Led by Dr Fiona Walter, this group focuses on factors contributing to the timely diagnosis and treatment of cancers with the aim of identifying cancers at less advanced stages in order to improve treatment outcomes.
The team includes: Prof Jon Emery, Senior Visiting Research Fellow & Winthrop Professor of General Practice at the Western University of Australia; Dr Helen Morris, Senior Research Associate; Dr Katie Mills, Research Associate; Dr Linda Birt, Research Associate; Dr Anna Barford, Research Associate; Dr Juliet Usher- Smith, Academic Clinical Fellow; Chantal Smeekens, PhD student; Debbie Hugh, Research Nurse; Kevin Houghton, Administrative Assistant.
Across the Cambridge Biomedical Campus we collaborate with a number of groups. In the University of Cambridge School of Clinical Medicine we worked recently with Dr Rebecca Fitzgerald, group lead in gastro-oesophageal cancer at the Department of Oncology’s Hutchinson MRC Research Centre.
Our research focuses on trials and the patient experience of the prevention and early diagnosis of serious conditions. To ensure results have the potential to inform clinical practice we collaborate with consultants, specialist nurses, research nurses and administrative staff in several NHS Hospital Trusts across the UK
We also have research collaborations with a number of universities across the UK, Europe and Australia.
The Cancer Prevention and Early Diagnosis Group have a long history of working collaboratively with Patient and Public Involvement (PPI) representatives. In accordance with best practice, there is PPI from the development of study design and set up stages, through to writing up and dissemination.
Research Interests, Projects and Publications
Early cancer diagnosis research has been characterised by a lack of precision and consistency. We have contributed to a range of initiatives aiming to improve the design and reporting of studies on early cancer diagnosis, including a theoretical framework based on previous models, and the Aarhus Statement which provides guidance on precise definitions and clearly identifiable measurement methods.
- Walter FM, Scott SE, Webster A, Emery JD. The Andersen Model of Total Patient Delay: a systematic review of its application in cancer diagnosis. Journal of Health Services Research & Policy 2012; doi:1258/jhsrp.2011.010113
- Scott SE, Walter FM, Webster A, Sutton S, Emery JD. The Model of Pathways to Treatment: conceptualisation and integration with existing theory. British Journal Health Psychology 2012; doi: 10.1111/j.2044-8287.2012.02077.x
- Weller D, Neal R, Rubin G, Walter FM, Emery J, Scott S, et al. The Aarhus Check-list: Improving design and reporting of studies on early cancer diagnosis. British Journal of Cancer 2012; doi:10.1038/bjc2012.68
- Scott S & Walter FM. Studying help-seeking for symptoms: The challenges of methods and models. Social and Personality Psychology Compass 2010; 4 (8): 531-547.
Patient awareness, symptom appraisal and presentation to primary care
These refined definitions and novel framework underpin a suite of studies currently investigating the patient pathway between recognition of first symptom, seeking help in primary care, and cancer diagnosis. In the NIHR-funded SYMPTOM Study (PIs Walter & Emery) we are using mixed methods approaches to identify the intervals between patients detecting symptoms of lung, colorectal and pancreatic cancer, and seeking help in primary care. Similarly, the Melanoma Interview Study (PI Walter), funded by Cancer Research UK, is a qualitative exploration of patients' symptom detection, help-seeking decisions, and experiences of the pathways to diagnosis, to characterise differences between people presenting with thinner and thicker melanomas with their consequent differences in outcomes. Both studies involve collaborations with primary care and specialist colleagues in other centres (Durham, Edinburgh), and the results from both studies will inform the development of rigorous, targeted interventions. The ASTRID study (PI Weller, Cancer Research UK/NAEDI funded) is in set-up and aims to develop a data collection tool to measure primary care delay in early cancer diagnosis research, based on the Aarhus Statement.
Primary care diagnosis
The use of novel diagnostic aids in primary care has been explored in 2 recent studies undertaken in collaboration with clinical colleagues from the Cambridge Biomedical Campus.
The MoleMate Trial (PI Walter), the first trial funded by the English School for Primary Care Research, showed that adding the MoleMate system (a hand-held scanner combining SIAscopy with a Primary Care Scoring Algorithm) to the systematic application of best practice guidelines did not improve the appropriateness of referral but both performed much better than reports of current practice in the management of pigmented skin lesions and potential melanomas.
- Walter FM, Morris HC, Humphrys E, Hall PN, Kinmonth A, Prevost A, Wilson EC, Burrows N, Norris P, Johnson M, Emery J. Management of suspicious pigmented lesions in primary care: randomised controlled trial of adding a SIAscopic diagnostic aid to best practice. British Medical Journal. In press
- Wilson ECF, Emery JD, Kinmonth AL, Prevost AT, Morris HC, Humphrys E, Hall PN, Bradshaw L, Burrows N, Norris P, Walls J, Johnson M, Walter FM. The cost-effectiveness of a novel diagnostic aid (the MoleMateTM system) for the management of pigmented skin lesions in primary care. Value in Health Care. In submission.
- Walter FM, Humphrys E, Tso S, Johnson M, Cohn S. Patient understanding of moles and skin cancer, and factors influencing presentation in primary care: a qualitative study. BMC Family Practice 2010; 11:62.
- Emery JD, Hunter J, Hall PN, Watson AJ, Hall PN, Moncrieff M, Walter FM. Accuracy of SIAscopy for pigmented skin lesions encountered in primary care: development and validation of a new diagnostic algorithm. BMC Dermatology 2010; 10:9.
