BMC Primary Care

Adaptation and pilot implementation of a hereditary cancer risk-assessment tool for primary care

Abstract Background Family history-based risk assessment for hereditary breast and ovarian cancer is guideline-recommended but clinical implementation remains limited. This is likely, in part, because it adds to the limited time primary care providers (PCPs) have to implement all guideline-recommended care. Methods We adapted Family History Screening 7 (or FHS7), designed for administration by a PCP, for self-report by primary care patients. We used the Framework for Reporting Adaptation and Modifications to Evidence-based Implementation Strategies (FRAME) to guide the modifications. We conducted a pilot feasibility study of hereditary prevention program using the adapted risk-assessment tool and report results from the first year of the program (February 2023-March 2024). Results Feedback from clinical stakeholders and our literature review revealed that, while hereditary cancer risk assessment was a priority for the primary care setting, implementation by PCPs was not feasible. We therefore adapted FHS7 for patient self-report by separating double-barreled items and eliminating jargon, resulting in nine items– six with binary (yes/no) and three with numeric responses. Outcomes from pilot implementation of the adapted FHS7 (n=4,355) showed high completion rate (77% completed all items), with greater completion via MyChart than in-person (87% vs. 13%), and higher non-response for the three items with numeric responses compared to the six with binary responses. Overall, positivity rate of the adapted FHS7 was 36%. Conclusion This paper describes our team’s process of adapting the FHS7 questionnaire to retain the core function (evaluating specific family history of cancer information) while adapting to fit the clinical context. Preliminary implementation data suggest high completion rate in the primary care setting.

Healthcare use and clinical investigations before a diagnosis of ovarian cancer: a register-based study in Denmark

Abstract Background Ovarian cancer (OC) is associated with a poor prognosis, which calls for earlier diagnosis. This study aimed to analyse the health care use in primary care and at hospitals among women with OC compared to non-cancerous women to identify a window of opportunity for earlier diagnosis. Methods This nationwide register-based observational cohort study included all Danish women aged ≥ 40 years who were diagnosed with a first-time OC or borderline ovarian tumour in 2012–2018 and with no previous cancer diagnosis (n = 4,255). For each case, ten non-cancerous women were identified (n = 42,550). We estimated monthly incidence rate ratios using a negative binomial regression model to assess the use of health care services. We calculated risk ratios of having multiple contacts to general practice before a diagnosis using a binary regression model. Results Cases had statistically significantly higher contact rates to general practice from five months prior to the diagnosis compared to references. From six to eight months prior to diagnosis, an increased use of transvaginal ultrasound and gynaecologist was seen for cases compared to references. Conclusions Increased healthcare use was seen relatively closely to the time of diagnosis for women with OC. This indicates a narrow window of opportunity for a timelier diagnosis. Still, the use of specialised assessment increased at six to eight months before the diagnosis. When women present unspecific symptoms, awareness of potential ovarian malignancies and safety-netting by the general practitioner may be pivotal. Trial registration Not relevant.

Barriers to cervical cancer screening: a cross-sectional study of non-adherent Portuguese women

Cervical cancer is preventable through effective screening programmes, yet adherence remains suboptimal in Portugal. This study aimed to explore the reasons for non-adherence to cervical cancer screening, including socio-demographic influences and women's perceptions, to inform targeted interventions. A cross-sectional study was conducted among women aged 25-60 years identified as non-adherent to cervical cancer screening within a primary care unit in northern Portugal. Participants were randomly selected and recruited via telephone. Data collection included socio-demographic characteristics, screening history, reasons for non-adherence, and knowledge of cervical cancer. Among 262 participants, 43.9% were not compliant with recommended screening intervals. The main barriers identified were lack of a healthcare provider's prescription (34.8%), personal discomfort or forgetfulness (17.4%), low health literacy (15.7%), and limited access to facilities (14.8%). Adherence was positively associated with higher education, access to private healthcare, and positive health self-perception, while lower education and overconfidence in symptom recognition were linked to reduced adherence. Non-adherence to cervical cancer screening reflects a complex interplay of systemic, educational, and personal factors. Addressing these requires improved provider-patient communication, targeted health literacy initiatives, and enhanced service accessibility. Tailored public health strategies are crucial for reducing disparities and supporting national and WHO cervical cancer elimination goals.

