General Practice - Research Publications

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    Optimization of a Quality Improvement Tool for Cancer Diagnosis in Primary Care: Qualitative Study
    Chima, S ; Martinez-Gutierrez, J ; Hunter, B ; Manski-Nankervis, J-A ; Emery, J (JMIR PUBLICATIONS, INC, 2022-08-01)
    BACKGROUND: The most common route to a diagnosis of cancer is through primary care. Delays in diagnosing cancer occur when an opportunity to make a timely diagnosis is missed and is evidenced by patients visiting the general practitioner (GP) on multiple occasions before referral to a specialist. Tools that minimize prolonged diagnostic intervals and reduce missed opportunities to investigate patients for cancer are therefore a priority. OBJECTIVE: This study aims to explore the usefulness and feasibility of a novel quality improvement (QI) tool in which algorithms flag abnormal test results that may be indicative of undiagnosed cancer. This study allows for the optimization of the cancer recommendations before testing the efficacy in a randomized controlled trial. METHODS: GPs, practice nurses, practice managers, and consumers were recruited to participate in individual interviews or focus groups. Participants were purposively sampled as part of a pilot and feasibility study, in which primary care practices were receiving recommendations relating to the follow-up of abnormal test results for prostate-specific antigen, thrombocytosis, and iron-deficiency anemia. The Clinical Performance Feedback Intervention Theory (CP-FIT) was applied to the analysis using a thematic approach. RESULTS: A total of 17 interviews and 3 focus groups (n=18) were completed. Participant themes were mapped to CP-FIT across the constructs of context, recipient, and feedback variables. The key facilitators to use were alignment with workflow, recognized need, the perceived importance of the clinical topic, and the GPs' perception that the recommendations were within their control. Barriers to use included competing priorities, usability and complexity of the recommendations, and knowledge of the clinical topic. There was consistency between consumer and practitioner perspectives, reporting language concerns associated with the word cancer, the need for more patient-facing resources, and time constraints of the consultation to address patients' worries. CONCLUSIONS: There was a recognized need for the QI tool to support the diagnosis of cancer in primary care, but barriers were identified that hindered the usability and actionability of the recommendations in practice. In response, the tool has been refined and is currently being evaluated as part of a randomized controlled trial. Successful and effective implementation of this QI tool could support the detection of patients at risk of undiagnosed cancer in primary care and assist in preventing unnecessary delays.
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    Identifying Novel Biomarkers Ready for Evaluation in Low-Prevalence Populations for the Early Detection of Lower Gastrointestinal Cancers: A Systematic Review and Meta-Analysis
    Druce, P ; Calanzani, N ; Snudden, C ; Milley, K ; Boscott, R ; Behiyat, D ; Martinez-Gutierrez, J ; Saji, S ; Oberoi, J ; Funston, G ; Messenger, M ; Walter, FM ; Emery, J (SPRINGER, 2021-04-27)
    INTRODUCTION: Lower gastrointestinal (GI) cancers are a major cause of cancer deaths worldwide. Prognosis improves with earlier diagnosis, and non-invasive biomarkers have the potential to aid with early detection. Substantial investment has been made into the development of biomarkers; however, studies are often carried out in specialist settings and few have been evaluated for low-prevalence populations. METHODS: We aimed to identify novel biomarkers for the detection of lower GI cancers that have the potential to be evaluated for use in primary care. MEDLINE, Embase, Emcare and Web of Science were systematically searched for studies published in English from January 2000 to October 2019. Reference lists of included studies were also assessed. Studies had to report on measures of diagnostic performance for biomarkers (single or in panels) used to detect colorectal or anal cancers. We included all designs and excluded studies with fewer than 50 cases/controls. Data were extracted from published studies on types of biomarkers, populations and outcomes. Narrative synthesis was used, and measures of specificity and sensitivity were meta-analysed where possible. RESULTS: We identified 142 studies reporting on biomarkers for lower GI cancers, for 24,844 cases and 45,374 controls. A total of 378 unique biomarkers were identified. Heterogeneity of study design, population type and sample source precluded meta-analysis for all markers except methylated septin 9 (mSEPT9) and pyruvate kinase type tumour M2 (TuM2-PK). The estimated sensitivity and specificity of mSEPT9 was 80.6% (95% CI 76.6-84.0%) and 88.0% (95% CI 79.1-93.4%) respectively; TuM2-PK had an estimated sensitivity of 81.6% (95% CI 75.2-86.6%) and specificity of 80.1% (95% CI 76.7-83.0%). CONCLUSION: Two novel biomarkers (mSEPT9 and TuM2-PK) were identified from the literature with potential for use in lower-prevalence populations. Further research is needed to validate these biomarkers in primary care for screening and assessment of symptomatic patients.
