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Hajdarevic, S., Högberg, C., Marzo-Castillejo, M., Siliņa, V., Sawicka-Powierza, J., Esteva, M., . . . Harris, M. (2023). Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis: a qualitative study. BJGP Open, 7(4), Article ID BJGPO.2023.0029.
Öppna denna publikation i ny flik eller fönster >>Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis: a qualitative study
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2023 (Engelska)Ingår i: BJGP Open, E-ISSN 2398-3795, Vol. 7, nr 4, artikel-id BJGPO.2023.0029Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background: While primary care physicians (PCPs) play a key role in cancer detection, they can find cancer diagnosis challenging, and some patients have considerable delays between presentation and onward referral.

Aim: To explore European PCPs’ experiences and views on cases where they considered that they had been slow to think of, or act on, a possible cancer diagnosis.

Design & setting: A multicentre European qualitative study, based on an online survey with open-ended questions, asking PCPs for their narratives about cases when they had missed a diagnosis of cancer.

Method: Using maximum variation sampling, PCPs in 23 European countries were asked to describe what happened in a case where they were slow to think of a cancer diagnosis, and for their views on why it happened. Thematic analysis was used to analyse the data.

Results: A total of 158 PCPs completed the questionnaire. The main themes were as follows: patients’ descriptions did not suggest cancer; distracting factors reduced PCPs’ cancer suspicions; patients’ hesitancy delayed the diagnosis; system factors not facilitating timely diagnosis; PCPs felt that they had acted wrongly; and problems with communicating adequately.

Conclusion: The study identified six overarching themes that need to be addressed. Doing so should reduce morbidity and mortality in the small proportion of patients who have a significant, avoidable delay in their cancer diagnosis. The ‘Swiss cheese’ model of accident causation showed how the themes related to each other.

Ort, förlag, år, upplaga, sidor
Royal College of General Practitioners, 2023
Nyckelord
Primary health care, physicians, primary care, cancer, Europe, diagnostic errors, qualitative research
Nationell ämneskategori
Omvårdnad Cancer och onkologi
Identifikatorer
urn:nbn:se:umu:diva-214654 (URN)10.3399/bjgpo.2023.0029 (DOI)37380218 (PubMedID)2-s2.0-85180193308 (Scopus ID)
Tillgänglig från: 2023-09-22 Skapad: 2023-09-22 Senast uppdaterad: 2024-02-19Bibliografiskt granskad
Lööv, A., Högberg, C., Lilja, M., Theodorsson, E., Hellström, P., Metsini, A. & Olsson, L. (2022). Diagnostic accuracy for colorectal cancer of a quantitative faecal immunochemical test in symptomatic primary care patients: a study protocol. Diagnostic and prognostic research, 6(1), Article ID 16.
Öppna denna publikation i ny flik eller fönster >>Diagnostic accuracy for colorectal cancer of a quantitative faecal immunochemical test in symptomatic primary care patients: a study protocol
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2022 (Engelska)Ingår i: Diagnostic and prognostic research, ISSN 2397-7523, Vol. 6, nr 1, artikel-id 16Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

BACKGROUND: There is increasing evidence supporting the use of faecal immunochemical tests (FIT) in patients reporting symptoms associated with colorectal cancer (CRC), but most studies until now have focused on selected subjects already referred for investigation. We therefore set out to determine the accuracy and predictive values of FIT in a primary care population.

METHOD: A prospective, multicentre, single-gated comparative diagnostic study on quantitative FIT in patients aged 40 years and above presenting in primary care with symptoms associated with CRC will be conducted. Patients representing the whole spectrum of severity of such symptoms met with in primary care will be eligible and identified by GPs. Participants will answer a short form on symptoms during the last month. They will provide two faecal samples from two separate days. Analyses will be performed within 5 days (QuikRead go®, Aidian Oy). The analytical working range is 10-200 μg Hb/g faeces. Reference test will be linked to the Swedish Colorectal Cancer Registry up to 2 years after inclusion. Accuracy, area under ROC curves, and predictive values will be calculated for one FIT compared to the highest value of two FIT and at cutoff < 10, 10-14.9, 15-19.9 and ≥ 20 μg Hb/g faeces. Subgroup analyses will be conducted for patients with anaemia and those reporting rectal bleeding. A model-based cost-effectiveness analysis based on the clinical accuracy study will be performed. Based on previous literature, we hypothesized that the sensitivity of the highest value of two FIT at cutoff 10 μg Hb/g faeces will be 95% (95% CI + / - 15%). The prevalence of CRC in the study population was estimated to be 2%, and the rate of non-responders to be 1/6. In all, 3000 patients will be invited at 30 primary care centres.

