists about their usual practice of follow-up.
Journal of Clinical Urology,
8(4), 240-245.
Abstract:
âCarrying on the way we are is becoming shambolicâ â an interview study with prostate cancer specialists about their usual practice of follow-up
Aim: This study aims to clarify what practice for the follow-up of prostate cancer is occurring at present and to explain the reasons behind any variation. Background: Prostate cancer has been increasing in incidence in the UK for several years. It has been suggested that men with prostate cancer could be better managed, and that some aspects of care are duplicated by primary and secondary care professionals. Methods: This study aimed to interview the prostate cancer specialists identified as working within the district general hospitals of a large health board. The interviews used a qualitative semi-structured approach. Analysis was performed using the Framework method. Findings: Current practice for the follow-up of prostate cancer is variable both within and between hospitals. Patients are followed up in secondary care for longer than National Institute for Health and Care Excellence (NICE) recommends due to a lack of trust of general practitioners’ management. This inevitably impacts upon waiting lists, and many patients’ appointments are long overdue. A remote prostate-specific antigen (PSA) surveillance system may be beneficial. It is generally thought that change to the usual practice of follow-up of prostate cancer patients is required.
Abstract.
2014
Neal RD, Hurt C, Roberts K, Rogers T, Hamilton W, Edwards RT, Tod AM, Parker D, Jones ET, Nelson A, et al (2014). A feasibility randomised controlled trial looking at the effect on lung cancer diagnosis of giving a chest X-ray to smokers aged over 60 with new chest symptoms - the ELCID trial.
LUNG CANCER,
83, S81-S82.
Author URL.
Walter FM, Mwaka AD, Neal RD (2014). Achieving earlier diagnosis of symptomatic cervical cancer.
BRITISH JOURNAL OF GENERAL PRACTICE,
64(627), 495-496.
Author URL.
Hamilton W, Neal RD, Stapley S (2014). Building the evidence base for the early symptomatic diagnosis of cancer (the ABC-DEEP Consortium - Workstream 3).
EUROPEAN JOURNAL OF CANCER CARE,
23, 7-7.
Author URL.
Neal RD, Campbell C, Hamilton W, Stapley S, Weller D, Lyratzopoulos G, Emery J, Torring ML, Vedsted P, Rubin G, et al (2014). Building the evidence base for the early symptomatic diagnosis of cancer (the ABC-DEEP consortium) - what are the policy and research implications for the international community?.
EUROPEAN JOURNAL OF CANCER CARE,
23, 34-34.
Author URL.
Hubbard G, Macmillan I, Canny A, Forbat L, Neal RD, O'Carroll RE, Haw S, Kyle RG (2014). Cancer symptom awareness and barriers to medical help seeking in Scottish adolescents: a cross-sectional study.
BMC PUBLIC HEALTH,
14 Author URL.
Pottle J, Neal R, Poolman M, Hiscock J (2014). Carer and Health Care Professionals' Views on caring for dying patients in their homes in North Wales. BMJ Supportive & Palliative Care, 4(Suppl 1).
Neal RD, Din NU, Hamilton W, GBRoumunne OC, Carter B, Stapley S, Rubin G (2014). Comparison of cancer diagnostic intervals before and after implementation of NICE guidelines: Analysis of data from the GBR General Practice Research Database.
British Journal of Cancer,
110(3), 584-592.
Abstract:
Comparison of cancer diagnostic intervals before and after implementation of NICE guidelines: Analysis of data from the GBR General Practice Research Database
Background:The primary aim was to use routine data to compare cancer diagnostic intervals before and after implementation of the 2005 NICE Referral Guidelines for Suspected Cancer. The secondary aim was to compare change in diagnostic intervals across different categories of presenting symptoms.Methods:Using data from the General Practice Research Database, we analysed patients with one of 15 cancers diagnosed in either 2001-2002 or 2007-2008. Putative symptom lists for each cancer were classified into whether or not they qualified for urgent referral under NICE guidelines. Diagnostic interval (duration from first presented symptom to date of diagnosis in primary care records) was compared between the two cohorts.Results:In total, 37 588 patients had a new diagnosis of cancer and of these 20 535 (54.6%) had a recorded symptom in the year prior to diagnosis and were included in the analysis. The overall mean diagnostic interval fell by 5.4 days (95% CI: 2.4-8.5; P
Abstract.
Neal RD, Din NU, Hamilton W, Ukoumunne OC, Carter B, Stapley S, Rubin G (2014). Comparison of cancer diagnostic intervals before and after implementation of NICE guidelines: analysis of data from the UK General Practice Research Database.
Br J Cancer,
110(3), 584-592.
Abstract:
Comparison of cancer diagnostic intervals before and after implementation of NICE guidelines: analysis of data from the UK General Practice Research Database.
BACKGROUND: the primary aim was to use routine data to compare cancer diagnostic intervals before and after implementation of the 2005 NICE Referral Guidelines for Suspected Cancer. The secondary aim was to compare change in diagnostic intervals across different categories of presenting symptoms. METHODS: Using data from the General Practice Research Database, we analysed patients with one of 15 cancers diagnosed in either 2001-2002 or 2007-2008. Putative symptom lists for each cancer were classified into whether or not they qualified for urgent referral under NICE guidelines. Diagnostic interval (duration from first presented symptom to date of diagnosis in primary care records) was compared between the two cohorts. RESULTS: in total, 37,588 patients had a new diagnosis of cancer and of these 20,535 (54.6%) had a recorded symptom in the year prior to diagnosis and were included in the analysis. The overall mean diagnostic interval fell by 5.4 days (95% CI: 2.4-8.5; P
Abstract.
Author URL.
Rose PW, Hamilton W, Aldersey K, Barisic A, Dawes M, Foot C, Grunfeld E, Hart N, Neal RD, Pirotta M, et al (2014). Development of a survey instrument to investigate the primary care factors related to differences in cancer diagnosis between international jurisdictions.
BMC Family Practice,
15(1).
Abstract:
Development of a survey instrument to investigate the primary care factors related to differences in cancer diagnosis between international jurisdictions
Background: Survival rates following a diagnosis of cancer vary between countries. The International Cancer Benchmarking Partnership (ICBP), a collaboration between six countries with primary care led health services, was set up in 2009 to investigate the causes of these differences. Module 3 of this collaboration hypothesised that an association exists between the readiness of primary care physicians (PCP) to investigate for cancer - the 'threshold' risk level at which they investigate or refer to a specialist for consideration of possible cancer - and survival for that cancer (lung, colorectal and ovarian). We describe the development of an international survey instrument to test this hypothesis. Methods. The work was led by an academic steering group in England. They agreed that an online survey was the most pragmatic way of identifying differences between the jurisdictions. Research questions were identified through clinical experience and expert knowledge of the relevant literature.A survey comprising a set of direct questions and five clinical scenarios was developed to investigate the hypothesis. The survey content was discussed and refined concurrently and repeatedly with international partners. The survey was validated using an iterative process in England. Following validation the survey was adapted to be relevant to the health systems operating in other jurisdictions and translated into Danish, Norwegian and Swedish, and into Canadian and Australian English. Results: This work has produced a survey with face, content and cross cultural validity that will be circulated in all six countries. It could also form a benchmark for similar surveys in countries with similar health care systems. Conclusions: the vignettes could also be used as educational resources. This study is likely to impact on healthcare policy and practice in participating countries. © 2014 Rose et al.; licensee BioMed Central Ltd.
Abstract.
Coxon D, Campbell C, Walter F, Scott S, Neal R, Vedsted P, Emery J, Rubin G, Hamilton W, Weller D, et al (2014). Development of the 'Aarhus Statement Tool for Researching Intervals in Diagnosis' (ASTRID): focus groups and interviews with patients, researchers and healthcare professionals.
EUROPEAN JOURNAL OF CANCER CARE,
23, 22-22.
Author URL.
Hammersley V, Neal R, Weller D, Campbell C, Consortium ABC-DEEP (2014). Examining the effectiveness of campaigns to increase cancer awareness and promote earlier presentation: a systematic rapid evidence assessment.
Author URL.
Weller D, Vedsted P, Neal R, Pati S (2014). Improving cancer control in Odisha, India, through primary care-based strategies: a joint project by Ca-PRI and the Public Health Foundation of India.
Author URL.
Neal RD, Hamilton W, Rogers TK (2014). Lung cancer.
BMJ,
349 Author URL.
Brain KE, Smits S, Simon AE, Forbes LJ, Roberts C, Robbe IJ, Steward J, White C, Neal RD, Hanson J, et al (2014). Ovarian cancer symptom awareness and anticipated delayed presentation in a population sample.
BMC CANCER,
14 Author URL.
Watson E, Rose P, Frith E, Hamdy F, Neal D, Kastner C, Russell S, Walter FM, Faithfull S, Wolstenholme J, et al (2014). PROSPECTIV-a pilot trial of a nurse-led psychoeducational intervention delivered in primary care to prostate cancer survivors: study protocol for a randomised controlled trial.
BMJ Open,
4(5).
Abstract:
PROSPECTIV-a pilot trial of a nurse-led psychoeducational intervention delivered in primary care to prostate cancer survivors: study protocol for a randomised controlled trial.