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    Results of a Randomized Controlled Trial to Increase Cervical Cancer Screening Among Rural Latinas
    Thompson, B ; Carosso, EA ; Jhingan, E ; Wang, L ; Holte, SE ; Byrd, TL ; Benavides, MC ; Lopez, C ; Martinez-Gutierrez, J ; Ibarra, G ; Gonzalez, VJ ; Gonzalez, NE ; Duggan, CR (WILEY, 2017-02-15)
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    Cervical cancer screening and adherence to follow-up among Hispanic women study protocol: a randomized controlled trial to increase the uptake of cervical cancer screening in Hispanic women
    Duggan, C ; Coronado, G ; Martinez, J ; Byrd, TL ; Carosso, E ; Lopez, C ; Benavides, M ; Thompson, B (BMC, 2012-05-06)
    BACKGROUND: In the US, Hispanic women have a higher incidence of, and mortality from, cervical cancer than non-Hispanic white women. The reason for this disparity may be attributable to both low rates of screening and poor adherence to recommended diagnostic follow-up after an abnormal Pap test. The 'Cervical Cancer Screening and Adherence to Follow-up Among Hispanic Women' study is a collaboration between a research institution and community partners made up of members from community based organizations, the Yakima Valley Farm Workers Clinic and the Breast, Cervical, and Colon Health Program of the Yakima District . The study will assess the efficacy of two culturally-appropriate, tailored educational programs designed to increase cervical cancer screening among Hispanic women, based in the Yakima Valley, Washington, US. METHODS/DESIGN: A parallel randomized-controlled trial of 600 Hispanic women aged 21-64, who are non-compliant with Papanicolau (Pap) test screening guidelines. Participants will be randomized using block randomization to (1) a control arm (usual care); (2) a low-intensity information program, consisting of a Spanish-language video that educates women on the importance of cervical cancer screening; or (3) a high-intensity program consisting of the video plus a 'promotora' or lay-community health educator-led, home based intervention to encourage cervical cancer screening. Participants who attend cervical cancer screening, and receive a diagnosis of an abnormal Pap test will be assigned to a patient navigator who will provide support and information to promote adherence to follow-up tests, and any necessary surgery or treatment. Primary endpoint: Participants will be tracked via medical record review at community-based clinics, to identify women who have had a Pap test within 7 months of baseline assessment. Medical record reviewers will be blinded to randomization arm. Secondary endpoint: An evaluation of the patient navigator program as a method to improve adherence and reduce time to follow-up among participants who receive an abnormal Pap test result. An additional secondary endpoint is the cost-effectiveness of the two different intensity intervention programs. DISCUSSION: This culturally sensitive intervention aims to increase compliance and adherence to cervical screening in a Hispanic population. If effective, such interventions may reduce incidence of cervical cancer. TRIAL REGISTRATION: NCT01525433.
