Critical items for assessing risk of lung and colorectal cancer in primary care: a Delphi study.

BACKGROUND: Patients with lung or colorectal cancer often present late and have a poor prognosis. Identifying diagnostic indicators to optimally assess the risk of these cancers in primary care would support early identification and timely referral for patients at increased risk. AIM: To obtain consensus regarding potential diagnostic indicators that are important for assessing the risk of lung or colorectal cancer in primary care consulters presenting with lung or abdominal symptoms. DESIGN AND SETTING: A Delphi study was conducted with 28 participants from primary and secondary care and academic settings in the UK and Europe. METHOD: Indicators were obtained from systematic reviews, recent primary studies and consultation with experts prior to the Delphi study being conducted. Over three rounds, participants rated each diagnostic indicator in terms of its importance, ranked them in order of importance, and rated each item as crucial or not crucial to assess during a GP consultation. RESULTS: The final round resulted in 25 items remaining for each type of cancer, including established cancer symptoms such as rectal bleeding for colorectal cancer and haemoptysis for lung cancer, but also less frequently used indicators such as patients' concerns about cancer. CONCLUSION: This study highlights the items clinicians feel would be most crucial to include in the clinical assessment of primary care patients, a number of which have rarely been noted in the previous literature. Their importance in assessing the risk of lung or colorectal cancer will be tested as part of a large prospective cohort study (CANDID).

Interventions to reduce primary care delay in cancer referral: a systematic review.

BACKGROUND: Reducing delay in the primary care part of the cancer care pathway is likely to improve cancer survival. Identifying effective interventions in primary care would allow action by primary healthcare professionals and local commissioners to reduce delay. AIM: To identify interventions that reduce primary care delay in the referral of patients with cancer to secondary care. DESIGN AND SETTING: Systematic review in primary care. METHOD: Eight electronic databases were searched using terms for primary care, cancer, and delay. Exclusion criteria included screening and the 2-week-wait referral system. Reference lists of relevant papers were hand searched. The quality of each paper was assessed using predefined criteria, and checked by a second reviewer. RESULTS: Searches identified 1798 references, of which 22 papers were found to meet the criteria. Interventions concerning education, audit and feedback, decision support software and guideline use, diagnostic tools, and other specific skills training were identified. Most studies reported a positive effect on their specified outcomes, although no study measured a direct effect on reducing delay. CONCLUSION: There was no evidence that any intervention directly reduced primary care delay in the diagnosis of cancer. Limited evidence suggests that complex interventions, including audit and feedback and specific skills training, have the potential to do so.

A coherent signature of anthropogenic nitrogen deposition to remote watersheds of the Northern Hemisphere.

Humans have more than doubled the amount of reactive nitrogen (Nr) added to the biosphere, yet most of what is known about its accumulation and ecological effects is derived from studies of heavily populated regions. Nitrogen (N) stable isotope ratios ((15)N:(14)N) in dated sediments from 25 remote Northern Hemisphere lakes show a coherent signal of an isotopically distinct source of N to ecosystems beginning in 1895 ± 10 years (±1 standard deviation). Initial shifts in N isotope composition recorded in lake sediments coincide with anthropogenic CO(2) emissions but accelerate with widespread industrial Nr production during the past half century. Although current atmospheric Nr deposition rates in remote regions are relatively low, anthropogenic N has probably influenced watershed N budgets across the Northern Hemisphere for over a century.

Positive predictive values of ≥5% in primary care for cancer: systematic review.

BACKGROUND: The positive predictive value (PPV) for cancer of symptoms, signs, and non-diagnostic test results of patients routinely consulting a GP (unselected primary care populations) can help to determine when malignancy should be excluded. Comparisons with other illness indicate that a value of 5% or more may be regarded as highly predictive. AIM: To identify symptoms, signs, and non-diagnostic test results in unselected primary care populations that are highly predictive of cancer. DESIGN OF STUDY: Systematic review. SETTING: Primary care. METHOD: Fourteen bibliographic databases were searched, using terms for primary care, cancer, and predictive values. Reference lists of relevant papers were hand-searched. Data were extracted and the quality of each paper was assessed using predefined criteria, and checked by a second reviewer. RESULTS: Twenty-five studies were identified. PPVs of 5% or more in specific age and sex groups were reported for: rectal bleeding, change in bowel habit, and iron deficiency anaemia and colorectal cancer; haematuria and urological cancer; malignant rectal examination and prostate cancer; haemoptysis and lung cancer; dysphagia and oesophageal cancer; breast lump and breast cancer; and postmenopausal bleeding and gynaecological cancer. CONCLUSION: Robust evidence was found for eight symptoms, signs, and non-diagnostic test results as strongly indicative of cancer for specific age and sex groups in unselected primary care populations. These have the potential to improve the early diagnosis of some cancers in primary care by the use of computer warning flags, improved guidelines, audit, and appraisal.

