Samuel William David Merriel

Ethnic inequalities in cancer incidence and outcomes are widespread, although the evidence available for people in the UK is more limited than in some other countries. This narrative review details the current evidence relating to ethnicity and differences in primary care cancer diagnosis in the UK and possible contributing factors. In general, cancer rates are higher for White individuals than for Asian or Black individuals in the UK, but for some cancer sites, the inverse is true. There are also differences in stage at diagnosis by ethnic group for some cancer sites. The routes through which cancer inequalities emerge are complex and difficult to attribute to a single patient characteristic. A variety of social, demographic, genetic and health service factors interact to influence outcomes. There is a wide research base demonstrating that Asian and Black individuals in the UK can experience a range of obstacles when interacting with health care services, including cancer investigations. Future research evidence and health service planning needs to include a diverse range of stakeholders in order to decrease cancer inequalities.

Background: Early cancer detection is aided by timely GP referrals. However, GP practices face pressures, particularly in deprived areas, which may be associated with diagnostic inequalities. Aim: To examine whether practice-level indicators of access, workforce, and population income deprivation were associated with diagnostic care indicators. Design and setting: Retrospective longitudinal study of 6,194 practices between 2015-2019 and 2022-2023. Method: Panel fixed-effects regression examined USC referral rates, USC PPV, USC sensitivity, and emergency presentation rates. Predictors were patient-reported access, GP workforce, and practice population income deprivation. Results: Per one SD increase within practices, (i) USC referral rates were lower with better appointment-making experience (-1.4%) and older average GP age (-3.5%), and higher with female GP share (+1.3%); GP FTE showed a small positive association (+0.7% to +0.8%). (ii) USC PPV increased with older average GP age (+2.2%). (iii) USC sensitivity was lower with older average GP age (-1.1%); emergency presentations showed limited association with access or workforce factors. Practices had higher emergency presentation rates when serving the most deprived rather than least deprived populations (+13.7%). There was little evidence that deprivation modified access and workforce associations. Average GP age was an exception: USC referral associations weakened from Q2 to Q5, USC PPV peaked at Q3, and USC sensitivity was significant in the most deprived quintile. Conclusion: Practice-level access and workforce factors were associated with USC referral activity. Persistent deprivation gaps in emergency presentation suggest value in monitoring practice-level USC referrals alongside their PPV and sensitivity, and practice-level burden of emergency presentations. How this fits in: USC referral rates vary widely between general practices, and previous studies link this variation to GP age, staffing, access, practice size, QOF achievement, and deprivation (1–3). Most evidence is cross-sectional, so it is unclear whether these factors explain stable differences between practices or changes within the same practice over time. We showed that access and workforce factors were associated mainly with referral volume, while deprivation was more strongly linked to practice-level burden of emergency presentation than to practice-level referral activity. Persistent deprivation gaps in emergency presentations, despite narrowing referral-rate gaps, suggest that equity efforts should look beyond referral volume alone.

Background Primary care is the main route to diagnosis for patients with prostate cancer, either following asymptomatic Prostate Specific Antigen (PSA) testing or investigating prostate-related symptoms. Whilst previous primary care studies suggest an association between symptoms and prostate cancer diagnosis, it remains unknown whether outcomes differ based on the presence or absence of symptoms. Aim To compare prostate cancer stage, grade, and mortality amongst symptomatic patients presenting to primary care with asymptomatic patients. Design and setting Retrospective cohort study using Clinical Practice Research Datalink (CPRD) Aurum. Included adult males aged 50 years and above with first presentation to primary care for coded lower urinary tract symptoms (LUTS), haematuria, or erectile dysfunction between 01/01/2011 and 31/12/2016 with up to two asymptomatic males matched by age, ethnicity, and GP practice. Method Main outcomes: Clinically significant prostate cancer (Gleason Grade Group ≥ 3); Early-stage prostate cancer; Cambridge Prognostic Group; prostate cancer mortality; all-cause mortality. Mixed effect logistic regression modelling was performed. Results 722,597 males were included (262,178 [36.3%] had coded symptoms). Mean age was 64.4 years (SD 9.76). 90.68% identified as White ethnicity. 12,297 new prostate cancer diagnoses within 24 months of index consultation (8,101 [65.88%] in symptomatic group). Clinically significant prostate cancer (Adjusted OR 1.14 95% CI 1.07, 1.23) was more likely in the symptomatic group. No difference was found in stage at diagnosis (aOR 1.02 95% CI 0.95,1.09). Conclusion Investigating symptomatic patients in primary care is more likely to detect clinically significant prostate cancer with no difference in stage at diagnosis.

