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Lesi OK, Igho-Osagie E, Walton SJ. The impact of COVID-19 pandemic on colorectal cancer patients at an NHS Foundation Trust hospital-A retrospective cohort study. Ann Med Surg (Lond) 2022; 73:103182. [PMID: 34931144 PMCID: PMC8673748 DOI: 10.1016/j.amsu.2021.103182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 12/13/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Current NHS guidelines recommend that treatment of colorectal patients referred through the two-week wait referral system should occur within sixty two days from the date of referral. The COVID-19 pandemic which started in March 2020 has however led to significant delays in the delivery of health services, including colorectal cancer treatments. This study investigates the effects of delayed colorectal cancer treatments during the COVID pandemic on disease progression. METHODS A retrospective chart review of 107 patients with histologically confirmed diagnosis of colorectal cancer was conducted. The occurrence of cancer upstaging after initial diagnosis was assessed and compared between patients with treatment delays and patients who received treatments within the period recommended by NHS guidelines. A logistic regression was performed to evaluate the association between treatment delays beyond 62 days and cancer upstaging. RESULTS The median age of the cohort was 71.2 years and 64.5% of the patients were over 65 years. Treatment delays were observed in 53.3% of reviewed patients. Patients with treatment delays received cancer treatments 95.8 (31.0) days on average after referral, compared to 46.3 (11.5) days in patients who experienced no treatment delays (p-value<0.0001). 38.6% of patients with treatment delays experienced cancer upstaging by the time of treatment, compared to 20% in the non-delay group (p-value = 0.036). Patients who received treatment after sixty two days from date of referral were 3.27 times more likely to experience colorectal cancer upstaging compared to those who received timely treatments. CONCLUSION Although an effective response to the Covid-19 pandemic requires the reallocation of healthcare resources, there is a need to ensure that treatments and health outcomes of patients with chronic diseases such as colorectal cancer continue to be prioritized and delivered in timely fashion.
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Affiliation(s)
- Omotara Kafayat Lesi
- Mid and South Essex NHS Foundation Trust, Basildon and Thurrock University Hospitals, Essex, United Kingdom
| | | | - Sarah-Jane Walton
- Mid and South Essex NHS Foundation Trust, Basildon and Thurrock University Hospitals, Essex, United Kingdom
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2
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Pumarega J, Camargo J, Gasull M, Olshan AF, Soliman A, Chen Y, Richardson D, Alguacil J, Poole C, Trasande L, Porta M. Timing of Toenail Collection and Concentrations of Metals in Pancreatic Cancer. Evidence Against Disease Progression Bias. EXPOSURE AND HEALTH 2021; 14:581-593. [PMID: 34722949 PMCID: PMC8533671 DOI: 10.1007/s12403-021-00436-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 09/27/2021] [Accepted: 09/30/2021] [Indexed: 05/03/2023]
Abstract
Trace elements such as cadmium, arsenic, zinc or selenium increase or decrease risk of a wide range of human diseases. Their levels in toenails may provide a measure of mid-term intake of trace elements for studies in humans. However, in biologically and clinically aggressive diseases as pancreatic cancer, the progression of the disease could modify such concentrations and produce reverse causation bias. The aim was to analyze the influence of specific time intervals between several clinical events and the collection of toenails upon concentrations of trace elements in patients with pancreatic cancer. Subjects were 118 incident cases of pancreatic adenocarcinoma prospectively recruited in eastern Spain. Toenails were collected at cancer diagnosis, and soon thereafter interviews were conducted. Information on cancer signs and symptoms was obtained from medical records and patient interviews. Levels of 12 trace elements were determined in toenail samples by inductively coupled plasma mass spectrometry. General linear models adjusting for potential confounders were applied to analyze relations between log concentrations of trace elements and the time intervals, including the interval from first symptom of cancer to toenail collection (iST). Toenail concentrations of the 12 trace elements were weakly or not influenced by the progression of the disease or the diagnostic procedures. Concentrations of aluminum were slightly higher in subjects with a longer iST (age, sex and stage adjusted geometric means: 11.44 vs. 7.75 µg/g for iST > 120 days vs. ≤ 40 days). There was a weak inverse relation of iST with concentrations of zinc and selenium (maximum differences of about 20 and 0.08 µg/g, respectively). Conclusions: concentrations of the trace elements were weakly or not influenced by the development of the disease before toenail collection. Only concentrations of aluminum increased slightly with increasing iST, whereas levels of zinc and selenium decreased weakly. Even in an aggressive disease as pancreatic cancer, toenail concentrations of trace elements may provide a valid measure of mid-term intake of trace elements, unaffected by clinical events and disease progression. Supplementary Information The online version contains supplementary material available at 10.1007/s12403-021-00436-2.
