Publications by authors named "Juliet A Usher-Smith"

68 Publications

Analysis of the components of cancer risk perception and links with intention and behaviour: A UK-based study.

PLoS One 2022 13;17(1):e0262197. Epub 2022 Jan 13.

Department of Public Health and Primary Care, Prevention Group, Primary Care Unit, University of Cambridge Clinical School, Cambridge, United Kingdom.

Risk perception refers to how individuals interpret their susceptibility to threats, and has been hypothesised as an important predictor of intentions and behaviour in many theories of health behaviour change. However, its components, optimal measurement, and effects are not yet fully understood. The TRIRISK model, developed in the US, conceptualises risk perception as deliberative, affective and experiential components. In this study, we aimed to assess the replicability of the TRIRISK model in a UK sample by confirmatory factor analysis (CFA), explore the inherent factor structure of risk perception in the UK sample by exploratory factor analysis (EFA), and assess the associations of EFA-based factors with intentions to change behaviour and subsequent behaviour change. Data were derived from an online randomised controlled trial assessing cancer risk perception using the TRIRISK instrument and intention and lifestyle measures before and after communication of cancer risk. In the CFA analysis, the TRIRISK model of risk perception did not provide a good fit for the UK data. A revised model developed using EFA consisted of two separate "numerical" and "self-reflective" factors of deliberative risk perception, and a third factor combining affective with a subset of experiential items. This model provided a better fit to the data when cross-validated. Using multivariable regression analysis, we found that the self-reflective and affective-experiential factors of the model identified in this study were reliable predictors of intentions to prevent cancer. There were no associations of any of the risk perception factors with behaviour change. This study confirms that risk perception is clearly a multidimensional construct, having identified self-reflective risk perception as a new distinct component with predictive validity for intention. Furthermore, we highlight the practical implications of our findings for the design of interventions incorporating risk perception aimed at behaviour change in the context of cancer prevention.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0262197PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8757986PMC
January 2022

Risk models for recurrence and survival after kidney cancer: a systematic review.

BJU Int 2021 Dec 16. Epub 2021 Dec 16.

Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.

Objective: To systematically identify and compare the performance of prognostic models providing estimates of survival or recurrence of localized renal cell cancer (RCC) in patients treated with surgery with curative intent.

Materials And Methods: We performed a systematic review (PROSPERO CRD42019162349). We searched Medline, EMBASE and the Cochrane Library from 1 January 2000 to 12 December 2019 to identify studies reporting the performance of one or more prognostic model(s) that predict recurrence-free survival (RFS), cancer-specific survival (CSS) or overall survival (OS) in patients who have undergone surgical resection for localized RCC. For each outcome we summarized the discrimination of each model using the C-statistic and performed multivariate random-effects meta-analysis of the logit transformed C-statistic to rank the models.

Results: Of a total of 13 549 articles, 57 included data on the performance of 22 models in external populations. C-statistics ranged from 0.59 to 0.90. Several risk models were assessed in two or more external populations and had similarly high discriminative performance. For RFS, these were the Sorbellini, Karakiewicz, Leibovich and Kattan models, with the UCLA Integrated Staging System model also having similar performance in European/US populations. All had C-statistics ≥0.75 in at least half of the validations. For CSS, they the models with the highest discriminative performance in two or more external validation studies were the Zisman, Stage, Size, Grade and Necrosis (SSIGN), Karakiewicz, Leibovich and Sorbellini models (C-statistic ≥0.80 in at least half of the validations), and for OS they were the Leibovich, Karakiewicz, Sorbellini and SSIGN models. For all outcomes, the models based on clinical features at presentation alone (Cindolo and Yaycioglu) had consistently lower discrimination. Estimates of model calibration were only infrequently included but most underestimated survival.

Conclusion: Several models had good discriminative ability, with there being no single 'best' model. The choice from these models for each setting should be informed by both the comparative performance and availability of factors included in the models. All would need recalibration if used to provide absolute survival estimates.
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http://dx.doi.org/10.1111/bju.15673DOI Listing
December 2021

Risk prediction models for symptomatic patients with bladder and kidney cancer: a systematic review.

Br J Gen Pract 2022 Jan 31;72(714):e11-e18. Epub 2021 Dec 31.

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

Background: Timely diagnosis of bladder and kidney cancer is key to improving clinical outcomes. Given the challenges of early diagnosis, models incorporating clinical symptoms and signs may be helpful to primary care clinicians when triaging at-risk patients.

Aim: To identify and compare published models that use clinical signs and symptoms to predict the risk of undiagnosed prevalent bladder or kidney cancer.

Design And Setting: Systematic review.

Method: A search identified primary research reporting or validating models predicting the risk of bladder or kidney cancer in MEDLINE and EMBASE. After screening identified studies for inclusion, data were extracted onto a standardised form. The risk models were classified using TRIPOD guidelines and evaluated using the PROBAST assessment tool.

Results: The search identified 20 661 articles. Twenty studies (29 models) were identified through screening. All the models included haematuria (visible, non-visible, or unspecified), and seven included additional signs and symptoms (such as abdominal pain). The models combined clinical features with other factors (including demographic factors and urinary biomarkers) to predict the risk of undiagnosed prevalent cancer. Several models ( = 13) with good discrimination (area under the receiver operating curve >0.8) were identified; however, only eight had been externally validated. All of the studies had either high or unclear risk of bias.

Conclusion: Models were identified that could be used in primary care to guide referrals, with potential to identify lower-risk patients with visible haematuria and to stratify individuals who present with non-visible haematuria. However, before application in general practice, external validations in appropriate populations are required.
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http://dx.doi.org/10.3399/BJGP.2021.0319DOI Listing
January 2022

Validation and public health modelling of risk prediction models for kidney cancer using the UK Biobank.

BJU Int 2021 Sep 19. Epub 2021 Sep 19.

Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.

Objectives: To externally validate risk models for the detection of kidney cancer, as early detection of kidney cancer improves survival and stratifying the population using risk models could enable an individually tailored screening programme.

Methods: We validated the performance of 30 existing phenotypic models predicting the risk of kidney cancer in the UK Biobank cohort (n = 450 687). We compared the discrimination and calibration of models for men, women, and a mixed-sex cohort. Population level data were used to estimate model performance in a screening scenario for a range of risk thresholds (6-year risk: 0.1-1.0%).

