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Fife AJ, Najor AJ, Aspir TB, Haines KE, Vilardo NA, Isani SS, Cowan M, Gressel GM, Ye KQ, Nevadunsky NS, Kuo DY, Lin KY. Reduced healthcare access contributes to delay of care in endometrial cancer. Gynecol Oncol 2024; 182:115-120. [PMID: 38262233 DOI: 10.1016/j.ygyno.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/16/2023] [Accepted: 01/08/2024] [Indexed: 01/25/2024]
Abstract
OBJECTIVE We aimed to characterize delays to care in patients with endometrioid endometrial cancer and the role healthcare access plays in these delays. METHODS A chart review was performed of patients with endometrioid endometrial cancer who presented with postmenopausal bleeding at a diverse, urban medical center between 2006 and 2018. The time from symptom onset to treatment was abstracted from the medical record. This interval was subdivided to assess for delay to presentation, delay to diagnosis, and delay to treatment. RESULTS We identified 484 patients who met the inclusion criteria. The median time from symptom onset to treatment was 4 months with an interquartile range of 2 to 8 months. Most patients had stage I disease at diagnosis (88.6%). There was no significant difference in race/ethnicity or disease stage at time of diagnosis between different groups. Patients who had not seen a primary care physician or general obstetrician-gynecologist in the year before symptom onset were more likely to have significantly delayed care (27.7% vs 14.3%, p = 0.02) and extrauterine disease (20.2% vs 4.9%, p < 0.01) compared to those with established care. Black and Hispanic patients were more likely to experience significant delays from initial biopsy to diagnosis. CONCLUSIONS Delays exist in the evaluation of endometrial cancer. This delay is most pronounced in patients without an established outpatient primary care provider or obstetrician-gynecologist.
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Affiliation(s)
- Alexander J Fife
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Montefiore Medical Center, 1695 Eastchester Road, Bronx, NY 10461, United States of America.
| | - Anna J Najor
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Montefiore Medical Center, 1695 Eastchester Road, Bronx, NY 10461, United States of America
| | - Tori B Aspir
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Montefiore Medical Center, 1695 Eastchester Road, Bronx, NY 10461, United States of America
| | - Kaitlin E Haines
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Montefiore Medical Center, 1695 Eastchester Road, Bronx, NY 10461, United States of America
| | - Nicole A Vilardo
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Montefiore Medical Center, 1695 Eastchester Road, Bronx, NY 10461, United States of America
| | - Sara S Isani
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Montefiore Medical Center, 1695 Eastchester Road, Bronx, NY 10461, United States of America
| | - Matthew Cowan
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Montefiore Medical Center, 1695 Eastchester Road, Bronx, NY 10461, United States of America
| | - Gregory M Gressel
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Montefiore Medical Center, 1695 Eastchester Road, Bronx, NY 10461, United States of America; Division of Gynecologic Oncology, Spectrum Health Cancer Center, 145 Michigan St NE, Suite 6300, Grand Rapids, MI 49503, United States of America
| | - Kenny Q Ye
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, 1300 Morris Park Ave, Block Building Room 310, Bronx, NY 10461, United States of America
| | - Nicole S Nevadunsky
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Montefiore Medical Center, 1695 Eastchester Road, Bronx, NY 10461, United States of America
| | - Dennis Y Kuo
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Montefiore Medical Center, 1695 Eastchester Road, Bronx, NY 10461, United States of America
| | - Ken Y Lin
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Montefiore Medical Center, 1695 Eastchester Road, Bronx, NY 10461, United States of America
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Medina-Lara A, Grigore B, Lewis R, Peters J, Price S, Landa P, Robinson S, Neal R, Hamilton W, Spencer AE. Cancer diagnostic tools to aid decision-making in primary care: mixed-methods systematic reviews and cost-effectiveness analysis. Health Technol Assess 2021; 24:1-332. [PMID: 33252328 DOI: 10.3310/hta24660] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Tools based on diagnostic prediction models are available to help general practitioners diagnose cancer. It is unclear whether or not tools expedite diagnosis or affect patient quality of life and/or survival. OBJECTIVES The objectives were to evaluate the evidence on the validation, clinical effectiveness, cost-effectiveness, and availability and use of cancer diagnostic tools in primary care. METHODS Two systematic reviews were conducted to examine the clinical effectiveness (review 1) and the development, validation and accuracy (review 2) of diagnostic prediction models for aiding general practitioners in cancer diagnosis. Bibliographic searches were conducted on MEDLINE, MEDLINE In-Process, EMBASE, Cochrane Library and Web of Science) in May 2017, with updated searches conducted in November 2018. A decision-analytic model explored the tools' clinical effectiveness and cost-effectiveness in colorectal cancer. The model compared patient outcomes and costs between strategies that included the use of the tools and those that did not, using the NHS perspective. We surveyed 4600 general practitioners in randomly selected UK practices to determine the proportions of general practices and general