BACKGROUND: Prostate cancer survivors can experience physical, sexual, psychological and emotional problems, and there is evidence that current follow-up practices fail to meet these men's needs. Studies show that secondary and primary care physicians see a greater role for primary care in delivering follow-up, and that primary care-led follow-up is acceptable to men with prostate cancer. METHODS AND ANALYSIS: a two-phase study with target population being men who are 9-24â
months from diagnosis. Phase 1 questionnaire aims to recruit 300 men and measure prostate-related quality of life and unmet needs. Men experiencing problems with urinary, bowel, sexual or hormonal function will be eligible for phase 2, a pilot trial of a primary care nurse-led psychoeducational intervention. Consenting eligible participants will be randomised either to intervention plus usual care, or usual care alone (40 men in each arm). The intervention, based on a self-management approach, underpinned by Bandura's Social Cognitive Theory, will provide advice and support tailored to these men's needs and address any problems they are experiencing. Telephone follow-up will take place at 6â
months. Study outcomes will be measured by a questionnaire at 7â
months. Phase 1 will allow us to estimate the prevalence of urinary, sexual, bowel and hormone-related problems in prostate cancer survivors and the level of unmet needs. 'Usual care' will also be documented. Phase 2 will provide information on recruitment and retention, acceptability of the intervention/outcome measures, effect sizes of the intervention and cost-effectiveness data, which is required to inform development of a larger, phase 3 randomised controlled trial. The main outcome of interest is change in prostate-cancer-related quality of life. Methodological issues will also be addressed. ETHICS AND DISSEMINATION: Ethics approval has been gained (Oxford REC a 12/SC/0500). Findings will be disseminated in peer-reviewed journals, at conferences, through user networks and relevant clinical groups. TRIAL REGISTRATION NUMBER: ISRCTN 97242511.
Abstract.
Author URL.
Neal RD, Nafees S, Pasterfield D, Hood K, Hendry M, Gollins S, Makin M, Stuart N, Turner J, Carter B, et al (2014). Patient-reported measurement of time to diagnosis in cancer: development of the Cancer Symptom Interval Measure (C-SIM) and randomised controlled trial of method of delivery.
BMC HEALTH SERVICES RESEARCH,
14 Author URL.
Rubin G, Walter F, Emery J, Neal R, Hamilton W, Wardle J (2014). Research into practice: prompt diagnosis of cancer in primary care.
Br J Gen Pract,
64(625), 428-430.
Author URL.
Kyle RG, MacMillan I, Forbat L, Neal RD, O'Carroll RE, Haw S, Hubbard G (2014). Scottish adolescents' sun-related behaviours, tanning attitudes and associations with skin cancer awareness: a cross-sectional study.
BMJ OPEN,
4(5).
Author URL.
Astin MP, Martins T, Neal RD, Rose PW, Hamilton W (2014). The diagnostic value of symptoms of possible oesophagogastric cancers: a systematic review and meta-analysis.
EUROPEAN JOURNAL OF CANCER CARE,
23, 27-28.
Author URL.
Keeble S, Abel GA, Saunders CL, McPhail S, Walter FM, Neal RD, Rubin GP, Lyratzopoulos G (2014). Variation in promptness of presentation among 10,297 patients subsequently diagnosed with one of 18 cancers: evidence from a National Audit of Cancer Diagnosis in Primary Care.
Int J Cancer,
135(5), 1220-1228.
Abstract:
Variation in promptness of presentation among 10,297 patients subsequently diagnosed with one of 18 cancers: evidence from a National Audit of Cancer Diagnosis in Primary Care.
Cancer awareness public campaigns aim to shorten the interval between symptom onset and presentation to a doctor (the ’patient interval’). Appreciating variation in promptness of presentation can help to better target awareness campaigns. We explored variation in patient intervals recorded in consultations with general practitioners among 10,297 English patients subsequently diagnosed with one of 18 cancers (bladder, brain, breast, colorectal, endometrial, leukaemia, lung, lymphoma, melanoma, multiple myeloma, oesophageal, oro-pharyngeal, ovarian, pancreatic, prostate, renal, stomach, and unknown primary) using data from of the National Audit of Cancer Diagnosis in Primary Care (2009-2010). Proportions of patients with ’prompt’/’non-prompt’ presentation (0-14 or 15+ days from symptom onset, respectively) were described and respective odds ratios were calculated by multivariable logistic regression. The overall median recorded patient interval was 10 days (IQR 0-38). of all patients, 56% presented promptly. Prompt presentation was more frequent among older or housebound patients (p < 0.001). Prompt presentation was most frequent for bladder and renal cancer (74% and 70%, respectively); and least frequent for oro-pharyngeal and oesophageal cancer (34% and 39%, respectively, p
Abstract.
Hulbert-Williams N, McHugh R, Semlyen J, Flowers P, Storey L, Ream E, Neal R (2014). What are the Experiences of Cancer Care in Gay, Lesbian and Bisexual Patients, and How to These Differ from Heterosexual Cancer Patients?.
Author URL.
2013
Hurt CN, Roberts K, Rogers TK, Griffiths GO, Hood K, Prout H, Nelson A, Fitzgibbon J, Barham A, Thomas-Jones E, et al (2013). A feasibility study examining the effect on lung cancer diagnosis of offering a chest X-ray to higher-risk patients with chest symptoms: Protocol for a randomized controlled trial.
Trials,
14(1).
Abstract:
A feasibility study examining the effect on lung cancer diagnosis of offering a chest X-ray to higher-risk patients with chest symptoms: Protocol for a randomized controlled trial
Background: in order to improve lung cancer survival in the UK, a greater proportion of resectable cancers must be diagnosed. It is likely that resectability rates would be increased by more timely diagnosis. Aside from screening, the only way of achieving this is to reduce the time to diagnosis in symptomatic cancers. Currently, lung cancers are mainly diagnosed by general practitioners (GPs) using the National Institute for Health and Clinical Excellence (NICE) guidelines for urgent referral for chest X-ray, which recommend urgent imaging or referral for patients who have one of a number of chest symptoms for more than 3 weeks. We are proposing to expand this recommendation to include one of a number of chest symptoms of any duration in higher-risk patients.Methods/Design: We intend to conduct a trial of imaging in these higher-risk patients and compare it with NICE guidelines to see if imaging improves stage at diagnosis and resection rates. This trial would have to be large (and consequently resource-intensive) because most of these patients will not have lung cancer, making optimal design crucial. We are therefore conducting a pilot trial that will ascertain the feasibility of running a full trial and provide key information that will be required in order to design the full trial.Discussion: This trial will assess the feasibility and inform the design of a large, UK-wide, clinical trial of a change to the NICE guidelines for urgent referral for chest X-ray for suspected lung cancer. It utilizes a combination of workshop, health economic, quality of life, qualitative, and quantitative methods in order to fully assess feasibility.Trial registration: Clinicaltrials.gov NCT01344005. © 2013 Hurt et al.; licensee BioMed Central Ltd.
Abstract.
Prout H, Neal R, Roberts K, Hurt C, Rogers T, Hamilton W, Edwards RT, Todd A, Parker D, Jones ET, et al (2013). ELCID: early lung cancer identification and diagnosis - an embedded interview study to explore patient participation and recruitment. Trials, 14(Suppl 1).
Weller DP, Campbell C, Murray S, Neal R (2013). FOLLOW UP OF PATIENTS WITH LUNG CANCER: THE ROLE OF PRIMARY CARE.
Author URL.
Lyratzopoulos G, Abel GA, McPhail S, Neal RD, Rubin GP (2013). Gender inequalities in the promptness of diagnosis of bladder and renal cancer after symptomatic presentation: evidence from secondary analysis of an English primary care audit survey.
BMJ Open,
3(6).
Abstract:
Gender inequalities in the promptness of diagnosis of bladder and renal cancer after symptomatic presentation: evidence from secondary analysis of an English primary care audit survey.
OBJECTIVES: to explore whether women experience greater delays in the diagnosis of bladder and renal cancer when first presenting to a general practitioner with symptoms caused by those cancers and potential reasons for such gender inequalities. DESIGN: Prospective national audit survey of cancer diagnosis. SETTING: English primary care (2009-2010). PARTICIPANTS: 920 patients with bladder and 398 patients with renal cancer (252 (27%) and 165 (42%), respectively, were women). PRIMARY AND SECONDARY OUTCOME MEASURES: Proportion of patients with three or more pre-referral consultations; number of days from first presentation to referral; proportion of patients who presented with haematuria and proportion of patients investigated in primary care. RESULTS: Women required three or more prereferral consultations more often than men (27% (95% CI 21% to 33%) vs 11% (9% to 14%) for bladder (p
Abstract.
Lyratzopoulos G, Abel GA, McPhail S, Neal RD, Rubin GP (2013). Measures of promptness of cancer diagnosis in primary care: secondary analysis of national audit data on patients with 18 common and rarer cancers.
Br J Cancer,
108(3), 686-690.
Abstract:
Measures of promptness of cancer diagnosis in primary care: secondary analysis of national audit data on patients with 18 common and rarer cancers.
BACKGROUND: Evidence is needed about the promptness of cancer diagnosis and associations between its measures. METHODS: We analysed data from the National Audit of Cancer Diagnosis in Primary Care 2009-10 exploring the association between the interval from first symptomatic presentation to specialist referral (the primary care interval, or ’interval’ hereafter) and the number of pre-referral consultations. RESULTS: Among 13,035 patients with any of 18 different cancers, most (82%) were referred after 1 (58%) or 2 (25%) consultations (median intervals 0 and 15 days, respectively) while 9%, 4% and 5% patients required 3, 4 or 5+ consultations (median intervals 34, 47 and 97 days, respectively) (Spearman’s r=0.70). The association was at least moderate for any cancer (Spearman’s r range: 0.55 (prostate)-0.77 (brain)). Patients with cancers with a higher proportion of three or more pre-referral consultations typically also had longer median intervals (e.g. multiple myeloma) and vice versa (e.g. breast cancer). CONCLUSION: the number of pre-referral consultations has construct validity as a measure of the primary care interval. Developing interventions to reduce the number of pre-referral consultations can help improve the timeliness of cancer diagnosis, and constitutes a priority for early diagnosis initiatives and research.
