Distress in suspected lung cancer patients following rapid and standard diagnostic programs: a prospective observational study

Pretreatment quality of life and survival in patients with lung cancer: a systematic review and meta-analysis

BACKGROUND

Although many studies have explored the correlation between quality of life and survival, none have reported this relationship for specific cancers assessed at distinct time points. This meta-analysis aimed to investigate the impact of pretreatment Global Quality of Life (QOL) and functioning QOL, including physical, social, role, emotional, and cognitive QOLs, on mortality risk in patients with lung cancer.

METHODS

A literature search was conducted across the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and PubMed databases for articles published between their inception and December 2022. Subsequently, 11 studies were selected based on predefined eligibility criteria to investigate the relationship between pretreatment QOLs and mortality risk in patients with lung cancer.

RESULTS

Pretreatment global, physical, social, role, and emotional QOLs were significantly associated with mortality risk as follows: Global QOL (hazard ratio [HR] = 1.08 95% confidence interval [CI] = 1.03-1.13); Physical QOL (HR = 1.04 95% CI = 1.02-1.05); Social QOL (HR = 1.02 95% CI = 1.01-1.03; Role QOL (HR = 1.01 95% CI = 1.01-1.02); Emotional QOL (HR = 1.01 95% CI = 1.00-1.03).

CONCLUSIONS

These findings underscore the importance of early QOL assessment after diagnosis as well as early provision of physical, social, and psychological support accommodating each patient's demands.

TRIAL REGISTRATION

The International Prospective Register of Systematic Reviews registration number CRD42023398206, Registered on February 20, 2023.

Cell-Free DNA Fragmentomes in the Diagnostic Evaluation of Patients With Symptoms Suggestive of Lung Cancer

BACKGROUND

The diagnostic workup of individuals suspected of having lung cancer can be complex and protracted because conventional symptoms of lung cancer have low specificity and sensitivity.

RESEARCH QUESTION

Among individuals with symptoms of lung cancer, can a blood-based approach to analyze cell-free DNA (cfDNA) fragmentation (the DNA evaluation of fragments for early interception [DELFI] score) enhance evaluation for the possible presence of lung cancer?

STUDY DESIGN AND METHODS

Adults were referred to Bispebjerg Hospital (Copenhagen, Denmark) for diagnostic evaluation of initial imaging anomalies and symptoms consistent with lung cancer. Numbers and types of symptoms were extracted from medical records. cfDNA from plasma samples obtained at the prediagnostic visit was isolated, sequenced, and analyzed for genome-wide cfDNA fragmentation patterns. The relationships among clinical presentation, cancer status, and DELFI score were examined.

RESULTS

A total of 296 individuals were analyzed. Median DELFI scores were higher for those with lung cancer (n = 98) than those without cancer (n = 198; 0.94 vs 0.19; P < .001). In a multivariate model adjusted for age, smoking history, and presenting symptoms, the addition of the DELFI score improved the prediction of lung cancer for those who demonstrated symptoms (area under the receiver operating characteristic curve, 0.74-0.94).

INTERPRETATION

The DELFI score distinguishes individuals with lung cancer from those without cancer better than suspicious symptoms do. These results represent proof-of-concept support that fragmentation-based biomarker approaches may facilitate diagnostic resolution for patients with concerning symptoms of lung cancer.

Psychobiological stress response to a lung cancer diagnosis: a prospective study of patients in Iceland and Sweden

BACKGROUND

A diagnostic work-up leading to a lung cancer diagnosis is a severely stressful experience that may impact tumor progression. Yet, prospective data are scarce on psychological and biological components of stress at the time of lung cancer diagnosis. The aim of this study was to assess pre-to-post diagnosis change in psychological distress and urinary excretion of catecholamines in patients with suspected lung cancer.

METHODS

Participants were 167 patients within the LUCASS study, recruited at referral for suspected lung cancer to University Hospitals in Iceland and Sweden. Patients completed questionnaires on perceived distress (Hospital Anxiety and Depression Scale, HADS) before and after diagnosis of lung cancer or a non-malignant origin. A subpopulation of 85 patients also provided overnight urine for catecholamine analysis before and at a median of 24 days after diagnosis but before treatment.

RESULTS

A lung cancer diagnosis was confirmed in 123 (73.7%) patients, with a mean age of 70.1 years. Patients diagnosed with lung cancer experienced a post-diagnosis increase in psychological distress (p = 0.010), while patients with non-malignant lung pathology showed a reduction in distress (p = 0.070). Both urinary epinephrine (p = 0.001) and norepinephrine (p = 0.032) levels were higher before the diagnosis among patients eventually diagnosed with lung cancer compared to those with non-malignant lung pathology. We observed indications of associations between pre-to-post diagnosis changes in perceived distress and changes in urinary catecholamine levels.

CONCLUSION

Receiving a lung cancer diagnosis is associated with an increase in psychological distress, while elevated catecholamine levels are evident already before lung cancer diagnosis.

Characterizing Variability in Lung Cancer Outcomes and Influence of a Lung Diagnostic Assessment Program in Southeastern Ontario, Canada

INTRODUCTION

Regional variability in lung cancer (LC) outcomes exists across Canada, including in the province of Ontario. The Lung Diagnostic Assessment Program (LDAP) in southeastern (SE) Ontario is a rapid-assessment clinic that expedites the management of patients with suspected LC. We evaluated the association of LDAP management with LC outcomes, including survival, and characterized the variability in LC outcomes across SE Ontario.