practitioners with access to, and using, cancer decision support tools. Association between access to these tools and practice-level cancer diagnostic indicators was explored. RESULTS Systematic review 1 - five studies, of different design and quality, reporting on three diagnostic tools, were included. We found no evidence that using the tools was associated with better outcomes. Systematic review 2 - 43 studies were included, reporting on prediction models, in various stages of development, for 14 cancer sites (including multiple cancers). Most studies relate to QCancer® (ClinRisk Ltd, Leeds, UK) and risk assessment tools. DECISION MODEL In the absence of studies reporting their clinical outcomes, QCancer and risk assessment tools were evaluated against faecal immunochemical testing. A linked data approach was used, which translates diagnostic accuracy into time to diagnosis and treatment, and stage at diagnosis. Given the current lack of evidence, the model showed that the cost-effectiveness of diagnostic tools in colorectal cancer relies on demonstrating patient survival benefits. Sensitivity of faecal immunochemical testing and specificity of QCancer and risk assessment tools in a low-risk population were the key uncertain parameters. SURVEY Practitioner- and practice-level response rates were 10.3% (476/4600) and 23.3% (227/975), respectively. Cancer decision support tools were available in 83 out of 227 practices (36.6%, 95% confidence interval 30.3% to 43.1%), and were likely to be used in 38 out of 227 practices (16.7%, 95% confidence interval 12.1% to 22.2%). The mean 2-week-wait referral rate did not differ between practices that do and practices that do not have access to QCancer or risk assessment tools (mean difference of 1.8 referrals per 100,000 referrals, 95% confidence interval -6.7 to 10.3 referrals per 100,000 referrals). LIMITATIONS There is little good-quality evidence on the clinical effectiveness and cost-effectiveness of diagnostic tools. Many diagnostic prediction models are limited by a lack of external validation. There are limited data on current UK practice and clinical outcomes of diagnostic strategies, and there is no evidence on the quality-of-life outcomes of diagnostic results. The survey was limited by low response rates. CONCLUSION The evidence base on the tools is limited. Research on how general practitioners interact with the tools may help to identify barriers to implementation and uptake, and the potential for clinical effectiveness. FUTURE WORK Continued model validation is recommended, especially for risk assessment tools. Assessment of the tools' impact on time to diagnosis and treatment, stage at diagnosis, and health outcomes is also recommended, as is further work to understand how tools are used in general practitioner consultations. STUDY REGISTRATION This study is registered as PROSPERO CRD42017068373 and CRD42017068375. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology programme and will be published in full in Health Technology Assessment; Vol. 24, No. 66. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Antonieta Medina-Lara
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Bogdan Grigore
- Exeter Test Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Ruth Lewis
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Jaime Peters
- Exeter Test Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Sarah Price
- Primary Care Diagnostics, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Paolo Landa
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Sophie Robinson
- Peninsula Technology Assessment Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Richard Neal
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - William Hamilton
- Primary Care Diagnostics, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Anne E Spencer
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
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Mitric C, Matanes E, Wissing M, Amajoud Z, Abitbol J, Yasmeen A, López-Ozuna V, Eisenberg N, Laskov I, Lau S, Salvador S, Gotlieb WH, Kogan L. The impact of wait times on oncological outcome in high-risk patients with endometrial cancer. J Surg Oncol 2020; 122:306-314. [PMID: 32291783 DOI: 10.1002/jso.25929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 03/31/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the impact of surgical wait times on outcome of patients with grade 3 endometrial cancer. METHODS All consecutive patients surgically treated for grade 3 endometrial cancer between 2007 and 2015 were included. Patients were divided into two groups based on the time interval between endometrial biopsy and surgery: wait time from biopsy to surgery ≤12 weeks (84 days) vs more than 12 weeks. Survival analyses were conducted using log-rank tests and Cox proportional hazards models. RESULTS A total of 136 patients with grade 3 endometrial cancer were followed for a median of 5.6 years. Fifty-one women (37.5%) waited more than 12 weeks for surgery. Prolonged surgical wait times were not associated with advanced stage at surgery, positive lymph nodes, increased lymphovascular space invasion, and tumor size (P = .8, P = 1.0, P = .2, P = .9, respectively). In multivariable analysis adjusted for clinical and pathological factors, wait times did not significantly affect disease-specific survival (adjusted hazard ratio [HR]: 1.2, 95% confidence interval [CI], 0.6-2.5, P = .6), overall survival (HR: 1.1, 95% CI, 0.6-2.1, P = .7), or progression-free survival (HR: 0.9, 95% CI, 0.5-1.7, P = .8). CONCLUSION Prolonged surgical wait time for poorly differentiated endometrial cancer seemed to have a limited impact on clinical outcomes compared to biological factors.
