Summary of the vignettes
| Vignette | Cancer | Patient details | Management options | Phase 1 | Phase 2 | Correlation between survival and referral or test at phase 1 (weighted regression analysis) | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Definitive actions | Non-definitive actions | PPV | Refer/test (%)* | PPV | Refer/test (%)* | 1-year survival p Value | Conditional 5-year survival p Value | ||||
| 1 | Lung | Phase 1 | 68-year-old woman, exsmoker with persistent cough for 3 weeks but no other symptoms, taking ramipril for hypertension. Ear, throat and chest examinations were normal | Secondary care referral Chest X-ray Chest CT | ▸ Antibiotics ▸ Oral steroids ▸ Antitussive medicines ▸ Stop ramipril ▸ Advise visit to pharmacy to try remedies there ▸ Tell her that no action is needed at this stage | 0.9 | 40–80 | 3.9 | 95–100 | 0.654 | 0.647 |
| Phase 2 | The patient returns after another 3 weeks, saying cough has persisted and now there are streaks of blood in the sputum. No weight loss, but a chest examination reveals some crepitations at the left base. Any tests previously undertaken were normal | 0.357 (excluding Denmark) | 0.911 (excluding Denmark) | ||||||||
| Phase 3 | The patient returns with ongoing symptoms and you decide to order a chest X-ray. The report says there is mild cardiomegaly but the lung fields are clear | ||||||||||
| 2 | Lung | Phase 1 | 62-year-old man with COPD, a heavy smoker for over 40 years. He presented with respiratory symptoms | Secondary care referral Chest X-ray Chest CT | ▸ Advise increased use of salbutamol inhaler ▸ Antibiotics ▸ Oral steroids ▸ Antibiotics and add new inhaler steroid or salmeterol ▸ Antitussive medicines ▸ Advise visit to pharmacy to try remedies there ▸ Tell him that no action is needed at this stage | 3.6 | 5–50 | >10.0 | 87–100 | <0.001 | <0.001 |
| Phase 2 | The patient returns in 3 weeks, reported constant ache in left shoulder. The patient attributes pain to persistent cough; he is also producing grey coloured sputum in larger quantities than usual, but no other chest symptoms. No weight loss. On examination he still has a bilateral upper lobe wheeze and some crepitations at the left base. Examination of his shoulder is normal | <0.001 (excluding Denmark) | <0.001 (excluding Denmark) | ||||||||
| 3 | Colorectal | Phase 1 | 43-year-old woman with IBS for more than 10 years, but the IBS has got worse recently. She has abdominal pain every day, unchanged bowel habit and no other symptoms. She has no family history of cancer. | Secondary care referral Colonoscopy Abdominal CT | ▸ Prescribe medication for IBS ▸ Give dietary advice ▸ Offer psychological therapies (counselling and CBT) ▸ Tell her that no action is needed at this stage | 0.7 | 5–45 | 1.2 | 48–89 | 0.014 | 0.025 |
| Phase 2 | The patient returns. Her recent blood test has returned a haemoglobin level of 10.5 g/dL. | 0.003 (excluding Denmark) | 0.002 (excluding Denmark) | ||||||||
| 4† | Colorectal | Phase 1 | 68-year-old man with no relevant medical history. He has experienced loose stools twice a day, most days for over 4 weeks. He has no other symptoms. Examination included rectal examination which was normal. | Secondary care referral Colonoscopy Abdominal CT | ▸ Offer medication, eg, loperamide, antispasmodic, analgaesia ▸ Advice on diet ▸ Tell him that no action is needed at this stage | 0.9 | 20–40 | 1.9 | 77–89 | 0.071 | 0.093 |
| Phase 2 | Any tests selected are negative. The patient returns 2 weeks later, describing that the diarrhoea remains much the same but he now also has intermittent sharp abdominal pain. Abdominal and PR examinations are normal. | 0.004 (excluding Denmark) | 0.001 (excluding Denmark) | ||||||||
| Phase 3 | All tests are negative. A further 2 weeks later the patient describes two brief episodes of rectal bleeding (bright red) 2 days apart. | ||||||||||
| 5† | Ovarian | Phase 1 | 53-year-old woman whose last period was 6 months ago. She had experienced abdominal pain for the past 3 weeks. She has had no other symptoms and the same sexual partner for 20 years. | Secondary care referral Abdominal ultrasound Pelvic CT | ▸ Prescribe analgesia ▸ Prescribe antispasmodic ▸ Undertake investigations now ▸ Tell her that no action is needed at this stage | 0.3 | 40–75 | 0.7 | 68–90 | 0.007 | 0.610 |
| Phase 2 | All investigations to date have been normal. The patient presents 1-month later with urinary frequency. She says the abdominal pain is still present but comes less often. Abdominal examination is normal. A urine dipstick for blood, protein, nitrite, white cells and sugar is negative. | 0.009 (excluding Denmark) | 0.744 (excluding Denmark) | ||||||||
| Phase 3 | The patient returns 6 weeks later saying pain is worse, she is passing urine every 3 h, day and night and has noticed that her abdomen seems swollen. After examination of her abdomen, it does look distended but cannot feel any other abnormality. | ||||||||||
*Range of respondent who completed the vignette at this stage by referral or undertaking a definitive diagnostic test.
†Stage 3 results not reported as nearly all respondents referred or undertook definitive test by this stage.
Bold typeface indicates significance.
CBT, cognitive behavioural therapy; COPD, chronic obstructive pulmonary disease; IBS, irritable bowel syndrome; PPV, positive predictive value; PR, rectal examination.