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    Identifying Novel Biomarkers Ready for Evaluation in Low-Prevalence Populations for the Early Detection of Upper Gastrointestinal Cancers: A Systematic Review
    Calanzani, N ; Druce, PE ; Snudden, C ; Milley, KM ; Boscott, R ; Behiyat, D ; Saji, S ; Martinez-Gutierrez, J ; Oberoi, J ; Funston, G ; Messenger, M ; Emery, J ; Walter, FM (SPRINGER, 2020-12-11)
    INTRODUCTION: Detecting upper gastrointestinal (GI) cancers in primary care is challenging, as cancer symptoms are common, often non-specific, and most patients presenting with these symptoms will not have cancer. Substantial investment has been made to develop biomarkers for cancer detection, but few have reached routine clinical practice. We aimed to identify novel biomarkers for upper GI cancers which have been sufficiently validated to be ready for evaluation in low-prevalence populations. METHODS: We systematically searched MEDLINE, Embase, Emcare, and Web of Science for studies published in English from January 2000 to October 2019 (PROSPERO registration CRD42020165005). Reference lists of included studies were assessed. Studies had to report on second measures of diagnostic performance (beyond discovery phase) for biomarkers (single or in panels) used to detect pancreatic, oesophageal, gastric, and biliary tract cancers. We included all designs and excluded studies with less than 50 cases/controls. Data were extracted on types of biomarkers, populations and outcomes. Heterogeneity prevented pooling of outcomes. RESULTS: We identified 149 eligible studies, involving 22,264 cancer cases and 49,474 controls. A total of 431 biomarkers were identified (183 microRNAs and other RNAs, 79 autoantibodies and other immunological markers, 119 other proteins, 36 metabolic markers, 6 circulating tumour DNA and 8 other). Over half (n = 231) were reported in pancreatic cancer studies. Only 35 biomarkers had been investigated in at least two studies, with reported outcomes for that individual marker for the same tumour type. Apolipoproteins (apoAII-AT and apoAII-ATQ), and pepsinogens (PGI and PGII) were the most promising biomarkers for pancreatic and gastric cancer, respectively. CONCLUSION: Most novel biomarkers for the early detection of upper GI cancers are still at an early stage of matureness. Further evidence is needed on biomarker performance in low-prevalence populations, in addition to implementation and health economic studies, before extensive adoption into clinical practice can be recommended.
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    AI Based Cancer Detection Models Using Primary Care Datasets
    Ristanoski, G ; Emery, J ; Martinez Gutierrez, J ; McCarthy, D ; Aickelin, U (ENGINEERING & TECHNOLOGY PUBLISHING, 2022-04-01)
    Cancer is one of the most common and serious medical conditions with more than 144 000 Australians having been diagnosed with cancer in 2019. The non-specific nature of cancer symptoms and its low prevalence make cancer diagnosis particularly challenging, especially for primary care physicians/general practitioners (GPs). Ongoing research in cancer diagnosis places a heavy focus on understanding the epidemiology of cancer symptoms. With GPs being the first point of contact for most patients, prediction models using the patient’s medical history from primary care data can be a useful decision tool for early cancer detection. Our work both investigates the opportunities to use primary care data, specifically pathology data, for developing such decision tools and tackles the challenges coming from uncertainty in the data such as irregular pathology records. We present opportunities using the results within the frequently ordered full blood count to determine relevance to a future cancer diagnosis. By using several different pathology metrics, we show how we can generate features suitable for AI models that can be used to detect cancer 3 months earlier than current practices. Though the work focuses on patients with lung cancer, the methodology can be adjusted to other types of cancer and other data within the medical records. Our findings demonstrate that even when working with incomplete or obscure patient history, hematological measures contain valuable information that can indicate the potential of cancer diagnosis for up to 8 out of 10 patients. The use of the proposed decision tool presents a way to incorporate pathology data in the current cancer diagnosis practices and to incorporate various pathology tests or other primary care datasets for similar purposes.
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    Handling uncertainty using features from pathology: Opportunities in primary care data for developing high risk cancer survival methods
    Ristanoski, G ; Emery, J ; Martinez Gutierrez, J ; McCarthy, D ; Aickelin, U (ACM, 2021)
    More than 144 000 Australians were diagnosed with cancer in 2019. Diagnosing cancer in primary care is challenging due to the non-specific nature of cancer symptoms and its low prevalence. Understanding the epidemiology of cancer symptoms and patterns of presentation in patient's medical history from primary care data could be important to improve earlier detection and cancer outcomes. As past medical data about a patient can be incomplete, irregular or missing, this creates additional challenges when attempting to use the patient's history for any new diagnosis. Our research aims to investigate the opportunities in a patient's pathology history available to a GP, initially focused on the results within the frequently ordered full blood count to determine relevance to a future high-risk cancer prognosis, and treatment outcome. We investigated how past pathology test results can lead to deriving features that can be used to predict cancer outcomes, with emphasis on patients at risk of not surviving the cancer within 2-year period. This initial work focuses on patients with lung cancer, although the methodology can be applied to other types of cancer and other data within the medical record. Our findings indicate that even in cases of incomplete or obscure patient history, hematological measures can be useful in generating features relevant for predicting cancer risk and survival. The results strongly indicate to add the use of pathology test data for potential high-risk cancer diagnosis, and utilize additional pathology metrics or other primary care datasets even more for similar purposes.