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Affiliation(s)
- José Pumarega
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- School of Medicine, Universitat Autònoma de Barcelona, Catalonia, Spain
| | - Judit Camargo
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
- School of Medicine, Universitat Autònoma de Barcelona, Catalonia, Spain
| | - Magda Gasull
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- School of Medicine, Universitat Autònoma de Barcelona, Catalonia, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
| | - Andrew F. Olshan
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA
| | - Amr Soliman
- Medical School of the City University of New York, New York, USA
| | - Yu Chen
- Departments of Environmental Medicine, and Population Health, New York University School of Medicine, New York, USA
| | - David Richardson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA
| | - Juan Alguacil
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Universidad de Huelva, Huelva, Spain
| | - Charles Poole
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA
| | - Leonardo Trasande
- Departments of Environmental Medicine, and Population Health, New York University School of Medicine, New York, USA
- Department of Pediatrics, New York University School of Medicine, New York, USA
- New York University College of Global Public Health, New York, USA
| | - Miquel Porta
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- School of Medicine, Universitat Autònoma de Barcelona, Catalonia, Spain
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA
- Department of Pediatrics, New York University School of Medicine, New York, USA
| | - for the PANKRAS II Study Group
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- School of Medicine, Universitat Autònoma de Barcelona, Catalonia, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA
- Medical School of the City University of New York, New York, USA
- Departments of Environmental Medicine, and Population Health, New York University School of Medicine, New York, USA
- Universidad de Huelva, Huelva, Spain
- Department of Pediatrics, New York University School of Medicine, New York, USA
- New York University College of Global Public Health, New York, USA
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3
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Franssen RFW, Strous MTA, Bongers BC, Vogelaar FJ, Janssen-Heijnen MLG. The Association Between Treatment Interval and Survival in Patients With Colon or Rectal Cancer: A Systematic Review. World J Surg 2021; 45:2924-2937. [PMID: 34175967 PMCID: PMC8322003 DOI: 10.1007/s00268-021-06188-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgery for colon or rectal cancer is associated with a high incidence of complications, especially in patients with a low aerobic fitness. Those patients might benefit from a comprehensive preoperative workup including prehabilitation. However, time between diagnosis and treatment is often limited due to current treatment guidelines. To date, it is unclear whether the treatment interval can be extended without compromising survival. METHODS A systematic review concerning the association between treatment intervals and survival in patients who underwent elective curative surgery for colon or rectal cancer was performed. A search up to December 2020 was conducted in PubMed, Cinahl and Embase. Original research articles were eligible. Quality assessment was performed using the Downs and Black checklist. RESULTS Eleven observational studies were included (897 947 patients). In colon cancer, treatment intervals that were statistically significant associated with reduced overall survival or cancer-specific survival ranged between > 30 and > 84 days. In rectal cancer, only one out of four studies showed that treatment intervals > 49 days was associated with reduced cancer-specific survival. CONCLUSIONS This systematic review identified that studies investigating the association between treatment intervals and survival are heterogeneous with regard to treatment interval definitions, treatment interval time intervals and used outcome measures. These aspects need standardization before a reliable estimate of an optimal treatment interval can be made. In addition, further research should focus on establishing optimal treatment intervals in patients at high risk for postoperative complications, as particularly these patients might benefit from extended diagnosis to treatment intervals permitting comprehensive preoperative preparation.
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Affiliation(s)
- Ruud F W Franssen
- Department of Clinical Physical Therapy, VieCuri Medical Center, Venlo Tegelseweg, Venlo, 210 5912BL, The Netherlands.
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | - Maud T A Strous
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, VieCuri Medical Center, Venlo, The Netherlands
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - F Jeroen Vogelaar
- Department of Surgery, VieCuri Medical Center, Venlo, The Netherlands
| | - Maryska L G Janssen-Heijnen
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Epidemiology, VieCuri Medical Center, Venlo, The Netherlands
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4
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DE Rosa M, Pasculli A, Rondelli F, Mariani L, Avenia S, Ceccarelli G, Testini M, Avenia N, Bugiantella W. Could diagnostic and therapeutic delay affect the prognosis of gastrointestinal primary malignancies in the COVID-19 pandemic era? A literature review. Minerva Surg 2021; 76:467-476. [PMID: 33890444 DOI: 10.23736/s2724-5691.21.08736-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Emergency situations, as the Covid-19 pandemic that is striking the world nowadays, stress the national health systems which are forced to rapidly reorganizing their sources. Therefore, many elective diagnostic and surgical procedures are being suspended or significantly delayed. Moreover, patients might find it difficult to refer to physicians and delay the diagnostic and even the therapeutic procedures because of emotional or logistic problems. The effect of diagnostic and therapeutic delay on survival in patients affected by gastrointestinal malignancies is still unclear. METHODS We carried out a review of the available literature, in order to determine whether the delay in performing diagnosis and curative-intent surgical procedures affects the oncological outcomes in patients with oesophageal, gastric, colorectal cancers, and colorectal liver metastasis. RESULTS The findings indicate that for oesophageal, gastric and colon cancers delaying surgery up to 2 months after the end of the staging process does not worsen the oncological outcomes. Oesophageal cancer should undergo surgery within 7-8 weeks after the end of neoadjuvant chemoradiation. Rectal cancers should undergo surgery within 31 days after the diagnostic process and within 12 weeks after neoadjuvant therapy. Adjuvant therapy should start within 4 weeks after surgery, especially in gastric cancer; a delay up to 42 days may be allowed for oesophageal cancer undergoing adjuvant radiotherapy. CONCLUSIONS Gastrointestinal malignancies can be safely managed taking into account that reasonable delays of planned treatments appear a generally safe approach, not having a significant impact on long-term oncological outcome.