Abstract.
Cotton SJ, Belcher J, Rose P, Jagadeesan SK, Neal RD (2013). The risk of a subsequent cancer diagnosis after herpes zoster infection: primary care database study.
BRITISH JOURNAL OF CANCER,
108(3), 721-726.
Author URL.
Fern LA, Birch R, Whelan J, Cooke M, Sutton S, Neal RD, Gerrand C, Hubbard G, Smith S, Lethaby C, et al (2013). Why can't we improve the timeliness of cancer diagnosis in children, teenagers, and young adults?.
BMJ-BRITISH MEDICAL JOURNAL,
347 Author URL.
2012
Lyratzopoulos G, Greenberg DC, Rubin GP, Abel GA, Walter FM, Neal RD (2012). Advanced stage diagnosis of cancer: who is at greater risk?. Expert Rev Anticancer Ther, 12(8), 993-996.
Hulbert-Williams N, Neal R, Morrison V, Hood K, Wilkinson C (2012). Anxiety, depression and quality of life after cancer diagnosis: what psychosocial variables best predict how patients adjust?.
PSYCHO-ONCOLOGY,
21(8), 857-867.
Author URL.
Hendry M, Pasterfield D, Lewis R, Clements A, Damery S, Neal RD, Adke R, Weller D, Campbell C, Patnick J, et al (2012). Are women ready for the new cervical screening protocol in England? a systematic review and qualitative synthesis of views about human papillomavirus testing.
Br J Cancer,
107(2), 243-254.
Abstract:
Are women ready for the new cervical screening protocol in England? a systematic review and qualitative synthesis of views about human papillomavirus testing.
BACKGROUND: a new protocol for human papillomavirus (HPV) testing within the UK cervical screening programme commenced in April 2011, creating new patient experiences. This is the first review to synthesise a substantial body of international evidence of women's information needs, views and preferences regarding HPV testing. We aimed to inform the development of educational materials to promote informed choice, reduce anxiety and improve disease control. METHODS: We searched 12 bibliographic databases. Two reviewers independently screened papers and assessed study quality; disagreements were resolved by discussion. Results were extracted verbatim and authors' findings treated as primary data. Studies were synthesised collaboratively using framework methods. RESULTS: We synthesised findings from 17 studies. Women had overwhelmingly negative concerns; an HPV diagnosis was daunting, had associated problems of disclosure of a sexually transmitted infection (STI), impacted on relationships and provoked fear of stigmatisation. Nevertheless, many thought HPV testing could be a preferable alternative to repeat cytology. Knowledge was poor; women struggled to interpret limited information in the context of existing knowledge about STIs and cervical cancer. CONCLUSION: Women are likely to be poorly informed, have limited understanding and many unanswered questions. This could increase anxiety and reduce ability to make informed choices, presenting a substantial challenge for those who design and provide information.
Abstract.
Author URL.
Brain K, Smits S, Simon A, Roberts C, Robbe I, Steward J, Neal R, Hanson J (2012). Ovarian cancer symptom awareness and anticipated presentation in a population sample.
Author URL.
Watson EK, Rose PW, Neal RD, Hulbert-Williams N, Donnelly P, Hubbard G, Elliott J, Campbell C, Weller D, Wilkinson C, et al (2012). Personalised cancer follow-up: risk stratification, needs assessment or both?.
Br J Cancer,
106(1), 1-5.
Author URL.
Weller D, Vedsted P, Rubin G, Walter FM, Emery J, Scott S, Campbell C, Andersen RS, Hamilton W, Olesen F, et al (2012). The Aarhus statement: improving design and reporting of studies on early cancer diagnosis. British Journal of Cancer
Hulbert-Williams NJ, Hulbert-Williams L, Morrison V, Neal RD, Wilkinson C (2012). The Mini-Mental Adjustment to Cancer Scale: re-analysis of its psychometric properties in a sample of 160 mixed cancer patients.
PSYCHO-ONCOLOGY,
21(7), 792-797.
Author URL.
Campbell C, Amoakwa E, Anandan C, Highet G, Murray S, Neal R, Rose P, Weller D (2012). The Role of Primary Care in Patients with Lung Cancer.
Author URL.
Stapley S, Peters TJ, Neal RD, Rose PW, Walter FM, Hamilton W (2012). The risk of oesophago-gastric cancer in symptomatic patients in primary care: a large case-control study using electronic records. British Journal of Cancer
Stapley S, Peters TJ, Neal RD, Rose PW, Walter FM, Hamilton W (2012). The risk of pancreatic cancer in symptomatic patients in primary care: a large case-control study using electronic records.
Br J Cancer,
106(12), 1940-1944.
Abstract:
The risk of pancreatic cancer in symptomatic patients in primary care: a large case-control study using electronic records.
BACKGROUND: over 8000 new pancreatic cancers are diagnosed annually in the UK; most at an advanced stage, with only 3% 5-year survival. We aimed to identify and quantify the risk of pancreatic cancer for features in primary care. METHODS: a case-control study using electronic primary care records identified and quantified the features of pancreatic cancer. Cases, aged ≥40 in the General Practice Research Database, UK, with primary pancreatic cancer were matched with controls on age, sex and practice. Putative features of pancreatic cancer were identified in the year before diagnosis. Odds ratios (OR) were calculated for features of cancer using conditional logistic regression. Positive predictive values (PPV) were calculated for consulting patients. RESULTS: in all, 3635 cases and 16,459 controls were studied. Nine features were associated with pancreatic cancer (all P
Abstract.
Author URL.
Lyratzopoulos G, Neal RD, Barbiere JM, Rubin GP, Abel GA (2012). Variation in number of general practitioner consultations before hospital referral for cancer: findings from the 2010 National Cancer Patient Experience Survey in England.
Lancet Oncol,
13(4), 353-365.
Abstract:
Variation in number of general practitioner consultations before hospital referral for cancer: findings from the 2010 National Cancer Patient Experience Survey in England.
BACKGROUND: Information from patient surveys can help to identify patient groups and cancers with the greatest potential for improvement in the experience and timeliness of cancer diagnosis. We aimed to examine variation in the number of pre-referral consultations with a general practitioner between patients with different cancers and sociodemographic characteristics. METHODS: We analysed data from 41,299 patients with 24 different cancers who took part in the 2010 National Cancer Patient Experience Survey in England. We examined variation in the number of general practitioner consultations with cancer symptoms before hospital referral to diagnose cancer. Logistic regression was used to identify independent predictors of three or more pre-referral consultations, adjusting for cancer type, age, sex, deprivation quintile, and ethnic group. FINDINGS: We identified wide variation between cancer types in the proportion of patients who had visited their general practitioner three or more times before hospital referral (7·4% [625 of 8408] for breast cancer and 10·1% [113 of 1124] for melanoma; 41·3% [193 of 467] for pancreatic cancer and 50·6% [939 of 1854] for multiple myeloma). In multivariable analysis, with patients with rectal cancer as the reference group, those with subsequent diagnosis of multiple myeloma (odds ratio [OR] 3·42, 95% CI 3·01-3·90), pancreatic cancer (2·35, 1·91-2·88), stomach cancer (1·96, 1·65-2·34), and lung cancer (1·68, 1·48-1·90) were more likely to have had three or more pre-referral consultations; conversely patients with subsequent diagnosis of breast cancer (0·19; 0·17-0·22), melanoma (0·34, 0·27-0·43), testicular cancer (0·47, 0·33-0·67), and endometrial cancer (0·59, 0·49-0·71) were more likely to have been referred to hospital after only one or two consultations. The probability of three or more pre-referral consultations was greater in young patients (OR for patients aged 16-24 years vs 65-74 years 2·12, 95% CI 1·63-2·75; p
Abstract.
2011
O'Brien R, Rose P, Campbell C, Weller D, Neal RD, Wilkinson C, McIntosh H, Watson E, Prostate Cancer Follow-up Group (2011). "I wish I'd told them": a qualitative study examining the unmet psychosexual needs of prostate cancer patients during follow-up after treatment.
Patient Educ Couns,
84(2), 200-207.
Abstract:
"I wish I'd told them": a qualitative study examining the unmet psychosexual needs of prostate cancer patients during follow-up after treatment.
OBJECTIVE: to gain insight into patients' experiences of follow-up care after treatment for prostate cancer and identify unmet psychosexual needs. METHODS: Semi-structured interviews were conducted with a purposive sample of 35 patients aged 59-82 from three UK regions. Partners were included in 18 interviews. Data were analyzed using constant comparison. RESULTS: (1) Psychosexual problems gained importance over time, (2) men felt they were rarely invited to discuss psychosexual side effects within follow-up appointments and lack of rapport with health care professionals made it difficult to raise problems themselves, (3) problems were sometimes concealed or accepted and professionals' attempts to explore potential difficulties were resisted by some, and (4) older patients were too embarrassed to raise psychosexual concerns as they felt they would be considered 'too old' to be worried about the loss of sexual function. CONCLUSION: Men with prostate cancer, even the very elderly, have psychosexual issues for variable times after diagnosis. These are not currently always addressed at the appropriate time for the patient. PRACTICE IMPLICATIONS: Assessments of psychosexual problems should take place throughout the follow-up period, and not only at the time of initial treatment. Further research examining greater willingness or reluctance to engage with psychosexual interventions may be particularly helpful in designing future interventions.