METHODS

We conducted a population-based retrospective cohort study by identifying patients with newly diagnosed LC through the Ontario Cancer Registry (January 2017-December 2019) and linked to the LDAP database to identify LDAP-managed patients. Descriptive data were collected. Using a Cox model approach, we compared 2-year survival for patients managed through LDAP vs. non-LDAP.

RESULTS

We identified 1832 patients, 1742 of whom met the inclusion criteria (47% LDAP-managed and 53% non-LDAP). LDAP management was associated with a lower probability of dying at 2 years (HR 0.76 vs. non-LDAP, p < 0.0001). Increasing distance from the LDAP was associated with a lower likelihood of LDAP management (OR 0.78 for every 20 km increase, p < 0.0001). LDAP-managed patients were more likely to receive specialist assessment and undergo treatments.

CONCLUSIONS

In SE Ontario, initial diagnostic care provided via LDAP was independently associated with improved survival in patients with LC.

Associations between diagnostic time intervals and health-related quality of life, clinical anxiety and depression in adolescents and young adults with cancer: cross-sectional analysis of the BRIGHTLIGHT cohort

BACKGROUND

The association of diagnostic intervals and outcomes is poorly understood in adolescents and young adults with cancer (AYA). We investigated associations between diagnostic intervals and health-related quality of life (HRQoL), anxiety and depression in a large AYA cohort.

METHODS

Participants aged 12-24 completed interviews post-diagnosis, providing data on diagnostic experiences and the patient-reported outcomes (PROs) HRQoL, anxiety and depression. Demographic and cancer information were obtained from clinical and national records. Six diagnostic intervals were considered. Relationships between intervals and PROs were examined using regression models.

RESULTS

Eight hundred and thirty participants completed interviews. In adjusted models, across 28 of 30 associations, longer intervals were associated with poorer PROs. Patient intervals (symptom onset to first seeing a GP) of ≥1 month were associated with greater depression (adjusted odds ratio (aOR):1.7, 95% Confidence Interval (CI):1.1-2.5) compared to <1 month. ≥3 pre-referral GP consultations were associated with greater anxiety (aOR:1.6, CI:1.1-2.3) compared to 1-2 consultations. Symptom onset to first oncology appointment intervals of ≥2 months was associated with impaired HRQoL (aOR:1.8, CI:1.2-2.5) compared to <2 months.

CONCLUSIONS

Prolonged diagnostic intervals in AYA are associated with an increased risk of impaired HRQoL, anxiety and depression. Identifying and delivering interventions for this high-risk group is a priority.

A multidisciplinary neuro-oncological triage panel reduces the time to referral and treatment for patients with a brain tumor

Background

Regional collaboration and appropriate referral management are crucial in neuro-oncological care. Lack of electronic access to medical records across health care organizations impedes interhospital consultation and may lead to incomplete and delayed referrals. To improve referral management, we have established a multidisciplinary neuro-oncological triage panel (NOTP) with digital image exchange and determined the effects on lead times, costs, and time investment.

Methods

A prospective cohort study was conducted from February 2019 to March 2020. All newly diagnosed patients referred to Brain Tumor Center Amsterdam were analyzed according to referral pathway: (1) standard referral (SR), (2) NOTP. The primary outcome was lead time, defined as time-to-referral, time-to-treatment, and total time (median days [interquartile range]). Secondary outcomes were costs and time investment.

Results

In total, 225 patients were included, of whom 153 had SR and 72 NOTP referral. Patients discussed in the NOTP were referred more frequently for first neurosurgical consultation (44.7% vs 28.8%) or combined neurological and neurosurgical consultation (12.8% vs 2.5%, P = .002). Time-to-referral was reduced for NOTP referral compared to SR (1 [0.25-4] vs 6 [1.5-10] days, P < .001). Total time decreased from 27 [14-48] days for the standard group to 15 [12-38.25] days for the NOTP group (P = .040). Costs and time investment were comparable for both groups.

Conclusion

Implementation of digital referral to a multidisciplinary NOTP is feasible and leads to more swift patient-tailored referrals at comparable costs and time investment as SR. This quality improvement initiative has the potential to improve collaboration and coordination of multidisciplinary care in the field of neuro-oncology.

Optimal communication associated with lower risk of acute traumatic stress after lung cancer diagnosis

PURPOSE

The aim of this study was to assess the role of the patient's background and perceived healthcare-related factors in symptoms of acute stress after lung cancer diagnosis.

METHODS

The study population consisted of 89 individuals referred for diagnostic work-up at Landspitali National University Hospital in Iceland and subsequently diagnosed with lung cancer. Before diagnosis, the patients completed questionnaires on sociodemographic characteristics, pre-diagnostic distress (Hospital Anxiety and Depression Scale), social support, and resilience. At a median of 16 days after diagnosis, the patients reported symptoms of acute stress on the Impact of Event Scale-Revised (IES-R) and experience of communication and support from healthcare professionals and family during the diagnostic period.

RESULTS

Patients were on average 68 years and 52% reported high levels of post-diagnostic acute stress (IES-R > 23) while 24% reported symptoms suggestive of clinical significance (IES-R > 32). Prior history of cancer (β = 6.7, 95% CI: 0.1 to 13.3) and pre-diagnostic distress were associated with higher levels of post-diagnostic acute stress (β = 8.8, 95% CI: 2.7 to 14.9), while high educational level (β = - 7.9, 95% CI: - 14.8 to - 1.1) was associated with lower levels. Controlling for the abovementioned factors, the patients' perception of optimal doctor-patient (β = - 9.1, 95% CI: - 14.9 to - 3.3) and family communication (β = - 8.6, 95% CI: - 14.3 to - 2.9) was inversely associated with levels of post-diagnostic acute stress after lung cancer diagnosis.