Abnormal bleeding patterns associated with menorrhagia in women in the community and in women presenting to primary care.

BACKGROUND: There is an assumption that in women with menorrhagia 'excessive menstrual loss in regular cycles is the most common clinical presentation' yet epidemiological studies show irregular cycles and bleeding are common. OBJECTIVES: To test the hypothesis that, in women who present to primary care with menorrhagia, excessive menstrual loss in regular cycles is the most common clinical presentation, and to determine the frequency with which symptoms known to be associated with gynaecological malignancy occur. METHODS: A postal survey of all women aged 18-54 years was used to identify symptoms of vaginal bleeding in an urban general practice with 10 000 registered patients. Follow-up surveys were carried out at 6 and 12 months. Consultation data from general practice held records were gathered from baseline to 18 months. Women who consulted with increased vaginal bleeding during the 18-month study period were separately analysed according to their self-reported symptoms in the questionnaire completed in the 6 months prior to the consultation. RESULTS: At baseline, of the 736 women in the community identified with menorrhagia, 46% had at least one symptom of irregular vaginal bleeding. In the subgroup of 138 women with menorrhagia who consulted primary care with increased vaginal bleeding, the proportion with at least one symptom of irregular vaginal bleeding was 73%. CONCLUSION: In women with heavy menstrual bleeding, excessive menstrual loss in regular cycles is not the most common clinical presentation in primary care. Guidelines on menorrhagia should acknowledge the variety of symptoms that women with heavy menstrual bleeding present to primary care.

A systematic review of postcoital bleeding and risk of cervical cancer.

BACKGROUND: Postcoital bleeding may be a symptom of cervical cancer. Guidance to aid a GP in determining whom to investigate or refer exists but recommendations vary. Women need to be involved in decisions about their care and this involves communicating risk and an exploration of the implications of the risk. Risk estimates of postcoital bleeding for cervical cancer are not available. AIM: To provide an estimate of the positive predictive values of postcoital bleeding for cervical cancer to aid decision making in primary care about whom to investigate for cervical cancer. DESIGN OF STUDY: A systematic review. SETTING: Community, primary and secondary care. METHOD: Six electronic databases were searched from the beginning of each of their time frames. Inclusion criteria were that the study was published in English and reported or contained enough data to calculate the prevalence or incidence of postcoital bleeding within the study population. No studies were excluded on issues of methodological quality. RESULTS: The search strategy identified 910 unique articles. The point prevalence of postcoital bleeding in the community ranged from 0.7 to 9% among women. One study reported an annual cumulative incidence of 6% of menstruating women. The prevalence of postcoital bleeding in women with cervical cancer ranged from 0.7 to 39%. Calculation of risk that a woman in the community developing postcoital bleeding has cervical cancer ranges from 1 in 44,000 at age 20-24 years to 1 in 2 400 aged 45-54 years. There was no information allowing the direct calculation of risk in women presenting to primary care. CONCLUSION: The evidence base for management strategies of postcoital bleeding and calculations of risk for cervical cancer in women with postcoital bleeding are poor. Recommendations for clinical practice are made on the current evidence.

Patterns of consent in epidemiologic research: evidence from over 25,000 responders.

Ethical guidelines in the United Kingdom require written consent from participants in epidemiologic studies for follow-up or review of medical records. This may cause bias in samples used for follow-up or medical record review. The authors analyzed data from seven general population surveys conducted in the United Kingdom (1996-2002), to which over 25,000 people responded. Associations of age, gender, and symptom under investigation with consent to follow-up and consent to review of medical records were examined. Consent to follow-up was approximately 75-95% among survey responders under age 50 years but fell among older people, particularly females. Consent to follow-up was also higher among responders who had the symptom under investigation (pooled odds ratio = 1.61, 95% confidence interval: 1.36, 1.92). Consent to review of medical records followed a similar pattern. Patterns of consent were relatively consistent and represented a high proportion of responders. Males, younger people, and subjects reporting the symptom under investigation were more likely to give consent, and these groups may be overrepresented in follow-up samples or reviews of medical records. Although consent is high among responders, the additive effect of nonresponse and nonconsent can substantially reduce sample size and should be taken into account in epidemiologic study planning.

An epidemiological survey of symptoms of menstrual loss in the community.

