Publications by authors named "Jon D Emery"

98 Publications

The SMARTscreen Trial: a randomised controlled trial investigating the efficacy of a GP-endorsed narrative SMS to increase participation in the Australian National Bowel Cancer Screening Program.

Trials 2022 Jan 12;23(1):31. Epub 2022 Jan 12.

Centre for Cancer Research, University of Melbourne, Melbourne, Australia.

Background: Increasing participation in the Australian National Bowel Cancer Screening Program (NBCSP) is the most efficient and cost-effective way of reducing mortality associated with colorectal cancer by detecting and treating early-stage disease. Currently, only 44% of Australians aged 50-74 years complete the NBCSP. This efficacy trial aims to test whether this SMS intervention is an effective method for increasing participation in the NBCSP. Furthermore, a process evaluation will explore the barriers and facilitators to sending the SMS from general practice.

Methods: We will recruit 20 general practices in the western region of Victoria, Australia to participate in a cluster randomised controlled trial. General practices will be randomly allocated with a 1:1 ratio to either a control or intervention group. Established general practice software will be used to identify patients aged 50 to 60 years old who are due to receive a NBCSP kit in the next month. The SMS intervention includes GP endorsement and links to narrative messages about the benefits of and instructions on how to complete the NBCSP kit. It will be sent from intervention general practices to eligible patients prior to receiving the NBCSP kit. We require 1400 eligible patients to provide 80% power with a two-sided 5% significance level to detect a 10% increase in CRC screening participation in the intervention group compared to the control group. Our primary outcome is the difference in the proportion of eligible patients who completed a faecal occult blood test (FOBT) between the intervention and control group for up to 12 months after the SMS was sent, as recorded in their electronic medical record (EMR). A process evaluation using interview data collected from general practice staff (GP, practice managers, nurses) and patients will explore the feasibility and acceptability of sending and receiving a SMS to prompt completing a NBCSP kit.

Discussion: This efficacy trial will provide initial trial evidence of the utility of an SMS narrative intervention to increase participation in the NBCSP. The results will inform decisions about the need for and design of a larger, multi-state trial of this SMS intervention to determine its cost-effectiveness and future implementation.

Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12620001020976 . Registered on 17 October 2020.
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http://dx.doi.org/10.1186/s13063-021-05877-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8753594PMC
January 2022

How to Realize the Benefits of Point-of-Care Testing at the General Practice: A Comparison of Four High-Income Countries.

Int J Health Policy Manag 2021 Oct 13. Epub 2021 Oct 13.

Health Technology and Services Research Department, Technical Medical Centre, University of Twente, Enschede, The Netherlands.

Background: In some countries, such as the Netherlands and Norway, point-of-care testing (POCT) is more widely implemented in general practice compared to countries such as England and Australia. To comprehend what is necessary to realize the benefits of POCT, regarding its integration in primary care, it would be beneficial to have an overview of the structure of healthcare operations and the transactions between stakeholders (also referred to as value networks). The aim of this paper is to identify the current value networks in place applying to POCT implementation at general practices in England, Australia, Norway and the Netherlands and to compare these networks in terms of seven previously published factors that support the successful implementation, sustainability and scale-up of innovations.

Methods: The value networks were described based on formal guidelines and standards published by the respective governments, organizational bodies and affiliates. The value network of each country was validated by at least two relevant stakeholders from the respective country.

Results: The analysis revealed that the biggest challenge for countries with low POCT uptake was the lack of effective communication between the several organizations involved with POCT as well as the high workload for general practitioners (GPs) aiming to implement POCT. It is observed that countries with a single national authority responsible for POCT have a better uptake as they can govern the task of POCT roll-out and management and reduce the workload for GPs by assisting with set-up, quality control, training and support.

Conclusion: Setting up a single national authority may be an effective step towards realizing the full benefits of POCT. Although it is possible for day-to-day operations to fall under the responsibility of the GP, this is only feasible if support and guidance are readily available to ensure that the workload associated with POCT is limited and as low as possible.
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http://dx.doi.org/10.34172/ijhpm.2021.143DOI Listing
October 2021

Informed choice and attitudes regarding a genomic test to predict risk of colorectal cancer in general practice.

Patient Educ Couns 2021 Aug 8. Epub 2021 Aug 8.

Centre for Cancer Research, University of Melbourne, Melbourne, Australia; Department of General Practice, University of Melbourne, Melbourne, Australia; The Primary Care Unit, University of Cambridge, Cambridge, UK. Electronic address:

Objective: A genomic test to predict personal risk of colorectal cancer (CRC) that targets screening and could be feasibly implemented in primary care. We explored informed decision-making and attitudes towards genomic testing in this setting.

Methods: A CRC genomic test was offered to 150 general practice patients with brief discussion of its implications. We measured informed choice about the test, consisting knowledge, attitudes and test uptake. Sixteen purposively-sampled participants were interviewed.

Results: Of 150, 142 (95%) completed the informed choice measure and of 27 invited, 16 (59%) completed an interview. 73% made an informed choice about the test. Interviews revealed that participants with inadequate knowledge on the informed choice scale still understood the gist of the test. While positive attitudes were most prevalent, some had concerns, and many were indifferent to the test. Positive attitudes included: that risk information could facilitate risk reduction; negative attitudes included: that risk results could cause worry and be used for insurance discrimination; indifferent attitudes included: that the test seemed benign and it was easy to do.

Conclusions: Our study adds to the evidence that genomic tests for CRC risk do not pose significant concern to patients in community settings.

Practice Implications: As genomic tests become more prevalent, this study's findings can be used to facilitate informed decision-making and ensure equitable access.
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http://dx.doi.org/10.1016/j.pec.2021.08.008DOI Listing
August 2021

Do ethnic patients report longer lung cancer intervals than Anglo-Australian patients?: Findings from a prospective, observational cohort study.

Eur J Cancer Care (Engl) 2021 Nov 26;30(6):e13492. Epub 2021 Jul 26.

Department of General Practice and Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.

Objective: Lung cancer patients from ethnic minorities have poorer outcomes than their Caucasian counterparts. We compared lung cancer intervals between culturally and linguistically diverse (CALD) and Anglo-Australian patients to identify ethnic disparities.