DISCUSSION: This study will generate important clinical real-life structured data on accuracy and predictive values of FIT in the most critical population for work-up of CRC, i.e. patients presenting with at times ambiguous symptoms in primary care. It will help establish the role of FIT in this large group.

Ort, förlag, år, upplaga, sidor
BioMed Central (BMC), 2022
Nyckelord
Colorectal cancer, Diagnostic accuracy study, Primary care, Quantitative faecal immunochemical test, Sensitivity
Nationell ämneskategori
Cancer och onkologi Allmänmedicin
Identifikatorer
urn:nbn:se:umu:diva-205820 (URN)10.1186/s41512-022-00129-7 (DOI)35978403 (PubMedID)
Forskningsfinansiär
CancerfondenCancerforskningsfonden i NorrlandNyckelfonden
Tillgänglig från: 2023-03-20 Skapad: 2023-03-20 Senast uppdaterad: 2023-03-21Bibliografiskt granskad
Högberg, C., Cronberg, O., Thulesius, H., Lilja, M., Jansson, S. & Gunnarsson, U. (2022). Use of faecal immunochemical tests common in patients with suspected colorectal cancer but unrelated to travel distance to secondary care: a population-based study from Swedish primary care. Scandinavian Journal of Primary Health Care, 40(4), 459-465
Öppna denna publikation i ny flik eller fönster >>Use of faecal immunochemical tests common in patients with suspected colorectal cancer but unrelated to travel distance to secondary care: a population-based study from Swedish primary care
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2022 (Engelska)Ingår i: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 40, nr 4, s. 459-465Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background: Evidence is increasing for the use of faecal immunochemical tests (FITs) for occult blood as diagnostic tools when colorectal cancer can be suspected. FITs have been used for this purpose in Swedish primary care since around 2005 despite absence of supporting guidelines. To our knowledge, the extent of this use has not been studied.

Objective: To investigate the use of FITs as diagnostic tools, and if the use was related to patient age, sex and travel time from primary care to diagnostic facilities in secondary care. Design: Population-based retrospective study using data from electronic health records.

Setting and subjects: Patients ≥18 years that provided FITs in primary care in five Swedish health care regions during 2015. Driving times from their primary care centres to secondary care were calculated. Main outcome measures: The proportion of patients that provided FITs was calculated for each region, different age intervals and grouped driving times. Results: 18,913 patients provided FITs. The proportion of listed patients in the five regions that provided FITs increased with age: 0.86–1.2% for ages <65 years, 3.6–4.1% for ages 65–79 years and 3.8–6.1% for ages ≥80 years. Differences between the regions were small. There was no overall correlation between the proportion of patients that provided FITs and driving time to secondary care.

Conclusion: FITs were used extensively in Swedish primary care with a higher use in older age groups. There was no tendency towards a higher use of FITs at primary care centres with longer driving times to secondary care.Key Points Evidence is increasing for the use of faecal immunochemical tests (FITs) as diagnostic tools when colorectal cancer can be suspected. We investigated the use of FITs in Sweden. FITs were used extensively in primary care especially in older age groups. There were small differences in the use of FITs between five studied health care regions. There was no tendency towards a higher use of FITs at primary care centres with longer driving times to diagnostic facilities in secondary care.

