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BackgroundPresenting to primary care with fatigue is associated with slightly increased cancer risk, although it is unknown how this varies in the presence of other ‘vague’ symptoms.AimTo quantify cancer risk in patients with fatigue who present with other ‘vague’ symptoms in the absence of ‘alarm’ symptoms for cancer.Design and settingCohort study of patients presenting in UK primary care with new-onset fatigue during 2007–2015, using Clinical Practice Research Datalink data linked to national cancer registration data.MethodPatients presenting with fatigue without co-occurring alarm symptoms or anaemia were identified, who were further characterised as having co-occurrence of 19 other ‘vague’ potential cancer symptoms. Sex- and age-specific 9-month cancer risk for each fatigue–vague symptom cohort were calculated.ResultsOf 285 382 patients presenting with new-onset fatigue, 84% (n= 239 846) did not have co-occurring alarm symptoms or anaemia. Of these, 38% (n= 90 828) presented with ≥1 of 19 vague symptoms for cancer. Cancer risk exceeded 3% in older males with fatigue combined with any of the vague symptoms studied. The age at which risk exceeded 3% was 59 years for fatigue–weight loss, 65 years for fatigue–abdominal pain, 67 years for fatigue–constipation, and 67 years for fatigue–other upper gastrointestinal symptoms. For females, risk exceeded 3% only in older patients with fatigue–weight loss (from 65 years), fatigue–abdominal pain (from 79 years), or fatigue–abdominal bloating (from 80 years).ConclusionIn the absence of alarm symptoms or anaemia, fatigue combined with specific vague presenting symptoms, alongside patient age and sex, can guide clinical decisions about referral for suspected cancer.

The COVID-19 infodemic is an overwhelming amount of information that has challenged pandemic communication and epidemic response. WHO has produced weekly infodemic insights reports to identify questions, concerns, information voids expressed and experienced by people online. Publicly available data was collected and categorized to a public health taxonomy to enable thematic analysis. Analysis showed three key periods of narrative volume peaks. Understanding how conversations change over time can help inform future infodemic preparedness and prevention planning.

The WHO Early AI-Supported Response with Social Listening (EARS) platform was developed to help inform infodemic response during the COVID-19 pandemic. There was continual monitoring and evaluation of the platform and feedback from end-users was sought on a continual basis. Iterations were made to the platform in response to user needs, including the introduction of new languages and countries, and additional features to better enable more fine-grained and rapid analysis and reporting. The platform demonstrates how a scalable, adaptable system can be iterated upon to continue to support those working in emergency preparedness and response.

Background The management of adults presenting with fatigue presents a diagnostic challenge, particularly regarding possible underlying cancer. Methods Using electronic health records, we examined cancer risk in patients presenting to primary care with new-onset fatigue in England during 2007–2013, compared to general population estimates. We examined variation by age, sex, deprivation, and time following presentation. Findings Of 250,606 patients presenting with fatigue, 12-month cancer risk exceeded 3% in men aged 65 and over and women aged 80 and over, and 6% in men aged 80 and over. Nearly half (47%) of cancers were diagnosed within 3 months from first fatigue presentation. Site-specific cancer risk was higher than the general population for most cancers studied, with greatest relative increases for leukaemia, pancreatic and brain cancers. Conclusions In older patients, new-onset fatigue is associated with cancer risk exceeding current thresholds for urgent specialist referral. Future research should consider how risk is modified by the presence or absence of other signs and symptoms. Excess cancer risk wanes rapidly after 3 months, which could inform the duration of a ‘safety-netting’ period. Fatigue presentation is not strongly predictive of any single cancer, although certain cancers are over-represented; this knowledge can help prioritise diagnostic strategies.