Methods: This was a prospective, observational cohort study comprising a patient survey and reviews of patients' hospital and general practice records. Across three states, 577 (407 Anglo-Australian and 170 CALD) patients were recruited and their hospital records reviewed. The survey was returned by 189 (135 Anglo-Australian and 54 CALD) patients, and a review was completed by general practitioners (GPs) of 99 (76 Anglo-Australian and 23 CALD) patients. Survival and Cox regression analyses were conducted.

Results: CALD patients had longer hospital diagnostic interval [median 30 days, 95% confidence interval (CI) 26-34] than Anglo-Australian patients (median 17, 95% CI 14-20), p = 0.005, hazard ratio (HR) = 1.32 (95% CI 1.09-1.60). This difference persisted after relevant factors were taken into consideration, adjusted HR = 1.26 (95% CI 1.03-1.54, p = 0.022). CALD patients also reported longer prehospital intervals; however, these differences were not statistically significant.

Conclusion: Target interventions need to be developed to address ethnic disparity in hospital diagnostic interval.
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http://dx.doi.org/10.1111/ecc.13492DOI Listing
November 2021

Factors Explaining Socio-Economic Inequalities in Survival from Colon Cancer: A Causal Mediation Analysis.

Cancer Epidemiol Biomarkers Prev 2021 Oct 16;30(10):1807-1815. Epub 2021 Jul 16.

Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia.

Background: Socio-economic inequalities in colon cancer survival exist in high-income countries, but the reasons are unclear. We assessed the mediating effects of stage at diagnosis, comorbidities, and treatment (surgery and intravenous chemotherapy) on survival from colon cancer.

Methods: We identified 2,203 people aged 15 to 79 years with first primary colon cancer diagnosed in Victoria, Australia, between 2008 and 2011. Colon cancer cases were identified through the Victorian Cancer Registry (VCR), and clinical information was obtained from hospital records. Deaths till December 31, 2016 ( = 807), were identified from Victorian and national death registries. Socio-economic disadvantage was based on residential address at diagnosis. For stage III disease, we decomposed its total effect into direct and indirect effects using interventional mediation analysis.

Results: Socio-economic inequalities in colon cancer survival were not explained by stage and were greater for men than women. For men with stage III disease, there were 161 [95% confidence interval (CI), 67-256] additional deaths per 1,000 cases in the 5 years following diagnosis for the most disadvantaged compared with the least disadvantaged. The indirect effects through comorbidities and intravenous chemotherapy explained 6 (95% CI, -10-21) and 15 (95% CI, -14-44) per 1,000 of these additional deaths, respectively. Surgery did not explain the observed gap in survival.

Conclusions: Disadvantaged men have lower survival from stage III colon cancer that is only modestly explained by having comorbidities or not receiving chemotherapy after surgery.

Impact: Future studies should investigate the potential mediating role of factors occurring beyond the first year following diagnosis, such as compliance with surveillance for recurrence and supportive care services.
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http://dx.doi.org/10.1158/1055-9965.EPI-21-0222DOI Listing
October 2021

Developing clinical indicators for oncology: the inaugural cancer care indicator set for the Australian Council on Healthcare Standards.

Med J Aust 2021 06 30;214(11):528-531. Epub 2021 May 30.

Icon Group, Brisbane, QLD.

Introduction: The Australian Council on Healthcare Standards (ACHS) sponsored an expert-led, consensus-driven, four-stage process, based on a modified Delphi methodology, to determine a set of clinical indicators as quality measures of cancer service provision in Australia. This was done in response to requests from institutional health care providers seeking accreditation, which were additional and complementary to the existing radiation oncology set. The steering group members comprised multidisciplinary key opinion leaders and a consumer representative. Five additional participants constituted the stakeholder group, who deliberated on the final indicator set.

Methods And Recommendations: An initial meeting of the steering group scoped the high level nature of the desired set. In stage 2, 65 candidate indicators were identified by a literature review and a search of international metrics. These were ranked by survey, based on ease of data accessibility and collectability and clinical relevance. The top 27 candidates were debated by the stakeholder group and culled to a final set of 16 indicators. A user manual was created with indicators mapped to clinical codes. The indicator set was ratified by the Clinical Oncology Society of Australia and is now available for use by health care organisations participating in the ACHS Clinical Indicator Program. This inaugural cancer clinical indicator set covers high level assessment of various critical processes in cancer service provision in Australia. Regular reviews and updates will ensure usability.

Changes In Management As A Result Of This Statement: This is the inaugural indicator set for cancer care for use across Australia and internationally under the ACHS Clinical Indicator Program. Multidisciplinary involvement through a modified Delphi process selected indicators representing both generic and specific aspects of care across the cancer journey pathway and will provide a functional tool to compare health care delivery across multiple settings. It is anticipated that this will drive continual improvement in cancer care provision.
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http://dx.doi.org/10.5694/mja2.51087DOI Listing
June 2021

Long-term consumer involvement in cancer research: Working towards partnership.

Health Expect 2021 08 5;24(4):1263-1269. Epub 2021 May 5.

Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences, Primary Care Collaborative Cancer Clinical Trials Group, Centre for Cancer Research, University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, Vic., Australia.

Background: Meaningful consumer involvement in health research is important. There are limited data on how to maintain long-term consumer involvement.

Objective: To identify barriers and facilitators to meaningful long-term consumer involvement in research.

Design: Six semi-structured interviews were conducted with members of the Primary Care Collaborative Cancer Clinical Trials Group (PC4) Community Advisory Group (CAG) and included the review of 40 supporting documents. Interviews and documents were analysed using inductive thematic analysis; the themes were mapped onto the domains of Cancer Australia's National Framework for Consumer Involvement in Cancer Control.

Results: Equality, respect and feeling valued were facilitators to long-term involvement. These elements were part of an overarching theme of organizational commitment. Creating balance, managing competing deadlines and integrating a consumer role with a personal life were key barriers to involvement. These themes mapped strongly to the National Framework for Consumer Involvement in Cancer Control domains of committed organizations, capable consumers, inclusive groups and shared focus.