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Affiliation(s)
- Michele DE Rosa
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Perugia, Italy
| | - Alessandro Pasculli
- Department of Biomedical Sciences and Human Oncology - Unit Of Endocrine, Digestive And Emergency Surgery, University A. Moro of Bari, Polyclinic of Bari, Bari, Italy
| | - Fabio Rondelli
- General and Specialized Surgery, Santa Maria Hospital, Terni, Italy.,Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Lorenzo Mariani
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Perugia, Italy
| | - Stefano Avenia
- Postgraduate School of General Surgery, University of Perugia, Perugia, Italy
| | - Graziano Ceccarelli
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Perugia, Italy
| | - Mario Testini
- Department of Biomedical Sciences and Human Oncology - Unit Of Endocrine, Digestive And Emergency Surgery, University A. Moro of Bari, Polyclinic of Bari, Bari, Italy
| | - Nicola Avenia
- General and Specialized Surgery, Santa Maria Hospital, Terni, Italy.,Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Walter Bugiantella
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Perugia, Italy -
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5
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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 2020; 24:1-332. [PMID: 33252328 PMCID: PMC7768788 DOI: 10.3310/hta24660] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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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6
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Abdulaal A, Arhi C, Ziprin P. Effect of Health Care Provider Delays on Short-Term Outcomes in Patients With Colorectal Cancer: Multicenter Population-Based Observational Study. Interact J Med Res 2020; 9:e15911. [PMID: 32706666 PMCID: PMC7395251 DOI: 10.2196/15911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 04/26/2020] [Accepted: 05/14/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The United Kingdom has lower survival figures for all types of cancers compared to many European countries despite similar national expenditures on health. This discrepancy may be linked to long diagnostic and treatment delays. OBJECTIVE The aim of this study was to determine whether delays experienced by patients with colorectal cancer (CRC) affect their survival. METHODS This observational study utilized the Somerset Cancer Register to identify patients with CRC who were diagnosed on the basis of positive histology findings. The effects of diagnostic and treatment delays and their subdivisions on outcomes were investigated using Cox proportional hazards regression. Kaplan-Meier plots were used to illustrate group differences. RESULTS A total of 648 patients (375 males, 57.9% males) were included in this study. We found that neither diagnostic delay nor treatment delay had an effect on the overall survival in patients with CRC (χ23=1.5, P=.68; χ23=0.6, P=.90, respectively). Similarly, treatment delays did not affect the outcomes in patients with CRC (χ23=5.5, P=.14). The initial Cox regression analysis showed that patients with CRC who had short diagnostic delays were less likely to die than those experiencing long delays (hazard ratio 0.165, 95% CI 0.044-0.616; P=.007). However, this result was nonsignificant following sensitivity analysis. CONCLUSIONS Diagnostic and treatment delays had no effect on the survival of this cohort of patients with CRC. The utility of the 2-week wait referral system is therefore questioned. Timely screening with subsequent early referral and access to diagnostics may have a more beneficial effect.
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Affiliation(s)
| | | | - Paul Ziprin
- Imperial College London, London, United Kingdom
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7
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Strous MT, Janssen-Heijnen ML, Vogelaar F. Impact of therapeutic delay in colorectal cancer on overall survival and cancer recurrence – is there a safe timeframe for prehabilitation? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2019; 45:2295-2301. [DOI: 10.1016/j.ejso.2019.07.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/19/2019] [Accepted: 07/03/2019] [Indexed: 11/17/2022]
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8
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Fujiya K, Irino T, Furukawa K, Omori H, Makuuchi R, Tanizawa Y, Bando E, Terashima M. Safety of prolonged wait time for gastrectomy in clinical stage I gastric cancer. Eur J Surg Oncol 2019; 45:1964-1968. [PMID: 31230983 DOI: 10.1016/j.ejso.2019.06.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/28/2019] [Accepted: 06/03/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Patients with stage I gastric cancer tend to wait for surgery. Although the cancer may progress during such a delay, effects of wait time for surgery on survival remain inconsistent. Here, we evaluated the safety of surgical wait time on survival of patients with clinical stage I gastric cancer. METHODS The outcomes of 556 patients who underwent gastrectomy for clinical stage I gastric cancer between January 2007 and December 2011 were retrospectively evaluated. Patients were stratified into three groups based on wait time: short- (<61 days, n = 185), intermediate- (61-90 days, n = 218), and long-wait (91-180 days, n = 153) groups. Clinicopathological findings and survival were compared among the groups. RESULTS The median wait time was 72 days. Age and comorbidities differed among the groups, but clinical and pathological cancer stages did not. Overall survival was comparable; the 5-year overall survival was 90.2%, 93.6%, and 88.8% in the short-, intermediate-, and long-wait groups, respectively. Multivariate analysis revealed that wait time was not an independent prognostic factor for overall survival. Adjusted hazard ratios (HRs) were 0.69 (p = 0.262) and 1.03 (p = 0.926) in the intermediate- and long-wait groups, respectively, with short wait time as the reference. Relapse-free survival was comparable among the groups (intermediate-wait HR = 0.80, p = 0.476; long-wait HR = 1.10, p = 0.740). CONCLUSION A half-year wait time for surgery was not independently associated with survival of patients with clinical stage I gastric cancer and may therefore be acceptable.