Background: Investigating changes in pre-diagnostic healthcare utilisation can help identify how much earlier conditions could be diagnosed. Such ‘diagnostic windows’ are established for cancer but remain relatively unexplored for non-neoplastic conditions. Aim: To extract evidence on the presence and length of diagnostic windows for non-neoplastic conditions. Design and setting: Systematic review of studies of pre-diagnostic healthcare utilisation. Method: A search strategy was developed to identify relevant studies from PubMed and Connected Papers. Data was extracted on pre-diagnostic healthcare use and evidence of diagnostic window presence and length was assessed. Results: Of 4,340 studies screened, 27 were included, covering 17 non-neoplastic conditions, including both chronic (e.g., Parkinson’s disease) and acute conditions (e.g., stroke). Pre-diagnostic healthcare events included primary care encounters and presentations with relevant symptoms. For 9 conditions, sufficient evidence to determine diagnostic window presence and length was available, ranging from 28 days (herpes simplex encephalitis) to 9 years (ulcerative colitis). For the remaining conditions, diagnostic windows were likely to be present, but insufficient study duration was often a barrier to robustly determining their length. Conclusion: Evidence of changing healthcare use before diagnosis exists for many non-neoplastic conditions, establishing that early diagnosis is possible, in principle. In particular, some conditions, such as coeliac disease, may be detectable in certain ways more than a decade earlier than they are currently diagnosed. Further research is required to accurately estimate diagnostic windows, determine how much earlier diagnosis may be possible, and how this might be achieved.

Background The aim of this work was to develop a National Evaluation Framework to facilitate the standardization of delivery, quality, reporting, and evaluation of diabetes education and support programs delivered throughout Australia through the National Diabetes Services Scheme (NDSS). The NDSS is funded by the Australian Government, and provides access to diabetes information, education, support, and subsidized product across diverse settings in each state and territory of Australia through seven independent service-providers. This article reports the approach undertaken to develop the Framework. Methods A participatory approach was undertaken, focused on adopting nationally consistent outcomes and indicators, nominating objectives and measurement tools, specifying evaluation processes, and developing quality standards. Existing programs were classified based on related, overarching indicators enabling the adoption of a tiered system of evaluation. Results Two outcomes (i.e., improved clinical, reduced cost) and four indicators (i.e., improved knowledge and understanding, self-management, self-determination, psychosocial adjustment) were adopted from the Eigenmann and Colagiuri national consensus position statement for diabetes education. This allowed for the identification of objectives (i.e., improved empowerment, reduced distress, autonomy supportive program delivery, consumer satisfaction) and related measurement instruments. Programs were categorized as comprehensive, topic-specific, or basic education, with comprehensive programs allocated to receive the highest-level of evaluation. Eight quality standards were developed, with existing programs tested against those standards. Based on the results of testing, two comprehensive (OzDAFNE for people with type 1 diabetes, DESMOND for people with type 2 diabetes), and eight topic-specific (CarbSmart, ShopSmart, MonitorSmart, FootSmart, MedSmart, Living with Insulin, Insulin Pump Workshop, Ready Set Go – Let’s Move) structured diabetes self-management education and support programs were nominated for national delivery. Conclusions The National Evaluation Framework has facilitated consistency of program quality, delivery, and evaluation of programs delivered by multiple service providers across diverse contexts. The Framework could be applied by other service providers who facilitate multiple diabetes education and support programs and could be adapted for use in other chronic disease populations where education and support are indicated.

Background It has been proposed that changes in healthcare use before cancer diagnosis could signal opportunities for quicker detection, but systematic appreciation of such evidence is lacking. We reviewed studies examining pre-diagnostic changes in healthcare utilisation (e.g. rates of GP or hospital consultations, prescriptions or diagnostic tests) among patients subsequently diagnosed with cancer. Methods We identified studies through Pubmed searches complemented by expert elicitation. We extracted information on the earliest time point when diagnosis could have been possible for at least some cancers, together with variation in the length of such ‘diagnostic windows’ by tumour and patient characteristics. Results Across twenty-eight studies, changes in healthcare use were observable at least six months pre-diagnosis for many common cancers, and potentially even earlier for colorectal cancer, multiple myeloma and brain tumours. Early changes were also identified for brain and colon cancer sub-sites. Conclusion Changing healthcare utilisation patterns before diagnosis indicate that future improvements in diagnostic technologies or services could help to shorten diagnostic intervals for cancer. There is greatest potential for quicker diagnosis for certain cancer types and patient groups, which can inform priorities for the development of decision support tools., Highlights • Emerging research has found that healthcare use changes months before eventual diagnosis of cancer. • This could identify which tumour or patient groups could be diagnosed sooner, and how much sooner. • Our review confirms that patients’ healthcare use changes at least six months before diagnosis for many common cancers. • Some studies suggested that patients with myeloma, brain tumours, or colorectal cancers could be diagnosed even sooner.