CONCLUSIONS

A high proportion of patients with newly diagnosed lung cancer experience high levels of acute traumatic stress of potential clinical significance. Efforts to improve doctor-patient and family communication may mitigate the risk of these adverse symptoms.

A Canadian Perspective on the Challenges for Delivery of Curative-Intent Therapy in Stage III Unresectable Non-Small Cell Lung Cancer

Stage III non-small cell lung cancer (NSCLC) comprises a highly heterogenous group of patients with regards to patient fitness and tumour size and distribution, resulting in a wide range of treatment goals and therapy options. Curative-intent multimodality treatment should be considered in all patients with stage III NSCLC. For patients with unresectable disease who are fit, have adequate lung function, and have a disease that can be encompassed within a radical radiation volume, concurrent chemoradiation therapy (cCRT) is the standard of care and can produce cure rates of 20–30%. Recently, consolidation immunotherapy with durvalumab has been recognized as the standard of care following cCRT based on significant improvement rates in overall survival at 4 years. The large heterogeneity of the stage III NSCLC population, along with the need for extensive staging procedures, multidisciplinary care, intensive cCRT, and now consolidation therapy makes the delivery of timely and optimal treatment for these patients complex. Several logistical, communication, and education factors hinder the delivery of guideline-recommended care to patients with stage III unresectable NSCLC. This commentary discusses the potential challenges patients may encounter at different points along their care pathway that can interfere with delivery of curative-intent therapy and suggests strategies for improving care delivery.

Use of Ultrasonography Facilitates Noninvasive Evaluation of Lymphadenopathy in a Lymph Node Diagnostic Clinic

BACKGROUND

Prompt and accurate diagnosis of lymphadenopathy is important, yet there is wide variability in clinical approach and referral patterns, leading to unnecessary investigations and delays in diagnosis. To address this, a lymph node diagnostic clinic (LNDC) was established at our tertiary referral center.

PATIENTS AND METHODS

We retrospectively analyzed data from 320 consecutive patients referred to the LNDC from March 2008 to March 2020, to describe their management and outcomes.

RESULTS

The most common diagnoses were reactive (57%) and malignant lymphadenopathy (28%). In those with reactive lymphadenopathy, 33% did not undergo further investigations, 37% underwent imaging only, and 29% underwent biopsy. For malignant lymphadenopathy, diagnosis was made at a median (interquartile range) of 9 (6-16) days from first LNDC review, with the decision to biopsy made at the first LNDC review in 95% of cases. Clinical features significantly associated with malignancy included age > 45, B symptoms, history of malignancy, and lymphadenopathy that was ≥ 2 cm, in multiple regions, bilateral, multiple nodes, or supraclavicular. At least 3 of these features were present in 88% of patients with malignant lymphadenopathy. Ultrasound had a sensitivity of 98% and negative predictive value of 97% for detecting malignant lymphadenopathy.

CONCLUSION

A dedicated LNDC in a tertiary referral center facilitates rapid assessment and diagnosis of lymphadenopathy through a risk-stratified model of management. Ultrasonography, as well as the presence of defined clinical risk factors, were most useful to differentiate benign from malignant lymphadenopathy.

From symptom to cancer diagnosis: Perspectives of patients and family members in Alberta, Canada

BACKGROUND

Significant intervals from the identification of suspicious symptoms to a definitive diagnosis of cancer are common. Streamlining pathways to diagnosis may increase survival, quality of life post-treatment, and patient experience. Discussions of pathways to diagnosis from the perspective of patients and family members are crucial to advancing cancer diagnosis.

AIM

To examine the perspectives of a group of patients with cancer and family members in Alberta, Canada, on factors associated with timelines to diagnosis and overall experience.

METHODS

A qualitative approach was used. In-depth, semi-structured interviews with patients with cancer (n = 18) and patient relatives (n = 5) were conducted and subjected to a thematic analysis.

FINDINGS

Participants struggled emotionally in the diagnostic period. Relevant to their experience were: potentially avoidable delays, concerns about health status, and misunderstood investigation process. Participants emphasized the importance of their active involvement in the care process, and had unmet supportive care needs.

CONCLUSION

Psychosocial supports available to potential cancer patients and their families are minimal, and may be important for improved experiences before diagnosis. Access to other patients' lived experiences with the diagnostic process and with cancer, and an enhanced supportive role of family doctors might help improve experiences for patients and families in the interval before receiving a diagnosis of cancer, which may have a significant impact on wellbeing.

Predictors of patient preference for either whole body magnetic resonance imaging (WB-MRI) or CT/ PET-CT for staging colorectal or lung cancer

INTRODUCTION

Whole body magnetic resonance imaging (WB-MRI) may be more efficient in staging cancers, but can be harder for patients to tolerate. We examined predictors of patient preference for WB-MRI vs. CT/ PET-CT for staging colorectal or lung cancer.

METHODS

Patients recruited prospectively to two multicentre trials comparing diagnostic accuracy of WB-MRI with standard staging scans were sent two questionnaires: the first, administered at trial registration, captured demographics, educational level and comorbidities; the second, administered after staging completion, measured emotional distress (GHQ-12), positive mood (PANAS), perceived scan burden, patients' beliefs about WB-MRI, and preference for either WB-MRI or CT (colorectal trial), WB-MRI or PET-CT (lung trial). Preference for WB-MRI or CT/ PET-CT was analysed using logistic regression.