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Affiliation(s)
- Keiichi Fujiya
- Division of Gastric Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Tomoyuki Irino
- Division of Gastric Surgery, Shizuoka Cancer Center, Shizuoka, Japan; Division of Surgery, Keio University School of Medicine, Tokyo, Japan
| | | | - Hayato Omori
- Division of Gastric Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Rie Makuuchi
- Division of Gastric Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yutaka Tanizawa
- Division of Gastric Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Etsuro Bando
- Division of Gastric Surgery, Shizuoka Cancer Center, Shizuoka, Japan
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9
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Cavallin F, Scarpa M, Cagol M, Alfieri R, Ruol A, Chiarion Sileni V, Rugge M, Ancona E, Castoro C. Time to diagnosis in esophageal cancer: a cohort study. Acta Oncol 2018; 57:1179-1184. [PMID: 29600882 DOI: 10.1080/0284186x.2018.1457224] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The association between shorter time to diagnosis and favorable outcome is still unproven in esophageal cancer. This study aims to evaluate the effect of time to diagnosis on patient prognosis. MATERIAL AND METHODS Retrospective cohort study of all 3613 symptomatic patients referred for esophageal cancer to our center from 1980 to 2011. Time to diagnosis was calculated as the number of days from first symptom onset to the diagnosis of esophageal cancer. The main outcome measures were: resectability and severe malnutrition at diagnosis; postoperative morbidity, mortality and survival. RESULTS Longer time to diagnosis was significantly associated with severe malnutrition at diagnosis (odds ratio (OR): 1.003, 95% confidence interval (C.I.).: 1.001-1.006) but not with resectability (OR: 0.997, 95% C.I.: 0.994-1.001). Longer time to diagnosis was not associated with postoperative morbidity (OR: 1.000, 95% C.I.: 0.998-1.003), postoperative mortality (OR: 1.002, 95% C.I.: 0.998-1.006), five-year overall survival (hazard ratio (HR): 0.999, 95% C.I.: 0.997-1.001) or five-year disease free survival (HR: 0.999, 95% C.I.: 0.998-1.001). CONCLUSION Longer time to diagnosis did not affect resectability, postoperative morbidity or survival. Further campaigns to raise awareness of cancer among population and primary health care providers may have limited effect on clinical outcome.
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Affiliation(s)
- Francesco Cavallin
- Surgical Oncology Unit, Veneto Institute of Oncology IOV IRCCS, Padova, Italy
| | - Marco Scarpa
- Surgical Oncology Unit, Veneto Institute of Oncology IOV IRCCS, Padova, Italy
| | - Matteo Cagol
- Surgical Oncology Unit, Veneto Institute of Oncology IOV IRCCS, Padova, Italy
| | - Rita Alfieri
- Surgical Oncology Unit, Veneto Institute of Oncology IOV IRCCS, Padova, Italy
| | - Alberto Ruol
- Clinica Chirurgica 3, Dipartimento di Scienze Chirurgiche Oncologiche e Gastroenterologiche DiSCOG, Azienda Ospedaliera-Università di Padova, Padova, Italy
| | | | - Massimo Rugge
- Department of Medicine (DIMED), Università di Padova, Padova, Italy
| | - Ermanno Ancona
- Surgical Oncology Unit, Veneto Institute of Oncology IOV IRCCS, Padova, Italy
| | - Carlo Castoro
- Department of Upper GI Surgery, Humanitas Research Hospital-Humanitas University, Rozzano, Italy
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10
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Patel R, Anderson JE, McKenzie C, Simpson M, Singh N, Ruzvidzo F, Sharma P, Scott R, MacDonald A. Compliance with the 62-day target does not improve long-term survival. Int J Colorectal Dis 2018; 33:65-69. [PMID: 29101452 DOI: 10.1007/s00384-017-2930-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2017] [Indexed: 02/04/2023]
Abstract
AIMS Scottish Intercollegiate Guidelines Network (SIGN) guidelines require patients with colorectal cancer to wait no longer than 62 days from first referral to initiation of definitive treatment. We previously demonstrated that failure to meet with these guidelines did not appear to lead to poor outcomes in the short term. This study investigates whether this holds true over a longer period. METHODS The survival status of 1,012 patients treated for colorectal cancer between January 1999 and June 2005 was reviewed. As in the previous audit, patients were placed into four groups, standard met (elective), standard met (emergency), standard failed (elective) and standard failed (emergency). Parameters analysed were pathological staging, 30-day mortality, long-term survival and cause of death. Data was analysed using log rank and chi-squared tests. RESULTS Operative mortality was higher in patients meeting the standard (7% elective, 20% emergency) compared to those who did not meet the standard (4% elective, 7% emergency). The proportion of early stage disease (Dukes' A and B) was highest in elective patients who failed the standard (50%) and lowest in emergencies meeting the standard (30%). Long-term survival was greatest in elective patients who failed the standard with 52% alive in October 2011 compared to 34% of elective cases meeting the standard. The most common cause of recorded death was colorectal cancer in all groups. CONCLUSIONS Patients who were not treated within the time frame set by the SIGN guidelines survived for longer following surgery. Reasons for this are likely to be multifactorial and include pathological cancer stage.