Objectives: JIA affects ∼1–2/2000 children in the UK. Adults with inflammatory arthritis have ∼10% increased malignancy risk. JIA malignancy rates in Nordic data are 3–5/10 000 person years, with conflicting evidence on comparative risk. This study calculated malignancy rates in England of patients with JIA, vs matched controls and general population estimates. Methods: Using UK Primary Care data (CPRD) Aurum, this retrospective cohort study matched patients with JIA (diagnosed <16 years) 4-to-1 with non-JIA controls in England by birth year, gender and practice. Malignancies were identified from (i) NHS-linked hospitalization data and (ii) CPRD read codes. Exposure started at first JIA code date (or matched date for controls), 1 January 2000, or CPRD entry date, whichever was latest. Follow-up continued until end of follow-up of JIA-matched patient (for controls), end of CPRD follow-up, 31 December 2018, first malignancy or death, whichever was first. Cox-proportional hazards models compared malignancy rates. Standardized incidence ratios (SIRs) were calculated against ONS general population estimates by calendar year, age and gender. Results: A total of 3714 patients with JIA and 10 858 matched controls were identified; demographics were similar. Malignancy rates were 6.8 per 10 000 (95% CI: 4.4–10.7) in JIA and 3.1 per 10 000 person years (95% CI: 2.0–4.6) in controls; HR 2.2 (95% CI: 1.2–4.1). Both cohorts had raised SIRs compared with ONS general population estimates. Conclusions: This study found that those with JIA had a doubling risk for malignancies compared with the matched control population. However, it is important to note that malignancy in this JIA patient population is extremely rare with the absolute risk remaining very low.

Background: Prostate cancer is the second most common cancer in men worldwide. The Prostate Specific Antigen (PSA) blood test is widely used for prostate cancer detection but suffers from high false-positive rates (up to 80%). Genetic risk scores (GRS/PRS) have a similar performance to PSA testing in predicting prostate cancer risk. Method: GRS269 for prostate cancer was derived using 269 known risk variants and applied to UK Biobank participants. We assessed whether GRS269 improved power to predict prostate cancer diagnosis on top of age and pre-prostatectomy PSA level among 17,380 cases. Longitudinal PSA measurements were processed as median, first, last (most recent), and random PSA. All models were adjusted for age. Results: Across all PSA measures, the integrated model combining GRS269, PSA, and age consistently outperformed models using GRS269 or PSA alone. The highest predictive performance was observed using the last PSA value combined with GRS269 (AUC = 0.82, 95% CI: 0.81-0.82), compared to GRS269 alone (AUC = 0.70, 95% CI: 0.68-0.72) or PSA alone (AUC = 0.73, 95% CI: 0.70-0.75). Conclusion: Combining genetic risk with PSA and age improves prostate cancer risk prediction in a population setting. These findings highlight the potential clinical implications of integrating GRS will enhance early prostate cancer prediction pathways in primary care.