RESULTS

Baseline and post-staging questionnaires were completed by 97 and 107 patients, respectively. Overall, 56/107 (52%) preferred WB-MRI over standard scans and were more likely to have no additional comorbidities, higher positive mood, greater awareness of potential benefits of WB-MRI and lower levels of perceived WB-MRI scan burden. In adjusted analyses, only awareness of potential WB-MRI benefits remained a significant predictor (OR: 1.516, 95% CIs 1.006-2.284, P = 0.047). Knowledge that WB-MRI does not use radiation predicted preference (adjusted OR: 3.018, 95% CIs 1.099-8.288, P = 0.032), although only 45/107 (42%) patients were aware of this attribute.

CONCLUSIONS

A small majority of patients undergoing staging of colorectal or lung cancer prefer WB-MRI to CT/ PET-CT. Raising awareness of the potential benefits of WB-MRI, notably lack of ionizing radiation, could influence preference.

Patient and physician perceptions of lung cancer care in a multidisciplinary clinic model

Background

Lung cancer (lc) is a complex disease requiring coordination of multiple health care professionals. A recently implemented lc multidisciplinary clinic (mdc) at Kingston Health Sciences Centre, an academic tertiary care hospital, improved timeliness of oncology assessment and treatment. This study describes patient, caregiver, and physician experiences in the mdc.

Methods

We qualitatively studied patient, caregiver, and physician experiences in a traditional siloed care model and in the mdc model. We used purposive sampling to conduct semi-structured interviews with patients and caregivers who received care in one of the models and with physicians who worked in both models. Thematic design by open coding in the ATLAS.ti software application (ATLAS.ti Scientific Software Development, Berlin, Germany) was used to analyze the data.

Results

Participation by 6 of 72 identified patients from the traditional model and 6 of 40 identified patients from the mdc model was obtained. Of 9 physicians who provided care in both models, 8 were interviewed (2 respirologists, 2 medical oncologists, 4 radiation oncologists). Four themes emerged: communication and collaboration, efficiency, quality of care, and effect on patient outcomes. Patients in both models had positive impressions of their care. Patients in the mdc frequently reported convenience and a positive effect of family presence at appointments. Physicians reported that the mdc improved communication and collegiality, clinic efficiency, patient outcomes and satisfaction, and consistency of information provided to patients. Physicians identified lack of clinic space as an area for mdc improvement.

Conclusions

This qualitative study found that a lc mdc facilitated patient communication and physician collaboration, improved quality of care, and had a perceived positive effect on patient outcomes.

Whole-body MRI compared with standard pathways for staging metastatic disease in lung and colorectal cancer: the Streamline diagnostic accuracy studies

BACKGROUND

Whole-body magnetic resonance imaging is advocated as an alternative to standard pathways for staging cancer.

OBJECTIVES

The objectives were to compare diagnostic accuracy, efficiency, patient acceptability, observer variability and cost-effectiveness of whole-body magnetic resonance imaging and standard pathways in staging newly diagnosed non-small-cell lung cancer (Streamline L) and colorectal cancer (Streamline C).

DESIGN

The design was a prospective multicentre cohort study.

SETTING

The setting was 16 NHS hospitals.

PARTICIPANTS

Consecutive patients aged ≥ 18 years with histologically proven or suspected colorectal (Streamline C) or non-small-cell lung cancer (Streamline L).

INTERVENTIONS

Whole-body magnetic resonance imaging. Standard staging investigations (e.g. computed tomography and positron emission tomography-computed tomography).

REFERENCE STANDARD

Consensus panel decision using 12-month follow-up data.

MAIN OUTCOME MEASURES

The primary outcome was per-patient sensitivity difference between whole-body magnetic resonance imaging and standard staging pathways for metastasis. Secondary outcomes included differences in specificity, the nature of the first major treatment decision, time and number of tests to complete staging, patient experience and cost-effectiveness.

RESULTS

Streamline C - 299 participants were included. Per-patient sensitivity for metastatic disease was 67% (95% confidence interval 56% to 78%) and 63% (95% confidence interval 51% to 74%) for whole-body magnetic resonance imaging and standard pathways, respectively, a difference in sensitivity of 4% (95% confidence interval -5% to 13%; p = 0.51). Specificity was 95% (95% confidence interval 92% to 97%) and 93% (95% confidence interval 90% to 96%) respectively, a difference of 2% (95% confidence interval -2% to 6%). Pathway treatment decisions agreed with the multidisciplinary team treatment decision in 96% and 95% of cases, respectively, a difference of 1% (95% confidence interval -2% to 4%). Time for staging was 8 days (95% confidence interval 6 to 9 days) and 13 days (95% confidence interval 11 to 15 days) for whole-body magnetic resonance imaging and standard pathways, respectively, a difference of 5 days (95% confidence interval 3 to 7 days). The whole-body magnetic resonance imaging pathway was cheaper than the standard staging pathway: £216 (95% confidence interval £211 to £221) versus £285 (95% confidence interval £260 to £310). Streamline L - 187 participants were included. Per-patient sensitivity for metastatic disease was 50% (95% confidence interval 37% to 63%) and 54% (95% confidence interval 41% to 67%) for whole-body magnetic resonance imaging and standard pathways, respectively, a difference in sensitivity of 4% (95% confidence interval -7% to 15%; p = 0.73). Specificity was 93% (95% confidence interval 88% to 96%) and 95% (95% confidence interval 91% to 98%), respectively, a difference of 2% (95% confidence interval -2% to 7%). Pathway treatment decisions agreed with the multidisciplinary team treatment decision in 98% and 99% of cases, respectively, a difference of 1% (95% confidence interval -2% to 4%). Time for staging was 13 days (95% confidence interval 12 to 14 days) and 19 days (95% confidence interval 17 to 21 days) for whole-body magnetic resonance imaging and standard pathways, respectively, a difference of 6 days (95% confidence interval 4 to 8 days). The whole-body magnetic resonance imaging pathway was cheaper than the standard staging pathway: £317 (95% confidence interval £273 to £361) versus £620 (95% confidence interval £574 to £666). Participants generally found whole-body magnetic resonance imaging more burdensome than standard imaging but most participants preferred the whole-body magnetic resonance imaging staging pathway if it reduced time to staging and/or number of tests.