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Affiliation(s)
- Ronak Patel
- Department of Colorectal Surgery, NHS Lanarkshire, Monklands Hospital, Monkscourt Avenue, Airdrie, North Lanarkshire, ML6 0JS, Scotland.
| | - John E Anderson
- Department of Colorectal Surgery, NHS Lanarkshire, Monklands Hospital, Monkscourt Avenue, Airdrie, North Lanarkshire, ML6 0JS, Scotland
| | - Claire McKenzie
- Department of Clinical Effectiveness, NHS Lanarkshire, Monklands Hospital, Airdrie, Scotland
| | - Mhairi Simpson
- Department of Clinical Effectiveness, NHS Lanarkshire, Monklands Hospital, Airdrie, Scotland
| | - Nina Singh
- Department of Colorectal Surgery, NHS Lanarkshire, Monklands Hospital, Monkscourt Avenue, Airdrie, North Lanarkshire, ML6 0JS, Scotland
| | - Fredrick Ruzvidzo
- Department of Colorectal Surgery, NHS Lanarkshire, Monklands Hospital, Monkscourt Avenue, Airdrie, North Lanarkshire, ML6 0JS, Scotland
| | - Praveen Sharma
- Department of Colorectal Surgery, NHS Lanarkshire, Monklands Hospital, Monkscourt Avenue, Airdrie, North Lanarkshire, ML6 0JS, Scotland
| | - Roy Scott
- Department of Colorectal Surgery, NHS Lanarkshire, Monklands Hospital, Monkscourt Avenue, Airdrie, North Lanarkshire, ML6 0JS, Scotland
| | - Angus MacDonald
- Department of Colorectal Surgery, NHS Lanarkshire, Monklands Hospital, Monkscourt Avenue, Airdrie, North Lanarkshire, ML6 0JS, Scotland
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11
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Bonfill X, Martinez-Zapata MJ, Vernooij RWM, Sánchez MJ, Suárez-Varela MM, De la Cruz J, Emparanza JI, Ferrer M, Pijoan JI, Palou J, Schmidt S, Madrid E, Abraira V, Zamora J. Clinical interval and diagnostic characteristics in a cohort of bladder cancer patients in Spain: a multicenter observational study. BMC Res Notes 2017; 10:708. [PMID: 29212556 PMCID: PMC5719559 DOI: 10.1186/s13104-017-3024-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 11/29/2017] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE We performed a cohort study in seven hospitals in Spain to determine the clinical characteristics of incident patients with bladder cancer, the diagnostic process, and the conditions that might affect health care interval times. RESULTS 314 patients with bladder cancer were included, 70.3 (Standard Deviation [SD] 11.2) years old and 85.0% male. Clinical stage was T1 in 45.9% of patients. The median interval time between first consultation and diagnosis was of 104.0 days (Inter quartile range [IQR]:112.0; range from 0 to 986), being shorter for those patients who attended a hospital for their first consultation. The median interval time between diagnosis and first treatment was of 0.0 days (IQR: 0.0; range from 0 to 366), being longer when the patient had a pathologic tumor stage ≥ T2a.
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Affiliation(s)
- Xavier Bonfill
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.,Iberoamerican Cochrane Centre, Institute of Biomedical Research Sant Pau (IIB Sant Pau), Barcelona, Spain.,Public Health and Clinical Epidemiology Service, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - María José Martinez-Zapata
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain. .,Iberoamerican Cochrane Centre, Institute of Biomedical Research Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - Robin W M Vernooij
- Iberoamerican Cochrane Centre, Institute of Biomedical Research Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - María José Sánchez
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.,Escuela Andaluza de Salud Pública, Instituto de Investigación Biosanitaria de Granada, Barcelona, Spain
| | - María Morales Suárez-Varela
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.,Unit of Public Health and Environmental Care, Department of Preventive Medicine, University of Valencia, Valencia, Spain
| | - Javier De la Cruz
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.,Hospital 12 de Octubre, Madrid, Spain
| | - José Ignacio Emparanza
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.,Clinical Epidemiology Unit, Hospital Universitario Donostia, BioDonostia, San Sebastian, Spain
| | - Montserrat Ferrer
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.,Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - José Ignacio Pijoan
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.,Clinical Epidemiology Unit, Hospital, Universitario Cruces. Biocruces, Barakaldo, Spain
| | - Joan Palou
- Fundació Puigvert, Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Stefanie Schmidt
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Eva Madrid
- Iberoamerican Cochrane Centre, Barcelona, Spain.,Biomedical Research Centre-Universidad de Valparaiso-Chile, Valparaiso, Chile.,Department of Public Health-School of Medicine, Universidad de Valparaiso-Chile, Valparaiso, Chile
| | - Víctor Abraira
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Javier Zamora
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.,Unidad de Bioestadística Clínica, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain.,Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK
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12
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Zarcos-Pedrinaci I, Fernández-López A, Téllez T, Rivas-Ruiz F, Rueda A A, Suarez-Varela MMM, Briones E, Baré M, Escobar A, Sarasqueta C, de Larrea NF, Aguirre U, Quintana JM, Redondo M. Factors that influence treatment delay in patients with colorectal cancer. Oncotarget 2017; 8:36728-36742. [PMID: 27888636 PMCID: PMC5482692 DOI: 10.18632/oncotarget.13574] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 11/12/2016] [Indexed: 01/07/2023] Open