Results: In all, 10 models had reasonable discrimination (area under the receiver-operating characteristic curve >0.60), although some had poor calibration. Modelling demonstrated similar performance of the best models over a range of thresholds. The models showed an improvement in ability to identify cases compared to age- and sex-based screening. All the models performed less well in women than men.

Conclusions: The present study is the first comprehensive external validation of risk models for kidney cancer. The best-performing models are better at identifying individuals at high risk of kidney cancer than age and sex alone; however, the benefits are relatively small. Feasibility studies are required to determine applicability to a screening programme.
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http://dx.doi.org/10.1111/bju.15598DOI Listing
September 2021

'Oh, I've got an appointment': A qualitative interview study exploring how to support attendance at diabetes screening after gestational diabetes.

Diabet Med 2021 Oct 29;38(10):e14650. Epub 2021 Jul 29.

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

Aims: To explore the views of women with a history of gestational diabetes mellitus (GDM) on suggested practical approaches to support diabetes screening attendance after GDM, which is recommended but poorly attended.

Methods: We conducted semi-structured interviews with 20 participants in Cambridgeshire, UK who had been diagnosed with GDM and were 3-48 months postpartum. Interviews covered whether participants had been screened and why, plans for future screening and their views on potential interventions to facilitate attendance (at the first postpartum test and annual testing). Framework analysis was used to analyse the transcripts. The interview schedule, suggested interventions and thematic framework were based on a recent systematic review.

Results: Sixteen participants had undergone screening since pregnancy, explaining that they had an appointment arranged and wanted reassurance that they did not have diabetes. The participants who had not been tested were not aware that it was recommended. Only 13 had planned to attend subsequent tests at the start of the interview. Eight themes to support future attendance were discussed. The majority of the participants agreed that changing the processes for arranging tests, offering choice in test location and combining appointments would facilitate attendance. Child-friendly clinics, more opportunities to understand GDM and the role of postpartum testing, stopping self-testing and increasing their GP's awareness of their pregnancy received inconsistent feedback. The nature of the test used did not appear to influence attendance.

Conclusions: The participants wanted to be screened for diabetes after GDM. We have identified interventions that could be relatively simply incorporated into routine practice to facilitate screening attendance, such as flexibility in the appointment location or time and sending invitations for tests.
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http://dx.doi.org/10.1111/dme.14650DOI Listing
October 2021

Impact of achievement and change in achievement of lifestyle recommendations in middle-age on risk of the most common potentially preventable cancers.

Prev Med 2021 Dec 7;153:106712. Epub 2021 Jul 7.

The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Box 113 Cambridge Biomedical Campus, Cambridge CB2 0SR, UK; MRC Epidemiology Unit, University of Cambridge, Institute of Metabolic Science, Cambridge CB2 0QQ, UK. Electronic address:

This study aimed to assess the association between achievement, and within-person change in achievement, of lifestyle recommendations in middle-age and incidence of the most common potentially preventable cancers. We used data from 44,572 participants from the Swedish Västerbotten Intervention Programme who had attended at least two health checks 9-11 years apart. We assessed the association between the mean number of healthy lifestyle recommendations achieved (lifestyle score), and change in lifestyle score between the health checks, and risk of one or more of the eight most common potentially preventable cancers using Cox regression. Participants were followed-up for 11.0 (SD 4.9) years. A higher mean lifestyle score was associated with a lower hazard of cancer in men (HR 0.81 (95%CI 0.74-0.90) per unit increase) and women (HR 0.90 (0.84-0.96)). There was no evidence of a linear association between change in lifestyle score and risk (HR 0.93 (0.85-1.03) and HR 1.004 (0.94-1.07) per unit change for men and women respectively). When comparing those with an increase in lifestyle score of ≥2 with those who improved less or declined in achievement the HR was 0.74 (0.54-1.00) and 1.02 (0.84-1.24) for men and women respectively. These findings support the inclusion of lifestyle recommendations in cancer prevention guidelines. They further suggest that interventions to change health behaviours in middle-age may reduce risk of the most common preventable cancers in men, but this association was not observed in women. Strategies to encourage healthy lifestyles earlier in the life course may be more effective.
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http://dx.doi.org/10.1016/j.ypmed.2021.106712DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8633845PMC
December 2021

The Costs and Benefits of Risk Stratification for Colorectal Cancer Screening Based On Phenotypic and Genetic Risk: A Health Economic Analysis.

Cancer Prev Res (Phila) 2021 08 26;14(8):811-822. Epub 2021 May 26.

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

Population-based screening for colorectal cancer is an effective and cost-effective way of reducing colorectal cancer incidence and mortality. Many genetic and phenotypic risk factors for colorectal cancer have been identified, leading to development of colorectal cancer risk scores with varying discrimination. However, these are not currently used by population screening programs. We performed an economic analysis to assess the cost-effectiveness, clinical outcomes, and resource impact of using risk-stratification based on phenotypic and genetic risk, taking a UK National Health Service perspective. Biennial fecal immunochemical test (FIT), starting at an age determined through risk-assessment at age 40, was compared with FIT screening starting at a fixed age for all individuals. Compared with inviting everyone from age 60, using a risk score with area under the receiver operating characteristic curve of 0.721 to determine FIT screening start age, produces 418 QALYs, costs £247,000, and results in 218 fewer colorectal cancer cases and 156 fewer colorectal cancer deaths per 100,000 people, with similar FIT screening invites. There is 96% probability that risk-stratification is cost-effective, with net monetary benefit (based on £20,000 per QALY threshold) estimated at £8.1 million per 100,000 people. The maximum that could be spent on risk-assessment and still be cost-effective is £114 per person. Lower benefits are produced with lower discrimination risk scores, lower mean screening start age, or higher FIT thresholds. Risk-stratified screening benefits men more than women. Using risk to determine FIT screening start age could improve the clinical outcomes and cost effectiveness of colorectal cancer screening without using significant additional screening resources. PREVENTION RELEVANCE: Colorectal cancer screening is essential for early detection and prevention of colorectal cancer, but implementation is often limited by resource constraints. This work shows that risk-stratification using genetic and phenotypic risk could improve the effectiveness and cost-effectiveness of screening programs, without using substantially more screening resources than are currently available.
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http://dx.doi.org/10.1158/1940-6207.CAPR-20-0620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7611464PMC
August 2021

Reasons for intending to accept or decline kidney cancer screening: thematic analysis of free text from an online survey.