ObjectivesCancer stage at diagnosis is a determinant of treatment options and survival. Previous research has shown differences in barriers to presentation with cancer between ethnic groups. The completeness and quality of cancer stage and ethnicity data has improved markedly over recent years in England, allowing for comparison of stage distributions at diagnosis between ethnic groups. This study aimed to assess relationships between ethnic group and two outcomes: unknown stage cancer and late stage (stages 3 and 4) cancer, after adjustment for confounders.Design and settingA retrospective secondary data analysis using data from NHS Digital’s National Cancer Registration and Analysis Service and Hospital Episode Statistics records from 2012 to 2016.ParticipantsThis study analysed newly diagnosed breast, colon, non-small cell lung cancer (NSCLC), ovary, prostate and uterine cancers in white British, Caribbean, African, Chinese and Asian patients aged 15–99 in England.ResultsCaribbean, African and Asian women with breast or ovarian cancer, Caribbean and African women with uterine or colon cancer, Caribbean women with NSCLC and Caribbean men with colon cancer had increased odds of late-stage disease at diagnosis compared with the white British cohort. In contrast, Caribbean and African men with prostate cancer had decreased odds of late-stage cancer. Where stage was known, there were variations in late-stage cancer by ethnic group.ConclusionsLow symptom awareness and barriers to presentation can cause delays, resulting in later stage diagnosis. Targeted intervention campaigns to help raise awareness of cancer signs and symptoms and the benefits of early diagnosis, along with removing barriers to appropriate referrals, could help to improve these inequalities.

ImportanceMental health morbidity (MHM) in patients presenting with possible cancer symptoms may be associated with prediagnostic care and time to cancer diagnosis.ObjectiveTo compare the length of intervals to cancer diagnosis by preexisting MHM status in patients who presented with symptoms of as-yet–undiagnosed colon cancer and evaluate their risk of emergency cancer diagnosis.Design, Setting, and ParticipantsThis cohort study was conducted using linked primary care data obtained from the population-based Clinical Practice Research Datalink, which includes primary care practices in England, linked to cancer registry and hospital data. Included participants were 3766 patients diagnosed with colon cancer between 2011 and 2015 presenting with cancer-relevant symptoms up to 24 months before their diagnosis. Data analysis was performed in January 2021 to April 2022.ExposuresMental health conditions recorded in primary care before cancer diagnosis, including anxiety, depression, schizophrenia, bipolar disorder, alcohol addiction, anorexia, and bulimia.Main Outcomes and MeasuresFast-track (also termed 2–week wait) specialist referral for investigations, time to colonoscopy and cancer diagnosis, and risk of emergency cancer diagnosis.ResultsAmong 3766 patients with colon cancer (median [IQR] age, 75 [65-82] years; 1911 [50.7%] women ), 623 patients [16.5%] had preexisting MHM recorded in primary care the year before cancer diagnosis, including 562 patients (14.9%) with preexisting anxiety or depression (accounting for 90.2% of patients with preexisting MHM) and 61 patients (1.6%) with other MHM; 3143 patients (83.5%) did not have MHM. Patients with MHM had records of red-flag symptoms or signs (ie, rectal bleeding, change in bowel habit, or anemia) in the 24 months before cancer diagnosis in a smaller proportion compared with patients without MHM (308 patients [49.4%] vs 1807 patients [57.5%]; P P = .01). Among 2115 patients with red-flag symptoms or signs, 308 patients with MHM experienced a more than 2-fold longer median (IQR) time to cancer diagnosis (326 [75-552] days vs 133 [47-422] days) and higher odds of emergency diagnosis (90 patients [29.2%] vs 327 patients [18.1%]; adjusted OR = 1.63; 95% CI, 1.23-2.24; P Conclusions and RelevanceThis study found that patients with MHM experienced large and prognostically consequential disparities in diagnostic care before a colon cancer diagnosis. These findings suggest that appropriate pathways and follow-up strategies after symptomatic presentation are needed for earlier cancer diagnoses and improved health outcomes in this large patient group.