Abstract
A prospective study was performed of patients diagnosed with colorectal cancer (CRC), distinguishing between colonic and rectal location, to determine the factors that may provoke a delay in the first treatment (DFT) provided.2749 patients diagnosed with CRC were studied. The study population was recruited between June 2010 and December 2012. DFT is defined as time elapsed between diagnosis and first treatment exceeding 30 days.Excessive treatment delay was recorded in 65.5% of the cases, and was more prevalent among rectal cancer patients. Independent predictor variables of DFT in colon cancer patients were a low level of education, small tumour, ex-smoker, asymptomatic at diagnosis and following the application of screening. Among rectal cancer patients, the corresponding factors were primary school education and being asymptomatic.We conclude that treatment delay in CRC patients is affected not only by clinicopathological factors, but also by sociocultural ones. Greater attention should be paid by the healthcare provider to social groups with less formal education, in order to optimise treatment attention.
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Affiliation(s)
- Irene Zarcos-Pedrinaci
- Research Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | | | - Teresa Téllez
- Research Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Francisco Rivas-Ruiz
- Research Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Antonio Rueda A
- Servicio de Oncología Médica, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - María Manuela Morales Suarez-Varela
- Unit of Public Health, Hygiene and Environmental Health, Department of Preventive Medicine and Public Health, Food Science, Toxicology and Legal Medicine, University of Valencia, CIBER-Epidemiology and Public Health (CIBERESP), Valencia, Spain
| | - Eduardo Briones
- Public Health Unit, Distrito Sanitario Sevilla, Consorcio de Investigación Biomédica de Epidemiología y Salud Pública, Madrid, Spain
| | - Marisa Baré
- Clinical Epidemiology and Cancer Screening, Corporació Sanitària Parc Taulí, Sabadell, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Antonio Escobar
- Research Unit, Hospital Universitario Basurto, Bilbao, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Cristina Sarasqueta
- Research Unit, Donostia University Hospital, San Sebastián, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Nerea Fernández de Larrea
- Area of Environmental Epidemiology and Cancer, National Epidemiology Centre, Instituto de Salud Carlos III, Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiología y Salud Pública, CIBERESP), Madrid, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Urko Aguirre
- Research Unit, Hospital Galdakao-Usansolo, Galdakao, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - José María Quintana
- Research Unit, Hospital Galdakao-Usansolo, Galdakao, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Maximino Redondo
- Research Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
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13
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Pita-Fernández S, González-Sáez L, López-Calviño B, Seoane-Pillado T, Rodríguez-Camacho E, Pazos-Sierra A, González-Santamaría P, Pértega-Díaz S. Effect of diagnostic delay on survival in patients with colorectal cancer: a retrospective cohort study. BMC Cancer 2016; 16:664. [PMID: 27549406 PMCID: PMC4994409 DOI: 10.1186/s12885-016-2717-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 08/09/2016] [Indexed: 12/14/2022] Open
Abstract
Background Disparate and contradictory results make studies necessary to investigate in more depth the relationship between diagnostic delay and survival in colorectal cancer (CRC) patients. The aim of this study is to analyse the relationship between the interval from first symptom to diagnosis (SDI) and survival in CRC. Methods Retrospective study of n = 942 CRC patients. SDI was calculated as the time from the diagnosis of cancer and the first symptoms of CRC. Cox regression was used to estimate five-year mortality hazard ratios as a function of SDI, adjusting for age and gender. SDI was modelled according to SDI quartiles and as a continuous variable using penalized splines. Results Median SDI was 3.4 months. SDI was not associated with stage at diagnosis (Stage I = 3.6 months, Stage II-III = 3.4, Stage IV = 3.2; p = 0.728). Shorter SDIs corresponded to patients with abdominal pain (2.8 months), and longer SDIs to patients with muchorrhage (5.2 months) and rectal tenesmus (4.4 months). Adjusting for age and gender, in rectum cancers, patients within the first SDI quartile had lower survival (p = 0.003), while in colon cancer no significant differences were found (p = 0.282). These results do not change after adjusting for TNM stage. The splines regression analysis revealed that, for rectum cancer, 5-year mortality progressively increases for SDIs lower than the median (3.7 months) and decreases as the delay increases until approximately 8 months. In colon cancer, no significant relationship was found between SDI and survival. Conclusions Short diagnostic intervals are significantly associated with higher mortality in rectal but not in colon cancers, even though a borderline significant effect is also observed in colon cancer. Longer diagnostic intervals seemed not to be associated with poorer survival. Other factors than diagnostic delay should be taken into account to explain this “waiting-time paradox”.