Ort, förlag, år, upplaga, sidor
Taylor & Francis, 2022
Nyckelord
Colorectal cancer, faecal immunochemical tests, occult blood, primary health care, Sweden, travel time
Nationell ämneskategori
Hälso- och sjukvårdsorganisation, hälsopolitik och hälsoekonomi Allmänmedicin
Identifikatorer
urn:nbn:se:umu:diva-201350 (URN)10.1080/02813432.2022.2144934 (DOI)000884694400001 ()36380479 (PubMedID)2-s2.0-85142305087 (Scopus ID)
Tillgänglig från: 2022-12-14 Skapad: 2022-12-14 Senast uppdaterad: 2023-07-14Bibliografiskt granskad
Högberg, C., Gunnarsson, U., Jansson, S., Thulesius, H., Cronberg, O. & Lilja, M. (2020). Diagnosing colorectal cancer in primary care: cohort study in Sweden of qualitative faecal immunochemical tests, haemoglobin levels, and platelet counts. British Journal of General Practice, 70(701), e843-e851
Öppna denna publikation i ny flik eller fönster >>Diagnosing colorectal cancer in primary care: cohort study in Sweden of qualitative faecal immunochemical tests, haemoglobin levels, and platelet counts
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2020 (Engelska)Ingår i: British Journal of General Practice, ISSN 0960-1643, E-ISSN 1478-5242, Vol. 70, nr 701, s. e843-e851Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background: Colorectal cancer (CRC) diagnostics are challenging in primary care and reliable diagnostic aids are desired. Qualitative faecal immunochemical tests (FITs) have been used for suspected CRC in Sweden since the mid-2000s, but evidence regarding their effectiveness is scarce. Anaemia and thrombocytosis are both associated with CRC.

Aim: To evaluate the usefulness of qualitative FITs requested for symptomatic patients in primary care, alone and combined with findings of anaemia and thrombocytosis, in the diagnosis of CRC.

Design and setting: A population-based cohort study using electronic health records and data from the Swedish Cancer Register, covering five Swedish regions.

Method: Patients aged ≥18 years in the five regions who had provided FITs requested by primary care practitioners from 1 January 2015 to 31 December 2015 were identified. FIT and blood-count data were registered and all CRC diagnoses made within 2 years were retrieved. Diagnostic measurements were calculated.

Results: In total, 15 789 patients provided FITs (four different brands); of these patients, 304 were later diagnosed with CRC. Haemoglobin levels were available for 13 863 patients, and platelet counts for 10 973 patients. Calculated for the different FIT brands only, the sensitivities for CRC were 81.6%–100%; specificities 65.7%–79.5%; positive predictive values 4.7%–8.1%; and negative predictive values 99.5%–100%. Calculated for the finding of either a positive FIT or anaemia, the sensitivities increased to 88.9–100%. Adding thrombocytosis did not further increase the diagnostic performance.

Conclusion: Qualitative FITs requested in primary care seem to be useful as rule-in tests for referral when CRC is suspected. A negative FIT and no anaemia indicate a low risk of CRC.

Ort, förlag, år, upplaga, sidor
London: Royal College of General Practitioners, 2020
Nyckelord
anaemia, colorectal neoplasms, general practice, occult blood, thrombocytosis
Nationell ämneskategori
Cancer och onkologi
Identifikatorer
urn:nbn:se:umu:diva-177340 (URN)10.3399/bjgp20X713465 (DOI)000594101500001 ()33139332 (PubMedID)2-s2.0-85096946830 (Scopus ID)
Forskningsfinansiär
Cancerforskningsfonden i Norrland, LP17-2168
Anmärkning

This study was supported by unrestricted grants from Region Jämtland Härjedalen (reference numbers: JLL-758141 and JLL-865141), Region Kronoberg (2019-04-19:2), the Cancer Research Foundation in Northern Sweden (LP17-2168), and Jämtland’s Cancer and Nursing Foundation (146/2018 and 2131/2017).

