British Journal of General Practice

Understanding ethnic inequalities in cancer diagnostic intervals: a cohort study of patients presenting suspected cancer symptoms to GPs in England

BackgroundUK Asian and Black patients experience longer cancer diagnostic intervals — the period between initial symptomatic presentation in primary care and cancer diagnosis.AimTo determine whether the differences in diagnostic intervals are because of prolonged primary care, referral, or secondary care interval.Design and settingA cohort study was undertaken of 70 971 patients with seven cancers (breast, lung, prostate, colorectal, oesophagogastric, myeloma, ovarian) diagnosed after symptom presentation in English primary care.MethodData on symptom presentation and diagnosis were extracted from cancer registry-linked primary care and secondary care data. Primary interval was defined as the period between first primary care presentation and secondary care referral, referral interval as the period between referral and first secondary care appointment, and secondary care interval as the period between the first secondary care appointment and diagnosis. Accelerated failure time models were used to investigate ethnic differences across all four intervals.ResultsAcross all sites, the median diagnostic interval was 46 days, ranging from 13 days for breast cancer to 116 days for lung cancer. It was 14% longer for Black patients (adjusted time ratio [ATR] 1.14, 95% confidence interval [CI] = 1.05 to 1.25) and 13% longer for Asian patients (ATR 1.13, 95% CI = 1.03 to 1.23) compared with White patients. Site-specific analyses showed that, for myeloma, lung, prostate, and colorectal cancer, the secondary care interval was longer in Asian and Black patients, who also had a longer primary care interval in breast and colorectal cancer. There was little evidence of ethnic differences in referral interval.ConclusionThis study found evidence of ethnic differences in diagnostic intervals, with prolonged secondary care intervals for four common cancers and prolonged primary care intervals for two. Although these differences are relatively modest, they are unjustified and may indicate shortcomings in healthcare delivery that disproportionately affect ethnic minorities.

A ‘smear campaign’ against patient-excluded policy changes: a reflection on the language used in cervical screening programmes

BackgroundCervical screening has transformed the diagnosis of cervical cancer. However, uptake within the national screening programme is not uniform across demographics. This raises the question of whether medical language, which conveys essential information but also shapes attitudes towards engaging with healthcare, is part of the problem. The term “smear test” has been used for generations and is embedded in colloquial and medical vocabulary. However, there is a danger that the phrase may conjure images of an unpleasant or even reckless ordeal, potentially contributing to unnecessary patient anxiety.AimTo evaluate patient attitudes towards the terms “cervical smear” and “cervical brush”.MethodFemale participants from a single GP surgery were randomly sampled. Data from questionnaires were then subjected to thematic analysis.ResultsHalf of patients interviewed did not feel either term would significantly influence cervical screening uptake. Equal numbers of patients expressed an overall preference for each of the two terms, and the remaining 28% expressed no preference. Qualitative data revealed some patients favoured the familiarity of the term “cervical smear”, and others preferred the descriptive accuracy of “cervical brush”.ConclusionIt is imperative to consult target groups and use inclusive language that minimises stigmatising or negative connotations. Modifying language alone is unlikely to remedy the current access barriers in UK cervical screening. Instead, a multifaceted approach that also targets education and addresses systemic issues could offer a more sustainable strategy. Ultimately, prioritising a patient-centred approach could improve access to life-saving screening.

Conundrum in primary care: should all cervical polyps be removed?

BackgroundThe management of asymptomatic cervical polyps has long been debated due to the scarcity of literature and guidelines regarding the need for polypectomy. While the majority of cervical polyps are diagnosed incidentally by GPs during routine cervical smears, there are no clear recommendations on referral pathways for further histological investigations.AimTo investigate the need for polypectomy in women presenting with asymptomatic polyps. In addition, the study explores potential suggestions and guidelines for the referral of asymptomatic cervical polyps in general practice.MethodA retrospective study on the histological findings of extracted cervical polyps examined by the pathology department at the Countess of Chester Hospital (COCH) over 9 years (2010– 2019).ResultsOf the 514 patients presented with cervical polyps (74% were asymptomatic), approximately 97% of the referrals made were by GPs. Additionally, we identified 74 inappropriate referrals through the 2-week wait cancer pathway. Overall, there were no malignant samples and five (0.97%) premalignant lesions were presented.ConclusionThis study supported the evidence that most cervical polyps are benign. However, inappropriate referrals prompt more education on cervical pathologies. Furthermore, there is a need for robust guidelines on the management of asymptomatic cervical polyps in general practice. To lessen the financial burden of managing cervical polyps in a secondary care setting, workshops on polyp removal can be developed for GPs.