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Affiliation(s)
- Salvador Pita-Fernández
- Clinical Epidemiology and Biostatistics Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Universidade da Coruña, A Coruña, Spain.
| | - Luis González-Sáez
- Surgery Department, Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Universidade da Coruña, A Coruña, Spain
| | - Beatriz López-Calviño
- Clinical Epidemiology and Biostatistics Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Universidade da Coruña, A Coruña, Spain
| | - Teresa Seoane-Pillado
- Clinical Epidemiology and Biostatistics Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Universidade da Coruña, A Coruña, Spain
| | - Elena Rodríguez-Camacho
- Department of Population Screening Programs, SERGAS, Santiago de Compostela, A Coruña, Spain
| | - Alejandro Pazos-Sierra
- Department of Information and Communication Technologies, Computer Science Faculty, University of A Coruña, A Coruña, Spain
| | | | - Sonia Pértega-Díaz
- Clinical Epidemiology and Biostatistics Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Universidade da Coruña, A Coruña, Spain
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14
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15
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Bonfill X, Martinez-Zapata MJ, Vernooij RWM, Sánchez MJ, Suárez-Varela MM, de la Cruz J, Emparanza JI, Ferrer M, Pijoán JI, Ramos-Goñi JM, Palou J, Schmidt S, Abraira V, Zamora J. Clinical intervals and diagnostic characteristics in a cohort of prostate cancer patients in Spain: a multicentre observational study. BMC Urol 2015; 15:60. [PMID: 26134117 PMCID: PMC4488131 DOI: 10.1186/s12894-015-0058-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 06/16/2015] [Indexed: 12/04/2022] Open
Abstract
Background Little is known about the healthcare process for patients with prostate cancer, mainly because hospital-based data are not routinely published. The main objective of this study was to determine the clinical characteristics of prostate cancer patients, the, diagnostic process and the factors that might influence intervals from consultation to diagnosis and from diagnosis to treatment. Methods We conducted a multicentre, cohort study in seven hospitals in Spain. Patients’ characteristics and diagnostic and therapeutic variables were obtained from hospital records and patients’ structured interviews from October 2010 to September 2011. We used a multilevel logistic regression model to examine the association between patient care intervals and various variables influencing these intervals (age, BMI, educational level, ECOG, first specialist consultation, tumour stage, PSA, Gleason score, and presence of symptoms) and calculated the odds ratio (OR) and the interquartile range (IQR). To estimate the random inter-hospital variability, we used the median odds ratio (MOR). Results 470 patients with prostate cancer were included. Mean age was 67.8 (SD: 7.6) years and 75.4 % were physically active. Tumour size was classified as T1 in 41.0 % and as T2 in 40 % of patients, their median Gleason score was 6.0 (IQR:1.0), and 36.1 % had low risk cancer according to the D’Amico classification. The median interval between first consultation and diagnosis was 89 days (IQR:123.5) with no statistically significant variability between centres. Presence of symptoms was associated with a significantly longer interval between first consultation and diagnosis than no symptoms (OR:1.93, 95%CI 1.29–2.89). The median time between diagnosis and first treatment (therapeutic interval) was 75.0 days (IQR:78.0) and significant variability between centres was found (MOR:2.16, 95%CI 1.45–4.87). This interval was shorter in patients with a high PSA value (p = 0.012) and a high Gleason score (p = 0.026). Conclusions Most incident prostate cancer patients in Spain are diagnosed at an early stage of an adenocarcinoma. The period to complete the diagnostic process is approximately three months whereas the therapeutic intervals vary among centres and are shorter for patients with a worse prognosis. The presence of prostatic symptoms, PSA level, and Gleason score influence all the clinical intervals differently.
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Affiliation(s)
- Xavier Bonfill
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. .,Institute of Biomedical Research (IIB Sant Pau), Iberoamerican Cochrane Centre, Barcelona, Spain. .,Universitat Autònoma de Barcelona, Barcelona, Spain. .,Public Health and Clinical Epidemiology Service, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
| | - María José Martinez-Zapata
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. .,Institute of Biomedical Research (IIB Sant Pau), Iberoamerican Cochrane Centre, Barcelona, Spain. .,Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Robin W M Vernooij
- Institute of Biomedical Research (IIB Sant Pau), Iberoamerican Cochrane Centre, Barcelona, Spain.
| | - María José Sánchez
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. .,Instituto de Investigación Biosanitaria de Granada, Escuela Andaluza de Salud Pública, Granada, Spain.
| | - María Morales Suárez-Varela
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. .,Department of Preventive Medicine, Unit of Public Health and Environmental Care, University of Valencia, Center for Public Health Research (CSISP), Valencia, Spain.
| | - Javier de la Cruz
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. .,Hospital 12 de Octubre, Madrid, Spain.
| | - José Ignacio Emparanza
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. .,Clinical Epidemiology Unit, Hospital Universitario Donostia, BioDonostia, San Sebastian, Spain.