LIMITATIONS

Whole-body magnetic resonance imaging was interpreted by practitioners blinded to other clinical data, which may not fully reflect how it is used in clinical practice.

CONCLUSIONS

In colorectal and non-small-cell lung cancer, the whole-body magnetic resonance imaging staging pathway has similar accuracy to standard staging pathways, is generally preferred by patients, improves staging efficiency and has lower staging costs. Future work should address the utility of whole-body magnetic resonance imaging for treatment response assessment.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN43958015 and ISRCTN50436483.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 66. See the NIHR Journals Library website for further project information.

Implementing a one-day testing model improves timeliness of workup for patients with lung cancer

Background

Patients with lung cancer often experience stressful delays throughout the diagnostic phase of care. To address that situation, our multidisciplinary team created a "Navigation Day," during which patients partake in a single-day visit that comprises nurse-led teaching, social work, smoking cessation counselling, symptom control, and dedicated test slots for integrated positron-emission tomography and computed tomography (pet/ct), pulmonary function tests (pfts), and magnetic resonance imaging (mri) of the brain. We evaluated the effects of that program on wait times and patient satisfaction.

Methods

Patients with a suspicion of lung cancer on chest ct imaging referred during 3 time periods were reviewed: 1 year before launch of the Navigation Day, 1 year post-launch, and 2 years post-launch. Patients were further stratified according to concordance of their test date with a Navigation Day date. Mean wait times for pet/ct, pfts, and mri brain were calculated for each group. Patient satisfaction was measured using a standardized provincial survey. The Student t-test and analysis of variance were used to assess for significance.

Results

After implementation, mean wait times in the first year improved to 9.2 days from 15.5 days for pet/ct (p < 0.0001), to 9.6 days from 15.7 days for pfts (p < 0.0001), and to 10.2 days from 16.0 days for mri brain (p < 0.0001). Patients who used a dedicated test slot experienced the shortest wait times, at 5.8 days for pet/ct, 5.8 days for pfts, and 6.3 days for mri brain (p < 0.0001). Those improvements were sustained at 2 years post-launch. Patient satisfaction in the categories of assistance, emotional support, and clarity remained high post-launch.

Conclusions

Navigation Day significantly improved the timeliness of diagnostic testing services in patients with suspected lung cancer.

Performance Status Is a Risk Factor for Depression before the Diagnosis of Lung Cancer Patients

Objective Previous studies have shown that lung cancer patients experience depression before their diagnosis. However, the patient characteristics that are risk factors for depression before the diagnosis of lung cancer are unclear. We therefore performed this study to identify the characteristics that are risk factors for depression in lung cancer patients. Methods We performed a prospective observational study that included 183 patients who visited our department for suspected lung cancer between August 2014 and March 2017. These patients completed a Quick Inventory of Depressive Symptomatology-Self Report questionnaire. Ten patients with a history of depression were excluded. Results Among the remaining 173 patients, 110 were diagnosed with lung cancer. Among these 110 patients, 57 had depression. A poor performance status (PS) was significantly more prevalent in patients with depression than in those without. Furthermore, a multivariate analysis revealed that a poor PS was the only independent risk factor for depression before the diagnosis of lung cancer. Conclusion Physicians can use this information to evaluate whether patients have depression before the diagnosis of lung cancer.

Depression and Health Care Utilization at End of Life Among Older Adults With Advanced Non-Small-Cell Lung Cancer

CONTEXT

Limited data exist regarding how depression diagnosed at different times relative to a cancer diagnosis may affect healthcare utilization at end of life (EOL).

OBJECTIVES

To assess the relationship between depression and health care utilization at EOL among older adults (ages >=67) diagnosed with advanced non-small cell lung cancer (NSCLC) from 2009 to 2011.

METHODS

Using the SEER-Medicare database, we fit multivariable logistic regression models to explore the association of depression with duration of hospice stay plus high-intensity care, for example inpatient admissions, in-hospital death, emergency department visits, and chemotherapy at EOL. We used a regression model to evaluate hospice enrollment, accounting for the competing risk of death.

RESULTS

Among 13,827 subjects, pre-cancer depression was associated with hospice enrollment (sub-hazard ratio 1.19, 95% confidence interval [CI] 1.11-1.28), 90 + hospice days (adjusted odds ratio [aOR] 1.29, 95% CI 1.06-1.58), and lower odds of most utilization; we found no association with EOL chemotherapy. Diagnosis-time depression was associated with hospice enrollment (SHR 1.16, 95% CI 1.05-1.29) but not high-intensity utilization. Post-diagnosis depression was associated with lower hospice enrollment (SHR 0.80, 95% CI 0.74-0.85) and higher odds of ICU admission (aOR 1.18, 95% CI 1.01-1.37).