Tillgänglig från: 2020-12-07 Skapad: 2020-12-07 Senast uppdaterad: 2023-03-24Bibliografiskt granskad
Högberg, C., Karling, P., Rutegård, J. & Lilja, M. (2020). Patient-reported and doctor-reported symptoms when faecal immunochemical tests are requested in primary care in the diagnosis of colorectal cancer and inflammatory bowel disease: a prospective study. BMC Family Practice, 21(1), Article ID 129.
Öppna denna publikation i ny flik eller fönster >>Patient-reported and doctor-reported symptoms when faecal immunochemical tests are requested in primary care in the diagnosis of colorectal cancer and inflammatory bowel disease: a prospective study
2020 (Engelska)Ingår i: BMC Family Practice, E-ISSN 1471-2296, Vol. 21, nr 1, artikel-id 129Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background: Rectal bleeding and a change in bowel habits are considered to be alarm symptoms for colorectal cancer and they are also common symptoms for inflammatory bowel disease. However, most patients with these symptoms do not have any of these diseases. Faecal immunochemical tests (FITs) for haemoglobin are used as triage tests in Sweden and other countries but little is known about the symptoms patients have when FITs are requested.

Objective: Firstly, to determine patients’ symptoms when FITs are used as triage tests in primary care and whether doctors record the symptoms that patients report, and secondly to evaluate the association between symptoms, FIT results and possible prediction of colorectal cancer or inflammatory bowel disease.

Methods and materials: This prospective study included 364 consecutive patients for whom primary care doctors requested a FIT. Questionnaires including gastrointestinal symptoms were completed by patients and doctors.

Results: Concordance between symptoms reported from patients and doctors was low. Rectal bleeding was recorded by 43.5% of patients versus 25.6% of doctors, FITs were negative in 58.3 and 52.7% of these cases respectively. The positive predictive value (PPV) of rectal bleeding recorded by patients for colorectal cancer or inflammatory bowel disease was 9.9% (95% confidence interval [CI] 5.2–14.7); for rectal bleeding combined with a FIT the PPV was 22.6% (95% CI 12.2–33.0) and the negative predictive value (NPV) was 98.9% (95% CI 96.7–100). For patient-recorded change in bowel habits the PPV was 6.1% (95% CI 2.4–9.8); for change in bowel habits combined with a FIT the PPV was 18.2% (95% CI 9.1–30.9) and the NPV 100% (95% CI 90.3–100).

Conclusions: Doctors should be aware that, during consultations, they do not record all symptoms experienced by patients. FITs requested in primary care, when found positive, may potentially be of help in prioritising referrals, also when patients present with rectal bleeding or change in bowel habits.

Ort, förlag, år, upplaga, sidor
BioMed Central, 2020
Nyckelord
Colorectal neoplasms, Faecal immunochemical test, Gastrointestinal symptoms, Occult blood, Primary care, Rectal bleeding
Nationell ämneskategori
Gastroenterologi Allmänmedicin
Identifikatorer
urn:nbn:se:umu:diva-173759 (URN)10.1186/s12875-020-01194-x (DOI)000547011400006 ()32611307 (PubMedID)2-s2.0-85087470983 (Scopus ID)
Forskningsfinansiär
Visare Norr, 467541Visare Norr, 557151
Tillgänglig från: 2020-07-31 Skapad: 2020-07-31 Senast uppdaterad: 2023-03-24Bibliografiskt granskad
Högberg, C., Gunnarsson, U., Cronberg, O., Thulesius, H., Lilja, M. & Jansson, S. (2020). Qualitative faecal immunochemical tests (FITs) for diagnosing colorectal cancer in patients with histories of rectal bleeding in primary care: a cohort study. International Journal of Colorectal Disease, 35(11), 2035-2040
Öppna denna publikation i ny flik eller fönster >>Qualitative faecal immunochemical tests (FITs) for diagnosing colorectal cancer in patients with histories of rectal bleeding in primary care: a cohort study
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2020 (Engelska)Ingår i: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 35, nr 11, s. 2035-2040Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

BACKGROUND: Rectal bleeding is considered an alarm symptom for colorectal cancer (CRC) but it is common and mostly caused by benign conditions. Qualitative faecal immunochemical tests (FITs) for occult blood have been used as diagnostic aids for many years in Sweden when CRC is suspected. The study aimed to evaluate the usefulness of FITs requested by primary care physicians for patients with and without histories of rectal bleeding, in the diagnosis of CRC.