Non-speculum sampling for cervical screening in older women

Non-speculum sampling for cervical screening

Uterine adenomyosis: an update for GPs

Detecting ovarian cancer in primary care: can we do better?

Attitudes of transgender men and non-binary people to cervical screening: a cross-sectional mixed-methods study in the UK

BackgroundTransgender men and non-binary people assigned female at birth (TMNB) who have not had surgery to remove the cervix are recommended to undertake cervical screening with the same frequency as cisgender women, but evidence suggests that TMNB have lower odds of lifetime and up-to-date cervical screening uptake.AimTo understand the attitudes towards and preferences for cervical screening among UK-based TMNB.Design and settingCross-sectional survey of TMNB at an NHS gender identity clinic (GIC) and an NHS sexual health service specialising in care of transgender people.MethodRecruitment was via email invitations to patients of the GIC and sexual health service. Inclusion criteria were: female sex assigned at birth; transgender man, masculine, or non-binary gender identity; aged ≥18 years; and UK resident. Quantitative results were analysed using descriptive statistics, and free-text comments were analysed thematically.ResultsIn total there were 137 participants; 80% identified as transmasculine,18% as non-binary, and the remaining participants reported other noncisgender identities. Sixty-four participants (47%) were eligible for cervical screening and 37 (58%) of those had been screened. Only 34 (53%) of those eligible felt they had sufficient information about cervical screening. Just over half (n = 71/134, 53%) stated they would like the option to self-swab for high-risk human papillomavirus. Only half (n = 68/134, 51%) of participants were in favour of an automatic invitation for cervical screening. Thematic analysis identified a number of additional barriers to and facilitators of screening.ConclusionTMNB have identified numerous potential areas for change that may improve cervical screening uptake and patient experience.

Cervical screening: the evolving landscape

Non-speculum clinician-taken samples for human papillomavirus testing: a cross-sectional study in older women

BackgroundCervical cancer incidence and mortality are high in women aged ≥65 years, despite the disease being preventable by screening. Speculum-based screening can become more uncomfortable after the menopause.AimTo examine test performance and acceptability of human papillomavirus (HPV) testing on clinician-collected vaginal samples without a speculum (non-speculum).Design and settingCross-sectional study in 11 GP practices and four colposcopy clinics in London, UK, between August 2017 and January 2019.MethodNon-speculum and conventional (speculum) samples were collected from women aged ≥50 years attending for a colposcopy (following a speculum HPV-positive screening result) or women aged ≥35 years (with confirmed cervical intraepithelial neoplasia (CIN) 2+), and women aged 50–64 years attending routine screening. Sensitivity to CIN2+ was assessed among women with confirmed CIN2+ (colposcopy). Specificity to HPV relative to speculum sampling and overall concordance was assessed among women with negative cytology (routine screening).ResultsThe sensitivity of non-speculum sampling for detecting CIN2+ was 83.3% (95% confidence interval [CI] = 60.8 to 94.2) (n = 15/18). There was complete concordance among women with positive CIN2+ who had a speculum sample ≤91 days prior to the non-speculum sample (n = 12). Among 204 women with negative cytology, the specificity to HPV was 96.4% (95% CI = 92.7 to 98.5), with 96.6% concordant results (κ 72.4%). Seventy-one percent (n = 120/170) of women preferred a non-speculum sample for their next screen.ConclusionHPV testing on non-speculum clinician-taken samples is a viable approach that warrants further exploration in larger studies. Overall test performance was broadly comparable with that of self-sampling.

CA125 test result, test-to-diagnosis interval, and stage in ovarian cancer at diagnosis: a retrospective cohort study using electronic health records