CONCLUSION

EOL healthcare utilization varied by timing of depression diagnosis. Those with pre-cancer depression had lower odds of high-intensity healthcare, were more likely to utilize hospice, and have longer hospice stays. Regular depression screening and treatment may help patients optimize decision-making for EOL care. Additionally, hospice providers may need additional resources to attend to mental health needs in this population.

Reducing Wait Time for Lung Cancer Diagnosis and Treatment: Impact of a Multidisciplinary, Centralized Referral Program

Background

A multidisciplinary, centralized referral program was established at our institution in 2014 to reduce delays in lung cancer diagnosis and treatment following diagnostic imaging observed with the traditional, primary care provider–led referral process. The main objectives of this retrospective cohort study were to determine if referral to a Thoracic Triage Panel (TTP): 1) expedites lung cancer diagnosis and treatment initiation; and 2) leads to more appropriate specialist consultation.

Methods

Patients with a diagnosis of lung cancer and initial diagnostic imaging between March 1, 2015, and February 29, 2016, at a Memorial University–affiliated tertiary care centre in St John's, Newfoundland, were identified and grouped according to whether they were referred to the TTP or managed through a traditional referral process. Wait times (in days) from first abnormal imaging to biopsy and treatment initiation were recorded. Statistical analysis was performed using the Wilcoxon rank-sum test.

Results

A total of 133 patients who met inclusion criteria were identified. Seventy-nine patients were referred to the TTP and 54 were managed by traditional means. There was a statistically significant reduction in median wait times for patients referred to the TTP. Wait time from first abnormal imaging to biopsy decreased from 61.5 to 36.0 days ( P < .0001). Wait time from first abnormal imaging to treatment initiation decreased from 118.0 to 80.0 days ( P < .001). The percentage of specialist consultations that led to treatment was also greater for patients referred to the TTP.

Conclusions

A collaborative, centralized intake and referral program helps to reduce wait time for diagnosis and treatment of lung cancer.

Patient-reported distress is prevalent in systemic light chain (AL) amyloidosis but not determined by severity of disease

We conducted this retrospective study to assess patient-reported distress in light chain (AL) amyloidosis, using the Distress Thermometer (DT) survey at first evaluation at our center. Of 78 patients who completed the survey, 75 scored their distress (distress: <4 - low, 4-6 - moderate, >6 - high). Moderate and high distress were self-reported by 30% and 17% patients, respectively. More patients with distress lived alone and had lower haemoglobin than patients without. AL stage did not correlate with distress (Stage I/II median DT 4 compared to 3 in Stage III/IV, p = .09), while cardiac AL was associated with lower distress at 3 compared to 5 in those without (p = .02). Karnofsky performance score (KPS) was concordant with stage (KPS ≥90 in 60% stage I/II versus 19% stage III/IV, p = .005) and cardiac involvement (26% with versus 63% without cardiac involvement had KPS ≥90, p = .01). Significant correlates of high distress included dealing with children, family health, depression, fears, nervousness, sadness, appearance, nausea, dry nose/congestion, memory/concentration, pain, sleep, neuropathy symptoms, and bathing/dressing. In conclusion, we demonstrate moderate to high distress in 47% of AL population at initial evaluation. Distress in amyloidosis is not influenced by amyloid stage or type of organ involvement.

Patient experience and perceived acceptability of whole-body magnetic resonance imaging for staging colorectal and lung cancer compared with current staging scans: a qualitative study

OBJECTIVE

To describe the experience and acceptability of whole-body magnetic resonance imaging (WB-MRI) staging compared with standard scans among patients with highly suspected or known colorectal or lung cancer.

DESIGN

Qualitative study using one-to-one interviews with thematic analysis.

SETTING

Patients recruited from 10 hospitals in London, East and South East England between March 2013 and July 2014.

PARTICIPANTS

51 patients (31 male, age range 40-89 years), with varying levels of social deprivation, were recruited consecutively from two parallel clinical trials comparing the diagnostic accuracy and cost-effectiveness of WB-MRI with standard scans for staging colorectal and lung cancer ('Streamline-C' and 'Streamline-L'). WB-MRI was offered as an additional scan as part of the trials.

RESULTS

In general WB-MRI presented a greater challenge than standard scans, although all but four patients completed the WB-MRI. Key challenges were enclosed space, noise and scan duration; reduced patient tolerance was associated with claustrophobia, pulmonary symptoms and existing comorbidities. Coping strategies facilitated scan tolerance and were grouped into (1) those intended to help with physical and emotional challenges, and (2) those focused on motivation to complete the scan, for example focusing on health benefit. Our study suggests that good staff communication could reduce anxiety and boost coping strategies.

CONCLUSIONS

Although WB-MRI was perceived as more challenging than standard scans, it was sufficiently acceptable and tolerated by most patients to potentially replace them if appropriate.

TRIAL REGISTRATION NUMBER

ISRCTN43958015 and ISRCTN50436483.

Prospective evaluation of anxiety, depression and quality of life in medically inoperable early stage non-small cell lung cancer patients treated with stereotactic ablative radiotherapy

AIM

The aim of this prospective study was to evaluate the level of anxiety, depression, and quality of life (QoL) in medically inoperable patients with early stage non-small cell lung cancer (NSCLC) treated with stereotactic ablative radiotherapy (SABR).