Conclusion: Research networks should reflect on several factors to maintain long-term consumer involvement. Networks should aim to build a meaningful relationship, using clear communication and education, that reinforces the value and scope of a consumers contributions. We found that consumer education needs do not diminish over time and adequate skill development, support and feedback need to be on-going. Creating regular opportunities for feedback and reflection are important to continue to meet best practice guidelines.
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http://dx.doi.org/10.1111/hex.13258DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8369080PMC
August 2021

Approaches to diagnosing cancer earlier in general practice.

Authors:
Jon D Emery

Br J Gen Pract 2021 05 29;71(706):196-197. Epub 2021 Apr 29.

Department of General Practice and Centre for Cancer Research, University of Melbourne, Australia.

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http://dx.doi.org/10.3399/bjgp21X715613DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8087303PMC
May 2021

Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review.

BMC Cancer 2021 Apr 7;21(1):373. Epub 2021 Apr 7.

Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.

Background: Successful breast cancer screening relies on timely follow-up of abnormal mammograms. Delayed or failure to follow-up abnormal mammograms undermines the potential benefits of screening and is associated with poorer outcomes. However, a comprehensive review of inadequate follow-up of abnormal mammograms in primary care has not previously been reported in the literature. This review could identify modifiable factors that influence follow-up, which if addressed, may lead to improved follow-up and patient outcomes.

Methods: A systematic literature review to determine the extent of inadequate follow-up of abnormal screening mammograms in primary care and identify factors impacting on follow-up was conducted. Relevant studies published between 1 January, 1990 and 29 October, 2020 were identified by searching MEDLINE®, Embase, CINAHL® and Cochrane Library, including reference and citation checking. Joanna Briggs Institute Critical Appraisal Checklists were used to assess the risk of bias of included studies according to study design.

Results: Eighteen publications reporting on 17 studies met inclusion criteria; 16 quantitative and two qualitative studies. All studies were conducted in the United States, except one study from the Netherlands. Failure to follow-up abnormal screening mammograms within 3 and at 6 months ranged from 7.2-33% and 27.3-71.6%, respectively. Women of ethnic minority and lower education attainment were more likely to have inadequate follow-up. Factors influencing follow-up included physician-patient miscommunication, information overload created by automated alerts, the absence of adequate retrieval systems to access patient's results and a lack of coordination of patient records. Logistical barriers to follow-up included inconvenient clinic hours and inconsistent primary care providers. Patient navigation and case management with increased patient education and counselling by physicians was demonstrated to improve follow-up.

Conclusions: Follow-up of abnormal mammograms in primary care is suboptimal. However, interventions addressing amendable factors that negatively impact on follow-up have the potential to improve follow-up, especially for populations of women at risk of inadequate follow-up.
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http://dx.doi.org/10.1186/s12885-021-08100-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8028768PMC
April 2021

Measuring patient experience of diagnostic care and acceptability of testing.

Diagnosis (Berl) 2021 08 28;8(3):317-321. Epub 2021 Jan 28.

Department of Behavioural Science and Health, UCL, London, UK.

A positive patient experience has been long recognised as a key feature of a high-quality health service, however, often assessment of patient experience excludes diagnostic care. Experience of diagnostic services and the acceptability of diagnostic tests are often conflated, with lack of clarity about when and how either should be measured. These problems contrast with the growth in the development and marketing of new tests and investigation strategies. Building on the appraisal of current practice, we propose that the experience of diagnostic services and the acceptability of tests should be assessed separately, and describe distinct components of each. Such evaluations will enhance the delivery of patient-centred care, and facilitate patient choice.
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http://dx.doi.org/10.1515/dx-2020-0112DOI Listing
August 2021

Validation of Australian and Victorian guidelines for colonoscopy triage.

Intern Med J 2021 Sep;51(9):1457-1462

Department of Medicine - Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.

Background: Managing the growing demand for colonoscopies is challenging.

Aims: To assess the diagnostic performance of National and Victorian colonoscopy triage guidelines and potential redistribution of triage categories.

Methods: This is a diagnostic validation study comparing colonoscopy triage guidelines against a reference colonoscopy dataset. Participants were a reference dataset of 2378 colonoscopies from 1 October 2014 to 30 June 2016. Comparison with triage categorisation determined using National Cancer Council Australia guidelines; Victorian triage guidelines; Optimal Cancer Care Pathways recommendations. Main outcome measures were as follows: (i) proportion of colonoscopies assigned to each triage category; (ii) detection rate (proportion of cancers assigned to triage Category 1); and (iii) conversion rate (proportion of triage Category 1 colonoscopies that diagnose a cancer).

Results: After adjusting for data absent in referrals, the National and Victorian guidelines reduced the proportion of Category 1 colonoscopies compared with the reference triage (National 76.3% vs 58.6%; 95% CI for difference 15.0-20.3%, P < 0.0001. Victorian 76.3% vs 66.3%; 95% CI for difference 7.4-12.6%, P < 0.0001). Victorian guidelines were associated with the highest detection rate (91.4%) and a conversion rate of 5.4% although the number of cancers limited the power to detect significant differences on these metrics. There was a higher proportion of unclassifiable colonoscopies using the National guidelines than the Victorian ones due to their focus on symptomatic indications.

Conclusions: The Victorian guidelines could reduce the proportion of Category 1 colonoscopies by 10% without reducing conversion or detection rates. This would require improvements in the quality of referrals and ordering faecal occult blood tests in 6% of symptomatic patients.
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http://dx.doi.org/10.1111/imj.15197DOI Listing
September 2021

Further evaluation is required for smartphone-aided diagnosis of skin cancer.

Lancet Digit Health 2020 03 20;2(3):e104-e105. Epub 2020 Feb 20.

Department of General Practice and the Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Science, Victorian Comprehensive Cancer Centre, University of Melbourne, VIC, Australia.

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http://dx.doi.org/10.1016/S2589-7500(20)30021-2DOI Listing
March 2020

Look who's talking now: Cancer in primary care on Twitter. An observational study.

BJGP Open 2021 Jan 23;5(1). Epub 2021 Feb 23.

Primary Care Collaborative Cancer Clinical Trials Group, Centre for Cancer Research and Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, Australia.

Background: Twitter is a microblogging platform that helps share information. It is a dynamic tool that has been embraced by many user types including consumers and healthcare professionals (HCPs). Currently, there are no data on how cancer in primary care features on Twitter.

Aim: To explore the type of users and information shared about cancer in primary care on Twitter.