BackgroundIn the UK, the cancer antigen 125 (CA125) test is recommended as a first-line investigation in women with symptoms of possible ovarian cancer.AimTo compare time between initial primary care CA125 test and diagnosis, tumour morphology, and stage in women with normal (<35 U/ml) and abnormal (≥35 U/ml) CA125 levels prior to ovarian cancer diagnosis.Design and settingRetrospective cohort study using English primary care and cancer registry data.MethodAssociations between CA125 test results and test-to-diagnosis interval, stage, and ovarian cancer morphology were examined.ResultsIn total, 456 women were diagnosed with ovarian cancer in the 12 months after having a CA125 test. Of these, 351 (77%) had an abnormal, and 105 (23%) had a normal, CA125 test result. The median test-to-diagnosis interval was 35 days (interquartile range [IQR] 21–53) for those with abnormal CA125 levels, and 64 days (IQR 42–127) for normal CA125 levels. Tumour morphology differed by CA125 result: indolent borderline tumours were less common in those with abnormal CA125 levels (n = 47, 13%) than those with normal CA125 levels (n = 51, 49%) (P<0.001). Staging data were available for 304 women with abnormal, and 77 with normal, CA125 levels. Of those with abnormal CA125 levels, 35% (n = 106) were diagnosed at an early stage, compared to 86% (n = 66) of women with normal levels. The odds of being diagnosed with early-stage disease were higher in women with normal as opposed to abnormal CA125 levels (odds ratio 12.2, 95% confidence interval = 5.8 to 25.1, P<0.001).ConclusionDespite longer intervals between testing and diagnosis, women with normal, compared with abnormal, CA125 levels more frequently had indolent tumours and were more commonly diagnosed at an early stage in the course of the disease. Although testing approaches that have greater sensitivity might expedite diagnosis for some women, it is not known if this would translate to earlier-stage diagnosis.

Non-speculum sampling approaches for cervical screening in older women: randomised controlled trial

BackgroundCervical cancer disproportionately affects women ≥65 years, especially those not screened regularly. Speculum use is a key barrier.AimTo assess if offering non-speculum clinician-taken sampling and self-sampling increases uptake for lapsed attenders aged 50–64 years.Design and settingPragmatic randomised control trial conducted at 10 general practices in East London, UK.MethodParticipants were 784 women aged 50–64 years, last screened 6–15 years before randomisation. Intervention participants received a letter offering the choice of non-speculum clinician- or self-sampling. Control participants received usual care. The main outcome measure was uptake within 4 months.ResultsScreening uptake 4 months after randomisation was significantly higher in the intervention arm: 20.4% (n = 80/393) versus 4.9% in the control arm (n = 19/391, absolute difference 15.5%, 95% confidence interval [CI] = 11.0% to 20.0%, P<0.001). This was maintained at 12 months: intervention 30.5% (n = 120/393) versus control 13.6% (n = 53/391) (absolute difference 17.0%, 95% CI = 11.3% to 22.7%, P<0.001). Conventional screening attendance within 12 months was very similar for both intervention 12.7% (n = 50/393) and control 13.6% (n = 53/391) arms. Ethnic differences were seen in screening modality preference. More White women opted for self-sampling (50.7%, n = 38/75), whereas most Asian and Black women and those from other ethnic backgrounds opted for conventional screening.ConclusionOffering non-speculum clinician-taken sampling and self-sampling substantially increases uptake in older lapsed attendee women. Non-speculum clinician sampling appeals to women who dislike the speculum but still prefer a clinician to take their sample. Providing a choice of screening modality may be important for optimising cervical screening uptake.

Challenges and opportunities for cervical screening in women over the age of 50 years: a qualitative study

BackgroundCervical cancer is a preventable disease. Cases in women age >50 years are predicted to rise by 60% in the next two decades, yet this group are less likely to attend for screening than younger women.AimTo seek novel solutions to the challenges of cervical screening in women >50 years of age by examining practitioner and service-user experiences.Design and settingSemi-structured interviews were conducted with 28 practitioners and 24 service users >50 years of age, recruited via UK primary care networks in Northern England in 2016–2017, to explore experiences related to cervical screening.MethodAn inductive thematic analysis was conducted to explore the data.ResultsFindings are presented under three key themes. The first,exploring the barriers to successful cervical screening, examines the influences of sexuality and early experiences of screening on attendance, and how preventive health care becomes a low priority as women age. The second,the role of relationships, explores how peer talk shapes attitudes towards cervical screening, how teamwork between practitioners engenders investment in cervical screening, and how interactions between service users and primary care over time can significantly affect intentions to screen. The third,what constitutes good practice, describes practical and sensitive approaches to screening tailored to women aged >50 years.ConclusionGood practice involves attention to structural and practical challenges, and an understanding of the role of relationships in shaping screening intentions. Experienced practitioners adapt procedures to increase sensitivity, and balance time invested in problem solving against the benefits of reaching practice targets for attendance. Building networks of expertise across multiple practices can increase practitioner skill in screening this age group.