BACKGROUND

Prolonged survival is equally important as maintaining high QoL and good psychological functioning during the treatment of lung cancer. Nowadays available SABR has markedly changed clinical care and outcomes in the group of medically inoperable patients. To our knowledge, analysis of QoL and psychological state has not been performed in Polish patients with early NSCLC treated with SABR.

MATERIALS AND METHODS

Research group consisted of medically inoperable, early NSCLC (T1-2aN0M0) patients qualified to SABR. Patients were asked to complete Polish versions of the European Organization for Research and Treatment of Cancer Quality of Life - Core Questionnaire (EORTC QLQ-C30) with the Lung Cancer Questionnaire (LC13) and Hospital Anxiety and Depression Scale (HAD). These questionnaires were repeated 2 weeks and then 3 months after treatment completion.

RESULTS

We enrolled 51 patients who met the inclusion criteria. SABR did not deteriorate QoL and psychological functioning. On the contrary, clinically meaningful improvement was observed in emotional functioning, level of insomnia, anxiety and depression. Significantly worse improvement was shown in patients with chronic obstructive pulmonary disease (COPD).

CONCLUSIONS

Our results confirm that SABR is well tolerated and does not have a deleterious effect on QoL and psychological state. Results of our study indicate the importance of additional psychological care in the group of patients with COPD.

Medical complexity and time to lung cancer treatment - a three-year retrospective chart review

Background

The time from a referral for suspected lung cancer is received at a hospital until treatment start has been defined as a quality indicator. Current Norwegian recommendation is that ≥70% should start surgery or radiotherapy within 42 calendar days and systemic therapy within 35 days. However, delays can occur due to medical complexity. The aim of this study was to quantify the proportion of patients who started treatment within the recommended timeframes; and to assess the proportion of non-complex patients for which there were no good reasons for delays.

Methods

We performed a retrospective chart review of all patients diagnosed with lung cancer at a university hospital during 2011–2013. We defined “non-complex” patients as those who underwent ≤1 tissue diagnostic procedure and had no delays due to comorbidity, intercurrent disease or complications to diagnostic procedures (“Medical delays”) of more than three days.

Results

Four hundred forty-nine cases were analyzed; 142 (32%) had >1 tissue diagnostic procedures; 67 (15%) had medical delays >3 days; 262 (58%) were non-complex and 363 (81%) received treatment for lung cancer. Median number of days until surgery or radiotherapy was 48 (overall) and 41 (non-complex patients). The proportions who started surgery or radiotherapy within 42 days were 41% (overall) and 56% (non-complex). Corresponding numbers for systemic therapy were 29 days (overall) and 25 days (non-complex), and 64% (overall) and 80% (non-complex).

Conclusion

Fewer lung cancer patients than desired started treatment within the recommended timeframes. Even among the least complex patients, too few patients received timely treatment. The reasons need to be identified and understood, and changes in the organization appear to be necessary in order to offer timely treatment to more patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1952-y) contains supplementary material, which is available to authorized users.

The experiences of health-related quality of life in patients with nonspecific symptoms who undergo a diagnostic evaluation for cancer: a qualitative interview study

The diagnostic phase of cancer can affect health-related quality of life (HRQoL). The aim of this study was to investigate how patients with nonspecific symptoms experience HRQoL while undergoing diagnostic evaluations for cancer. Twenty-one participants who had completed a fast-track evaluation for possible cancer at one of three hospitals in the Capital Region, Denmark were interviewed 2-4 weeks after completing diagnostic evaluations. The interviews were semi-structured and were supported by an interview guide based on the same themes as in The European Organisation for Research and Treatment of Cancer Quality of Life questionnaire (EORCT-QLQ-C30). Data analysis was based on qualitative content analysis by Krippendorff. The analysis generated six categories: symptoms, physical-, role-, emotional-, cognitive- and social functioning, and the diagnostic fast-track experience. From these categories, a main theme was identified: Health-related quality of life is not solely affected by the diagnostic process. The results provide a comprehensive understanding of HRQoL in the diagnostic phase of possible cancer, which can be used not only to enhance evidence-based care, but also in the interpretation of the EORTC-QLQ-C30 scores. Psycho-social support with a focus on individual informational needs during the diagnostic phase may be warranted.

Health-related quality of life, anxiety and depression in the diagnostic phase of suspected cancer, and the influence of diagnosis

Background

Undergoing diagnostic evaluation for cancer has been associated with a high prevalence of anxiety and depression and affected health-related quality of life (HRQoL). The aims of this study were to assess HRQoL, anxiety, and depression pre- and post-diagnosis in patients undergoing diagnostic evaluations for cancer due to non-specific symptoms; to examine changes over time in relation to final diagnosis (cancer yes/no); and to assess the predictive value of pre-diagnostic psychological, socio-demographic and clinical factors.

Methods

A prospective, multicenter survey study of patients suspected to have cancer based on non-specific symptoms was performed. Participants completed the EORTC-QLQ-C30 quality of life scale, HADS, SOC-13 and self-rated health before and after completing diagnostic evaluations. Intra- and inter-group differences between patients diagnosed with cancer versus patients with non-cancer diagnoses were calculated. The impact of baseline psychological, socio-demographic, and medical factors on HRQoL, anxiety and depression at follow-up was explored by bootstrapped multivariate linear regression analyses and logistic regression analyses.