BMJ Open 2021 05 18;11(5):e044961. Epub 2021 May 18.

The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK

Objectives: Kidney cancer has been identified as a disease for which screening might provide significant benefit for patients. The aim of this study was to understand in detail the facilitators and barriers towards uptake of a future kidney cancer screening programme, and to compare these across four proposed screening modalities.

Design: An online survey including free-text responses.

Setting: UK PARTICIPANTS: 668 adults PRIMARY AND SECONDARY OUTCOME MEASURES: The survey assessed participants' self-reported intention to take-up kidney cancer screening with four different test methods (urine test, blood test, ultrasound scan and low-dose CT). We conducted thematic analysis of 2559 free-text comments made within the survey using an inductive approach.

Results: We identified five overarching themes that influenced screening intention: 'personal health beliefs', 'practicalities', 'opinions of the test', 'attitudes towards screening' and 'cancer apprehension'. Overall, participants considered the tests presented as simple to complete and the benefits of early detection to outweigh any drawbacks to screening. Dominant facilitators and barriers varied with patterns of intention to take up screening across the four tests. Most intended to take up screening by all four tests, and for these participants, screening was seen as a positive health behaviour. A significant minority were driven by practicalities and the risks of the tests offered. A smaller proportion intended to reject all forms of screening offered, often due to fear or worry about results and unnecessary medical intervention or a general negative view of screening.

Conclusions: Most individuals would accept kidney cancer screening by any of the four test options presented because of strong positive attitudes towards screening in general and the perceived simplicity of the tests. Providing information about the rationale for screening in general and the potential benefits of early detection will be important to optimise uptake among uncertain individuals.
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http://dx.doi.org/10.1136/bmjopen-2020-044961DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8137225PMC
May 2021

Barriers to postpartum diabetes screening: a qualitative synthesis of clinicians' views.

Br J Gen Pract 2021 06 27;71(707):e473-e482. Epub 2021 May 27.

Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge.

Background: Gestational diabetes mellitus (GDM) is an important risk factor for developing type 2 diabetes mellitus (T2DM) later in life. Postpartum screening provides an opportunity for early detection and management of T2DM, but uptake is poor.

Aim: To explore barriers to screening from clinicians' perspectives to guide future interventions to increase uptake of postpartum screening.

Design And Setting: Systematic review and qualitative synthesis.

Method: Qualitative studies included in a previous review were assessed, and then five electronic databases were searched from January 2013 to May 2019 for qualitative studies reporting clinicians' perspectives on postpartum glucose screening after GDM. Study quality was assessed against the Critical Appraisal Skills Programmes checklist. Qualitative data from the studies were analysed using thematic synthesis.

Results: Nine studies were included, containing views from 187 clinicians from both community and hospital care. Three main themes were identified: difficulties in handover between primary and secondary care (ambiguous roles and communication difficulties); short-term focus in clinical consultations (underplaying risk so as not to overwhelm patients and competing priorities); and patient-centric barriers such as time pressures.

Conclusion: Barriers to diabetes screening were identified at both system and individual levels. At the system level, clarification of responsibility for testing among healthcare professionals and better systems for recall are needed. These could be achieved through registers, improved clinical protocols, and automatic flagging and prompts within electronic medical records. At the individual level, clinicians should be supported to prioritise the importance of screening within consultations and better educational resources made available for women. Making it more convenient for women to attend may also facilitate screening.
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http://dx.doi.org/10.3399/BJGP.2020.0928DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8103924PMC
June 2021

Electronic clinical decision support tool for assessing stomach symptoms in primary care (ECASS): a feasibility study.

BMJ Open 2021 03 18;11(3):e041795. Epub 2021 Mar 18.

School of Medicine, University of Leeds, Leeds, UK.

Objective: To 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 Setting: Feasibility study in 42 general practices in two regions of England, cluster randomised controlled trial design without blinding, nested qualitative and health economic evaluation.

Participants: Patients 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.

Intervention: Practices 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.

Outcomes: Patient 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.

Results: From 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.

Conclusions: The 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 Number: ISRCTN125595588.
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http://dx.doi.org/10.1136/bmjopen-2020-041795DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7978254PMC
March 2021

Interventions to reduce social isolation and loneliness during COVID-19 physical distancing measures: A rapid systematic review.

PLoS One 2021 17;16(2):e0247139. Epub 2021 Feb 17.

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

Background: A significant proportion of the worldwide population is at risk of social isolation and loneliness as a result of the COVID-19 pandemic. We aimed to identify effective interventions to reduce social isolation and loneliness that are compatible with COVID-19 shielding and social distancing measures.

Methods And Findings: In this rapid systematic review, we searched six electronic databases (Medline, Embase, Web of Science, PsycINFO, Cochrane Database of Systematic Reviews and SCOPUS) from inception to April 2020 for systematic reviews appraising interventions for loneliness and/or social isolation. Primary studies from those reviews were eligible if they included: 1) participants in a non-hospital setting; 2) interventions to reduce social isolation and/or loneliness that would be feasible during COVID-19 shielding measures; 3) a relevant control group; and 4) quantitative measures of social isolation, social support or loneliness. At least two authors independently screened studies, extracted data, and assessed risk of bias using the Downs and Black checklist. Study registration: PROSPERO CRD42020178654. We identified 45 RCTs and 13 non-randomised controlled trials; none were conducted during the COVID-19 pandemic. The nature, type, and potential effectiveness of interventions varied greatly. Effective interventions for loneliness include psychological therapies such as mindfulness, lessons on friendship, robotic pets, and social facilitation software. Few interventions improved social isolation. Overall, 37 of 58 studies were of "Fair" quality, as measured by the Downs & Black checklist. The main study limitations identified were the inclusion of studies of variable quality; the applicability of our findings to the entire population; and the current poor understanding of the types of loneliness and isolation experienced by different groups affected by the COVID-19 pandemic.