Abstract.
Author URL.
Edwards RT, Neal RD, Linck P, Bruce N, Mullock L, Nelhans N, Pasterfield D, Russell D, Russell I, Woodfine L, et al (2011). Enhancing ventilation in homes of children with asthma: cost-effectiveness study alongside randomised controlled trial.
BRITISH JOURNAL OF GENERAL PRACTICE,
61(592).
Author URL.
Woodfine L, Neal RD, Bruce N, Edwards RT, Linck P, Mullock L, Nelhans N, Pasterfield D, Russell D, Russell I, et al (2011). Enhancing ventilation in homes of children with asthma: pragmatic randomised controlled trial.
BRITISH JOURNAL OF GENERAL PRACTICE,
61(592), 674-675.
Author URL.
Highet G, Murray SA, Campbell C, Kendall M, Rainey P, Neal R, Rose P, Anandan C, Amoakwa E, Weller D, et al (2011). Resolving tensions: optimising the role of primary care in lung cancer follow-up care. BMJ Supportive & Palliative Care, 1(Suppl 1).
Astin MP, Neal RD, Rose PW, Hamilton W (2011). The diagnostic value of symptoms for colorectal cancer in primary care response.
BRITISH JOURNAL OF GENERAL PRACTICE,
61(588), 441-441.
Author URL.
Astin M, Griffin T, Neal RD, Rose P, Hamilton W (2011). The diagnostic value of symptoms for colorectal cancer in primary care: a systematic review.
Br J Gen Pract,
61(586), e231-e243.
Abstract:
The diagnostic value of symptoms for colorectal cancer in primary care: a systematic review.
BACKGROUND: over 37,000 new colorectal cancers are diagnosed in the UK each year. Most present symptomatically to primary care. AIM: to conduct a systematic review of the diagnostic value of symptoms associated with colorectal cancer. DESIGN: Systematic review. METHOD: MEDLINE, Embase, Cochrane Library, and CINAHL were searched to February 2010, for diagnostic studies of symptomatic adult patients in primary care. Studies of asymptomatic patients, screening, referred populations, or patients with colorectal cancer recurrences, or with fewer than 100 participants were excluded. The target condition was colorectal cancer. Data were extracted to estimate the diagnostic performance of each symptom or pair of symptoms. Data were pooled in a meta-analysis. The quality of studies was assessed with the QUADAS tool. RESULTS: Twenty-three studies were included. Positive predictive values (PPVs) for rectal bleeding from 13 papers ranged from 2.2% to 16%, with a pooled estimate of 8.1% (95% confidence interval [CI] = 6.0% to 11%) in those aged ≥ 50 years. Pooled PPV estimates for other symptoms were: abdominal pain (three studies) 3.3% (95% CI = 0.7% to 16%); and anaemia (four studies) 9.7% (95% CI = 3.5% to 27%). For rectal bleeding accompanied by weight loss or change in bowel habit, pooled positive likelihood ratios (PLRs) were 1.9 (95% CI = 1.3 to 2.8) and 1.8 (95% CI = 1.3 to 2.5) respectively, suggesting higher risk when both symptoms were present. Conversely, the PLR was one or less for abdominal pain, diarrhoea, or constipation accompanying rectal bleeding. CONCLUSION: the findings suggest that investigation of rectal bleeding or anaemia in primary care patients is warranted, irrespective of whether other symptoms are present. The risks from other single symptoms are lower, though multiple symptoms also warrant investigation.
Abstract.
Author URL.
Watson EK, O'Brien R, Campbell C, Weller D, Neal RD, Wilkinson C, Rose PW, Prostate Cancer Follow-Up Study Group (2011). Views of health professionals on the role of primary care in the follow-up of men with prostate cancer.
Fam Pract,
28(6), 647-654.
Abstract:
Views of health professionals on the role of primary care in the follow-up of men with prostate cancer.
BACKGROUND: Follow-up care for prostate cancer has traditionally been led by secondary care in hospital out-patient clinics. As the number of men with prostate cancer increases and secondary care resources face pressure, alternative follow-up models are being sought. Current National Institute for Health and Clinical Excellence guidance recommends follow-up outside the hospital setting for patients who are stable 2 years following radical treatment and for those undergoing 'watchful waiting'. OBJECTIVE: to describe current practice in a sample of relevant health care professionals and to seek their views on the role of primary care in prostate cancer follow-up. METHODS: Semi-structured telephone interviews with 38 UK health care professionals, from both secondary and primary care. Transcripts were analysed using the constant comparative method. RESULTS: There are marked variations in current follow-up practice around the country, with hospital-based follow-up ranging from 6 months to lifetime. The predominant, although not universal, view expressed was that there is both scope and support for primary care to play a greater role, particularly for men with stable disease. This was qualified by the need for supporting education, including guidance on interpretation of prostate-specific antigen values, introduction of robust follow-up systems in primary care, easy access back into secondary (hospital) care, a mechanism for ensuring follow-up data can still be collected for audit purposes and appropriate resourcing. CONCLUSIONS: If primary care is to play a significant role in providing high-quality follow-up care for men with prostate cancer, then steps need to be taken to address the barriers to increased primary care involvement identified by this study.
Abstract.
Author URL.
2010
Neal RD (2010). Cancer diagnosis - the role of urgent referral guidelines.
BRITISH JOURNAL OF GENERAL PRACTICE,
60(571), 127-127.
Author URL.
Hamilton WT, Astin MP, Griffin T, Neal RD, Rose PW (2010). Colorectal cancer Secondary care data may mislead.
BRITISH MEDICAL JOURNAL,
340 Author URL.
O'Brien R, Rose PW, Campbell C, Weller D, Neal RD, Wilkinson C, Watson EK, Prostate Cancer Follow-up Group (2010). Experiences of follow-up after treatment in patients with prostate cancer: a qualitative study.
BJU Int,
106(7), 998-1003.
Abstract:
Experiences of follow-up after treatment in patients with prostate cancer: a qualitative study.
OBJECTIVE: to develop an understanding of experiences of follow-up in patients with prostate cancer, to seek explanations as to why men's needs might not be well met, and explore views on the possible role of primary care in follow-up. The experiences of these patients, and views on the delivery of follow-up care, have been relatively neglected compared to those diagnosed with other cancers. PATIENTS AND METHODS: in all, 35 patients were recruited from 20 practices across three regions in the UK. Maximum variation was sought by purposely sampling by age (59-82 years), treatment, length (0.75-14 years) and mode of follow-up. RESULTS: Patients' descriptions of the content and organization of follow-up showed the shortcomings of follow-up, which included system failings causing patients to be lost to follow-up, and unmet psychosexual needs. Patients were mainly positive about the prospect of follow-up taking place outside the hospital setting. However, some expressed concerns about current follow-up practices and suggested several improvements that need considering if primary care were to take a greater role. CONCLUSION: This study identified some general deficiencies with the current system of follow-up, and our data indicate that primary care could have a role in addressing some of these.
Abstract.
Author URL.
2009
Hulbert-Williams N, Neal RD, Wilkinson C, Morrison V, Makin M (2009). Appraisal and emotional adjustment to cancer diagnosis.
Author URL.
Neal RD (2009). Do diagnostic delays in cancer matter?.
BRITISH JOURNAL OF CANCER,
101, S9-S12.
Author URL.
McIntosh HM, Neal RD, Rose P, Watson E, Wilkinson C, Weller D, Campbell C, Prostate Cancer Follow-up Group (2009). Follow-up care for men with prostate cancer and the role of primary care: a systematic review of international guidelines.
Br J Cancer,
100(12), 1852-1860.
Abstract:
Follow-up care for men with prostate cancer and the role of primary care: a systematic review of international guidelines.
The optimal role for primary care in providing follow-up for men with prostate cancer is uncertain. A systematic review of international guidelines was undertaken to help identify key elements of existing models of follow-up care to establish a theoretical basis for evaluating future complex interventions. Many guidelines provide insufficient information to judge the reliability of the recommendations. Although the PSA test remains the cornerstone of follow-up, the diversity of recommendations on the provision of follow-up care reflects the current lack of research evidence on which to base firm conclusions. The review highlights the importance of transparent guideline development procedures and the need for robust primary research to inform future evidence-based models of follow-up care for men with prostate cancer.
Abstract.
Author URL.
2008
Hulbert-Williams N, Neal R, Wilkinson C, Morrison V, Makin M (2008). An interpretative phenomenological analysis of appraisals, emotions, and adjustment in cancer patients.
Author URL.
Hulbert-Williams N, Neal R, Wilkinson C, Morrison V (2008). Cancer-related stress: is Lazarus's transactional model sufficient?.
Author URL.
Neal RD, Pasterfield D, Wilkinson C, Hood K, Makin M, Lawrence H (2008). Determining patient and primary care delay in the diagnosis of cancer - lessons from a pilot study of patients referred for suspected cancer.
BMC FAMILY PRACTICE,
9 Author URL.
Neal RD, Cannings-John R, Hood K, Sowden J, Lawrence H, Jones C, Jones J (2008). Excision of malignant melanomas in North Wales: effect of location and surgeon on time to diagnosis and quality of excision.
Fam Pract,
25(4), 221-227.
Abstract:
Excision of malignant melanomas in North Wales: effect of location and surgeon on time to diagnosis and quality of excision.