Design & Setting: A descriptive exploratory study took place of publicly available Twitter data.

Method: Tweets were searched between July 2015 and June 2017 for 'GP', 'general practice', 'primary care', or 'general practitioner' in conjunction with 'cancer'. A 20% random sample was coded for geographic location, user type, type of tweet, and theme. Tweet sentiment was analysed using R package sentimentr. Content that gained traction was compared by combining original tweets, retweets, favourites, and duration.

Results: There were a total of 3413 tweets from 1611 users in 44 countries. Consumers were the largest user group followed by health organisations, healthcare professionals, and the media. The most common theme across user types was diagnostic delay. Other themes that emerged included cancer screening, symptom awareness, and early diagnosis. Consumers published more negative tweets, particularly in relation to diagnostic delay. Health organisations focused on symptom awareness and screening. Over half of media tweets were stories that featured delayed diagnosis or screening.

Conclusion: A broad range of users engage with Twitter to share information about cancer in primary care. Content is different between user groups, but diagnostic delay and symptom awareness are common themes. Healthcare and professional organisations may need to consider approaches to counter negative messages about diagnostic delay.
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http://dx.doi.org/10.3399/bjgpopen20X101134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7960530PMC
January 2021

The Impact of a Comprehensive Risk Prediction Model for Colorectal Cancer on a Population Screening Program.

JNCI Cancer Spectr 2020 Oct 18;4(5):pkaa062. Epub 2020 Jul 18.

Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.

Background: In many countries, population colorectal cancer (CRC) screening is based on age and family history, though more precise risk prediction could better target screening. We examined the impact of a CRC risk prediction model (incorporating age, sex, lifestyle, genomic, and family history factors) to target screening under several feasible screening scenarios.

Methods: We estimated the model's predicted CRC risk distribution in the Australian population. Predicted CRC risks were categorized into screening recommendations under 3 proposed scenarios to compare with current recommendations: 1) highly tailored, 2) 3 risk categories, and 3) 4 sex-specific risk categories. Under each scenario, for 35- to 74-year-olds, we calculated the number of CRC screens by immunochemical fecal occult blood testing (iFOBT) and colonoscopy and the proportion of predicted CRCs over 10 years in each screening group.

Results: Currently, 1.1% of 35- to 74-year-olds are recommended screening colonoscopy and 56.2% iFOBT, and 5.7% and 83.2% of CRCs over 10 years were predicted to occur in these groups, respectively. For the scenarios, 1) colonoscopy was recommended to 8.1% and iFOBT to 37.5%, with 36.1% and 50.1% of CRCs in each group; 2) colonoscopy was recommended to 2.4% and iFOBT to 56.0%, with 13.2% and 76.9% of cancers in each group; and 3) colonoscopy was recommended to 5.0% and iFOBT to 54.2%, with 24.5% and 66.5% of cancers in each group.

Conclusions: A highly tailored CRC screening scenario results in many fewer screens but more cancers in those unscreened. Category-based scenarios may provide a good balance between number of screens and cancers detected and are simpler to implement.
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http://dx.doi.org/10.1093/jncics/pkaa062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7583148PMC
October 2020

Breast Cancer Chemoprevention: Use and Views of Australian Women and Their Clinicians.

Cancer Prev Res (Phila) 2021 01 28;14(1):131-144. Epub 2020 Oct 28.

Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.

Guidelines endorse the use of chemoprevention for breast cancer risk reduction. This study examined the barriers and facilitators to chemoprevention use for Australian women at increased risk of breast cancer, and their clinicians. Surveys, based on the Theoretical Domains Framework, were mailed to 1,113 women at ≥16% lifetime risk of breast cancer who were enrolled in the Kathleen Cuningham Foundation Consortium for Research into Familial Breast Cancer cohort study (kConFab), and their 524 treating clinicians. Seven hundred twenty-five women (65%) and 221 (42%) clinicians responded. Only 10 (1.4%) kConFab women had ever taken chemoprevention. Three hundred seventy-eight (52%) kConFab women, two (3%) breast surgeons, and 51 (35%) family physicians were not aware of chemoprevention. For women, the strongest barriers to chemoprevention were side effects (31%) and inadequate information (23%), which operate in the Theoretical Domains Framework domains of "beliefs about consequences" and "knowledge," respectively. Strongest facilitators related to tamoxifen's long-term efficacy (35%, "knowledge," "beliefs about consequences," and "goals" domains), staying healthy for family (13%, "social role" and "goals" domains), and abnormal breast biopsy (13%, "environmental context" domain). The strongest barrier for family physicians was insufficient knowledge (45%, "knowledge" domain) and for breast surgeons was medication side effects (40%, "beliefs about consequences" domain). The strongest facilitators for both clinician groups related to clear guidelines, strong family history, and better tools to select patients ("environmental context and resources" domain). Clinician knowledge and resources, and beliefs about the side-effect consequences of chemoprevention, are key domains that could be targeted to potentially enhance uptake. PREVENTION RELEVANCE: Despite its efficacy in reducing breast cancer incidence, chemoprevention is underutilised. This survey study of Australian women and their clinicians used behavioural change theory to identify modifiable barriers to chemoprevention uptake, and to suggest interventions such as policy change, educational resources and public campaigns, that may increase awareness and use..
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http://dx.doi.org/10.1158/1940-6207.CAPR-20-0369DOI Listing
January 2021

A Genomic Test for Colorectal Cancer Risk: Is This Acceptable and Feasible in Primary Care?

Public Health Genomics 2020 20;23(3-4):110-121. Epub 2020 Jul 20.

Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia.

Introduction: Genomic tests can predict risk and tailor screening recommendations for colorectal cancer (CRC). Primary care could be suitable for their widespread implementation.

Objective: We aimed to assess the feasibility and acceptability of administering a CRC genomic test in primary care.

Methods: Participants aged 45-74 years recruited from 4 Australian general practices were offered a genomic CRC risk test. Participants received brief verbal information about the test comprising 45 CRC-associated single-nucleotide polymorphisms, before choosing whether to undertake the test. Personalized risks were given to testers. Uptake and knowledge of the genomic test, cancer-specific anxiety (Cancer Worry Scale), psychosocial impact (Multidimensional Impact of Cancer Risk Assessment [MICRA] score), and impact on CRC screening behaviour within 6 months were measured.