- Watson T, Walter FM, Wood A, Morris H, Hall PN, Karner S, Emery J. Learning a novel technique to identify possible melanomas: are Australian general practitioners better than their UK colleagues? Asia Pacific Family Medicine 2009; 8:3.
- Wood A, Morris H, Emery J, Hall P, Cotton S, Prevost AT, Walter FM. Evaluation of the MoleMateTM training program for assessment of suspicious pigmented lesions in primary care. Informatics in Primary Care 2008; 16:41-50.
- Walter FM, Prevost AT, Vasconcelos J, Hall PN, Burrows, Morris HC, Emery JD. How useful is the seven-point checklist in general practice? A diagnostic accuracy study. Under review
The BEST study (PI Fitzgerald, MRC and NIHR funded) showed promising and acceptable performance of the primary care-based Cytosponge test for Barrett’s oesophagus, pre-cursor of oesophageal adenocarcinoma we are now analysing the psychosocial assessments of its use.
- Kadri SR, Lao-Sirieix P, O’Donovan M, Debiram I, Das M, Blazeby JM, Emery J, Boussioutas A, Morris H, Walter FM, Pharoah P, Hardwick RH, Fitzgerald RC. Acceptability and accuracy of non-endoscopic screening test for Barrett's oesophagus in primary care: cohort study. BMJ 2010; 341:c4372.
The NIHR-funded DISCOVERY programme (PI Hamilton, Peninsula Medical School, Deputy PI Walter) is a collaboration across 6 universities (Bristol, Cambridge, Cardiff, Durham, Exeter, Oxford) investigating the diagnosis of symptomatic cancer.
- Stapley S, Peters TJ, Neal R, Rose P, Walter FM, Hamilton W. The risk of pancreatic cancer in symptomatic patients in primary care: a large case-control study using electronic records. British Journal of Cancer 2012; doi: 10.1038/bjc.2012.190
- Shephard E, Stapley S, Neal RD, Rose P, Walter FM, Hamilton WT. Clinical features of bladder cancer in primary care. British Journal of General Practice 2012. In press
Screening using family history
As family history is a key risk factor for many cancers it can be used to identify people in primary care who may benefit from targeted primary prevention strategies.
The FAST study (PI Walter, funded by the NIHR’s Research for Patient Benefit programme) has developed and validated a short (6 item) family history screening tool for breast and colorectal cancer as well as ischaemic heart disease and T2 diabetes, which shows very good performance in men and women. The diagnostic characteristics and psychosocial assessments are currently being completed and written up.
- Walter FM & Emery JD. Genetic advances in medicine- has the promise been fulfilled in general practice? British Journal of General Practice 2012; 62(596):120-1.
- Emery JD, Walter FM, Ravine D. Family history: the neglected risk factor in disease prevention. Medical Journal of Australia 2010; 192 (12):677-8.
- Reid G, Walter FM, Brisbane J, Emery J. Family history questionnaires designed for clinical use: a systematic review. Public Health Genomics 2009;12:73–83.
Cancer survivors can experience physical, psychological and social consequences as a result of the disease and the treatments received, and the recent National Cancer Survivorship Initiative (NCSI) highlighted the range of issues which cancer survivors may face and the need for health professionals to organise care accordingly. The PROSPECTIV study (PI Watson, Oxford Brookes University; funder Prostate Cancer Charity) is a pilot randomized controlled trial of a nurse-led psycho-educational intervention delivered in primary care to prostate cancer survivors, set in Oxford and Cambridge, and due to start recruitment late summer 2012.
Early diagnosis and other conditions
Juliet Usher-Smith (Academic Clinical Fellow) has focused on the diagnosis of type 1 diabetes in children and improving the evidence base on which to develop an intervention to improve the timely diagnosis of the disease in children. This has included systematic reviews exploring the factors associated with diabetic ketoacidosis at diagnosis and the variations in frequency of diabetic ketoacidosis at diagnosis between countries, and a mixed methods exploration of the pathway to diagnosis of type 1diabetes in children from the perspective of the child, family and GP using interviews and a questionnaire study.
- Usher-Smith JA, Thompson M, Sharp SJ, Walter FM. Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review. British Medical Journal 2011; 343:d4092
- Usher-Smith JA, Thompson M, Ercole A, Walter FM. Variation between countries in the frequency of diabetic ketoacidosis at first presentation of type 1 diabetes in children: a systematic review. Under review
Collaboration with University of Western Australia
Jon Emery is Professor of General Practice at UWA where Fiona Walter is a Clinical Associate Professor. Their strong collaboration has led to the development of parallel programs of synergistic research on cancer in primary care. Examples of related research include:
- The Rural Cancer Initiative, a factorial cluster randomized trial of community and general practice interventions aimed at promoting earlier presentation and subsequent investigation of symptoms suggestive of common cancer.
- FAST-Australia, which has validated a similar family history screening questionnaire to FAST-UK in an Australian general practice population.
- BEST-Australia. In collaboration with Rebecca Fitzgerald and Alex Boussioutas we are conducting a validation and acceptability study of the BEST cytosponge in a general practice population in Melbourne.
- CHEST-Australia, in collaboration with Neil Campbell and Peter Murchie at Aberdeen University, we are testing a novel behavioural intervention aimed at promoting earlier help-seeking in people at increased risk of lung cancer.
- ProCare, in collaboration with researchers at the Peter MacCallum Cancer Centre in Melbourne, we are conducting a trial of a shared care model of follow-up designed to meet the unmet physical and psychosocial needs to men after treatment for prostate cancer. The outcome measures in this trial have informed selection of measures for the related PROSPECTIV study.