BACKGROUND: the epidemiology of melanoma is changing and its current management is variable, with some lesions being removed in general practice. We aimed to determine the quality of excision and time to diagnosis relating to the excising surgeon and the place of excision. METHOD: Analysis of data from the North Wales Melanoma Database. RESULTS: in total, 578 cases were diagnosed 1993-2001. There was a gender difference with anatomical location, with 107 (65%) males with lesions on their trunk compared to 57 (35%) females. Median Breslow thickness was 1.10 mm (range 0.05-16.0 mm). Ninety-five (16%) lesions were removed in general practice, of which 49 (52%) were referred on to hospital. In total, 266 (61%) lesions were excised with 'adequate' margins and 170 (39%) excised with margins narrower than the guidelines. General practice excisions were from a younger group than hospital excisions. There were no differences in quality of excision between general practice and hospital excisions. Time to diagnosis was shorter overall for general practice excisions than hospital excisions (median 12 versus 41 days, P < 0.001). CONCLUSION: These findings are of policy importance in that there is no evidence from this study that general practice excisions are managed poorly or have a worse prognosis.
Abstract.
Author URL.
Pascoe SW, Neal RD, Heywood PL, Allgar VL, Miles JN, Stefoski-Mikeljevic J (2008). Identifying patients with a cancer diagnosis using general practice medical records and Cancer Registry data.
FAMILY PRACTICE,
25(4), 215-220.
Author URL.
Neal RD (2008). NICE prostate cancer clinical guideline: implications for primary care.
BRITISH JOURNAL OF GENERAL PRACTICE,
58(554), 607-608.
Author URL.
Edwards AGK, Hulbert-Williams N, Neal RD (2008). Psychological interventions for women with metastatic breast cancer.
COCHRANE DATABASE OF SYSTEMATIC REVIEWS(3).
Author URL.
Hulbert-Williams N, Neal R, Wilkinson C, Morrison V (2008). Understanding patient perceptions of participation in psychosocial oncology research.
Author URL.
2007
Hulbert-Williams NJ, Neal RD, Wilkinson C, Morrison VL (2007). Anxiety, depression, and quality of life in the first six months after cancer diagnosis: the contribution of personality, appraisals, and emotions.
Author URL.
Pascoe SW, Neal RD, Bedford YE, McMain SS (2007). Initiation, choice and satisfaction of nursing appointments in general practice: a cross-sectional survey of patients and nurses.
JOURNAL OF CLINICAL NURSING,
16(6), 1068-1071.
Author URL.
Neal RD, Allgar VL, Ali N, Leese B, Heywood P, Proctor G, Evans J (2007). Stage, survival and delays in lung, colorectal, prostate and ovarian cancer: comparison between diagnostic routes.
BRITISH JOURNAL OF GENERAL PRACTICE,
57(536), 212-219.
Author URL.
Neal RDA, Stuart N, Wilkinson C (2007). Testicular cancer: seminoma.
BMJ clinical evidence,
2007Abstract:
Testicular cancer: seminoma
INTRODUCTION: More than half of painless solid swellings of the body of the testis are malignant, with a peak incidence in men aged 25-35 years. About half of testicular cancers are seminomas, which tend to affect older men and have a good prognosis.
Abstract.
2006
Aldridge C, Neal R, Sowden J, Jones H (2006). Analysis of the North Wales, UK, melanoma database 1993-2001.
Author URL.
Ali N, Atkin K, Neal R (2006). The role of culture in the general practice consultation process.
ETHNICITY & HEALTH,
11(4), 389-408.
Author URL.
Allgar VL, Neal RD, Ali N, Leese B, Heywood P, Proctor G, Evans J (2006). Urgent GP referrals for suspected lung, colorectal, prostate and ovarian cancer.
BRITISH JOURNAL OF GENERAL PRACTICE,
56(526), 355-362.
Author URL.
2005
Allgar VL, Neal RD (2005). Delays in the diagnosis of six cancers: Analysis of data from the National Survey of NHS Patients: Cancer.
British Journal of Cancer,
92(11), 1959-1970.
Abstract:
Delays in the diagnosis of six cancers: Analysis of data from the National Survey of NHS Patients: Cancer
The aim of this paper is to describe and compare components of diagnostic delay (patient, primary care, referral, secondary care) for six cancers (breast, colorectal, lung, ovarian, prostate and non-Hodgkin's lymphoma), and to compare delays in patients who saw their GP prior to diagnosis with those who did not. Secondary data analysis of the National Survey of NHS Patients: Cancer was undertaken (65 192 patients). Breast cancer patients experienced the shortest total delays (mean 55.2 days), followed by lung (88.5), ovarian (90.3), non-Hodgkin's lymphoma (102.8), colorectal (125.7) and prostate (148.5). Trends were similar for all components of delay. Compared with patient and primary care delays, referral delays and secondary care delays were much shorter. Patients who saw their GP prior to diagnosis experienced considerably longer total diagnostic delays than those who did not. There were significant differences in all components of delay between the six cancers. Reducing diagnostic delays with the intention of increasing the proportion of early stage cancers may improve cancer survival in the UK, which is poorer than most other European countries. Interventions aimed at reducing patient and primary care delays need to be developed and their effect on diagnostic stage and psychological distress evaluated. © 2005 Cancer Research UK.
Abstract.
Allgar VL, Neal RD (2005). General practictioners' management of cancer in England: Secondary analysis of data from the National Survey of NHS Patients - Cancer.
European Journal of Cancer Care,
14(5), 409-416.
Abstract:
General practictioners' management of cancer in England: Secondary analysis of data from the National Survey of NHS Patients - Cancer
Relatively little is understood concerning the exact role of general practice in the cancer patients' pre-diagnostic, and post-diagnostic journey. This paper aims to explore this role using data from the National Survey of NHS Patients - Cancer. Data from 65 192 patients relating to five questions from this survey were analysed in detail with particular relevance to differences between the six cancers [breast, colorectal, lung, ovarian, prostate and non-Hodgkin's lymphoma (NHL)], and socio-demographic variables (age, gender and social class). There were considerable differences between patients with the six cancers, and the role of general practice in the cancer diagnosis, and post-diagnosis management. The vast majority of patients saw their general practitioner (GP) with symptoms prior to being seen in hospital. A significant minority were told their diagnosis by their GP. About half the sample were told to contact their GP post-discharge, and about half did so. Being told to contact the GP post-discharge was strongly associated with actually seeing the GP. Most patients felt that their GP was given enough information about their treatment or condition. In conclusion, this work has quantified the central role of general practice in cancer diagnosis and management in England. There remain considerable resource, educational and research needs to continue to provide high-quality cancer care in primary care. © 2005 Blackwell Publishing Ltd.
Abstract.
Neal RD, Hussain-Gambles M, Allgar VL, Lawlor DA, Dempsey O (2005). Reasons for and consequences of missed appointments in general practice in the UK: Questionnaire survey and prospective review of medical records.
BMC Family Practice,
6Abstract:
Reasons for and consequences of missed appointments in general practice in the UK: Questionnaire survey and prospective review of medical records
Background: Missed appointments are a common occurrence in primary care in the UK, yet little is known about the reasons for them, or the consequences of missing an appointment. This paper aims to determine the reasons for missed appointments and whether patients who miss an appointment subsequently consult their general practitioner (GP). Secondary aims are to compare psychological morbidity, and the previous appointments with GPs between subjects and a comparison group. Methods: Postal questionnaire survey and prospective medical notes review of adult patients missing an appointment and the comparison group who attended appointments over a three week period in seven general practices in West Yorkshire. Results: of the 386 who missed appointments 122 (32%) responded. of the 386 in the comparison group 223 (58%) responded, resulting in 23 case-control matched pairs with complete data collection. Over 40% of individuals who missed an appointment and participated said that they forgot the appointment and a quarter said that they tried very hard to cancel the appointment or that it was at an inconvenient time. A fifth reported family commitments or being too ill to attend. Over 90% of the patients who missed an appointment subsequently consulted within three months and of these nearly 60% consulted for the stated problem that was going to be presented in the missed consultation. The odds of missing an appointment decreased with increasing age and were greater among those who had missed at least one appointment in the previous 12 months. However, estimates for comparisons between those who missed appointment and the comparison group were imprecise due to the low response rate. Conclusion: Patients who miss appointments tend to cite practice factors and their own forgetfulness as the main reasons for doing so, and most attend within three months of a missed appointment. This study highlights a number of implications for future research. More work needs to be done to engage people who miss appointments into research in a meaningful way. © 2005 Neal et al; licensee BioMed Central Ltd.
Abstract.
Neal RD, Allgar VL (2005). Sociodemographic factors and delays in the diagnosis of six cancers: Analysis of data from the 'National Survey of NHS Patients: Cancer'.
British Journal of Cancer,
92(11), 1971-1975.
Abstract:
Sociodemographic factors and delays in the diagnosis of six cancers: Analysis of data from the 'National Survey of NHS Patients: Cancer'
This paper aims to explore the relationship between sociodemographic factors and the components of diagnostic delay (total, patient and primary care, referral, secondary care) for these six cancers (breast, colorectal, lung, ovarian, prostate, or non-Hodgkin's lymphoma). Secondary analysis of patient-reported data from the 'National Survey of NHS patients: Cancer' was undertaken (65 192 patients). Data were analysed using univariate analysis and Generalised Linear Modelling. With regard to total delay, the findings from the GLM showed that for colorectal cancer, the significant factors were marital status and age, for lung and ovarian cancer none of the factors were significant, for prostate cancer the only significant factor was social class, for non-Hodgkin's lymphoma the only significant factor was age, and for breast cancer the significant factors were marital status and ethnic group. Where associations between any of the component delays were found, the direction of the association was always in the same direction (female subjects had longer delays than male subjects, younger people had longer delays than older people, single and separated/divorced people had longer delays than married people, lower social class groups had longer delays than higher social class groups, and Black and south Asian people had longer delays than white people). These findings should influence the design of interventions aimed at reducing diagnostic delays with the aim of improving morbidity, mortality, and psychological outcomes through earlier stage diagnosis. © 2005 Cancer Research UK.