Objective To quantify geographic variation in the use of lymphadenectomy and/or external-beam radiotherapy (EBRT) for endometrial cancer in England. Design Cross-sectional analysis of population-based data. Setting English cancer registry data, linked to chemotherapy, radiotherapy and hospital episodes statistics data. Population Twenty-two thousand four hundred and eighty-three women with endometrial cancer presenting without clinical or radiological evidence of distant metastatic spread, diagnosed in England from 2013 to 2016. Methods Proportions of patients receiving lymphadenectomy and/or EBRT were compared across 19 Cancer Alliances, to identify variations in clinical practice. Two separate logistic regression models assessed the impact on variation of adjustment for tumour and patient characteristics. Main outcome measures Receipt of lymphadenectomy, receipt of EBRT. Results There was substantial variation by Cancer Alliance in the adjusted proportion of women with endometrial cancer receiving lymphadenectomy (range 5% [95% CI 4-6%] to 48% [95% CI 45-52%]) and EBRT (range 10% [95% CI 7-12%] to 31% [95% CI 28-33%]), after adjusting for variation in pathological grade, age, comorbidities, deprivation, ethnic group and (EBRT only) FIGO stage. Different approaches to clinical practice were identified; (i) one Cancer Alliance had significantly higher than average lymphadenectomy and significantly lower than average EBRT use, (ii) three had high use of both lymphadenectomy and EBRT, (iii) one had low lymphadenectomy use and high EBRT use, and (iv) three had low use of both lymphadenectomy and EBRT. Conclusions Lymphadenectomy is probably used to triage for EBRT when lymphadenectomy use is high and EBRT use is low. This is probably a result of variation in local endometrial cancer management guidelines, suggesting that UK recommendations should be clarified. Tweetable abstract There is geographic variation in England in the use of lymphadenectomy and radiotherapy to treat endometrial cancer.

Many corporations use central data centers to avoid building and maintaining a separate data center and are finding and adopting new ways to make the data centers more energy efficient. This chapter provides a relevant summary of key concepts for understanding the complexity of data centers and the types and value of data centers. Its purpose is to provide information and understanding needed to manage massive data generated every day in the era of internet technology.

This study evaluated the impact of three interventions on uptake of the guaiac faecal occult blood test (gFOBT) in Greater London. The interventions were designed to improve awareness and understanding of the NHS Bowel Cancer Screening Programme (BCSP) and assist stool sampling. Logistic regression analysis of BCSP London data (N=205,541invitees aged 60–74) compared uptake at 12 weeks between intervention groups and a control group, sent kits as usual between January-April 2013 and January-April 2014. An endorsement flyer, included with gFOBT kits, had no impact on uptake (P=0.68). In 60–69-year-olds, there was a small but significant increase in modelled uptake amongst invitees sent both the flyer and a kit enhancement pack compared with controls (45.1% versus 43.4%,OR=1.07,P=0.047). In North East London, the flyer together with outdoor advertising was associated with a small but significant increase (45.6% versus 43.4%,OR=1.09,P=0.027). The largest increases were seen when all three interventions (flyer, pack, and advertising) were combined (49.5% versus 43.4%,OR=1.28,P<0.001). The increased uptake in the intervention groups was largest in “first-timers” and smaller amongst previous nonresponders and previously screened invitees.

Background The accessibility of open data means that ever more information is available, and it is important that the public and policy makers are able to make sense of it. Cancer Research UK developed an interactive website that places cancer data in a local context. The aim is to support decision makers and health professionals by highlighting areas for improvement at a local level. In addition to the interactive website, more in-depth analysis of general practice statistics provides general practitioners with better contextualisation of their local population. Methods The interactive website compiles publicly available local data for epidemiology, risk factors, and early diagnosis from a range of sources. Locations can be compared with the national average and with other areas on the basis of statistically significant differences. Local area statistics are also matched to parliamentary constituencies to engage policy makers. Data are converted to intelligence with recommended actions and presented by means of infographics. In addition, to support general practitioners, regression analysis of screening coverage data for general practices linked to practice demographic data provided a model to predict the expected screening coverage. Findings Local statistics show variation in risk factor prevalence and hence cancer burden and outcomes. These data inform evidence-based discussions with politicians as demonstrated by Members of Parliament referencing our analyses during parliamentary debates and in constituency press releases. Our user surveys indicate that 70% of health professionals using the interative website found the content relevant. Modelling of screening data shows that variation in screening coverage across general practices is explained to varying degrees by several patient population characteristics. The difference between the expected and actual coverage identified whether each practice achieved a higher or lower screening coverage than predicted. Users found the results helpful as demonstrated by requests for additional analysis and further partnership working. Interpretation This web resource enables local variations in data to be explored, highlighting the challenges and opportunities for improving outcomes locally, helping to raise cancer awareness, and identifying where action needs to be taken to reduce inequalities. Modelling results communicated with general practitioners face-to-face provides an improved indication of practice screening performance, and supports them in improving early diagnosis. Funding None.