Perceptions and beliefs of general practitioners on their role in the cancer screening programmes in the Netherlands: a mixed-methods study

Abstract Background In the Netherlands, population-based cancer screening programmes (CSPs) are organized aiming at cervical, breast and colorectal cancer. For a CSP to be effective, high participation rates are essential; however, there is an alarming downward trend, including wide regional variation in screening uptake. General practitioner (GP) involvement can have a stimulating effect on screening participation. Current GP involvement is however, limited, varies between the programmes and has changed over time. Unexplored is what GPs think of their role(s) in the CSPs. The aim of this study was therefore to map the perceptions and beliefs of GPs regarding their current and future role in the Dutch CSPs. Methods A mixed-methods sequential explanatory study was conducted in the Leiden/The Hague area of the Netherlands, between the end of 2021 and 2022. A questionnaire was developed and distributed among 110 GPs. The aggregated results obtained from the questionnaires served as starting points for conducting semi-structured interviews, with purposefully selected GPs. With this sequential approach we aimed to further enhance the understanding of the questionnaire data, and delved into the topics that emerged from the questionnaire responses. Results In total, 46 GPs completed the online questionnaire (response rate 42%). Subsequent five semi-structured comprehensive interviews were conducted. GPs indicated that they frequently encounter the CSP in their daily practice and consider it important. They also emphasised it is important that GPs remain closely involved with the CSPs in the future. Nevertheless, GPs also repeatedly mentioned that they are not eager to take on more logistical/organizational tasks. They are however willing to empower CSPs in a positive manner. Conclusion GPs were generally positive about the CSPs and their current role within these programmes. Nevertheless, several options have been proposed to improve the CSPs, especially to increase screening uptake for populations in a socioeconomically disadvantaged position. Since it is of utmost importance to screen those who are most at risk of developing the screening-specific tumours, efforts should be made to achieve this goal.

Symptoms and signs of urogenital cancer in primary care

Abstract Background Urogenital cancers are common, accounting for approximately 20% of cancer incidence globally. Cancers belonging to the same organ system often present with similar symptoms, making initial management challenging. In this study, 511 cases of cancer were recorded after the date of consultation among 61,802 randomly selected patients presenting in primary care in six European countries: a subgroup analysis of urogenital cancers was carried out in order to study variation in symptom presentation. Methods Initial data capture was by completion of standardised forms containing closed questions about symptoms recorded during the consultation. The general practitioner (GP) provided follow-up data after diagnosis, based on medical record data made after the consultation. GPs also provided free text comments about the diagnostic procedure for individual patients. Results The most common symptoms were mainly associated with one or two specific types of cancer: ‘Macroscopic haematuria’ with bladder or renal cancer (combined sensitivity 28.3%), ‘Increased urinary frequency’ with bladder (sensitivity 13.3%) or prostatic (sensitivity 32.1%) cancer, or to uterine body (sensitivity 14.3%) cancer, ‘Unexpected genital bleeding’ with uterine cancer (cervix, sensitivity 20.0%, uterine body, sensitivity 71.4%). ‘Distended abdomen, bloating’ had sensitivity 62.5% (based on eight cases of ovarian cancer). In ovarian cancer, increased abdominal circumference and a palpable tumour also were important diagnostic elements. Specificity for ‘Macroscopic haematuria’ was 99.8% (99.7–99.8). PPV > 3% was noted for ‘Macroscopic haematuria’ and bladder or renal cancer combined, for bladder cancer in male patients. In males aged 55–74, PPV = 7.1% for ‘Macroscopic haematuria’ and bladder cancer. Abdominal pain was an infrequent symptom in urogenital cancers. Conclusions Most types of urogenital cancer present with rather specific symptoms. If the GP considers ovarian cancer, increased abdominal circumference should be actively determined. Several cases were clarified through the GP’s clinical examination, or laboratory investigations.

Link between the referring physician and breast and cervical cancers screening: a cross-sectional study in France

Abstract Background The aims of the “médecin traitant” or referring physician (RP) reform, introduced in France in 2004, were to improve the organisation and quality of care and to allow for greater equity, particularly in terms of prevention. The objective of our study was to evaluate the effect of having a declared RP on the uptake of screening for breast and cervical cancers, and to explore the mechanisms involved. Methods We used an existing dataset of 1,072,289 women, which combines data from the Health Insurance information systems, with census data. We built multivariable logistic regression models to study the effect of having a RP on the uptake of mammography and pap smear, adjusted for age, socio-economic level, health status and healthcare provision. We secondarily added to this model the variable “having consulted a General Practitioner (GP) within the year”. Finally, we evaluated the interaction between the effect of having a referring physician and the area of residence (metropolitan/urban/rural). Results Patients who had a declared RP had a significantly higher uptake of mammography and pap smear than those who did not. The strength of the association was particularly important in very urban areas. The effect of having visited a GP seemed to explain a part of the correlation between having a RP and uptake of screening. Conclusions Lower rates of gynaecological screening among women without an RP compared to those with an RP may partly reflect a specific behaviour pattern in women less adherent to the health care system. However, this result also shows the importance of the RP, who assumes the key role of relaying public health information in a more personalised and adapted way.