Background:Reducing diagnostic delays in primary care by improving the assessment of symptoms associated with cancer could have significant impacts on cancer outcomes. Symptom risk assessment tools could improve the diagnostic assessment of patients with symptoms suggestive of cancer in primary care. We aimed to explore the use of a cancer risk tool, which implements the QCancer model, in consultations and its potential impact on clinical decision making.Methods:We implemented an exploratory ‘action design' method with 15 general practitioners (GPs) from Victoria, Australia. General practitioners applied the risk tool in simulated consultations, conducted semi-structured interviews based on the normalisation process theory and explored issues relating to implementation of the tool.Results:The risk tool was perceived as being potentially useful for patients with complex histories. More experienced GPs were distrustful of the risk output, especially when it conflicted with their clinical judgement. Variable interpretation of symptoms meant that there was significant variation in risk assessment. When a risk output was high, GPs were confronted with numerical risk outputs creating challenges in consultation.Conclusions:Significant barriers to implementing electronic cancer risk assessment tools in consultation could limit their uptake. These relate not only to the design and integration of the tool but also to variation in interpretation of clinical histories, and therefore variable risk outputs and strong beliefs in personal clinical intuition.
PURPOSEWe conducted this review to identify published randomized controlled trials (RCTs) of cancer risk assessment tools used in primary care and to determine their impact on clinical utility (clinicians), screening uptake (patients), and psychosocial outcomes (patients). METHODSWe searched EMBASE, PubMed and the Cochrane databases for RCTs of cancer risk assessment tools in primary care up to May 2014. Only studies set in primary care, with patients eligible for screening, and English-language articles were included. RESULTSThe review included 11 trials of 7 risk tools. The trials were heterogeneous with respect to type of tool that was used, type(s) of cancer assessed, and outcomes measured. Evidence suggested risk tools improved patient risk perception, knowledge, and screening intentions, but not necessarily screening behavior. Overall, uptake of a tool was greater if initiated by patients, if used by a dedicated clinician, and when combined with decision support. There was no increase in cancer worry. Health promotion messages within the tool had positive effects on behavior change. Trials were limited by low-recruitment uptake, and the heterogeneity of the findings necessitated a narrative review rather than a meta-analysis.CONCLUSIONS Risk tools may increase intentions to have cancer screening, but additional interventions at the clinician or health system levels may be needed to increase risk-appropriate cancer screening behavior. INTRODUCTIONC ancer screening programs have been introduced in many countries for breast, 1 colorectal, 2 and cervical 3 cancer. With the growing recognition of the potential harms from population-based cancer screening programs, 4 risk-stratified screening is being proposed as a way of reducing harm and focusing on populations at higher risk of cancer. This concept can also be applied to primary preventive measures, especially as the evidence to support chemoprevention for common cancers such as breast and colorectal builds. 5,6 If risk-stratified cancer prevention is to be implemented, it requires risk assessment tools that can be used in primary care to identify those most likely to benefit from tailored prevention. 7 Cancer risk prediction models, based on epidemiologic data, calculate an individual's likelihood of developing cancer, identify an individual's risk of carrying a genetic mutation for a specific cancer (eg, BRCA 1 or BRCA 2), or both. 8,9 Newer risk models are beginning to incorporate genomic profiles and environmental exposures, 10 a trend that is likely to grow with the movement toward precision medicine.11 Risk assessment tools facilitate the translation of these risk models to estimate an individual's likelihood of developing different cancers by assessing the combination of risk factors including genetic, environmental 12,13 Primary care has an important role in the delivery of cancer screening programs and can increase screening uptake.18 Successful implementation of risk assessment tools into primary care is needed if risk-stratified cancer p...
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