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Affiliation(s)
- Cristina Mitric
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Emad Matanes
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.,Gynecologic Oncology Laboratory, Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Quebec, Canada
| | - Michel Wissing
- Division of Cancer Epidemiology, Department of Oncology, McGill University, Montreal, Quebec, Canada
| | - Zainab Amajoud
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jeremie Abitbol
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Amber Yasmeen
- Gynecologic Oncology Laboratory, Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Quebec, Canada
| | - Vanessa López-Ozuna
- Gynecologic Oncology Laboratory, Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Quebec, Canada
| | - Neta Eisenberg
- Department of Obstetrics and Gynecology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montreal, Quebec, Canada
| | - Ido Laskov
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Susie Lau
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Shannon Salvador
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Walter H Gotlieb
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.,Gynecologic Oncology Laboratory, Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Quebec, Canada
| | - Liron Kogan
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.,Gynecologic Oncology Laboratory, Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Quebec, Canada.,Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew university of Jerusalem, Jerusalem, Israel
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Shalowitz DI, Epstein AJ, Buckingham L, Ko EM, Giuntoli RL. Survival implications of time to surgical treatment of endometrial cancers. Am J Obstet Gynecol 2017; 216:268.e1-268.e18. [PMID: 27939327 DOI: 10.1016/j.ajog.2016.11.1050] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/18/2016] [Accepted: 11/30/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Optimal care for women with endometrial cancers often involves transfer of care from diagnosing physicians (eg, obstetrician-gynecologists) to treating physicians (eg, gynecologic oncologists.) It is critical to determine the effect of time to treatment on cancer outcomes to set best practices guidelines for referral processes. OBJECTIVE We sought to determine the impact of time from diagnosis of endometrial cancer to surgical treatment on mortality and to characterize those patients who may be at highest risk for worsened survival related to surgical timing. STUDY DESIGN The National Cancer Database was queried for incident endometrial cancers in adults from 2003 through 2012. Cancers were classified as low risk (grade 1 or 2 endometrioid histologies) or high risk (nonendometrioid and grade 3 endometrioid histologies) and analyzed separately. Demographic, clinicopathologic, and health system factors were collected. Unadjusted and adjusted hazard ratios for mortality were calculated by interval between diagnosis and surgery. Linear regression of patient and health care system characteristics was performed on diagnosis-to-surgery interval. RESULTS For low-risk cancers (N = 140,078), surgery in the first and second weeks after diagnosis was independently associated with mortality risk (hazard ratio, 1.4; 95% confidence interval, 1.3-1.5; and hazard ratio, 1.1; 95% confidence interval, 1.0-1.2, respectively). The 30-day postoperative mortality was significantly higher among patients undergoing surgery in the first or second week postdiagnosis, compared to patients treated in the third or fourth week postdiagnosis (0.7% vs 0.4%; P < .001). Mortality risk was also significantly higher than baseline when time between diagnosis and surgery was >8 weeks. Independent associations with added time to surgery of at least 1 week were seen with black race (1.1 weeks; 95% confidence interval, 0.9-1.4), uninsurance (1.3 weeks; 95% confidence interval, 1.1-1.5), Medicaid insurance (1.7 weeks; 95% confidence interval, 1.5-1.9), and Charlson-Deyo comorbidity score >1 (1.0 weeks; 95% confidence interval, 0.8-1.2). For high-risk cancers (N = 68,360), surgery in the first and second weeks after diagnosis was independently associated with mortality risk (hazard ratio, 1.5; 95% confidence interval, 1.3-1.6; and hazard ratio, 1.2; 95% confidence interval, 1.1-1.2, respectively). The 30-day postoperative mortality was significantly higher among patients undergoing surgery in the first or second week postdiagnosis, compared to patients treated in the third or fourth week postdiagnosis (2.5% vs 1.0%; P < .001). Surgery after the third week postdiagnosis was not associated with a statistically significant increase in the adjusted risk of mortality. Independent associations with added time to surgery of at least 1 week were seen with uninsurance (1.4 weeks; 95% confidence interval, 0.9-1.9) and Medicaid insurance (1.4 weeks; 95% confidence interval, 1.1-1.7). CONCLUSION Surgery in the first 2 weeks after diagnosis of endometrial cancer was associated with worsened survival associated with elevated perioperative mortality and treatment in low-volume hospitals. Delay in surgical treatment was a risk factor for mortality in low-risk cancers only and was likely associated with poor access to specialty care. We suggest that the target interval between diagnosis and treatment of endometrial cancers be ≤8 weeks; however, referral to an experienced surgeon and adequate preoperative optimization should be prioritized over expedited surgery.