Results

A total of 838 patients participated in this study; 679 (81 %) completed the follow-up. Twenty-two percent of the patients received a cancer diagnosis at the end of the follow-up. Patients presented initially with a high burden of symptoms and affected role and emotional functioning and global health/QL, irrespective of diagnosis. The prevalence of clinical anxiety prior to knowledge of the diagnosis was 32 % in patients with cancer and 35 % in patients who received a non-cancer diagnosis. HRQoL and anxiety improved after diagnosis, and a larger improvement was seen in patients who received a non-cancer diagnosis. There were no intra- or inter-group differences in the depression scores. The strongest predictors of global QL, anxiety, and depression after a known diagnosis were baseline scores, co-morbidity and poor self-rated health.

Conclusions

Patients undergoing diagnostic evaluations for cancer based on non-specific symptoms experience a high prevalence of anxiety and affected quality of life prior to knowledge of the diagnosis. The predictive value of the baseline scores is important when assessing the psychological impact of undergoing diagnostic evaluations for cancer.

Pre-referral general practitioner consultations and subsequent experience of cancer care: evidence from the English Cancer Patient Experience Survey

Prolonged diagnostic intervals may negatively affect the patient experience of subsequent cancer care, but evidence about this assertion is sparse. We analysed data from 73 462 respondents to two English Cancer Patient Experience Surveys to examine whether patients with three or more (3+) pre-referral consultations were more likely to report negative experiences of subsequent care compared with patients with one or two consultations in respect of 12 a priori selected survey questions. For each of 12 experience items, logistic regression models were used, adjusting for prior consultation category, cancer site, socio-demographic case-mix and response tendency (to capture potential variation in critical response tendencies between individuals). There was strong evidence (P < 0.01 for all) that patients with 3+ pre-referral consultations reported worse care experience for 10/12 questions, with adjusted odds ratios compared with patients with 1-2 consultations ranging from 1.10 (95% confidence intervals 1.03-1.17) to 1.68 (1.60-1.77), or between +1.8% and +10.6% greater percentage reporting a negative experience. Associations were stronger for processes involving primary as opposed to hospital care; and for evaluation than report items. Considering 1, 2, 3-4 and '5+' pre-referral consultations separately a 'dose-response' relationship was apparent. We conclude that there is a negative association between multiple pre-diagnostic consultations with a general practitioner and the experience of subsequent cancer care.

Perceived diagnostic delay and cancer-related distress: a cross-sectional study of patients with colorectal cancer

OBJECTIVE

This study aimed to examine the effect of perceived diagnostic delay on cancer-related distress and determine whether fear of cancer-recurrence and quality of life mediate this relationship.

METHODS

Cross-sectional study in which 311 colorectal cancer (CRC) survivors in Scotland completed a survey, which included questions on cancer-related distress (IES-R), perceived diagnostic delay, quality of life (trial outcome index of the FACT-C: FACT-C TOI) and fear of cancer recurrence. Fifteen patients withheld consent to data matching with medical records, leaving a sample size of 296. Participants were an average of 69 years old (range 56 to 81) and between 3.5 and 12 years post-diagnosis. Multiple regressions were used to test predictors of distress and regression and bootstrapping to test for mediation.

RESULTS

Perceived diagnostic delay was correlated with higher cancer-related distress, while objective markers of diagnostic delay (disease stage at diagnosis and treatment received) were not. Some of the relationship between perceived diagnostic delay and cancer-related distress was mediated by quality of life, but not by fear of cancer recurrence.

CONCLUSIONS

Perceived diagnostic delay was associated with higher cancer-related distress among CRC survivors. While poorer quality of life partly explained such associations, fear of cancer recurrence, stage at diagnosis and treatment did not. The exact features of diagnostic delay that are associated with cancer-related distress remain unclear. Future research should examine the experiences patients go through prior to diagnosis that may increase distress, in an effort to improve our understanding of the factors affecting emotional wellbeing among CRC survivors. Copyright © 2016 John Wiley & Sons, Ltd.

Undergoing Diagnostic Evaluation for Possible Cancer Affects the Health-Related Quality of Life in Patients Presenting with Non-Specific Symptoms

AIM

Undergoing diagnostic evaluation for possible cancer can affect health-related quality of life (HRQoL). The aims of this study were to examine the HRQoL in patients undergoing a diagnostic evaluation for possible cancer due to non-specific symptoms and further to investigate the impact of socio-demographic and medical factors associated with HRQoL at the time of diagnosis.

METHODS

This was a prospective, multicenter survey study that included patients who were referred for a diagnostic evaluation due to non-specific cancer symptoms. Participants completed the EORTC-QLQ-C30 quality of life scale before and after completing the diagnostic evaluation. The baseline and follow-up EORTC-QLQ-C30 scores were compared with reference populations. The impact of socio-demographic and medical factors on HRQoL at follow-up was explored by bootstrapped multivariate linear regression.

RESULTS

A total of 838 patients participated in the study; 680 (81%) also completed follow-up. Twenty-two percent of the patients received a cancer diagnosis at the end of follow-up. Patients presented initially with a high burden of symptoms, less role and emotional functioning and a lower global health/QoL. Most domains improved after diagnosis and no clinically important difference between baseline and follow-up scores was found. Patients reported effects on HRQoL both at baseline and at follow-up compared with the Danish reference population and had similar scores as a cancer reference population. Co-morbidity, being unemployed and receiving a cancer diagnosis had the greatest effect on HRQoL around the time of diagnosis.

CONCLUSIONS

Patients with non-specific symptoms reported an affected HRQoL while undergoing a diagnostic evaluation for possible cancer. Morbidity, being unemployed and receiving a cancer diagnosis had the greatest effect on HRQoL around the time of diagnosis.