Results: In 150 participants, test uptake was high (126, 84%), with 125 (83%) having good knowledge of the genomic test. Moderate risk participants were impacted more by the test (MICRA mean: 15.9) than average risk participants (mean: 9.5, difference in means: 6.4, 95% confidence interval (CI): 1.5, 11.2, p = 0.01), but all scores were low. Average risk participants' cancer-specific anxiety decreased (mean differences from baseline: 1 month -0.5, 95% CI: -1.0, -0.1, p = 0.03; 6 months -0.6, 95% CI: -1.0, -0.2, p = 0.01). We found limited evidence for genomic testers being more likely to complete the risk-appropriate CRC screening than non-testers (41 vs. 17%, odds ratio = 3.4, 95% CI: 0.6, 34.8, p = 0.19), but some mediators of screening behaviour were altered in genomic testers.

Conclusions: Genomic testing for CRC risk in primary care is acceptable and likely feasible. Further development of the risk assessment intervention could strengthen the impact on screening behaviour.
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http://dx.doi.org/10.1159/000508963DOI Listing
February 2021

Comparing Pathways to Diagnosis and Treatment for Rural and Urban Patients With Colorectal or Breast Cancer: A Qualitative Study.

J Rural Health 2020 09 2;36(4):517-535. Epub 2020 Jun 2.

School of Psychology, Deakin University, Burwood, Australia.

Purpose: Colorectal cancer patients living in rural areas have poorer outcomes than urban counterparts, but such disparities are not found for breast cancer. Although time to care may contribute to rural-urban disparities, few studies examine patient experiences to understand how and why delays may occur. We compared rural and urban patient experiences of pathways to colorectal or breast cancer diagnosis and treatment in Victoria, Australia.

Methods: Semistructured telephone interviews were conducted with 43 patients (49% colorectal; 60% rural, median 7 months postdiagnosis). A framework analysis was applied using the Model of Pathways to Treatment.

Findings: Rural and urban patients expressed similar attitudes and reasons for prolonged symptom appraisal and help-seeking triggers. However, some rural patients reported long waiting times to see a Primary Care Practitioner (PCP) and perceived greater gatekeeping to diagnostic services. Patient perceptions of the urgency of PCP referral could impact behavior, such as waiting longer to book appointments. Colorectal cancer patients reported more variable types of symptoms, interpretation, and coping strategies, as well as diverse presentation routes and reduced sense of urgency, compared to breast cancer patients. Waiting time for colonoscopy could be long, particularly in the public health system, but mammograms were quickly arranged.

Conclusions: Pathway variation was more evident by cancer type than residential location. However, access to primary care and diagnostic services for rural patients with colorectal cancer may be important policy targets. Future research should investigate the impact of diagnostic service accessibility on PCP referral behavior to further understand rural-urban disparities.
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http://dx.doi.org/10.1111/jrh.12437DOI Listing
September 2020

Effect of a Skin Self-monitoring Smartphone Application on Time to Physician Consultation Among Patients With Possible Melanoma: A Phase 2 Randomized Clinical Trial.

JAMA Netw Open 2020 02 5;3(2):e200001. Epub 2020 Feb 5.

The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.

Importance: Melanoma is among the most lethal skin cancers; it has become the fifth most common cancer in the United Kingdom, and incidence rates are rising. Population approaches to reducing incidence have focused on mass media campaigns to promote earlier presentation and potentially improve melanoma outcomes; however, interventions using smartphone applications targeting those with the greatest risk could promote earlier presentation to health care professionals for individuals with new or changing skin lesions.

Objective: To study the effect of a commercially available skin self-monitoring (SSM) smartphone application among individuals with increased risk of melanoma on their decision to seek help for changing skin lesions.

Design, Setting, And Participants: This phase 2 randomized clinical trial was conducted in 12 family practices in Eastern England between 2016 and 2017. A total of 238 participants, aged 18 to 75 years and with an increased risk of melanoma, were identified using a real-time melanoma risk assessment tool in family practice waiting rooms. Analysis was intention to treat. Participants were observed for 12 months, and data analysis was conducted from January to August 2018.

Intervention: The intervention and control groups received a consultation with standard written advice on sun protection and skin cancer detection. The intervention group had an SSM application loaded on their smartphone and received instructions for use and monthly self-monitoring reminders.

Main Outcomes And Measures: The coprimary outcomes were skin consultation rates with family practice physicians and patient intervals, measured as the time between noticing a skin change and consulting with a family practice clinician. Follow-up questionnaires were sent at 6 and 12 months, and consultation rates were extracted from family practice records. Secondary outcomes included skin self-examination benefits and barriers, self-efficacy for consulting without delay, perceived melanoma risk, sun protection habits, and potential harms.

Results: A total of 238 patients were randomized (median [interquartile range] age, 55 [43-65] years, 131 [55.0%] women, 227 [95.4%] white British; 119 [50.0%] randomized to the intervention group). Overall, 51 participants (21.4%) had consultations regarding skin changes during the 12 months of follow-up, and 157 participants (66.0%) responded to at least 1 follow-up questionnaire. There were no significant differences in skin consultation rates (adjusted risk ratio, 0.96; 95% CI, 0.56 to 1.66; P = .89), measures of SSM (adjusted mean difference, 0.08; 95% CI, -0.83 to 1.00; P = .86), or psychological harm (eg, Melanoma Worry Scale: adjusted mean difference, -0.12; 95% CI, -0.56 to 0.31; P = .58).

Conclusions And Relevance: In this study, recruitment, retention, and initial delivery of the intervention were feasible, and this research provided no evidence of harm from the SSM smartphone application. However, no evidence of benefit on skin self-examination or health care consulting was found, and there is no reason at this stage to recommend its implementation in this population at increased risk of melanoma.

Trial Registration: isrctn.org Identifier: ISRCTN16061621.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.0001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7137684PMC
February 2020

External Validation of Risk Prediction Models Incorporating Common Genetic Variants for Incident Colorectal Cancer Using UK Biobank.

Cancer Prev Res (Phila) 2020 06 18;13(6):509-520. Epub 2020 Feb 18.

The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.