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Time interval between endometrial biopsy and surgical staging for type I endometrial cancer: association between tumor characteristics and survival outcome. Obstet Gynecol 2015; 125:424-433. [PMID: 25569000 DOI: 10.1097/aog.0000000000000636] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To examine whether wait time between endometrial biopsy and surgical staging correlates with tumor characteristics and affects survival outcomes in patients with type I endometrial cancer. METHODS A retrospective study was conducted to examine patients with grade 1 and 2 endometrioid adenocarcinoma diagnosed by preoperative endometrial biopsy who subsequently underwent hysterectomy-based surgical staging between 2000 and 2013. Patients who received neoadjuvant chemotherapy or hormonal treatment were excluded. Time interval and grade change between endometrial biopsy and hysterectomy were correlated to demographics and survival outcomes. RESULTS Median wait time was 57 days (range 1-177 days) among 435 patients. Upgrading of the tumor to grade 3 in the hysterectomy specimen was seen in 4.7% of 321 tumors classified as grade 1 and 18.4% of 114 tumors classified as grade 2 on the endometrial biopsy, respectively. Wait time was not associated with grade change (P>.05). Controlling for age, ethnicity, body habitus, medical comorbidities, CA 125 level, and stage, multivariable analysis revealed that wait time was not associated with survival outcomes (5-year overall survival rates, wait time 1-14, 15-42, 43-84, and 85 days or more; 62.5%, 93.6%, 95.2%, and 100%, respectively, P>.05); however, grade 1 to 3 on the hysterectomy specimen remained as an independent prognosticator associated with decreased survival (5-year overall survival rates, grade 1 to 3 compared with grade change 1 to 1, 82.1% compared with 98.5%, P=.01). Among grade 1 preoperative biopsies, grade 1 to 3 was significantly associated with nonobesity (P=.039) and advanced stage (P=.019). CONCLUSION Wait time for surgical staging was not associated with decreased survival outcome in patients with type I endometrial cancer.
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Neal RD, Tharmanathan P, France B, Din NU, Cotton S, Fallon-Ferguson J, Hamilton W, Hendry A, Hendry M, Lewis R, Macleod U, Mitchell ED, Pickett M, Rai T, Shaw K, Stuart N, Tørring ML, Wilkinson C, Williams B, Williams N, Emery J. Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review. Br J Cancer 2015; 112 Suppl 1:S92-107. [PMID: 25734382 PMCID: PMC4385982 DOI: 10.1038/bjc.2015.48] [Citation(s) in RCA: 614] [Impact Index Per Article: 68.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND It is unclear whether more timely cancer diagnosis brings favourable outcomes, with much of the previous evidence, in some cancers, being equivocal. We set out to determine whether there is an association between time to diagnosis, treatment and clinical outcomes, across all cancers for symptomatic presentations. METHODS Systematic review of the literature and narrative synthesis. RESULTS We included 177 articles reporting 209 studies. These studies varied in study design, the time intervals assessed and the outcomes reported. Study quality was variable, with a small number of higher-quality studies. Heterogeneity precluded definitive findings. The cancers with more reports of an association between shorter times to diagnosis and more favourable outcomes were breast, colorectal, head and neck, testicular and melanoma. CONCLUSIONS This is the first review encompassing many cancer types, and we have demonstrated those cancers in which more evidence of an association between shorter times to diagnosis and more favourable outcomes exists, and where it is lacking. We believe that it is reasonable to assume that efforts to expedite the diagnosis of symptomatic cancer are likely to have benefits for patients in terms of improved survival, earlier-stage diagnosis and improved quality of life, although these benefits vary between cancers.