METHODS: Results of all FITs requested in primary care for symptomatic patients in the Örebro region during 2015 were retrieved. Data on each patient's history of rectal bleeding was gathered from electronic health records. Patients diagnosed with CRC within 2 years were identified from the Swedish Cancer Register. The analysis focused on three-sample FITs, the customary FIT in Sweden.

RESULTS: A total of 4232 patients provided three-sample FITs. Information about the presence/absence of rectal bleeding was available for 2027 patients, of which 59 were diagnosed with CRC. For 606 patients with the presence of rectal bleeding, the FIT showed sensitivity 96.2%, specificity 60.2%, positive predictive value 9.8% (95% CI 6.1-13.4) and negative predictive value 99.7% (95% CI 99.2-100) for CRC. For 1421 patients without rectal bleeding, the corresponding figures were 100%, 73.6%, 8.3% (95% CI 5.6-10.9) and 100% (95% CI 99.6-100).

CONCLUSION: The diagnostic performance of a qualitative three-sample FIT provided by symptomatic patients in primary care was similar for those with and without a history of rectal bleeding. FITs seem useful for prioritising patients also with rectal bleeding for further investigation.

Ort, förlag, år, upplaga, sidor
Springer, 2020
Nyckelord
Colorectal neoplasms, Faecal immunochemical tests, Occult blood, Primary health care, Rectal bleeding
Nationell ämneskategori
Cancer och onkologi
Identifikatorer
urn:nbn:se:umu:diva-173259 (URN)10.1007/s00384-020-03672-1 (DOI)000544184800001 ()32602056 (PubMedID)2-s2.0-85087126851 (Scopus ID)
Forskningsfinansiär
Cancerforskningsfonden i Norrland, LP 17-2168, LP 20-2231
Anmärkning

Grant supportJLL-758141, JLL-865141, JLL-930237/Region Jämtland HärjedalenLP 17-2168, LP 20-2231/Cancer Research Foundation in Northern Sweden

Tillgänglig från: 2020-07-01 Skapad: 2020-07-01 Senast uppdaterad: 2023-03-23Bibliografiskt granskad
Högberg, C., Karling, P., Rutegård, J. & Lilja, M. (2017). Diagnosing colorectal cancer and inflammatory bowel disease in primary care: The usefulness of tests for faecal haemoglobin, faecal calprotectin, anaemia and iron deficiency: A prospective study. Scandinavian Journal of Gastroenterology, 52(1), 69-75
Öppna denna publikation i ny flik eller fönster >>Diagnosing colorectal cancer and inflammatory bowel disease in primary care: The usefulness of tests for faecal haemoglobin, faecal calprotectin, anaemia and iron deficiency: A prospective study
2017 (Engelska)Ingår i: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 52, nr 1, s. 69-75Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

OBJECTIVE: Abdominal complaints are common reasons to consult primary care but they are seldom caused by colorectal cancer (CRC), high-risk adenomas (HRAs), or inflammatory bowel disease (IBD). Reliable diagnostic aids would be helpful in deciding which patients to refer for bowel imaging. Our aim was to assess the value of a faecal immunochemical test (FIT) and a faecal calprotectin (FC) test in detecting CRC, HRAs and IBD in primary care, and the value of combining these tests with anaemia and iron-deficiency tests.

MATERIALS AND METHODS: This prospective study included 373 consecutive patients that received a FIT or a FC test ordered by a primary care physician. We collected samples for FITs, FC tests, full blood counts and iron-deficiency tests. Physicians were instructed to refer patients with a positive FIT or FC test (cut-off ≥100μg/g) for bowel imaging. The patients' presenting symptoms were recorded. Patients were followed for 2 years.

RESULTS: The best test for detecting CRC and IBD was the combination of the FIT and haemoglobin concentration. This test had a sensitivity, specificity, positive predictive value and negative predictive value of 100%, 61.7%, 11.7% and 100%, respectively. The FIT detected a significantly larger proportion of CRC, HRAs and IBD than the FC test (0.92 versus 0.46, 95% confidence interval 0.22-0.67).