The aim of this study was to compare and externally validate risk scores developed to predict incident colorectal cancer that include common genetic variants (SNPs), with or without established lifestyle/environmental (questionnaire-based/classical/phenotypic) risk factors. We externally validated 23 risk models from a previous systematic review in 443,888 participants ages 37 to 73 from the UK Biobank cohort who had 6-year prospective follow-up, no prior history of colorectal cancer, and data for incidence of colorectal cancer through linkage to national cancer registries. There were 2,679 (0.6%) cases of incident colorectal cancer. We assessed model discrimination using the area under the operating characteristic curve (AUC) and relative risk calibration. The AUC of models including only SNPs increased with the number of included SNPs and was similar in men and women: the model by Huyghe with 120 SNPs had the highest AUC of 0.62 [95% confidence interval (CI), 0.59-0.64] in women and 0.64 (95% CI, 0.61-0.66) in men. Adding phenotypic risk factors without age improved discrimination in men but not in women. Adding phenotypic risk factors and age increased discrimination in all cases ( < 0.05), with the best performing models including SNPs, phenotypic risk factors, and age having AUCs between 0.64 and 0.67 in women and 0.67 and 0.71 in men. Relative risk calibration varied substantially across the models. Among middle-aged people in the UK, existing polygenic risk scores discriminate moderately well between those who do and do not develop colorectal cancer over 6 years. Consideration should be given to exploring the feasibility of incorporating genetic and lifestyle/environmental information in any future stratified colorectal cancer screening program.
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http://dx.doi.org/10.1158/1940-6207.CAPR-19-0521DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7610623PMC
June 2020

Using an electronic self-completion tool to identify patients at increased risk of melanoma in Australian primary care.

Australas J Dermatol 2020 Aug 12;61(3):231-236. Epub 2020 Feb 12.

Department of General Practice and Centre for Cancer Research, University of Melbourne, Melbourne, Australia.

Background/objectives: Some international guidelines recommend a risk-based approach to screening for melanoma, but few suggest how to account for multiple risk factors or how to implement risk-based screening in practice. This study investigated the acceptability and feasibility of identifying patients at increased risk of melanoma in Australian general practice using a self-completed risk assessment tool. Stratification of risk was based on the validated Williams melanoma risk prediction model.

Methods: Patients and companions aged 18 or older in Australian general practices were approached in the waiting room and invited to enter information about their melanoma risk factors into the tool using an iPad. Acceptability was measured by the proportion of people willing to participate from those invited and feasibility by the number of people able to complete the tool unaided. Risk of developing melanoma was stratified into four risk categories using the Williams model.

Results: 1535 (90.4%) participants were recruited from two general practices. Only 200 participants (13%) needed assistance to complete the tool. The mean risk score for participants was 15.2 (±SD 9.8). The Williams model estimated between 5% and 19% of the sample were at increased risk accounting for an estimated 30% to 60% of future incident melanomas.

Conclusions: A risk-stratified tool using the Williams model was acceptable and feasible for patients to self-complete in general practice clinics. This could be an effective way to identify people in primary care for implementing risk-based targeted melanoma screening and prevention.
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http://dx.doi.org/10.1111/ajd.13244DOI Listing
August 2020

Patient symptom experience prior to a diagnosis of oesophageal or gastric cancer: a multi-methods study.

BJGP Open 2020 1;4(1). Epub 2020 May 1.

Senior Social Scientist, The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK.

Background: Late stage diagnosis of oesophageal and gastric cancer is common, which limits treatment options and contributes to poor survival.

Aim: To explore patients' understanding, experience and presentation of symptoms before a diagnosis of oesophageal or gastric cancer.

Design & Setting: Between May 2016 and October 2017, all patients newly diagnosed with oesophageal or gastric cancer were identified at weekly multidisciplinary team meetings at two large hospitals in England. A total of 321 patients were invited to participate in a survey and secondary care medical record review; 127 (40%) participants responded (102 patients had oesophageal cancer and 25 had gastric cancer). Of these, 26 participated in an additional face-to-face interview.

Method: Survey and medical record data were analysed descriptively. Interviews were analysed using thematic analysis, informed by the Model of Pathways to Treatment.

Results: Participants experienced multiple symptoms before diagnosis. The most common symptom associated with oesophageal cancer was dysphagia ( = 66, 65%); for gastric cancer, fatigue or tiredness ( = 20, 80%) was the most common symptom. Understanding of heartburn, reflux and indigestion, and associated symptoms differed between participants and often contrasted with clinical perspectives. Bodily changes attributed to personal and/or lifestyle factors were self-managed, with presentation to primary care prompted when symptoms persisted, worsened, or impacted daily life, or were notably severe or unusual. Participants rarely presented all symptoms at the initial consultation.

Conclusion: The patient interval may be lengthened by misinterpretation of key terms, such as heartburn, or misattribution or non-recognition of important bodily changes. Clearly defined symptom awareness messages may encourage earlier help-seeking, while eliciting symptom experience and meanings in primary care consultations could prompt earlier referral and diagnosis.
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http://dx.doi.org/10.3399/bjgpopen20X101001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330188PMC
May 2020

Benefits and harms of aspirin to reduce colorectal cancer risk: a cross-sectional study of methods to communicate risk in primary care.

Br J Gen Pract 2019 Dec 28;69(689):e843-e849. Epub 2019 Nov 28.

Centre for Cancer Research, Department of General Practice, University of Melbourne, Melbourne, Australia; Primary Care Collaborative Cancer Clinical Trials Group (PC4), Melbourne, Australia; Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.

Background: New Australian guidelines recommend that GPs actively consider prescribing low-dose aspirin to patients aged 50-70 years to reduce their risk of developing colorectal cancer (CRC). Patients and GPs need to understand the relative benefits and harms to support informed decision making.

Aim: To develop and examine different methods to communicate the benefits and harms of taking aspirin for CRC prevention.

Design And Setting: A cross-sectional, vignette study with patients aged 50-70 years consecutively recruited from general practices in Melbourne, Australia, between July and August 2018.

Method: Summary estimates from meta-analyses of the effects of aspirin on the incidence of CRC, cardiovascular disease, gastrointestinal bleeding, and incidence rates in the Australian population to estimate outcomes in a hypothetical population of 10 000 people aged 50-70 years. These estimates were presented using four different risk communication formats. Participants were shown these different formats and asked if they would take aspirin to prevent CRC.