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Affiliation(s)
- R D Neal
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - P Tharmanathan
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - B France
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - N U Din
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - S Cotton
- Betsi Cadwaladr University Health Board, Wrexham Maelor Hospital, Wrexham LL13 7TD, UK
| | - J Fallon-Ferguson
- Primary Care Collaborative Cancer Clinical Trials Group, School of Primary, Aboriginal, and Rural Healthcare, University of Western Australia, M706, 35 Stirling Highway, Crawley, Western Australia 6009, Australia
| | - W Hamilton
- University of Exeter Medical School, Exeter EX1 2LU, UK
| | - A Hendry
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - M Hendry
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - R Lewis
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - U Macleod
- Centre for Health and Population studies, Hull York Medical School, University of Hull, Hull HU6 7RX, UK
| | - E D Mitchell
- Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9LJ, UK
| | - M Pickett
- Betsi Cadwaladr University Health Board, Wrexham Maelor Hospital, Wrexham LL13 7TD, UK
| | - T Rai
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor LL57 2PZ, UK
| | - K Shaw
- Primary Care Collaborative Cancer Clinical Trials Group, School of Primary, Aboriginal, and Rural Healthcare, University of Western Australia, M706, 35 Stirling Highway, Crawley, Western Australia 6009, Australia
| | - N Stuart
- School of Medical Sciences, Bangor University, Bangor, LL57 2AS UK
| | - M L Tørring
- Research Unit for General Practice, Aarhus University, Bartholins Alle 2, Aarhus DK-8000, Denmark
| | - C Wilkinson
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - B Williams
- Primary Care Collaborative Cancer Clinical Trials Group, School of Primary, Aboriginal, and Rural Healthcare, University of Western Australia, M706, 35 Stirling Highway, Crawley, Western Australia 6009, Australia
| | - N Williams
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor LL57 2PZ, UK
| | - J Emery
- Primary Care Collaborative Cancer Clinical Trials Group, School of Primary, Aboriginal, and Rural Healthcare, University of Western Australia, M706, 35 Stirling Highway, Crawley, Western Australia 6009, Australia
- General Practice & Primary Care Academic Centre, University of Melbourne, 200 Berkeley Street, Melbourne, Victoria 3053, Australia
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Affiliation(s)
- Joseph Menczer
- Edith Wolfson Medical Center, Holon; Tel Aviv University, Tel Aviv, Israel
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Influence of the Time Interval Between Hysteroscopy, Dilation and Curettage, and Hysterectomy on Survival in Patients With Endometrial Cancer. Obstet Gynecol 2008; 112:1098-101. [DOI: 10.1097/aog.0b013e31818b149f] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cost-Effectiveness Analysis of Endometrial Cancer Prevention Strategies for Obese Women. Obstet Gynecol 2008; 112:56-63. [DOI: 10.1097/aog.0b013e31817d53a4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Bacci G, Balladelli A, Forni C, Longhi A, Serra M, Fabbri N, Alberghini M, Ferrari S, Benassi MS, Picci P. Ewing’s sarcoma family tumours. ACTA ACUST UNITED AC 2007; 89:1229-33. [PMID: 17905963 DOI: 10.1302/0301-620x.89b9.19422] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite local treatment with systemic chemotherapy in Ewing’s sarcoma family tumours (ESFT), patients with detectable metastases at presentation have a markedly worse prognosis than those with apparently localised disease. We investigated the clinical, pathological and laboratory differences in 888 patients with ESFT, 702 with localised disease and 186 with overt metastases at presentation, seen at our institution between 1983 and 2006. Multivariate analyses showed that location in the pelvis, a high level of serum lactic dehydrogenase, the presence of fever and a short interval between the onset of symptoms and diagnosis were indicative of metastatic disease. The rate of overt metastases at presentation was 10% without these four risk factors, 22.7% with one, 31.4% with two, and 50% for those with three or four factors. We concluded that in ESFT the site, the serum level of lactic dehydrogenase, fever, and the interval between the onset of symptoms and diagnosis are indicators of tumours having a particularly aggressive metastatic behaviour.