BACKGROUND: For the early detection of gynaecological malignancy, guidance based on presenting symptoms exists to aid a general practitioner (GP) in determining who to investigate or refer. The evidence for this advice is based on the prevalence of symptoms in women with gynaecological malignancy or within specialist clinics. There are no studies on the incidence of symptoms within the community. AIM: To provide an estimate of the incidence of self-reported symptoms of menstrual loss in the community population of a single general practice. DESIGN OF STUDY: A prospective population-based cohort study of women identified through a baseline postal survey and followed 6 and 12 months later. SETTING: An urban general practice with four partners and 10,000 registered patients. METHOD: A postal baseline survey was undertaken on all women aged 18-54 years on the practice age-sex register. Responders who consented to follow-up were sent further questionnaires at 6 and 12 months. All questionnaires enquired about the presence or absence of symptoms related to vaginal bleeding. Twelve-month cumulative incidence rates were calculated using responders to the baseline, 6-month and 12-month questionnaires. RESULTS: A total of 2435 questionnaires were initially sent out at baseline and 1513 (62%) women replied to all three questionnaires. The 12-month cumulative incidence of symptoms in menstruating women was: menorrhagia 25% (95% confidence interval [CI] = 22 to 29); periods heavier than usual, 21% (95% CI = 18 to 23); change in pattern of cycle, 29% (95% CI = 26 to 32); short cycle 21% (95% CI = 19 to 24); long cycle 15% (95% CI = 13 to 18); intermenstrual bleeding 17% (95% CI = 14 to 19); postcoital bleeding 6% (95% CI = 5 to 8); prolonged period 9% (95% CI = 7 to 11). CONCLUSION: The development of symptoms of menstrual loss among women in the community is common, in contrast to the rarity of gynaecological malignancy. This raises concern about the usefulness of current guidelines, based on symptoms, advising women when to consult, and for the early detection of gynaecological malignancy in the community and primary care.

Increased vaginal bleeding and psychological distress: a longitudinal study of their relationship in the community.

OBJECTIVE: To explore the temporal relationship between the development of self-reported symptoms of vaginal bleeding and the development of psychological distress among women in the community. DESIGN: Prospective cohort study using postal surveys at baseline and at 6 and 12 months. SETTING: An urban four-partner general practice with 10000 registered patients. POPULATION: All women aged 18-54 years on the practice age-sex register. METHODS: Baseline postal questionnaire with follow up questionnaires sent at 6 and 12 months. MAIN OUTCOME MEASURES: The associations between the development of heavy periods and psychological distress. RESULTS: Two thousand and four hundred and thirty-five baseline questionnaires were sent out with an initial response rate of 76%. One thousand and five hundred and thirteen women (62%) responded to all three questionnaires. Women with psychological distress at baseline were more likely to develop heavy periods 6 months later than women without distress (adjusted odds ratio 1.87, 95% CI 1.15, 3.02). Women with heavy periods at baseline were no more likely to develop psychological distress 6 months later than women with non-heavy periods (adjusted odds ratio 1.09, 95% CI 0.73, 1.63). Similar findings existed with respect to intermenstrual bleeding and postcoital bleeding. Results of the 12-month analysis were similar. CONCLUSION: In the community, psychological distress appears to influence the future self-reporting of heavy periods and other symptoms of vaginal bleeding.

Why women consult with increased vaginal bleeding: a case-control study.

BACKGROUND: Many women with heavy periods and irregular bleeding do not consult about them. It has been suggested that some of these symptoms are associated with psychological distress and that this influences consultation behaviour which may account for why some women present with a menstrual disturbance and others with apparently the same problem do not. AIM: To explore the relationship between symptom severity, psychological distress, and the seeking of medical help in primary care among women aged 54 years or less with increased vaginal bleeding. DESIGN OF STUDY: Case control. SETTING: An urban four-partner general practice of 10,000 patients. METHOD: Questionnaires were sent to women who were consulting with new episodes of 'increased vaginal bleeding' and two groups of controls: consulting controls with 'acute respiratory tract infection' (RTI) or 'other illness' as identified by weekly computerised searches, and community controls, selected from the practice age-sex register. RESULTS: Nine hundred and forty-three questionnaires were sent out to 108 cases and 835 controls with an 80% response rate. Of these, 60.9% of the cases, 47.0% of the consulting controls, and 39.7% of the community controls were subjects with probable psychological distress on the General Health Questionnaire (chi2 test, P = 0.002). Cases were more likely than community controls to have heavy periods (odds ratio [OR] = 2.86, 95% confidence interval [CI] = 1.53-5.35) and heavy periods interfering with life (OR = 3.69, 95% CI = 2.02-6.75). After controlling for heaviness of periods, cases were still more likely to have psychological distress (OR = 1.80, 95% CI = 1.00-3.24). The same relationships prevailed when comparing cases and consulting controls. CONCLUSION: Interference in life caused by heaviness of periods appears to be a powerful initiator of consultation with increased vaginal bleeding. Perceived heavy periods and psychological disturbance are weaker predictors. Women presenting to primary care with increased vaginal bleeding are more likey to have a psychological disturbance than women from the community or those consulting with another illness.