Conclusions: Many effective interventions involved cognitive or educational components, or facilitated communication between peers. These interventions may require minor modifications to align with COVID-19 shielding/social distancing measures. Future high-quality randomised controlled trials conducted under shielding/social distancing constraints are urgently needed.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0247139PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7888614PMC
March 2021

The impact of information about different absolute benefits and harms on intention to participate in colorectal cancer screening: A think-aloud study and online randomised experiment.

PLoS One 2021 16;16(2):e0246991. Epub 2021 Feb 16.

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

Background: There is considerable heterogeneity in individuals' risk of disease and thus the absolute benefits and harms of population-wide screening programmes. Using colorectal cancer (CRC) screening as an exemplar, we explored how people make decisions about screening when presented with information about absolute benefits and harms, and how those preferences vary with baseline risk, between screening tests and between individuals.

Method: We conducted two linked studies with members of the public: a think-aloud study exploring decision making in-depth and an online randomised experiment quantifying preferences. In both, participants completed a web-based survey including information about three screening tests (colonoscopy, sigmoidoscopy, and faecal immunochemical testing) and then up to nine scenarios comparing screening to no screening for three levels of baseline risk (1%, 3% and 5% over 15 years) and the three screening tests. Participants reported, after each scenario, whether they would opt for screening (yes/no).

Results: Of the 20 participants in the think-aloud study 13 did not consider absolute benefits or harms when making decisions concerning CRC screening. In the online experiment (n = 978), 60% expressed intention to attend at 1% risk of CRC, 70% at 3% and 77% at 5%, with no differences between screening tests. At an individual level, 535 (54.7%) would attend at all three risk levels and 178 (18.2%) at none. The 27% whose intention varied by baseline risk were more likely to be younger, without a family history of CRC, and without a prior history of screening.

Conclusions: Most people in our population were not influenced by the range of absolute benefits and harms associated with CRC screening presented. For an appreciable minority, however, magnitude of benefit was important.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246991PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7886213PMC
August 2021

Should colorectal cancer screening start at different ages for men and women? Cost-effectiveness analysis for a resource-constrained service.

Cancer Rep (Hoboken) 2021 08 2;4(4):e1344. Epub 2021 Feb 2.

The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, School of Clinical Medicine, Cambridge, UK.

Background: Men have a greater risk of colorectal cancer (CRC) than women, but population screening currently starts at the same age for both sexes.

Aim: This analysis investigates whether, in a resource-constrained setting, it would be more effective and cost-effective for men and women to start screening for CRC at different ages.

Methods And Results: An economic modeling analysis was carried out using the Microsimulation Model in Cancer of the Bowel to compare sex-stratification against screening everyone from the same age, taking an English National Health Service perspective. Screening men from age 56 and women from age 60, rather than screening everyone from age 58 using a Fecal Immunochemical Test (FIT) threshold of 120 μg/g is expected to produce an additional 0.0004 QALYs for a cost of £0.55 per person at model start (Incremental Cost-effectiveness Ratio = £1392), and to reduce CRC cases and mortality by 25 and 19 per 100 000 people respectively, while using a similar amount of screening resources. Probabilistic sensitivity analysis indicates a 61% probability that sex-stratification is more cost-effective than screening everyone at age 58. Similar benefits of sex-stratification are found at other FIT thresholds, but become negligible if mean screening start age is reduced to 50.

Conclusion: Where resources are constrained and it is not feasible to screen everyone from the age of 50, starting screening earlier in men than women is likely to be more cost-effective and gain more health benefits overall than strategies where men and women start screening at the same age.
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http://dx.doi.org/10.1002/cnr2.1344DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8388164PMC
August 2021

Incorporating a brief intervention for personalised cancer risk assessment to promote behaviour change into primary care: a multi-methods pilot study.

BMC Public Health 2021 01 23;21(1):205. Epub 2021 Jan 23.

The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Box 113 Cambridge Biomedical Campus, Cambridge, CB2 0SR, UK.

Background: Approximately 40% of cancers could be prevented if people lived healthier lifestyles. We have developed a theory-based brief intervention to share personalised cancer risk information and promote behaviour change within primary care. This study aimed to assess the feasibility and acceptability of incorporating this intervention into primary care consultations.

Method: Patients eligible for an NHS Health Check or annual chronic disease review at five general practices were invited to participate in a non-randomised pilot study. In addition to the NHS Health Check or chronic disease review, those receiving the intervention were provided with their estimated risk of developing the most common preventable cancers alongside tailored behaviour change advice. Patients completed online questionnaires at baseline, immediately post-consultation and at 3-month follow-up. Consultations were audio/video recorded. Patients (n = 12) and healthcare professionals (HCPs) (n = 7) participated in post-intervention qualitative interviews that were analysed using thematic analysis.

Results: 62 patients took part. Thirty-four attended for an NHS Health Check plus the intervention; 7 for a standard NHS Health Check; 16 for a chronic disease review plus the intervention; and 5 for a standard chronic disease review. The mean time for delivery of the intervention was 9.6 min (SD 3) within NHS Health Checks and 9 min (SD 4) within chronic disease reviews. Fidelity of delivery of the intervention was high. Data from the questionnaires demonstrates potential improvements in health-related behaviours following the intervention. Patients receiving the intervention found the cancer risk information and lifestyle advice understandable, useful and motivating. HCPs felt that the intervention fitted well within NHS Health Checks and facilitated conversations around behaviour change. Integrating the intervention within chronic disease reviews was more challenging.

Conclusions: Incorporating a risk-based intervention to promote behaviour change for cancer prevention into primary care consultations is feasible and acceptable to both patients and HCPs. A randomised trial is now needed to assess the effect on health behaviours. When designing that trial, and other prevention activities within primary care, it is necessary to consider challenges around patient recruitment, the HCP contact time needed for delivery of interventions, and how best to integrate discussions about disease risk within routine care.
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http://dx.doi.org/10.1186/s12889-021-10210-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7824918PMC
January 2021

Cervical screening attendance and cervical cancer risk among women who have sex with women.

J Med Screen 2021 09 21;28(3):349-356. Epub 2021 Jan 21.

Primary Care Unit, University of Cambridge, Cambridge, UK.