Background: Platelet count and C-reactive protein (CRP) are blood tests commonly used in primary care as part of diagnostic work up for symptomatic patients. Abnormal results of these tests can indicate an undetected cancer; however, it is not known whether the association between an abnormal test result and cancer risk varies by patient ethnicity. Methods: This cohort study used routinely collected primary and secondary health care records in England with linkage to national cancer registry data. Included patients had a record of ethnicity, no prior malignancy, a platelet count or CRP record between 1 ^st January 2010 and 31 ^st December 2017, and were aged 40 years or over at the time of that test. Ethnicity was categorised as White, Asian, Black, Other, and Mixed. Multi-level logistic regression models estimated cancer incidence within one-year of testing, adjusted for age, sex, comorbidities, BMI, deprivation, and year of test. Results: Among 4,948,342 patients with a platelet record and 811,559 with a CRP record, one-year cancer incidence was highest among White patients and lowest among Asian patients. Following a normal platelet count, cancer incidence was 1.3% (95% CI 1.3-1.3%) for White patients and 0.63% (0.60-0.66%) for Asian patients; following thrombocytosis, incidence increased to 4.1% (4.0-4.2%) and 1.8% (1.5-2.0%), respectively. After a normal CRP result, cancer incidence was 1.5% (1.4-1.5%) for White patients and 0.79% (0.71-0.88%) for Asian patients, rising to 3.6% (3.5-3.7%) and 1.9% (1.7-2.2%) for a high CRP result, respectively. No significant interactions were found between ethnicity, blood test result, and overall cancer diagnosis, and similar diagnostic odds ratios (dOR) were observed across all ethnic groups. However, for colorectal cancer, Black patients with abnormal results showed higher diagnostic odds ratios (dOR) compared with White patients, relative to a normal result. The dOR for thrombocytosis was 11.1 (7.8-15.6) for Black patients versus 5.7 (5.4-6.0) for White patients (interaction p -value p -value=0.043). Conclusion: This large primary care study underscores the need for ethnically diverse cohorts when evaluating diagnostic tests to avoid widening healthcare inequalities.

Background: People with an intellectual disability (ID) are at increased risk of bowel cancer. However, evidence on their presenting symptoms, diagnostic pathways, treatments and survival remains limited. Methods: A matched cohort study was conducted using linked primary care (Clinical Practice Research Datalink), hospital, cancer, and mortality records. Outcomes included symptoms associated with bowel cancer, faecal immunochemical or faecal occult blood (FIT/FOB) testing, urgent suspected cancer (USC) referral, endoscopy, surgery, systemic anticancer therapy (SACT), and bowel cancer-specific mortality. Adjusted incidence rate ratios (aIRRs), risk ratios (aRRs), and hazard ratios (aHRs) were estimated using Poisson, modified Poisson and Cox regression. Results: A total of 111,034 individuals with an ID were matched to 1,964,420 comparators. ID was associated with increased risk of bowel cancer (aHR 1.30, 1.18-1.44), particularly before age 50 years (aRR 2.19, 1.68-2.85). People with an ID presented more frequently with symptoms associated with bowel cancer (aIRR 2.59, 2.53-2.65) but, following such symptoms, were less likely to undergo FIT/FOB testing (aRR 0.74, 0.67-0.83), USC referral (aRR 0.57, 0.52-0.62), endoscopy (aRR 0.45, 0.42-0.49), or receive a diagnosis within 56 days (aRR 0.52, 0.41-0.67). They were also less likely to be diagnosed via screening (aRR 0.27, 0.14-0.50) or USC referral (aRR 0.62, 0.50-0.76), and more likely to be diagnosed via emergency presentation (aRR 1.76, 1.52-2.02), on the date of death (aRR 5.08, 2.92-8.84), or with stage IV disease (aRR 1.25, 1.01-1.56). ID was associated with similar proportions receiving curative surgery for stage I-III disease (aRR 0.98, 0.79-1.19), but markedly lower proportions receiving SACT for stage IV (aRR 0.15, 0.05-0.46), and higher bowel cancer-specific mortality across all stages (aHR 2.00, 1.71-2.33). Conclusions: People with an ID experience worse outcomes across nearly all stages of the bowel cancer care pathway, including referral, investigation, treatment and survival. Earlier screening may be justified given the elevated risk in those under age 50 years.