Effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low-income and middle-income countries: a systematic review.

OBJECTIVES: To systematically synthesise available evidence on the nature and effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low and middle-income countries (LMICs). DESIGN: A systematic review of published evidence. The review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses. DATA SOURCES: A comprehensive search of published literature was conducted. In addition, relevant grey literature sources and bibliographical references of included studies were searched for potentially eligible evidence. STUDY SELECTION: Studies published between January 2010 and November 2020 were eligible for inclusion. To be eligible, studies had to report on interventions/strategies targeted at women, the general public or healthcare workers, aimed at improving the timely diagnosis of breast and/or cervical cancers in LMIC settings. DATA EXTRACTION AND SYNTHESIS: Literature search, screening, study selection, data extraction and quality appraisal were conducted by two independent reviewers. Evidence was synthesised and reported using a global taxonomy framework for early cancer diagnosis. RESULTS: From the total of 10 593 records identified, 21 studies conducted across 20 LMICs were included in this review. Most of the included studies (16/21) focused primarily on interventions addressing breast cancers; two focused on cervical cancer while the rest examined multiple cancer types. Reported interventions targeted healthcare workers (12); women and adolescent girls (7) and both women and healthcare workers (3). Eight studies reported on interventions addressing access delays; seven focused on interventions addressing diagnostic delays; two reported on interventions targeted at addressing both access and diagnostic delays, and four studies assessed interventions addressing access, diagnostic and treatment delays. While most interventions were demonstrated to be feasible and effective, many of the reported outcome measures are of limited clinical relevance to diagnostic timeliness. CONCLUSIONS: Though limited, evidence suggests that interventions aimed at addressing barriers to timely diagnosis of breast and cervical cancer are feasible in resource-limited contexts. Future interventions need to address clinically relevant measures to better assess efficacy of interventions. PROSPERO REGISTRATION NUMBER: CRD42020177232.

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.

Diagnostic performance of a faecal immunochemical test for patients with low-risk symptoms of colorectal cancer in primary care: an evaluation in the South West of England.

BACKGROUND: The faecal immunochemical test (FIT) was introduced to triage patients with low-risk symptoms of possible colorectal cancer in English primary care in 2017, underpinned by little primary care evidence. METHODS: All healthcare providers in the South West of England (population 4 million) participated in this evaluation. 3890 patients aged ≥50 years presenting in primary care with low-risk symptoms of colorectal cancer had a FIT from 01/06/2018 to 31/12/2018. A threshold of 10 µg Hb/g faeces defined a positive test. RESULTS: Six hundred and eighteen (15.9%) patients tested positive; 458 (74.1%) had an urgent referral to specialist lower gastrointestinal (GI) services within three months. Forty-three were diagnosed with colorectal cancer within 12 months. 3272 tested negative; 324 (9.9%) had an urgent referral within three months. Eight were diagnosed with colorectal cancer within 12 months. Positive predictive value was 7.0% (95% CI 5.1-9.3%). Negative predictive value was 99.8% (CI 99.5-99.9%). Sensitivity was 84.3% (CI 71.4-93.0%), specificity 85.0% (CI 83.8-86.1%). The area under the ROC curve was 0.92 (CI 0.86-0.96). A threshold of 37 µg Hb/g faeces would identify patients with an individual 3% risk of cancer. CONCLUSIONS: FIT performs exceptionally well to triage patients with low-risk symptoms of colorectal cancer in primary care; a higher threshold may be appropriate in the wake of the COVID-19 crisis.