Objectives: To describe cervical cancer screening participation among women who have sex exclusively with women (WSEW) and women who have sex with women and men (WSWM) compared with women who have sex exclusively with men (WSEM), and women who have never had sex and compare this with bowel (colorectal) and breast screening participation. To explore whether there is evidence of differential stage 3 cervical intraepithelial neoplasia (CIN3) or cervical cancer risk.

Methods: We describe cervical, bowel and breast cancer screening uptake in age groups eligible for the national screening programmes, prevalent CIN3 and cervical cancer at baseline, and incident CIN3 and cervical cancer at five years follow-up, among 218,674 women in UK Biobank, a cohort of healthy volunteers from the UK.

Results: Compared with WSEM, in adjusted analysis [odds ratio (95% confidence interval)], WSEW 0.10 (0.08-0.13), WSWM 0.73 (0.58-0.91), and women who have never had sex 0.02 (0.01-0.02) were less likely to report ever having attended cervical screening. There were no differences when considering bowel cancer screening uptake ( = 0.61). For breast cancer screening, attendance was lower among WSWM 0.79 (0.68 to 0.91) and women who have never had sex 0.47 (0.29-0.58), compared with WSEM. There were incident and prevalent cases of both CIN3 and cervical cancer among WSEW and WSWM. Compared with WSEM with a single male partner, among WSEW there was a twofold increase in CIN3 1.91 (1.01 to 3.59); among WSWM with only one male partner, this was 2.25 (1.19 to 4.24).

Conclusions: These findings highlight the importance of improving uptake of cervical screening among all women who have sex with women and breast screening among WSWM and women who have never had sex.
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http://dx.doi.org/10.1177/0969141320987271DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8366122PMC
September 2021

The absolute and relative risk of type 2 diabetes after gestational diabetes: A systematic review and meta-analysis of 129 studies.

Diabetes Res Clin Pract 2021 Jan 15;171:108625. Epub 2020 Dec 15.

The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK; MRC Epidemiology Unit, Institute of Metabolic Science, School of Clinical Medicine, University of Cambridge, Cambridge, UK. Electronic address:

Aims: To estimate development of type 2 diabetes (T2DM) in women with previous gestational diabetes (GDM) and investigate characteristics associated with higher diagnoses, building on previous meta-analyses and exploring heterogeneity.

Methods: Systematic literature review of studies published up to October 2019. We included studies reporting progression to T2DM ≥6 months after pregnancy, if diagnostic methods were reported and ≥50 women with GDM participated. We conducted random-effects meta-analyses and meta-regression of absolute and relative T2DM risk.

Prospero Id: CRD42017080299.

Results: In 129 included studies, the percentage diagnosed with T2DM was 12% (95% confidence interval 8-16%) higher for each additional year after pregnancy, with a third developing diabetes within 15 years. Development was 18% (5-34%) higher per unit BMI at follow-up, and 57% (39-70%) lower in White European populations compared to others (adjusted for ethnicity and follow-up). Women with GDM had a relative risk of T2DM of 8.3 (6.5-10.6). 17.0% (15.1-19.0%) developed T2DM overall, although heterogeneity between studies was substantial (I 99.3%), and remained high after accounting for various study-level characteristics.

Conclusions: Percentage developing T2DM after GDM is highly variable. These findings highlight the need for sustained follow-up after GDM through screening, and interventions to reduce modifiable risk factors.
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http://dx.doi.org/10.1016/j.diabres.2020.108625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7610694PMC
January 2021

Acceptability and potential impact on uptake of using different risk stratification approaches to determine eligibility for screening: A population-based survey.

Health Expect 2021 04 2;24(2):341-351. Epub 2020 Dec 2.

Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK.

Background: Using risk stratification approaches to determine eligibility has the potential to improve efficiency of screening.

Objectives: To compare the public acceptability and potential impact on uptake of using different approaches to determine eligibility for screening.

Design: An online population-based survey of 668 adults in the UK aged 45-79 including a series of scenarios in the context of a potential kidney cancer screening programme in which eligibility was determined by age, sex, age and sex combined, a simple risk score (age, sex, body mass index, smoking status), a complex risk score additionally incorporating family history and lifestyle, or a genetic risk score.

Outcome Measures: We used multi-level ordinal logistic regression to compare acceptability and potential uptake within individuals and multivariable ordinal logistic regression differences between individuals.

Results: Using sex, age and sex, or the simple risk score were less acceptable than age (P < .0001). All approaches were less acceptable to women than men. Over 70% were comfortable waiting until they were older if the complex risk score or genetics indicated a low risk. If told they were high risk, 85% would be more likely to take up screening. Being told they were low risk had no overall influence on uptake.

Conclusions: Varying the starting age of screening based on estimated risk from models incorporating phenotypic or genetic risk factors would be acceptable to most individuals and may increase uptake.

Patient Or Public Contribution: Two members of the public contributed to the development of the survey and have commented on this paper.
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http://dx.doi.org/10.1111/hex.13175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8077132PMC
April 2021

Public attitudes towards screening for kidney cancer: an online survey.

BMC Urol 2020 Oct 28;20(1):170. Epub 2020 Oct 28.

The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB2 0SR, UK.

Background: Kidney cancer is often asymptomatic, leading to proposals for a screening programme. The views of the public towards introducing a new screening programme for kidney cancer are unknown. The aim of this study was to explore attitudes towards kidney cancer screening and factors influencing intention to attend a future screening programme.

Methods: We conducted an online population-based survey of 1021 adults aged 45-77 years. The main outcome measure was intention to attend four possible screening tests (urine, blood, ultrasound scan, low-dose CT) as well as extended low-dose CT scans within lung cancer screening programmes. We used multivariable regression to examine the association between intention and each screening test.

Results: Most participants stated that they would be 'very likely' or 'likely' to undergo each of the screening tests [urine test: n = 961 (94.1%); blood test: n = 922 (90.3%); ultrasound: n = 914 (89.5%); low-dose CT: n = 804 (78.8%); lung CT: n = 962 (95.2%)]. Greater intention to attend was associated with higher general cancer worry and less perceived burden/inconvenience about the screening tests. Less worry about the screening test was also associated with higher intention to attend, but only in those with low general cancer worry (cancer worry scale ≤ 5). Compared with intention to take up screening with a urine test, participants were half as likely to report that they intended to undergo blood [OR 0.56 (0.43-0.73)] or ultrasound [OR 0.50 (0.38-0.67)] testing, and half as likely again to report that they intended to take part in a screening programme featuring a low dose CT scan for kidney cancer screening alone [OR 0.19 (0.14-0.27)].