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Affiliation(s)
- G Bacci
- Istituti Ortopedici Rizzoli, Via Pupilli 1, 40136 Bologna, Italy.
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Levy T, Golan A, Menczer J. Endometrial endometrioid carcinoma: a glimpse at the natural course. Am J Obstet Gynecol 2006; 195:454-7. [PMID: 16626613 DOI: 10.1016/j.ajog.2006.01.092] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2005] [Accepted: 01/20/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This study was undertaken to assess the natural course of endometrial endometrioid carcinoma by identifying untreated patients and those with a prolonged (>6 months) treatment delay. STUDY DESIGN A chart review of 252 patients with histologically confirmed endometrial endometrioid carcinoma was conducted and clinical data of untreated patients and those with a prolonged treatment delay were abstracted. RESULTS Seven patients (3 untreated and 4 with prolonged treatment delay) were identified. Five had clinical stage I and 5 had well-differentiated tumors. The survival of the untreated patients ranged from 5 to 59 months. Of the patients with prolonged treatment delay, 2 died more than 5 years after diagnosis and 2 are alive more than 5 years after diagnosis. CONCLUSION The lengthy survival of our patients seems to indicate that the natural progression course, even in untreated patients, may be very slow in endometrial endometrioid carcinoma with favorable prognostic factors.
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Affiliation(s)
- Tally Levy
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, E. Wolfson Medical Center, Holon, Israel
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Madison T, Schottenfeld D, James SA, Schwartz AG, Gruber SB. Endometrial cancer: socioeconomic status and racial/ethnic differences in stage at diagnosis, treatment, and survival. Am J Public Health 2004; 94:2104-11. [PMID: 15569961 PMCID: PMC1448599 DOI: 10.2105/ajph.94.12.2104] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2003] [Indexed: 11/04/2022]
Abstract
OBJECTIVE We evaluated the association between socioeconomic status and racial/ ethnic differences in endometrial cancer stage at diagnosis, treatment, and survival. METHODS We conducted a population-based study among 3656 women. RESULTS Multivariate analyses showed that either race/ethnicity or income, but not both, was associated with advanced-stage disease. Age, stage at diagnosis, and income were independent predictors of hysterectomy. African American ethnicity, increased age, aggressive histology, poor tumor grade, and advanced-stage disease were associated with increased risk for death; higher income and hysterectomy were associated with decreased risk for death. CONCLUSIONS Lower income was associated with advanced-stage disease, lower likelihood of receiving a hysterectomy, and lower rates of survival. Earlier diagnosis and removal of barriers to optimal treatment among lower-socioeconomic status women will diminish racial/ethnic differences in endometrial cancer survival.
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Affiliation(s)
- Terri Madison
- School of Public Health, University of Michigan, Ann Arbor, MI, USA.
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Bacci G, Ferrari S, Longhi A, Forni C, Zavatta M, Versari M, Smith K. High-grade osteosarcoma of the extremity: differences between localized and metastatic tumors at presentation. J Pediatr Hematol Oncol 2002; 24:27-30. [PMID: 11902735 DOI: 10.1097/00043426-200201000-00008] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In osteosarcoma, as in other tumors, the presence of metastases at presentation is generally considered a consequence of late diagnosis. To verify this, the authors investigated whether there was a relationship between the stage of the disease at presentation and several clinical and pathologic characteristics, including the interval between the onset of first symptoms or signs and the final diagnosis. PATIENTS AND METHODS One thousand seventy-one patients with high-grade osteosarcoma of the extremity were observed between 1980 and 1999. Of these, 891 had a localized tumor and 180 had metastases at the time of diagnosis. RESULTS Compared with patients with localized disease, patients with detectable metastases at the time of diagnosis had higher serum levels of alkaline phosphatase, larger primary lesions, and tumors often located in the femur and humerus. In terms of time to diagnosis, the interval between the onset of first symptoms and the final diagnosis was significantly shorter in patients with metastases than in patients with localized tumor. This surprising finding probably reflects a more rapid growth of the tumor. CONCLUSIONS These results suggest a different biologic phenotype and aggressiveness of the tumor in a subgroup of patients and that the stage of the disease at presentation depends more on the properties of these tumors than on late diagnosis.