Abstract.
Neal R, Stuart N, Wilkinson C (2005). Testicular cancer: seminoma. Clinical evidence(14), 1119-1134.
2004
Neal RD, Ali N, Allgar V, Coleman T (2004). Consent rates for video-recording general practice consultations: Effect of ethnicity and other factors.
Family Practice,
21(2), 219-220.
Abstract:
Consent rates for video-recording general practice consultations: Effect of ethnicity and other factors
We sought consent for video-recording general practice consultations from 260 consecutive attenders in nine surgeries. Intensive fieldwork including language support, from both the researcher and professional interpreters, was undertaken. The overall consent rate was 77.3%. No significant differences in consent rates were found between white and south Asian patients, even after controlling for age, gender and self-reported understanding of English. No differences in consent rates were found with respect to age, gender and self-reported understanding of English. © Oxford University Press 2004, all rights reserved.
Abstract.
Hussain-Gambles M, Neal RD, Dempsey O, Lawlor DA, Hodgson J (2004). Missed appointments in primary care: Questionnaire and focus group study of health professionals.
British Journal of General Practice,
54(499), 108-113.
Abstract:
Missed appointments in primary care: Questionnaire and focus group study of health professionals
Background: the issue of missed appointments in primary care is important for patients and staff. Little is known about how missed appointments, and the people who miss them, are managed in primary care, or about effective strategies for managing missed appointments. Aims: to understand the perceptions of primary care staff as to why patients miss appointments, to determine how these perceptions influence their management, and to explore the merit of different management strategies. Design of study: a postal questionnaire survey and focus group interviews. Setting: General practices in Yorkshire. Results: Missed appointments were regarded as an important problem. Patient factors rather than practice factors were perceived as most important in causing missed appointments. Intervention strategies appeared to be driven by perceptions of why patients miss appointments. Negative attitudes, embodied in terms such as 'offenders' to refer to those who missed appointments were prevalent, and favoured intervention strategies included punishing the patient in some way. Receptionists believed that general practitioners should address the issue of the missed appointment with the patient. General practitioners felt guarded about addressing missed appointments with their patients in case it affected the doctor-patient relationship. Conclusion: People who miss appointments were viewed negatively by primary care staff, and most of the reasons for missed appointments were focused on patients. These beliefs underpinned intervention strategies aimed mainly at punishment. Since there is no evidence base concerning interventions that are effective in reducing missed appointments, these negative attitudes may not be beneficial to staff or their patients.
Abstract.
Pascoe SW, Neal RD, Allgar VL (2004). Open-access versus bookable appointment systems: Survey of patients attending appointments with general practitioners.
British Journal of General Practice,
54(502), 367-369.
Abstract:
Open-access versus bookable appointment systems: Survey of patients attending appointments with general practitioners
Access to consultations with general practitioners (GPs) is an important health policy issue. one method of providing 24-hour access is through the provision of open-access surgeries. The study aimed to compare patients, perceptions of 'bookable' and 'non-bookable' (open-access) appointments. A cross-sectional survey design was used and recruited 834 patients in a general practice. There were statistically significant differences between the bookable and the non-bookable appointments for the questions on 'choice of doctor', 'whether able to see the doctor in the time they needed to', and 'convenience of the appointment'. More patients with bookable appointments saw their doctor of choice. One-fifth of patients, equally distributed between the two groups, did not feel that they were seen within the time they needed to be. Almost three-fifths of patients, equally distributed between the two groups, reported that it was either 'easy' or 'very easy' to make the appointment. Greater convenience was reported by those with bookable appointments. These findings support the hypothesis that within a single practice, there is scope for a combined appointment system in which patients can self-select, with equal satisfaction, the type of appointment that they prefer, dependent upon their own preferences or needs at the time. © British Journal of General Practice.
Abstract.
Edwards AG, HulbertâWilliams N, Neal R (2004). Psychological interventions for women with metastatic breast cancer. In (Ed) Cochrane Database of Systematic Reviews.
Pascoe SW, Neal RD, Allgar VL, Selby PJ, Wright EP (2004). Psychosocial care for cancer patients in primary care? Recognition of opportunities for cancer care.
Family Practice,
21(4), 437-442.
Abstract:
Psychosocial care for cancer patients in primary care? Recognition of opportunities for cancer care
The paper outlines psychosocial problems experienced by cancer patients and the current barriers to service delivery. New models of psychosocial service provision are put forward, emphasizing information, communication and technology aids in an attempt to improve co-ordination of care. The management of cancer patients has evolved greatly over the past decades, and patients are well placed to benefit from the experiences of primary care professionals in the delivery of chronic illness disease management strategies. © Oxford University Press 2004, all rights reserved.
Abstract.
2003
Allgar VL, Neal RD, Pascoe SW (2003). Cancer patients consultation patterns in primary care and levels of psychological morbidity: Findings from the health survey for England.
Psycho-Oncology,
12(7), 736-740.
Abstract:
Cancer patients consultation patterns in primary care and levels of psychological morbidity: Findings from the health survey for England
Aim. To determine the consultations patterns in general practice, for people with cancer and other chronic illnesses, and to assess the levels of psychological morbidity. Methods. The following questions from the 1999 Health Survey for England were analysed: presence of a self-reported long-standing illness and its nature, numbers of contacts with general practitioner (GP) in the previous 2 weeks, contact with a GP in the previous year for anxiety/depression or a mental, nervous or emotional problem, presence of a self-reported long-standing illness of mental illness, anxiety or depression, and GHQ12 scores. For comparison purposes, data from respondents reporting having asthma, arthritis, diabetes, other long-standing illness, and no long-standing illness are presented. Results. A third of respondents with cancer had contact with a GP in the last 2 weeks, which was slightly higher than the other illness group, however the pattern of attendances for those respondents who did consult were similar between groups. A quarter of people with cancer had spoken to a GP in the last year about being anxious/depressed, or about a mental, nervous or emotional problem. A third of cancer respondents reported high GHQ12 scores, but self-reported long-standing illness of 'mental illness/anxiety/depression' was low (4%). Conclusion. The findings suggest that psychological morbidity may be unrecognised in some cancer patients. There is potential for these symptoms to be identified and treated in primary care, especially given the ongoing nature of the patient-doctor relationship and the easy access primary care affords. Copyright © 2003 John Wiley & Sons, Ltd.
Abstract.
Wood E, Neal R, Heywood P, Atkin K (2003). Delays in the Diagnosis of Colorectal Cancer: In-Depth, Patient-Centred, Qualitative Study. Clinical Science, 104(s49), 28p-28p.
Mikeljevic JS, Johnston C, Adamson PJ, Wright A, Bishop JAN, Batman P, Neal RD, Forman D (2003). How complete has skin cancer registration been in the UK? a study from Yorkshire.
European Journal of Cancer Prevention,
12(2), 125-133.
Abstract:
How complete has skin cancer registration been in the UK? a study from Yorkshire
The completeness of skin cancer registration in the Yorkshire region was evaluated for the year 1994 by the independent case ascertainment method. Patients diagnosed with skin cancer were identified from regional pathology laboratories, inpatient and outpatient hospital departments and general practices, and were matched against records held by the Northern and Yorkshire Cancer Registry and Information Services (NYCRIS). Out of 5987 skin cancer cases identified from 14 pathology laboratories, 123 general practices, 16 NHS Trusts inpatient databases and 7 dermatology outpatient departments, 83.5% had a matching record on the Cancer Register. The proportion of registered malignant melanoma (MM) and non-melanoma skin cancer (NMSC) cases were 87.5% (95% confidence interval (CI) 84.0-90.4) and 83.1% (95% CI 81.9-84.2) respectively. Skin cancers found in the pathology laboratories, the main notification sources of the registry, were under-ascertained by 15% (10% MM and 150% NMSC). Cases identified from general practices had a significantly lower proportion of matching registry records in comparison with other information sources. No record of histological confirmation could be found for 11% MM and 13% NMSC. Complete capture of pathology laboratory information, histological confirmation of all lesions suspected of skin cancer and routine receipt of hospital patient administration system information supplementary to that from pathology laboratories are measures that would provide the most substantial improvement to ascertainment of skin cancer data. © 2003 Lippincott Williams & Wilkins.
Abstract.
2002
Neal R (2002). Quality care through clinical evidence - the SAPC Annual Scientific Meeting in Birmingham.
BRITISH JOURNAL OF GENERAL PRACTICE,
52(481), 690-690.
Author URL.
2001
Colledge M, Neal R (2001). An applied, practice-based approach to research training in general practice. Education for General Practice, 12(2), 163-168.
Neal RD, Lawlor DA, Allgar V, Colledge M, Ali S, Hassey A, Portz C, Wilson A (2001). Missed appointments in general practice: Retrospective data analysis from four practices.
British Journal of General Practice,
51(471), 830-832.