Conclusion: Participants in this study expressed high levels of intention to accept an invitation to screening for kidney cancer, both within a kidney cancer specific screening programme and in conjunction with lung cancer screening. The choice of screening test is likely to influence uptake. Together these findings support on-going research into kidney cancer screening tests and the potential for combining kidney cancer screening with existing or new screening programmes.
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http://dx.doi.org/10.1186/s12894-020-00724-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592501PMC
October 2020

Fidelity of the delivery of NHS Health Checks in general practice: an observational study.

BJGP Open 2020 Oct 27;4(4). Epub 2020 Oct 27.

The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK

Background: The NHS Health Check programme aims to reduce the risk of common preventable diseases by providing risk information and behaviour change advice. Failure to deliver the consultation appropriately could undermine its efficacy. To date, to the authors' knowledge, there are no published data on the fidelity of delivery of NHS Health Checks.

Aim: To assess the fidelity of delivery of NHS Health Checks in general practice.

Design & Setting: Fidelity assessment of video and audio recordings of NHS Health Check consultations conducted in four GP practices across the East of England.

Method: A secondary analysis of 38 NHS Health Check consultations, which were video or audio recorded as part of a pilot study of introducing discussions of cancer risk into NHS Health Checks. Using a checklist based on the , fidelity of delivery was assessed as the proportion of key elements completed during the consultations.

Results: The mean number of elements of the NHS Health Check completed across all consultations was 14.5/18 (80.6%), with a range of 10 to 17 (55.6% to 94.4%). The mean fidelity for risk assessment, risk communication, and risk management sections was 8.7/10 (87.0%), 4.1/5 (82.0%), and 1.7/3 (56.7%), respectively. Clinically appropriate lifestyle advice was given in 34/38 consultations. Elements with the lowest fidelity were ethnicity assessment ( = 12/38; 31.6%), family history of cardiovascular disease (CVD) assessment ( = 25/38; 65.8%), AUDIT-C communication ( = 13/38; 34.2%), and dementia risk management ( = 6/38; 15.8%).

Conclusion: Although fidelity of delivery was high overall, important elements of the NHS Health Check were being regularly omitted. Opportunities for behaviour change, particularly relating to alcohol consumption and dementia risk management, may be being missed.
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http://dx.doi.org/10.3399/bjgpopen20X101077DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7606139PMC
October 2020

Risk Prediction Models for Kidney Cancer: A Systematic Review.

Eur Urol Focus 2021 Nov 14;7(6):1380-1390. Epub 2020 Jul 14.

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

Context: Early detection of kidney cancer improves survival; however, low prevalence means that population-wide screening may be inefficient. Stratification of the population into risk categories could allow for the introduction of a screening programme tailored to individuals.

Objective: This review will identify and compare published models that predict the risk of developing kidney cancer in the general population.

Evidence Acquisition: A search identified primary research reporting or validating models predicting the risk of kidney cancer in Medline and EMBASE. After screening identified studies for inclusion, we extracted data onto a standardised form. The risk models were classified using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) guidelines and evaluated using the PROBAST assessment tool.

Evidence Synthesis: The search identified 15 281 articles. Sixty-two satisfied the inclusion criteria; performance measures were provided for 11 models. Some models predicted the risk of prevalent undiagnosed disease and others future incident disease. Six of the models had been validated, two using external populations. The most commonly included risk factors were age, smoking status, and body mass index. Most of the models had acceptable-to-good discrimination (area under the receiver-operating curve >0.7) in development and validation. Many models also had high specificity; however, several had low sensitivity. The highest performance was seen for the models using only biomarkers to detect kidney cancer; however, these were developed and validated in small case-control studies.

Conclusions: We identified a small number of risk models that could be used to stratify the population according to the risk of kidney cancer. Most exhibit reasonable discrimination, but a few have been validated externally in population-based studies.

Patient Summary: In this review, we looked at mathematical models predicting the likelihood of an individual developing kidney cancer. We found several suitable models, using a range of risk factors (such as age and smoking) to predict the risk for individuals. Most of the models identified require further testing in the general population to confirm their usefulness.
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http://dx.doi.org/10.1016/j.euf.2020.06.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8642244PMC
November 2021

A randomised controlled trial of the effect of providing online risk information and lifestyle advice for the most common preventable cancers.

Prev Med 2020 09 29;138:106154. Epub 2020 May 29.

The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Box 113, Cambridge Biomedical Campus, Cambridge CB2 0SR, UK. Electronic address:

Few trial data are available concerning the impact of personalised cancer risk information on behaviour. This study assessed the short-term effects of providing personalised cancer risk information on cancer risk beliefs and self-reported behaviour. We randomised 1018 participants, recruited through the online platform Prolific, to either a control group receiving cancer-specific lifestyle advice or one of three intervention groups receiving their computed 10-year risk of developing one of the five most common preventable cancers either as a bar chart, a pictograph or a qualitative scale alongside the same lifestyle advice. The primary outcome was change from baseline in computed risk relative to an individual with a recommended lifestyle (RRI) at three months. Secondary outcomes included: health-related behaviours, risk perception, anxiety, worry, intention to change behaviour, and a newly defined concept, risk conviction. After three months there were no between-group differences in change in RRI (p = 0.71). At immediate follow-up, accuracy of absolute risk perception (p < 0.001), absolute and comparative risk conviction (p < 0.001) and intention to increase fruit and vegetables (p = 0.026) and decrease processed meat (p = 0.033) were higher in all intervention groups relative to the control group. The increases in accuracy and conviction were only seen in individuals with high numeracy and low baseline conviction, respectively. These findings suggest that personalised cancer risk information alongside lifestyle advice can increase short-term risk accuracy and conviction without increasing worry or anxiety but has little impact on health-related behaviour. Trial registration: ISRCTN17450583. Registered 30 January 2018.
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http://dx.doi.org/10.1016/j.ypmed.2020.106154DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7378571PMC
September 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

Development and usability testing of a very brief intervention for personalised cancer risk assessment to promote behaviour change in primary care using normalisation process theory.