CONCLUSION: A negative FIT combined with a normal haemoglobin concentration could rule out CRC and IBD with a high degree of safety. This could be useful in prioritising referrals for bowel imaging from primary care.

Nyckelord
Anaemia, faecal calprotectin, colorectal cancer, faecal immunochemical test, inflammatory bowel disease, occult blood, primary care
Nationell ämneskategori
Gastroenterologi
Identifikatorer
urn:nbn:se:umu:diva-128594 (URN)10.1080/00365521.2016.1228120 (DOI)000392486600013 ()27623716 (PubMedID)2-s2.0-84987641571 (Scopus ID)
Tillgänglig från: 2016-12-07 Skapad: 2016-12-07 Senast uppdaterad: 2023-03-23Bibliografiskt granskad
Högberg, C. (2017). Diagnosing colorectal cancer in primary care: the value of symptoms, faecal immunochemical tests, faecal calprotectin and anaemia. (Doctoral dissertation). Umeå: Umeå Universitet
Öppna denna publikation i ny flik eller fönster >>Diagnosing colorectal cancer in primary care: the value of symptoms, faecal immunochemical tests, faecal calprotectin and anaemia
2017 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

Background: Colorectal cancer (CRC) is the third most common cancer in men and the second most common in women worldwide. Adenomas can be precursors to CRC, and inflammatory bowel disease (IBD) can present with the same symptoms as CRC. The majority of patients with CRC initially consult primary care. Symptoms associated with CRC are also common among primary care patients, but seldom caused by any significant disease. Reliable diagnostic aids would be helpful in deciding which patients to refer. Faecal immunochemical tests (FITs) are commonly used for this purpose in primary care in Sweden, but there is little evidence to support this use. Faecal calprotectin (FC) has been suggested as an additional test.

Aim: To explore how doctors in primary care investigate patients with suspected CRC, the value of FITs, symptoms and presence of anaemia in diagnosing CRC and adenomas in primary care, and whether FC tests could contribute to diagnosis.

Methods: Three studies (1-3) were carried out in Region Jämtland Härjedalen, Sweden. There was no screening programme for CRC. We used a point of care qualitative dip-stick 3-sample FIT with a cut-off of 25-50μg haemoglobin/g faeces, and a calprotectin enzyme-linked immunosorbent assay (ELISA) test with a cut-off of 100 μg/g faeces. 1: A retrospective, population-based study including all patients diagnosed with CRC or adenomas with high-grade dysplasia (HGD) during the period 2005-2009 that initially consulted primary care. Symptoms, FIT results, anaemia and time to diagnosis were retrieved from medical records. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated from FIT results at the region’s health centres 2008- 2009. (Paper I.) 2: A prospective cohort study including consecutive patients where primary care doctors requested FITs and/or FC tests, at four health centres, from 30 Jan 2013 to 31 May 2014. FITs, FC tests, haemoglobin and iron deficiency tests were analysed; patients and doctors answered questionnaires about symptoms. Patients were examined with bowel imaging or followed for two years. Findings of CRC, adenomas with HGD, adenomas with low grade dysplasia (LGD) ≥1 cm and IBD were registered. (Papers II and III.) 3: A qualitative study of interviews with eleven primary care doctors. We explored what made them suspect CRC, and their practices regarding investigation and referral with particular attention to their use of FITs. Qualitative content analysis with an inductive approach was used for the analysis. (Paper IV.)

Results: 1: Paper I: Of 495 patients 323 (65.3%) started the investigation in primary care. FITs were analysed in 215. In 23 cases with CRC, FITs were negative; 15 (65.2%) had anaemia. In 33 cases with CRC, FITs were performed due to asymptomatic anaemia; 10 (30.3%) had negative FITs. The time from start of investigation, to the diagnosis of CRC or adenomas with HGD, was significantly longer for patients with negative FITs.