Results: A total of 313 participants were recruited (95.1% recruitment rate), of whom 304 completed the study. Most participants (71.7-75.3%) reported they would take aspirin irrespective of risk format presented. Bar charts (odds ratio [OR] 1.20, 95% confidence intervals [CI] = 1.01 to 1.44) and expected frequency trees (OR 1.18, 95% CI = 0.99 to 1.41) were more strongly associated with the intentions to take aspirin compared with icon arrays. Bar charts were most preferred for presenting risk information.

Conclusion: A large proportion of participants in this study intended to take aspirin to reduce their CRC risk regardless of risk communication format. Bar charts and expected frequency trees were the preferred methods to present the benefits and harms of taking aspirin to prevent CRC.
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http://dx.doi.org/10.3399/bjgp19X706613DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6863681PMC
December 2019

Decision support tools to improve cancer diagnostic decision making in primary care: a systematic review.

Br J Gen Pract 2019 Dec 28;69(689):e809-e818. Epub 2019 Nov 28.

NHMRC practitioner fellow, Centre for Cancer Research and Department of General Practice, Victorian Comprehensive Cancer Centre, University of Melbourne, Melbourne, Australia.

Background: The diagnosis of cancer in primary care is complex and challenging. Electronic clinical decision support tools (eCDSTs) have been proposed as an approach to improve GP decision making, but no systematic review has examined their role in cancer diagnosis.

Aim: To investigate whether eCDSTs improve diagnostic decision making for cancer in primary care and to determine which elements influence successful implementation.

Design And Setting: A systematic review of relevant studies conducted worldwide and published in English between 1 January 1998 and 31 December 2018.

Method: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched, and a consultation of reference lists and citation tracking was carried out. Exclusion criteria included the absence of eCDSTs used in asymptomatic populations, and studies that did not involve support delivered to the GP. The most relevant Joanna Briggs Institute Critical Appraisal Checklists were applied according to study design of the included paper.

Results: Of the nine studies included, three showed improvements in decision making for cancer diagnosis, three demonstrated positive effects on secondary clinical or health service outcomes such as prescribing, quality of referrals, or cost-effectiveness, and one study found a reduction in time to cancer diagnosis. Barriers to implementation included trust, the compatibility of eCDST recommendations with the GP's role as a gatekeeper, and impact on workflow.

Conclusion: eCDSTs have the capacity to improve decision making for a cancer diagnosis, but the optimal mode of delivery remains unclear. Although such tools could assist GPs in the future, further well-designed trials of all eCDSTs are needed to determine their cost-effectiveness and the most appropriate implementation methods.
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http://dx.doi.org/10.3399/bjgp19X706745DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6863677PMC
December 2019

Benefits and harms of selective oestrogen receptor modulators (SERMs) to reduce breast cancer risk: a cross-sectional study of methods to communicate risk in primary care.

Br J Gen Pract 2019 Dec 28;69(689):e836-e842. Epub 2019 Nov 28.

Centre for Cancer Research and Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia; Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, UK.

Background: In Australia, evidence-based guidelines recommend that women consider taking selective oestrogen receptor modulators (SERMs) to reduce their risk of breast cancer. In practice, this requires effective methods for communicating the harms and benefits of taking SERMs so women can make an informed choice.

Aim: To evaluate how different risk presentations influence women's decisions to consider taking SERMs.

Design And Setting: Cross-sectional, correlational study of Australian women in general practice.

Method: Three risk communication formats were developed that included graphics, numbers, and text to explain the reduction in breast cancer risk and risk of side effects for women taking SERMs (raloxifene or tamoxifen). Women aged 40-74 years in two general practices were shown the risk formats using vignettes of hypothetical women at moderate or high risk of breast cancer and asked to choose 'If this was you, would you consider taking a SERM?' Descriptive statistics and predictors (risk format, level of risk, and type of SERM) of choosing SERMs were determined by logistic regression.

Results: A total of 288 women were recruited (an 88% response rate) between March and May 2017. The risk formats that showed a government statement and an icon array were associated with a greater likelihood of considering SERMs relative to one that showed a novel expected frequency tree. Risk formats for raloxifene and for the high-risk vignettes were also more strongly associated with choosing to consider SERMs. No associations were found with any patient demographics.

Conclusion: Specific risk formats may lead to more women considering taking SERMs to reduce breast cancer risk, especially if they are at high risk of the condition. Raloxifene may be a more acceptable SERM to patients.
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http://dx.doi.org/10.3399/bjgp19X706841DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6805163PMC
December 2019

Tools to facilitate communication during physician-patient consultations in cancer care: An overview of systematic reviews.

CA Cancer J Clin 2019 11 24;69(6):497-520. Epub 2019 Jul 24.

Center for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia.

Tools have been developed to facilitate communication and support information exchange between people diagnosed with cancer and their physicians. Patient-reported outcome measures, question prompt lists, patient-held records, tape recordings of consultations, decision aids, and survivorship care plans have all been promoted as potential tools, and there is extensive literature exploring their impact on patient outcomes. Eleven systematic reviews of studies evaluating tools to facilitate patient-physician communication were reviewed and summarized in this overview of systematic reviews. Across the systematic reviews, 87 publications reported on 84 primary studies involving 15,381 participants. Routine use of patient-reported outcome measures and feedback of results to clinicians can improve pain management, physician-patient communication, and symptom detection and control; increase utilization of supportive care; and increase patient involvement in care. Question prompt lists can increase the number of questions asked by patients without increasing consultation length and may encourage them to reflect and plan questions before the consultation. There is limited benefit in audio recording consultations or using patient-held records during consultations. Physicians should be supported by adequately resourced health services to respond effectively to the range of clinical and broader patient needs identified through the routine use of tools to facilitate communication.
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http://dx.doi.org/10.3322/caac.21573DOI Listing
November 2019

Risk Prediction Models for Colorectal Cancer Incorporating Common Genetic Variants: A Systematic Review.

Cancer Epidemiol Biomarkers Prev 2019 10 10;28(10):1580-1593. Epub 2019 Jul 10.

The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.