Abstract:
Missed appointments in general practice: Retrospective data analysis from four practices
Little is known about which patients miss appointments or why they do so. Using routinely collected data from four practices, we aimed to determine whether patients who missed appointments differed in terms of their age, sex, and deprivation scores from those who did not, and to examine differences between the practices with respect to missed appointments. The likelihood of someone missing at least one appointment was independently associated with being female, living in a deprived area, and being a young adult. Living in a deprived area was associated with a threefold increase in the likelihood of missing an appointment, and the extent of this association was the same across all four practices. Interventions aimed at reducing missed appointments need to be based upon these findings.
Abstract.
Dempsey OP, Neal RD, Russell I (2001). Short-term admission of acutely ill older people to nursing homes by general practitioners: a national questionnaire survey [4]. Age and Ageing, 30(4), 357-359.
Neal RD, Wickenden G, Cottrell D, Mason J, Rugiano J, Clarkson P, Bearpark A (2001). The use of primary, secondary, community and social care by families who frequently consult their general practitioner.
Health and Social Care in the Community,
9(6), 375-382.
Abstract:
The use of primary, secondary, community and social care by families who frequently consult their general practitioner
There have been very few studies that have examined either the use of other health and social services by patients who frequently consult their general practitioner, or the patterns of service use of frequently attending families. This study has three aims: to quantify the number of contacts to primary, secondary, community and social services of families who frequently attend their general practitioner; to examine the temporal patterns of these contacts and the patterns of use within families; and to determine the nature of these contacts and how they were valued by patients and health professionals. Thirty-five individuals in seven families completed diaries of health service use for 8 weeks; records from primary and community care records were analysed; health professionals and patients provided satisfaction scores for their contacts. The data were compared to standard datasets. The subjects made far more consultations with all health services than predicted, and less than half of these were with the general practitioner. Thirty-two per cent of the contacts with staff based within the health centre were not reported on the diary sheets. Temporal patterns of consulting were apparent within the families. The 'index frequent attenders' within each family had most contacts. The differences between professional groups for the nature of the contact were marked, with over two-thirds of general practitioner contacts being for 'specific symptoms or problems', and over two-thirds of health visitor contacts being for 'weight problems'. These findings show that patients who make high use of general practitioners' services also have a large number of contacts for health reasons with a range of other health and social services. These need to be considered as an outcome measure for trials of intervention for frequent attendance. More work is needed to explore why some individuals and their families make high use of health services.
Abstract.
2000
Neal RD, Heywood PL, Morley S (2000). 'I always seem to be there' - a qualitative study of frequent attenders.
British Journal of General Practice,
50(458), 716-723.
Abstract:
'I always seem to be there' - a qualitative study of frequent attenders
Background. Much is still unknown about the consultation behaviour of frequent attenders, including why they consult as often as they do and why they consult in the patterns that they do. Aim. To determine why frequent attenders to general practice consult in the patterns that they do. Method. A qualitative study based on semi-structured interviews. Twenty-eight frequent attenders were purposively sampled from three practices; 13 exhibited a 'burst and gap' pattern of attendance and 15 exhibited a 'regular' pattern of attendance. Results. A two-part model is proposed. The first part encompasses each individual decision to consult and is based around eight questions that may be asked as part of the decision-making process (these concern the perception of the general practitioner's [GP's] role, past experience of symptoms and consulting, comparison with others' consulting, relationship with the GP, balancing fears, lay consulting, individual reasons, and whether it was a symptom that they would not normally consult for). The second part determines the pattern of consulting and has four major themes: predominantly medical reasons for attending, experience of what happens during the consultation, accessibility of the GP, and periods of not consulting. Two further themes are proposed: 'multiplicity', whereby the reasons for consulting lead to further consulting for related and unrelated problems, and 'passivity', whereby consulting seems to be out of control. Conclusions. The reasons underpinning each individual decision to consult were complex. The control that GPs were perceived to have over the pattern of consulting, for example concerning prescribing, review visits, and in addressing further help-seeking behaviour, may provide more possibilities for developing intervention strategies than targeting frequent attenders themselves. An understanding of the processes behind the consulting behaviour of frequent attenders may lead to more functional consultations and better clinical care as a result.
Abstract.
Lawlor DA, Keen S, Neal RD (2000). Can general practitioners influence the nation's health through a population approach to provision of lifestyle advice?.
British Journal of General Practice,
50(455), 455-459.
Abstract:
Can general practitioners influence the nation's health through a population approach to provision of lifestyle advice?
Background. Lifestyle advice from general practitioners (GPs) has been shown to have a positive effect on population health. In practice, GPs provide lifestyle advice to a minority of their patients only, those who are high risk or already have symptoms. Aim. To look in depth at GPs' attitudes towards adopting a population approach to lifestyle advice and to use these results to identify ways of maximising the potential of GPs to affect population health. Method. Thirty-six GPs, purposively sampled by identifying characteristics likely to affect their health promotion activity, participated in a focus group study. Data from the focus groups were transcribed verbatim and analysed using standard methods. Results. The main themes that emerged suggested that GPs do not take a population approach to lifestyle advice because they prefer a high risk approach and doubt their ability to be effective in a population approach. GPs believed that social, cultural, and environmental factors were the most important determinants of population health. Furthermore, they were concerned about the detrimental effects on the doctor-patient relationship of providing lifestyle advice to all patients. GPs believed that a multi-agency, centrally co-ordinated approach was the preferred way to improve population health and that their role should be limited to secondary prevention. Conclusion. Large amounts of resources would be necessary to convince GPs to adopt a population approach to lifestyle advice. Measures to tackle the social and environmental determinants of health may be a more effective and efficient means of improving the nation's health.
Abstract.
Neal RD, Heywood PL, Morley S (2000). Freight trains and supernovas: the use of a sorting task to determine patterns within long-term frequent attendance to general practitioners.
Primary Health Care Research and Development,
1(1), 39-50.
Abstract:
Freight trains and supernovas: the use of a sorting task to determine patterns within long-term frequent attendance to general practitioners
Little is understood about the patterns in which frequent attenders consult primary care over time, or about the clinical or behavioural reasons for doing so. The aim of this study was to use a sorting task to identify the important features of patterns of attendance to general practitioners generated by frequent attenders over a period of 44 months. A total of 12 experts performed a sorting task on consulting patterns of the 100 most frequent attenders from one general practice in Leeds. A similarity matrix was constructed which was then subjected to cluster analysis. A range and diversity of patterns was clearly demonstrated within the data. The determining factors of the groupings by the experts included frequency, regularity, bursts of consultations, patterns of consulting after bursts, periods of not consulting, and seasonal or annual trends. The cluster analysis provided six final clusters, the largest of which had no fixed or classifiable pattern of attendance. The other five clusters were ‘regular without bursts’, ‘supernovas’, ‘gap and prolonged burst’, ‘bursts and sporadic attending’ and ‘regular as clockwork'. Distinct patterns of frequent attendance exist, and it seems likely that the clinical and behavioural reasons underpinning such behaviours differ. This work furthers our understanding of the way in which frequent attenders consult, and the results have implications both for general practice and for future research. The methodology described may have applications in other areas of primary care and biomedical research. © 2000, Cambridge University Press. All rights reserved.
Abstract.
Neal RD, Heywood PL, Morley S (2000). Frequent attenders' consulting patterns with general practitioners.
British Journal of General Practice,
50(461), 972-976.
Abstract:
Frequent attenders' consulting patterns with general practitioners
Background. Despite the growing literature on frequent attendance, little is known about the consulting patterns of frequent attenders with different doctors. To develop appropriate intervention strategies and to improve the clinical care of frequent attenders, a full understanding of these consulting patterns is essential. Aims. This paper has three aims: to determine whether frequent attenders consult more with some doctors than others; to determine how many different doctors frequent attenders consult with; and to determine whether frequent attenders exhibit greater continuity of care than non-frequent attenders. Method. Analysis of validated dataset of 592 028 consultations made by 61 055 patients from four practices over 41 months. Comparisons between the consulting patterns of the frequent attenders, defined as the most frequently consulting 3% of the population by practice, with non-frequent attenders and the overall practice populations. Results. There was considerable variation in the numbers and proportions of consultations with frequent attenders between individual doctors. Most of the frequent attenders consulted with most or all of the doctors within practices over the timeframe. Frequent attenders exhibited more continuity of care than non-frequent attenders. Conclusion. The reasons why some doctors have more consultations with frequent attenders is unclear. Some doctors may actively encourage frequent attendance. While many frequent attenders have clear allegiances to one doctor, many also consult widely with a large number of doctors. The consequences of such behaviour are unknown. These findings have important implications in the development of appropriate interventions for reducing problematic frequent attendance.
Abstract.
Neal R (2000). Medical retina CD-ROM.
FAMILY PRACTICE,
17(3), 282-282.
Author URL.
Scaife B, Gill PS, Heywood PL, Neal RD (2000). Socio-economic characteristics of adult frequent attenders in general practice: Secondary analysis of data.
Family Practice,
17(4), 298-304.
