Journals Watch: Cancer, MI and type 2 diabetes

A review of research impacting primary care, covering cancer referrals, MI, and diabetes. By Dr Raj Thakkar

Patients with lung cancer were likely to have three or more GP consultations before hospital referral (Photograph: SPL)
Patients with lung cancer were likely to have three or more GP consultations before hospital referral (Photograph: SPL)

Number of GP consultations before cancer referral - Lancet Oncol 2012 doi:10.1016/S1470-2045(12)70041-4
Missing a cancer diagnosis is something GPs fear most. At the same time, the health economic climate means we use fewer diagnostic tests and refer to secondary care less readily. Additional factors contributing to a delay in referral may include GP behaviour, the nature of the cancer and when the patient presents.

This study used the National Cancer Patient Experience survey to understand why there is a variation in the number of consultations before referral. More than 40,000 people with cancer took part in the survey.

The study results are thought-provoking. Of patients who had at least three GP consultations before referral, 7.4% had breast cancer and 10.1%, melanoma, whereas 41.3% had pancreatic cancer and 50.6%, myeloma.

Compared to rectal cancer, those with stomach, lung, pancreatic cancers or myeloma were significantly more likely to have three or more GP consultations before referral. This may be partly due to the diagnostic process, such as ordering and reviewing blood, urine and radiographic tests. Those with breast, testicular and endometrial cancers were more likely to have had only one or two GP consultations, compared with those with rectal disease.

Three or more consultations were also more likely in women, young people and those from ethnic minorities. There may be plausible explanations for some of these results, but this study helps GPs to remain focused on what is important, the medicine.

Age, sex and MI symptoms
JAMA 2012; 307(8): 813-22

I carried out a survey several years ago on patients who had experienced an acute coronary syndrome (ACS) within the past five days. At least a quarter thought they had indigestion, rather than a cardiac cause for their symptoms.

Understanding the nuances of ACS presentation, particularly these days when classic ST elevation MI presentation appears to be declining, is crucial. This study attempted to understand the relationship between age, gender and mortality in patients with MI without chest pain.

More than a million people were involved in the study; 42% of women and 30.7% of men who were diagnosed with MI experienced no chest pain. Women were more likely to have MI without chest pain at younger ages. Overall, the mortality rates in hospital were 14.6% for women and 10.3% for men. This sex difference was apparent at younger ages and became equal and then reversed in favour of women with advancing age.

Febrile seizures and epilepsy after vaccination
JAMA 2012; 307(8): 823-31

It is not unknown for parents to express concerns about the side-effects of vaccinations and their questions are often sensible and valid. In many cases, however, there is insufficient data available to offer a satisfactory answer.

It is known that the whole-cell pertussis vaccination carries a risk of febrile seizure. The question in this study was whether the combined diphtheria-tetanus toxoids/acellular pertussis/inactivated poliovirus/Hib (DTaP/IPV/Hib) vaccination at three, five and 12 months increases the risk of febrile seizures or epilepsy.

More than 378,000 children were included in the study. The incidence rate of seizures was 0.8 per 100,000 person-days in the first week after the first injection, 1.3 per 100,000 person-days after the second vaccination and 8.5 per 100,000 person-days after the third vaccination. Overall, compared with controls, there was no higher risk of convulsion after vaccination.

Further analysis showed there was an increased risk on the day of the vaccinations for the first and second, but not the third, vaccination. DTaP/IPV/Hib vaccination was not shown to be a risk factor for epilepsy.

Studies such as this should help GPs and practice nurses to manage patients' anxieties more effectively.

Treating type 2 diabetes
Lancet 2012 doi:10.1016/S0140-6736(11)61879-5

Several epidemiological models forecast a disturbing increase in the incidence of diabetes. Treatment has changed radically, but more needs to be done.

This phase II RCT tested whether activation of free fatty acid receptor 1 (FFAR1) in patients with type 2 diabetes improved gylcaemic control. Patients were included if their diabetes was not controlled by diet alone or metformin. They received a placebo, the sulfonylurea glimepiride 4mg or the FFAR1 agonist TAK-875.

A total of 426 patients were involved. Dose-dependent reductions of up to 1.12% in HbA1c were found in patients randomised to TAK-875 compared with 1.05% with glimepiride and 0.13% in the placebo group. Importantly, hypoglycaemic events with TAK-875 were comparable to placebo. Obviously further trials are required.

More needs to be done to develop the treatment of patients with diabetes

Violence against adults with disabilities
Lancet 2012 doi:10.1016/S0140-6736(11)61851-5

This systematic review and meta-analysis selected 26 studies reflecting data on more than 21,000 disabled adults. The results were alarming, with 24.3% of adults with mental illness and 6.1% of adults with intellectual impairments subjected to recent violence, including physical and sexual assault.

People with mental illness were thought to be at 3.86 times the risk of violence compared with those without disability, although this had a range of 0.91-16.43 times. This study highlights the need for GPs to be vigilant for signs of abuse.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

  • Dr Thakkar is a GP in Wooburn Green, Buckinghamshire, and a member of our team who regularly review the journals

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Highlight that patients with mental illness are at risk of abuse by adding a Read code to your review template.
  • Invite the urgent care lead in your CCG and a cardiologist to talk about how you balance referring unwell patients who may be having a silent MI, with consideration of budgetary constraints.
  • Review the presentations of pancreatic cancer and myeloma and present this at a practice meeting.

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