Prim Health Care Res Dev 2020 01 14;21:e1. Epub 2020 Jan 14.

Clinical Senior Research Associate, The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge, UK.

Background: Cancer is the second leading cause of death worldwide. Lifestyle choices play an important role in the aetiology of cancer with up to 4 in 10 cases potentially preventable. Interventions delivered by healthcare professionals (HCPs) that incorporate risk information have the potential to promote behaviour change. Our aim was to develop a very brief intervention incorporating cancer risk, which could be implemented within primary care.

Methods: Guided by normalisation process theory (NPT), we developed a prototype intervention using literature reviews, consultation with patient and public representatives and pilot work with patients and HCPs. We conducted focus groups and interviews with 65 HCPs involved in delivering prevention activities. Findings were used to refine the intervention before 22 HCPs completed an online usability test and provided further feedback via a questionnaire incorporating a modified version of the NoMAD checklist.

Results: The intervention included a website where individuals could provide information on lifestyle risk factors view their estimated 10-year risk of developing one or more of the five most common preventable cancers and access lifestyle advice incorporating behaviour change techniques. Changes incorporated from feedback from the focus groups and interviews included signposting to local services and websites, simplified wording and labelling of risk information. In the usability testing, all participants felt it would be easy to collect the risk information. Ninety-one percent felt the intervention would enable discussion about cancer risk and believed it had potential to be easily integrated into National Health Service (NHS) Health Checks. However, only 36% agreed it could be delivered within 5 min.

Conclusions: With the use of NPT, we developed a very brief intervention that is acceptable to HCPs in primary care and could be potentially integrated into NHS Health Checks. However, further work is needed to assess its feasibility and potential effectiveness.
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http://dx.doi.org/10.1017/S146342361900080XDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7005588PMC
January 2020

Software tools to support title and abstract screening for systematic reviews in healthcare: an evaluation.

BMC Med Res Methodol 2020 01 13;20(1). Epub 2020 Jan 13.

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

Background: Systematic reviews are vital to the pursuit of evidence-based medicine within healthcare. Screening titles and abstracts (T&Ab) for inclusion in a systematic review is an intensive, and often collaborative, step. The use of appropriate tools is therefore important. In this study, we identified and evaluated the usability of software tools that support T&Ab screening for systematic reviews within healthcare research.

Methods: We identified software tools using three search methods: a web-based search; a search of the online "systematic review toolbox"; and screening of references in existing literature. We included tools that were accessible and available for testing at the time of the study (December 2018), do not require specific computing infrastructure and provide basic screening functionality for systematic reviews. Key properties of each software tool were identified using a feature analysis adapted for this purpose. This analysis included a weighting developed by a group of medical researchers, therefore prioritising the most relevant features. The highest scoring tools from the feature analysis were then included in a user survey, in which we further investigated the suitability of the tools for supporting T&Ab screening amongst systematic reviewers working in medical research.

Results: Fifteen tools met our inclusion criteria. They vary significantly in relation to cost, scope and intended user community. Six of the identified tools (Abstrackr, Colandr, Covidence, DRAGON, EPPI-Reviewer and Rayyan) scored higher than 75% in the feature analysis and were included in the user survey. Of these, Covidence and Rayyan were the most popular with the survey respondents. Their usability scored highly across a range of metrics, with all surveyed researchers (n = 6) stating that they would be likely (or very likely) to use these tools in the future.

Conclusions: Based on this study, we would recommend Covidence and Rayyan to systematic reviewers looking for suitable and easy to use tools to support T&Ab screening within healthcare research. These two tools consistently demonstrated good alignment with user requirements. We acknowledge, however, the role of some of the other tools we considered in providing more specialist features that may be of great importance to many researchers.
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http://dx.doi.org/10.1186/s12874-020-0897-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6958795PMC
January 2020

Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a clinical practice guideline.

BMJ 2019 Oct 2;367:l5515. Epub 2019 Oct 2.

Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.

Clinical Question: Recent 15-year updates of sigmoidoscopy screening trials provide new evidence on the effectiveness of colorectal cancer screening. Prompted by the new evidence, we asked: "Does colorectal cancer screening make an important difference to health outcomes in individuals initiating screening at age 50 to 79? And which screening option is best?"

Current Practice: Numerous guidelines recommend screening, but vary on recommended test, age and screening frequency. This guideline looks at the evidence and makes recommendations on screening for four screening options: faecal immunochemical test (FIT) every year, FIT every two years, a single sigmoidoscopy, or a single colonoscopy.

Recommendations: These recommendations apply to adults aged 50-79 years with no prior screening, no symptoms of colorectal cancer, and a life expectancy of at least 15 years. For individuals with an estimated 15-year colorectal cancer risk below 3%, we suggest no screening (weak recommendation). For individuals with an estimated 15-year risk above 3%, we suggest screening with one of the four screening options: FIT every year, FIT every two years, a single sigmoidoscopy, or a single colonoscopy (weak recommendation). With our guidance we publish the linked research, a graphic of the absolute harms and benefits, a clear description of how we reached our value judgments, and linked decision aids.

How This Guideline Was Created: A guideline panel including patients, clinicians, content experts and methodologists produced these recommendations using GRADE and in adherence with standards for trustworthy guidelines. A linked systematic review of colorectal cancer screening trials and microsimulation modelling were performed to inform the panel of 15-year screening benefits and harms. The panel also reviewed each screening option's practical issues and burdens. Based on their own experience, the panel estimated the magnitude of benefit typical members of the population would value to opt for screening and used the benefit thresholds to inform their recommendations.

The Evidence: Overall there was substantial uncertainty (low certainty evidence) regarding the 15-year benefits, burdens and harms of screening. Best estimates suggested that all four screening options resulted in similar colorectal cancer mortality reductions. FIT every two years may have little or no effect on cancer incidence over 15 years, while FIT every year, sigmoidoscopy, and colonoscopy may reduce cancer incidence, although for FIT the incidence reduction is small compared with sigmoidoscopy and colonoscopy. Screening related serious gastrointestinal and cardiovascular adverse events are rare. The magnitude of the benefits is dependent on the individual risk, while harms and burdens are less strongly associated with cancer risk.