Colorectal cancer screening reduces colorectal cancer incidence and mortality. Risk models based on phenotypic variables have relatively good discrimination in external validation and may improve efficiency of screening. Models incorporating genetic variables may perform better. In this review, we updated our previous review by searching Medline and EMBASE from the end date of that review (January 2014) to February 2019 to identify models incorporating at least one SNP and applicable to asymptomatic individuals in the general population. We identified 23 new models, giving a total of 29. Of those in which the SNP selection was on the basis of published genome-wide association studies, in external or split-sample validation the AUROC was 0.56 to 0.57 for models that included SNPs alone, 0.61 to 0.63 for SNPs in combination with other risk factors, and 0.56 to 0.70 when age was included. Calibration was only reported for four. The addition of SNPs to other risk factors increases discrimination by 0.01 to 0.06. Public health modeling studies suggest that, if determined by risk models, the range of starting ages for screening would be several years greater than using family history alone. Further validation and calibration studies are needed alongside modeling studies to assess the population-level impact of introducing genetic risk-based screening programs.
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http://dx.doi.org/10.1158/1055-9965.EPI-19-0059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7610631PMC
October 2019

The CRISP-P study: feasibility of a self-completed colorectal cancer risk prediction tool in primary care.

Fam Pract 2019 11;36(6):730-735

Department of General Practice, Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, Victorian Comprehensive Cancer Centre, University of Melbourne, Victoria, Australia.

Objective: Australia and New Zealand have the highest incidence of colorectal cancer (CRC) globally. Our research team has developed a CRC risk prediction tool for use in primary care to increase targeted screening. This study, Colorectal cancer RISk Prediction tool - patient ('CRISP-P'), aimed to determine the following to inform a future trial design: (i) the feasibility of self-reporting; (ii) the feasibility of recruitment methods; and (iii) the prevalence of CRC risk.

Methods: Participants aged between 40 and 75 years were recruited consecutively from three primary care waiting rooms. Participants input data into CRISP on a tablet without receiving clinical advice. Feasibility was evaluated using recruitment rate, timely completion, a self-reported 'ease-of-use', score and field notes. Prevalence of CRC risk was calculated using the CRISP model.

Results: Five hundred sixty-one (90%) patients agreed to use the tool and 424 (84%) rated the tool easy to use. Despite this, 41% of people were unable to complete the questions without assistance. Patients who were older, without tertiary education or with English as their second language were more likely to require assistance (P < 0.001). Thirty-nine percent of patients were low risk, 58% at slightly increased and 2.4% were at moderately increased risk of developing colorectal cancer in the next 5 years.

Conclusions: The tool was perceived as easy to use, although older, less educated people, and patients with English as their second language needed help. The data support the recruitment methods but not the use of a self-completed tool for an efficacy trial.
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http://dx.doi.org/10.1093/fampra/cmz029DOI Listing
November 2019

Ability of known susceptibility SNPs to predict colorectal cancer risk for persons with and without a family history.

Fam Cancer 2019 10;18(4):389-397

Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, 3010, Australia.

Before SNP-based risk can be incorporated in colorectal cancer (CRC) screening, the ability of these SNPs to estimate CRC risk for persons with and without a family history of CRC, and the screening implications need to be determined. We estimated the association with CRC of a 45 SNP-based risk using 1181 cases and 999 controls, and its correlation with CRC risk predicted from detailed family history. We estimated the predicted change in the distribution across predefined risk categories, and implications for recommended screening commencement age, from adding SNP-based risk to family history. The inter-quintile risk ratio for colorectal cancer risk of the SNP-based risk was 3.28 (95% CI 2.54-4.22). SNP-based and family history-based risks were not correlated (r = 0.02). For persons with no first-degree relatives with CRC, screening could commence 4 years earlier for women (5 years for men) in the highest quintile of SNP-based risk. For persons with two first-degree relatives with CRC, screening could commence 16 years earlier for men and women in the highest quintile, and 7 years earlier for the lowest quintile. This 45 SNP panel in conjunction with family history, can identify people who could benefit from earlier screening. Risk reclassification by 45 SNPs could inform targeted screening for CRC prevention, particularly in clinical genetics settings when mutations in high-risk genes cannot be identified. Yet to be determined is cost-effectiveness, resources requirements, community, patient and clinician acceptance, and feasibility with potentially ethical, legal and insurance implications.
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http://dx.doi.org/10.1007/s10689-019-00136-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6785388PMC
October 2019

Evaluating diagnostic strategies for early detection of cancer: the CanTest framework.

BMC Cancer 2019 Jun 14;19(1):586. Epub 2019 Jun 14.

Centre for Cancer Research and Department of General Practice, University of Melbourne, 10th floor, Victorian Comprehensive Cancer Centre, 305 Grattan St, Melbourne, VIC, 3010, Australia.

Background: Novel diagnostic triage and testing strategies to support early detection of cancer could improve clinical outcomes. Most apparently promising diagnostic tests ultimately fail because of inadequate performance in real-world, low prevalence populations such as primary care or general community populations. They should therefore be systematically evaluated before implementation to determine whether they lead to earlier detection, are cost-effective, and improve patient safety and quality of care, while minimising over-investigation and over-diagnosis.

Methods: We performed a systematic scoping review of frameworks for the evaluation of tests and diagnostic approaches.

Results: We identified 16 frameworks: none addressed the entire continuum from test development to impact on diagnosis and patient outcomes in the intended population, nor the way in which tests may be used for triage purposes as part of a wider diagnostic strategy. Informed by these findings, we developed a new framework, the 'CanTest Framework', which proposes five iterative research phases forming a clear translational pathway from new test development to health system implementation and evaluation.

Conclusion: This framework is suitable for testing in low prevalence populations, where tests are often applied for triage testing and incorporated into a wider diagnostic strategy. It has relevance for a wide range of stakeholders including patients, policymakers, purchasers, healthcare providers and industry.
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http://dx.doi.org/10.1186/s12885-019-5746-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6570853PMC
June 2019

Lung cancer.

BMJ 2019 06 3;365:l1725. Epub 2019 Jun 3.

Leeds Teaching Hospitals Trust, St James's Hospital, Leeds LS9 7TF, UK.

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http://dx.doi.org/10.1136/bmj.l1725DOI Listing
June 2019
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