Title: Supporting clinical decision making in patients with symptoms of cancer and pre-existing health conditions.
Funder: Department of Health and Social Care

Abstract: BackgroundCancer is a leading cause of death in the UK; an excess of 5,000-10,000 lives are lost annually compared to the European average, most ascribed to diagnostic delay. Primary care is an important setting for targeted intervention for earlier cancer diagnosis, as most cases present with symptoms in the year before diagnosis. Comorbidities (long-term health conditions that coexist with another condition of interest) in patients with cancer are on the rise; more than 75% of people with cancer have at least one comorbidity. Many share common risk factors and clinical features with cancer, which presents a great challenge for general practitioners (GPs). GPs are supported by NICE guidance in identifying patients with suspected cancer, but the research behind that guidance (most of which was carried out in the host research group) does not take the influence of comorbidities into account. Evidence shows that patients with comorbidities and cancer are diagnosed later, and have significantly poorer survival, than those without comorbidities. Research is needed to improve and expedite cancer diagnosis in people with comorbidities. Aims This fellowship will 1) develop and validate a series of Risk Assessment Tools (cRATs) for patients with comorbidities and symptoms of possible cancer; 2) determine the impact of the cRATs on time to diagnosis for patients with comorbidities and cancer, and on the number of patients who would be identified as at risk of cancer by the cRATs; 3) model the impact of the cRATs on stage at diagnosis for patients with comorbidities and cancer. MethodsA series of case control studies will be used to develop the cRATs; these will be validated in English and Dutch primary care data. The impact of the cRATs on time to diagnosis, and the number of patients identifies as at risk of cancer, will be investigated with observational studies using electronic medical records. The impact of the cRATs on cancer stage at diagnosis will be investigated with advanced modelling techniques. Timelines for deliveryThis fellowship spans four years. The cRATs will be developed, validated, and published by the end of year 2, with the impact studies carried out over the final two years. Impact and disseminationFor patients who do harbour an undetected cancer, the potential impact is huge; earlier diagnosis; easier, cheaper, and more effective treatment options; and better survival. The extent of this impact will be quantified in the fellowship. Patients without cancer, and correctly identified as such, will benefit by avoiding unnecessary diagnostic investigation. As with any cancer detection strategy, there will be false negatives and false positives; this will also be assessed in the fellowship. Aside from the traditional academic routes to dissemination (high impact papers and conference presentations), my placement at the Department of Health will achieve further dissemination to policy makers. My PPI collaborators will co-create dissemination materials and activities for patients and the public.

Lay abstract: Background In the UK fewer people survive after being diagnosed with cancer than in similar European countries, partly because we diagnose cancer at a later stage - when it is more difficult to treat, manage, and cure. The NHS aims to increase the number of cancers diagnosed at an early stage and help more people survive for longer. Earlier diagnosis is particularly difficult in people with cancer who also have pre-existing long-term health conditions, known as 'comorbidities'. The symptoms of their comorbidities can mask cancer symptoms. Also, when they see their doctor, people with comorbidities might not have time to talk about symptoms that could be caused by cancer. The number of people with comorbidities is increasing every year. Now, most cases of cancer are diagnosed in people who have at least one long-term health condition. This is a challenge for diagnosis. Existing tools that help general practitioners (GPs) identify cancer do not take the effects of pre-existing health conditions into account. GPs are on the front line for diagnosing cancer, as most people with cancer see their family doctor with concerns about their health before they are diagnosed. Fellowship aimsIn this fellowship, I will develop Risk Assessment Tools (cRATs) that present the risk of cancer in individual patients with certain pre-existing health conditions, depending on their symptoms and their pre-existing health conditions. These can be used to helps GPs identify cancer. Three common diseases will be studies: high blood pressure, heart disease, and one further choice made with my patient collaborators. The cRATs will improve the chances that a GP will be able to tell a patient if they have cancer before it becomes too serious. I will test the cRATs to see how good they are at identifying cancer, and adjust them if necessary. I will also use mathematical techniques to understand what would happen to patients if these tools were being used in consultations between doctors and patients, and how many people would be affected. The fellowship sits alongside, and expands upon, a wider programme of work which has been funded by the National Institute for Health Research (NIHR) to address problems with diagnosing cancer in patients with long-term health conditions. In that programme, I am the lead researcher in the work package that will develop three more cRATs for patients with diabetes, lung disease, and obesity. Patient involvement I will recruit three patient collaborators to work with me throughout this fellowship. This will ensure the patient perspective is included in the research. The patient collaborators will have opportunities to carrying out some research. The patient collaborators will decide for themselves how they want to be involved. Dissemination This research will be published in journals and presented at conferences, to reach researchers and doctors. I will also undertake a research placement at the Department of Health to explore ways to get the findings to policy makers. My patient collaborators will co-create materials to communicate the findings to patients and the public. Use of findings When the cRATs identify a patient who may have cancer, the patient and their doctor will decide together what further tests are needed to find if cancer is present. cRATs have huge potential to improve earlier detection of cancer, for thousands of people each year. The outputs of this programme of research can be used across the UK and in other countries.

Research activity codes: 4.2 EVALUATION OF MARKERS AND TECHNOLOGIES
Health categories: CANCER AND NEOPLASMS