School of Social and Community Medicine, University of Bristol, Bristol, UK.
School of Social and Community Medicine, University of Bristol, Bristol, UK.
Lancet Oncol. 2014 Feb;15(2):232-40. doi: 10.1016/S1470-2045(13)70588-6. Epub 2014 Jan 14.
The UK lags behind many European countries in terms of cancer survival. Initiatives to address this disparity have focused on barriers to presentation, symptom recognition, and referral for specialist investigation. Selection of patients for further investigation has come under particular scrutiny, although preferences for referral thresholds in the UK population have not been studied. We investigated preferences for diagnostic testing for colorectal, lung, and pancreatic cancers in primary-care attendees.
In a vignette-based study, researchers recruited individuals aged at least 40 years attending 26 general practices in three areas of England between Dec 6, 2011, and Aug 1, 2012. Participants completed up to three of 12 vignettes (four for each of lung, pancreatic, and colorectal cancers), which were randomly assigned. The vignettes outlined a set of symptoms, the risk that these symptoms might indicate cancer (1%, 2%, 5%, or 10%), the relevant testing process, probable treatment, possible alternative diagnoses, and prognosis if cancer were identified. Participants were asked whether they would opt for diagnostic testing on the basis of the information in the vignette.
3469 participants completed 6930 vignettes. 3052 individuals (88%) opted for investigation in their first vignette. We recorded no strong evidence that participants were more likely to opt for investigation with a 1% increase in risk of cancer (odds ratio [OR] 1·02, 95% CI 0·99-1·06; p=0·189), although the association between risk and opting for investigation was strong when colorectal cancer was analysed alone (1·08, 1·03-1·13; p=0·0001). In multivariable analysis, age had an effect in all three cancer models: participants aged 60-69 years were significantly more likely to opt for investigation than were those aged 40-59 years, and those aged 70 years or older were less likely. Other variables associated with increased likelihood of opting for investigation were shorter travel times to testing centre (colorectal and lung cancers), a family history of cancer (colorectal and lung cancers), and higher household income (colorectal and pancreatic cancers).
Participants in our sample expressed a clear preference for diagnostic testing at all risk levels, and individuals want to be tested at risk levels well below those stipulated by UK guidelines. This willingness should be considered during design of cancer pathways, particularly in primary care. The public engagement with our study should encourage general practitioners to involve patients in referral decision making.
The National Institute for Health Research Programme Grants for Applied Research programme.
在癌症存活率方面，英国落后于许多欧洲国家。为了解决这一差距，已经采取了一些举措来解决就诊障碍、症状识别和转介给专家进行调查的问题。虽然对英国人群中进一步调查的转诊阈值的偏好尚未进行研究，但对患者的选择进行了特别审查。我们调查了在初级保健就诊者中对结直肠癌、肺癌和胰腺癌进行诊断性检测的偏好。
在基于案例的研究中，研究人员招募了 2011 年 12 月 6 日至 2012 年 8 月 1 日期间在英格兰三个地区的 26 家普通诊所至少 40 岁的患者。参与者完成了最多 12 个案例中的 3 个（每个肺癌、胰腺癌和结直肠癌各 4 个），案例是随机分配的。案例概述了一系列症状、这些症状可能表明癌症的风险（1%、2%、5%或 10%）、相关的检测过程、可能的治疗、可能的其他诊断和如果确诊癌症的预后。根据案例中的信息，参与者被要求是否选择进行诊断性检查。
3469 名参与者完成了 6930 个案例。3052 名参与者（88%）在第一个案例中选择了进行检查。我们没有记录到任何有力证据表明，随着癌症风险增加 1%，参与者更有可能选择进行检查（比值比 [OR] 1·02，95%CI 0·99-1·06；p=0·189），尽管当单独分析结直肠癌时，风险与选择检查之间的关联很强（1·08，1·03-1·13；p=0·0001）。在多变量分析中，年龄在所有三种癌症模型中都有影响：60-69 岁的参与者比 40-59 岁的参与者更有可能选择进行检查，而 70 岁或以上的参与者则不太可能选择进行检查。与选择进行检查的可能性增加相关的其他变量包括到检测中心的旅行时间更短（结直肠癌和肺癌）、癌症家族史（结直肠癌和肺癌）和家庭收入更高（结直肠癌和胰腺癌）。
我们样本中的参与者清楚地表达了对所有风险水平的诊断性检测的偏好，并且个人希望在低于英国指南规定的风险水平下接受检测。在设计癌症途径时，特别是在初级保健中，应考虑到这种意愿。公众对我们研究的参与应鼓励全科医生让患者参与转诊决策。
英国国民健康保险制度应用研究计划拨款。