Abstract:
Socio-economic characteristics of adult frequent attenders in general practice: Secondary analysis of data
Objective. This study was carried out to determine the effect of a range of socio-economic features on frequent attendance in general practice from a large database of general practice consultations using two definitions of frequent attendance. Methods. Secondary analysis were carried out of data from the Fourth National Survey of Morbidity in General Practice covering 60 general practices in England and Wales. A total of 283 842 adult patients and their consultations between September 1991 and August 1992 were examined. The main outcome measure was the odds ratio of being a frequent attender (95% confidence intervals). Results. Using a definition of 12+ consultations/year, men were less likely to be frequent attenders (OR 0.14, 95% Cl 0.13-0.17); however, the difference between men and women lessens with age. Patients who were more likely to be frequent attenders included those who were divorced or widowed (1.41, 1.31-1.51); from social classes IIIM (1.23, 1.17-1.29) and IV/V (1.33, 1.26-1.41); South Asian people (1.38, 1.16-1.65); or unemployed (1.61, 1.46-1.77). Other factors signifying isolation or poverty were also linked to frequent attendance. Using the definition of '6+ consultations for minor problems' produced broadly similar results although the relative weight of the factors showed some differences. Conclusions. Socio-economic factors were important indicators of frequent attendance in general practice. Results were very similar using either definition, suggesting that both are valid for further work. Furthermore, frequent attendance is a complex process associated with many factors outside the control of the GP.
Abstract.
Neal RD, Colledge M (2000). The effect of the full moon on general practice consultation rates.
Family Practice,
17(6), 472-474.
Abstract:
The effect of the full moon on general practice consultation rates
Background. The effect of the full moon on human behaviour, the so-called 'Transylvania hypothesis', has fascinated the public and occupied the mind of researchers for centuries. Objective. The aim of the present study was to determine whether or not there was any change in general practice consultation patterns around the time of the full moon. Method. We analysed data from the fourth national morbidity study of general practice. The data set was split into two groups and analysed separately: consultations on ordinary weekdays and consultations on weekends and bank holidays. The data were split randomly into two equal sets, one for model building and one for model validation. The lunar cycle effect was assumed to be sinusoidal, on the grounds that any effect would be maximal at the time of the full moon and decline to the new moon, following a cosine curve (with a period of 29.54 days, the mean length of a lunar cycle). Results. There was a statistically significant, but small, effect associated with the lunar cycle of 1.8% of the mean value [95% confidence interval (Cl) 0.9-2.7%]. This equates to an average difference between the two extremes during the cycle of 3.6%. For this data set, this accounts for 190 (95% Cl 95-285) more consultations on days at the peak of the cycle compared with those at the bottom of the cycle, or, put another way, about three consultations per practice. Conclusion. We can speculate neither as to what the nature of these moon-related problems may be, nor as to the mechanisms underpinning such behaviour. However, we have confirmed that it does not seem to be related to anxiety and depression.
Abstract.
Vautrey R, Neal R (2000). Using peer review visits to carry out the clinical governance baseline assessment in one primary care group.
Journal of Clinical Governance,
8(3), 135-140.
Abstract:
Using peer review visits to carry out the clinical governance baseline assessment in one primary care group
This paper reports the process of the clinical governance baseline assessment undertaken by one primary care group. The method chosen in order to undertake this was peer review practice visits, facilitated by prior completion of a detailed questionnaire. This questionnaire covered a number of clinical and organisational areas including access and availability, chronic disease management, risk management, education and training, and included a simple audit of the management of patients with ischaemic heart disease. The visits provided a forum for discussion of these areas. Twenty two (out of 29) practices received a visit; most reported that the process was acceptable. The practices reported educational benefits of the process. If more practices are to engage in this in the future, then the issues of financial incentives, clinical workload, and a service requirement to engage in the process need to be addressed. The true success of the clinical governance agenda in primary care can only be judged in the longer term by measures of quality improvement.
Abstract.
1999
Neal R (1999). Oxford Handbook of Patients' Welfare: a Doctor's Guide to Benefits and Services. BMJ, 318(7188).
1998
Neal R (1998). Conflict in general practice.
BMJ,
317(7173).
Author URL.
Neal RD, Heywood PL, Morley S, Clayden AD, Dowell AC (1998). Frequency of patients' consulting in general practice and workload generated by frequent attenders: Comparisons between practices.
British Journal of General Practice,
48(426), 895-898.
Abstract:
Frequency of patients' consulting in general practice and workload generated by frequent attenders: Comparisons between practices
Background. Patients who attend frequently may present a problem for general practitioners (GPs) in several ways. The frequency of patients' consulting, comparisons between practices, and the effect of frequent consulting on the clinical workload have not been quantified previously. Aims. To examine the distribution of the number of consultations per patient in four general practices. To estimate the clinical workload generated by frequent attenders. To model the data to demonstrate the contribution of age, sex, and practice on the likelihood of attending frequently. Method. Analysis and modelling of a validated data set of date records of consultations collected routinely over a 41-month period from four practices in and around Leeds, representing 44,146 patients and 470,712 consultations. Results. A minority of patients consulted with extreme frequency. All practices had similar distributions but varied with respect to the numbers of frequent attenders, and the frequencies of their consulting the most frequent 1% of attenders accounted for 6% of all consultations, and the most frequent 3% for 15% of all consultations. Females and older people were more likely to be frequent attenders. Conclusion. Frequent attenders have an important effect on GPs' clinical workload. Between one in six and one in seven consultations are with the top 3% of attenders. Further research is needed to explain the behaviour underpinning frequent attendance in order to identify appropriate management strategies; such strategies could have an important effect on clinical workload.
Abstract.
Williams M, Neal RD (1998). Time for a change? the process of lengthening booking intervals in general practice.
British Journal of General Practice,
48(436), 1783-1786.
Abstract:
Time for a change? the process of lengthening booking intervals in general practice
Longer booking intervals between appointments in general practice are generally seen as 'a good thing', and have a strong 'evidence base' to support them. Changing to longer booking intervals is regarded as a pipe dream by many general practitioners (GPs). This paper reports the process and outcomes of a change to longer booking intervals in one practice, identifies the key elements of the change, and examines lessons learned for the practice, to help other practices to do similarly. The most important factor in bringing about change was the influence of facilitation by outside parties; first, by management consultants who identified solutions to the practice's problems, and secondly, by recruitment to a research study. Other outside influences were an awareness of the success of other practices in changing to 10-minute booking intervals, and the increasing 'evidence base' to support such change. Internal influences on the process were a desire to change as a result a perception that the practice was under-performing, and the stress associated with this. As a result of the change, the number of doctor consultations fell and the number of nurse consultations rose, fewer patients reconsulted and marginal improvements were reported on doctor and patient satisfaction. Other practices may benefit from such change; the use of management consultants as facilitators may instigate such change.
Abstract.
1997
Hughes P, Neal RD, Maskrey N (1997). General practitioners prefer to work in cooperatives for out of hours work [4]. British Medical Journal, 314(7098).
1996
Gill PS, Dowell AC, Neal RD, Heywood P, Wilson AE, Smith N (1996). Correction: Evidence based general practice (British Medical Journal (1996) 13 July (114-115)). British Medical Journal, 313(7051).
Gill P, Dowell AC, Neal RD, Smith N, Heywood P, Wilson AE (1996). Evidence based general practice: a retrospective study of interventions in one training practice.
British Medical Journal,
312(7034), 819-821.
Abstract:
Evidence based general practice: a retrospective study of interventions in one training practice
Objectives - to estimate the proportion of interventions in general practice that are based on evidence from clinical trials and to assess the appropriateness of such an evaluation. Design - Retrospective review of case notes. Setting - One suburban training general practice. Subjects - 122 consecutive doctor-patient consultations over two days. Main outcome measures - Proportions of interventions based on randomised controlled trials (from literature search with Medline, pharmaceutical databases, and standard textbooks), on convincing non-experimental evidence, and without substantial evidence. Results - 21 of the 122 consultations recorded were excluded due to insufficient data; 31 of the interventions were based on randomised controlled trial evidence and 51 based on convincing non-experimental evidence. Hence 82/101 (81%) of interventions were based on evidence meeting our criteria. Conclusions - Most interventions within general practice are based on evidence from clinical trials, but the methods used in such trials may not be the most appropriate to apply to this setting.
Abstract.
Neal R, Dowell A, Heywood P, Morley S (1996). Frequent attenders: Who needs treatment?.
BRITISH JOURNAL OF GENERAL PRACTICE,
46(404), 131-132.
Author URL.
Marshall T, Neal RD, Heywood PL, Dowell AC, Morley S (1996). Home visiting by general practitioners in England and Wales [11]. British Medical Journal, 313(7064).
Neal RD, Heywood PI, Dowell AC, Morley S (1996). Home visiting by general practitioners in England and Wales. Phenomena that underpin frequent attendance need clarification. BMJ (Clinical research ed.), 313(7064).
Neal RD, Heywood PL, Morley S (1996). Real world data-retrieval and validation of consultation data from four general practices.
Family Practice,
13(5), 455-461.
Abstract:
Real world data-retrieval and validation of consultation data from four general practices
Objective. We aimed to retrieve data on consultations from general practice databases and to develop and use appropriate methods of validation for these data. Method. MIQUEST software was used to retrieve the data from four practices. The data were validated by comparing them with figures generated by practice-based searches, measuring the uptake of recording of consultations over time, and comparing records of consultations in the case notes with those on the practice computers. Results. The required data were retrieved from general practice databases, but the path to success was difficult, and typified by uncertainty and unpredictability. The recording of consultations on the computers of four practices was more complete than the recording in the paper case records. There was a time period in the early months of computer use when the recording of consultations was less complete. There were differences in the completeness of recording consultations between practices, doctors, and patients. Conclusions. This study confirms the potential of general practice databases for research, demonstrates how MIQUEST software can be a useful tool in retrieving data from general practice databases, and indicates how the completeness of data recording permitted further analysis for the purposes of our study.
Abstract.
1995
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Neal RD (1995). Glaucoma screening. The British journal of general practice : the journal of the Royal College of General Practitioners, 45(393).
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