Understanding The Recommendation: Based on benefits, harms, and burdens of screening, the panel inferred that most informed individuals with a 15-year risk of colorectal cancer of 3% or higher are likely to choose screening, and most individuals with a risk of below 3% are likely to decline screening. Given varying values and preferences, optimal care will require shared decision making.
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http://dx.doi.org/10.1136/bmj.l5515DOI Listing
October 2019

A Decision Analysis Evaluating Screening for Kidney Cancer Using Focused Renal Ultrasound.

Eur Urol Focus 2021 03 14;7(2):407-419. Epub 2019 Sep 14.

Cambridge Centre for Health Services Research, University of Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge, UK; Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK. Electronic address:

Background: Screening for renal cell carcinoma (RCC) has been identified as a key research priority; however, no randomised control trials have been performed. Value of information analysis can determine whether further research on this topic is of value.

Objective: To determine (1) whether current evidence suggests that screening is potentially cost-effective and, if so, (2) in which age/sex groups, (3) identify evidence gaps, and (4) estimate the value of further research to close those gaps.

Design, Setting, And Participants: A decision model was developed evaluating screening in asymptomatic individuals in the UK. A National Health Service perspective was adopted.

Intervention: A single focused renal ultrasound scan compared with standard of care (no screening).

Outcome Measurements And Statistical Analysis: Expected lifetime costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER), discounted at 3.5% per annum.

Results And Limitations: Given a prevalence of RCC of 0.34% (0.18-0.54%), screening 60-yr-old men resulted in an ICER of £18 092/QALY (€22 843/QALY). Given a prevalence of RCC of 0.16% (0.08-0.25%), screening 60-yr-old women resulted in an ICER of £37327/QALY (€47 129/QALY). In the one-way sensitivity analysis, the ICER was <£30000/QALY as long as the prevalence of RCC was ≥0.25% for men and ≥0.2% for women at age 60yr. Given the willingness to pay a threshold of £30000/QALY (€37 878/QALY), the population-expected values of perfect information were £194 million (€244 million) and £97 million (€123 million) for 60-yr-old men and women, respectively. The expected value of perfect parameter information suggests that the prevalence of RCC and stage shift associated with screening are key research priorities.

Conclusions: Current evidence suggests that one-off screening of 60-yr-old men is potentially cost-effective and that further research into this topic would be of value to society.

Patient Summary: Economic modelling suggests that screening 60-yr-old men for kidney cancer using ultrasound may be a good use of resources and that further research on this topic should be performed.
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http://dx.doi.org/10.1016/j.euf.2019.09.002DOI Listing
March 2021

Effect of interventions including provision of personalised cancer risk information on accuracy of risk perception and psychological responses: A systematic review and meta-analysis.

Patient Educ Couns 2020 01 11;103(1):83-95. Epub 2019 Aug 11.

The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK. Electronic address:

Objective: To synthesize the literature on the effect of provision of personalised cancer risk information to individuals at population level risk on accuracy of risk perception and psychological responses.

Methods: A systematic review and random effects meta-analysis of articles published from 01/01/2000 to 01/07/2017.

Results: We included 23 studies. Immediately after provision of risk information 87% of individuals were able to recall the absolute risk estimate. Less than half believed that to be their risk, with up to 71% believing their risk to be higher than the estimate. Provision of risk information increased accuracy of perceived absolute risk immediately after risk information compared with no information (pooled RR 4.16 (95%CI 1.28-13.49), 3 studies). There was no significant effect on comparative risk accuracy (pooled RR 1.39 (0.72-2.69), 2 studies) and either no change or a reduction in cancer worry, anxiety and fear.

Conclusion: These findings highlight the complex cognitive processes involved in the conceptualisation of risk.

Practice Implications: Individuals who appear to understand and are able to recall risk information most likely do not believe it reflects their own risk.
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http://dx.doi.org/10.1016/j.pec.2019.08.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6919334PMC
January 2020

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

Effect of communicating phenotypic and genetic risk of coronary heart disease alongside web-based lifestyle advice: the INFORM Randomised Controlled Trial.

Heart 2019 07 30;105(13):982-989. Epub 2019 Mar 30.

MRC Epidemiology Unit, School of Clinical Medicine, Institute of Metabolic Science, University of Cambridge, Cambridge, UK.

Objective: To determine whether provision of web-based lifestyle advice and coronary heart disease risk information either based on phenotypic characteristics or phenotypic plus genetic characteristics affects changes in objectively measured health behaviours.

Methods: A parallel-group, open randomised trial including 956 male and female blood donors with no history of cardiovascular disease (mean [SD] age=56.7 [8.8] years) randomised to four study groups: control group (no information provided); web-based lifestyle advice only (lifestyle group); lifestyle advice plus information on estimated 10-year coronary heart disease risk based on phenotypic characteristics (phenotypic risk estimate) (phenotypic group) and lifestyle advice plus information on estimated 10-year coronary heart disease risk based on phenotypic (phenotypic risk estimate) and genetic characteristics (genetic risk estimate) (genetic group). The primary outcome was change in physical activity from baseline to 12 weeks assessed by wrist-worn accelerometer.

Results: 928 (97.1%) participants completed the trial. There was no evidence of intervention effects on physical activity (difference in adjusted mean change from baseline): lifestyle group vs control group 0.09 milligravity (mg) (95% CI -1.15 to 1.33); genetic group vs phenotypic group -0.33 mg (95% CI -1.55 to 0.90); phenotypic group and genetic group vs control group -0.52 mg (95% CI -1.59 to 0.55) and vs lifestyle group -0.61 mg (95% CI -1.67 to 0.46). There was no evidence of intervention effects on secondary biological, emotional and health-related behavioural outcomes except self-reported fruit and vegetable intake.

Conclusions: Provision of risk information, whether based on phenotypic or genotypic characteristics, alongside web-based lifestyle advice did not importantly affect objectively measured levels of physical activity, other health-related behaviours, biological risk factors or emotional well-being.

Trial Registration Number: ISRCTN17721237; Pre-results.
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http://dx.doi.org/10.1136/heartjnl-2018-314211DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6582721PMC
July 2019
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