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Affiliation(s)
- Gaetano Bacci
- Department of Chemotherapy, Rizzoli Orthopedic Institute, Bologna, Italy.
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Rozenberg S, Auvertin S, Ham H. A survey of physicians' attitude towards women with postmenopausal bleeding. Maturitas 2001; 39:189-93. [PMID: 11574177 DOI: 10.1016/s0378-5122(01)00214-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To study how gynaecologist manage postmenopausal bleeding in women not using HRT. The impact on the physicians' attitude of risk factors for endometrial cancer and of the endometrial thickness was essentially accounted for. METHODS Two different case-types were defined by modifying the risk level of developing endometrial cancer. Also the level of endometrial thickness, assessed by ultrasound, was made to vary. In total four case-types were constructed. One case-type was sent at random to each Belgian gynaecologist (n=970). RESULTS Response rate: 55%. The proportion of physicians who would not investigate the patients' endometrium varied between 2% (high-risk patient with abnormal ultrasound) and 34% (low risk patient, normal ultrasound). Significant differences were observed in relation to the level of risk factors for endometrial cancer and in relation to endometrial thickness. No significant relationship was found between the choice of the method of endometrial investigation and the risk situation or the ultrasound result. CONCLUSIONS The attitude of Belgian gynaecologists towards postmenopausal bleeding is modified by the presence of risk factors and by the level of endometrium thickness. About one third of physicians would not further investigate the endometrium of a patient with a low risk profile and a normal endometrium as assessed by ultrasound.
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Affiliation(s)
- S Rozenberg
- Department of Obstetrics and Gynaecology, CHU St Pierre, Free University of Brussels (ULB), rue Haute 322, B-1000, Brussels, Belgium.
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Bacci G, Ferrari S, Longhi A, Mellano D, Giacomini S, Forni C. Delay in Diagnosis of High-Grade Osteosarcoma of the Extremities. Has it any Effect on the Stage of Disease? TUMORI JOURNAL 2000; 86:204-6. [PMID: 10939599 DOI: 10.1177/030089160008600305] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In 965 patients with high-grade osteosarcoma of the extremities, we investigated the correlation between diagnostic delay and the stage of the tumor at presentation. The mean interval between the onset of first symptoms and the final diagnosis was significantly shorter in patients with metastatic disease than in patients with localized disease at the time of the diagnosis. The difference was due to a late presentation of patients with localized disease to the physician and not to delays in performing radiologic examinations or in referring patients to a specialized hospital for biopsy and treatment. We conclude that in high-grade osteosarcoma of the extremity the shorter interval between onset of symptoms and diagnosis observed in patients with disseminated disease at the time of the diagnosis reflects a more aggressive behavior of tumors that are metastatic at presentation.
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Affiliation(s)
- G Bacci
- Department of Musculoskeletal Oncology, Istituti Ortopedici Rizzoli, Bologna, Italy.
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Menczer J. Diagnosis and treatment delay in gynecological malignancies. Does it affect outcome? Int J Gynecol Cancer 2000; 10:89-94. [PMID: 11240658 DOI: 10.1046/j.1525-1438.2000.00020.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Delay of diagnosis and treatment of malignant tumors is perceived as unfavorably affecting outcome. However, tumor behavior may be determined early in the histogenesis process and the outcome may be more a function of the biologic properties of the tumor than of our ability to make an early diagnosis. The objective of the present review is to evaluate data concerning the effect of diagnosis and treatment delay on outcome in gynecological malignancies. A medline search including the terms diagnosis delay, treatment delay, outcome, vulvar carcinoma, cervical carcinoma, endometrial carcinoma and ovarian carcinoma was conducted and all pertinent articles in the English language were included. Relatively few investigations deal with the effect of diagnosis and treatment delay on prognostic factors and on outcome in invasive gynecological malignancies. The reviewed data do not seem to indicate an unequivocal deleterious effect of a delay of several weeks or even several months in patients with some gynecological malignancies. Intentional delay of diagnosis or treatment of gynecologic malignancies is unjustified; however, the data presented should encourage a closer scrutiny and possibly a revision of the concept of "early" diagnosis and of the notion that delay of any duration has a definite, unfavorable effect on outcome.
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Affiliation(s)
- J. Menczer
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, and Sackler Faculty of Medicine, Tel Aviv University, Edith Wolfson Medical Center, Holon, Israel
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