2: 377 patients (9 diagnosed with CRC, 10 with IBD) were included. Paper II: Concordance of positive answers about symptoms from patients and doctors was generally low. Rectal bleeding (recorded by 43.5% of patients and 25.6% of doctors) was the only symptom related to CRC and IBD. The FIT showed a better PPV than rectal bleeding for CRC and IBD. When patients recorded rectal bleeding, the FIT had a PPV of 22.6% and a NPV of 98.9% for CRC and IBD. Paper III: The best test for detecting CRC and IBD was the combination of a positive FIT and/or anaemia with a sensitivity, specificity, PPV and NPV of 100%, 61.7%, 11.7% and 100% respectively. The FC test had no additional value to the FIT alone. The sensitivity, specificity, PPV and NPV of the FIT for CRC in study 1 was estimated at 88.4%, 73.3%, 6.2% and 99.7% respectively. In study 2, corresponding figures were 88.9%, 67.4%, 6.3% and 99.6% respectively.

3: Paper IV: We identified four categories: “Careful listening – with awareness of the pit-falls”, “tests can help – the FIT can also complicate the diagnosis”, “to refer or not to refer – safety margins are necessary”, and “growing more confident – but also more humble”. All doctors had found their own way to handle FIT results in the absence of guidelines.

Conclusion: The diagnostic process when suspecting CRC can be described as navigating uncertain waters with safety margins. FITs were often used by primary care doctors but with considerable variations in interpretation and handling of results. Rectal bleeding was the only symptom related to CRC and IBD, but the FIT showed a better PPV than rectal bleeding. The combination of a negative FIT and no anaemia may be useful as a rule-out test when CRC is suspected in primary care, and this potentially also applies when patients present with rectal bleeding. Further studies are needed to confirm this and to determine the optimal FIT cut-off value for this use. 

Ort, förlag, år, upplaga, sidor
Umeå: Umeå Universitet, 2017. s. 69
Serie
Umeå University medical dissertations, ISSN 0346-6612 ; 1893
Nyckelord
colorectal cancer, faecal immunochemical tests, faecal calprotectin, anaemia, symptomatic patients, rectal bleeding, primary care
Nationell ämneskategori
Allmänmedicin Cancer och onkologi
Identifikatorer
urn:nbn:se:umu:diva-133628 (URN)978-91-7601-680-0 (ISBN)
Disputation
2017-05-19, Hörsalen Snäckan, Östersunds sjukhus, Östersund, 13:00 (Svenska)
Opponent
Handledare
Tillgänglig från: 2017-04-28 Skapad: 2017-04-18 Senast uppdaterad: 2018-06-09Bibliografiskt granskad
Högberg, C., Söderström, L. & Lilja, M. (2017). Faecal immunochemical tests for the diagnosis of symptomatic colorectal cancer in primary care: the benefit of more than one sample. Scandinavian Journal of Primary Health Care, 35(4), 369-372
Öppna denna publikation i ny flik eller fönster >>Faecal immunochemical tests for the diagnosis of symptomatic colorectal cancer in primary care: the benefit of more than one sample
2017 (Engelska)Ingår i: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 35, nr 4, s. 369-372Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Objective: Faecal immunochemical tests (FITs) are used to screen for colorectal cancer (CRC) and as diagnostic aids in symptomatic patients. However, the number of samples per FIT varies. It is unclear if there is any advantage to analyse multiple-sample FITs in symptomatic patients.

Design and setting: This is a post hoc analysis of a retrospective study that included all cases of CRC and adenomas with high-grade dysplasia (HGD) between 2005 and 2009 in the county of Jamtland, Sweden.

Subjects: All patients with CRC and adenomas with HGD that initially presented with symptoms to primary care and delivered FITs.

Main outcome measure: The likelihood of a positive FIT in cases of CRC and adenomas with HGD; when analysing one, two or three samples.

Results: Of 195 patients, 160 delivered three-sample FITs. Using the 139 cases in which at least one sample was positive, the likelihood of detecting a positive sample upon analysis of only one of the three samples was 0.91 (95% CI: 0.85-0.95), indicating that 13 positive cases may have been missed.

Conclusion: Use of a one-sample FIT instead of a three-sample FIT as a diagnostic aid may result in the missing of one tenth of symptomatic CRCs and adenomas with HGD.

Ort, förlag, år, upplaga, sidor
TAYLOR & FRANCIS LTD, 2017
Nyckelord
Colorectal neoplasms, faecal immunochemical test, number of faecal samples, occult blood, primary health care, symptomatic patients
Nationell ämneskategori
Cancer och onkologi
Identifikatorer
urn:nbn:se:umu:diva-143168 (URN)10.1080/02813432.2017.1397255 (DOI)000416735200010 ()29183266 (PubMedID)2-s2.0-85035747225 (Scopus ID)
Tillgänglig från: 2017-12-20 Skapad: 2017-12-20 Senast uppdaterad: 2023-03-24Bibliografiskt granskad
Högberg, C., Samuelsson, E., Lilja, M. & Fhärm, E. (2015). Could it be colorectal cancer?: general practitioners' use of the faecal occult blood test and decision making - a qualitative study. BMC Family Practice, 16(1), 153-161
Öppna denna publikation i ny flik eller fönster >>Could it be colorectal cancer?: general practitioners' use of the faecal occult blood test and decision making - a qualitative study
2015 (Engelska)Ingår i: BMC Family Practice, E-ISSN 1471-2296, Vol. 16, nr 1, s. 153-161Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

BACKGROUND: Abdominal complaints are common reasons for contacting primary care physicians, and it can be challenging for general practitioners (GPs) to identify patients with suspected colorectal cancer (CRC) for referral to secondary care. The immunochemical faecal occult blood test (iFOBT) is used as a diagnostic aid in primary care, but it is unclear how test results are interpreted. Studies show that negative tests are associated with a risk of delayed diagnosis of CRC and that some patients with positive tests are not investigated further. The aim of this study was to explore what makes GPs suspect CRC and to investigate their practices regarding investigation and referral, with special attention on the use of iFOBTs.

METHOD: Semi-structured individual interviews were conducted with eleven purposely selected GPs and registrars in Region Jämtland Härjedalen, Sweden, and subjected to qualitative content analysis.

RESULTS: In the analysis of the interviews four categories were identified that described what made the physicians suspect CRC and their practices. Careful listening-with awareness of the pitfalls: Attentive listening was described as essential, but there was a risk of being misled by, for example, the patient's own explanations. Tests can help-the iFOBT can also complicate the diagnosis: All physicians used iFOBTs to various extents. In the absence of guidelines, all found their own ways to interpret and act on the test results. To refer or not to refer-safety margins are necessary: Uncertainty was described as a part of everyday work and was handled in different ways. Common vague symptoms could be CRC and thus justified referral with safety margins. Growing more confident-but also more humble: With increasing experience, the GPs described becoming more confident in their decisions but they were also more cautious.

CONCLUSIONS: Listening carefully to the patient's history was essential. The iFOBT was frequently used as support, but there were considerable variations in the interpretation and handling of the results. The diagnostic process can be described as navigating uncertain waters with safety margins, while striving to keep the patient's best interests in mind. The iFOBT may be useful as a diagnostic aid in primary care, but more research and evidence-based guidelines are needed.

Ort, förlag, år, upplaga, sidor
BioMed Central, 2015
Nyckelord
Colorectal neoplasms, Diagnostic techniques and procedures, Occult blood, General practitioners, Primary health care, Qualitative research
Nationell ämneskategori
Allmänmedicin
Identifikatorer
urn:nbn:se:umu:diva-111201 (URN)10.1186/s12875-015-0371-1 (DOI)000363448700001 ()26498374 (PubMedID)2-s2.0-84945956000 (Scopus ID)
Anmärkning

This study was made possible by unrestricted grants from the Region Jämtland Härjedalen, the Regional Cancer Centre North, the Northern County Councils (Visare Norr), the Swedish Society of Medicine, the Cancer Research Foundation in Northern Sweden, and the Jämtland County Cancer and Nursing Fund.

Tillgänglig från: 2015-11-11 Skapad: 2015-11-09 Senast uppdaterad: 2023-03-23Bibliografiskt granskad
Organisationer
Identifikatorer
ORCID-id: ORCID iD iconorcid.org/0000-0001-8846-7681

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