| | - Montserrat Ferrer
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. .,IMIM (Hospital del Mar Medical Research Institute), Health Services Research Group, Barcelona, Spain.
| | - José Ignacio Pijoán
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. .,Unidad de Epidemiología Clínica y Soporte Metodológico, UICEC de BioCruces-SCReN, Barakaldo, Spain.
| | - Juan M Ramos-Goñi
- Health Services Research on Chronic Patients Network (REDISSEC), HTA Unit of the Canary Islands Health Service (SESCS), S/C de Tenerife, La Laguna, Spain.
| | - Joan Palou
- Universitat Autònoma de Barcelona, Barcelona, Spain. .,Fundació Puigvert, Barcelona, Spain.
| | - Stefanie Schmidt
- Department of Experimental and Health Sciences, Universidad Pompeu Fabra (UPF), Barcelona, Spain.
| | - Víctor Abraira
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. .,Unidad de Bioestadística Clínica, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain.
| | - Javier Zamora
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. .,Unidad de Bioestadística Clínica, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain.
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16
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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: 649] [Impact Index Per Article: 72.1] [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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Abstract
OBJECTIVE This study aimed to evaluate the trends in the incidence, survival, and surgical therapy for Canadian patients affected by pancreatic cancer (PC). METHODS The incidence, mortality, number of resections, and outcomes of patients with PC stratified by year, sex, and province were extracted from Canadian cancer databases. RESULTS In 2012, PC was diagnosed in 4600 Canadians and it was responsible for 4300 deaths. The age-standardized incidence was 9 to 10 new cases per 100,000 individuals. The mortality rate remained the highest among all the solid tumors with a case-to-fatality ratio of 0.93. The age-standardized 5-year relative survival was 9.1% (95% confidence interval [CI], 8.3-10). There were geographic variations among provinces with the highest survival registered in Ontario (10.9%; 95% CI, 9.9-12) and the lowest survival reported in Nova Scotia (4.7%; 95% CI, 2.8-7.2). The percentage of patients who underwent surgery decreased from 19% (2006-2007) to 17% (2009-2010). Pancreatic resections were performed in high-volume centers in 74% of cases. In-hospital mortality was 5%, 93% of patients were discharged home, and 36% of patients required home support after discharge. CONCLUSIONS Long-term outcomes of Canadian patients affected by PC remain unsatisfactory, with only 9% of the patients surviving at 5 years. Surgical therapy was performed only in 17% to 19% of patients.
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Time from (clinical or certainty) diagnosis to treatment onset in cancer patients: the choice of diagnostic date strongly influences differences in therapeutic delay by tumor site and stage. J Clin Epidemiol 2013; 66:928-39. [DOI: 10.1016/j.jclinepi.2012.12.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 10/30/2012] [Accepted: 12/14/2012] [Indexed: 11/20/2022]
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Factors affecting 5- and 10-year survival of women with breast cancer: An analysis based on a public general hospital in Barcelona. Cancer Epidemiol 2012; 36:554-9. [DOI: 10.1016/j.canep.2012.07.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 07/03/2012] [Accepted: 07/08/2012] [Indexed: 11/23/2022]
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20
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Valentín-López B, Ferrándiz-Santos J, Blasco-Amaro JA, Morillas-Sáinz JD, Ruiz-López P. Assessment of a rapid referral pathway for suspected colorectal cancer in Madrid. Fam Pract 2012; 29:182-8. [PMID: 21976660 DOI: 10.1093/fampra/cmr080] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To assess the results achieved with a rapid referral pathway for suspected colorectal cancer (CRC), comparing with the standard referral pathway. METHODS Three-year audit of patients suspected of having CRC routed via a rapid referral pathway, and patients with CRC routed via the standard referral pathway of a health care district serving a population of 498,000 in Madrid (Spain). Outcomes included referral criteria met, waiting times, cancer diagnosed and stage of disease. RESULTS Two hundred and seventy-two patients (mean age 68.8 years, SD 14.0; 51% male) were routed via the rapid referral pathway for colonoscopy. Seventy-nine per cent of referrals fulfilled the criteria for high risk of CRC. Fifty-two cancers were diagnosed: 26% Stage A (Astler-Coller), 36% Stage B, 24% Stage C and 14% Stage D. Average waiting time to colonoscopy for the rapid referral patients was 18.5 days (SD 19.1) and average waiting time to surgery was 28.6 days (SD 23.9). Colonoscopy was performed within 15 days in 65% of CRC rapid referral patients compared to 43% of standard pathway patients (P = 0.004). Overall waiting time for patients with CRC in the rapid referral pathway was 52.7 days (SD 32.9); while for those in the standard pathway, it was 71.5 days (SD 57.4) (P = 0.002). Twenty-six per cent Stage A CRC was diagnosed in the rapid referral pathway compared to 12% in the standard pathway (P < 0.001). CONCLUSION The rapid referral pathway reduced waiting time to colonoscopy and overall waiting time to final treatment and appears to be an effective strategy for diagnosing CRC in its early stages.
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Diagnostic interval and mortality in colorectal cancer: U-shaped association demonstrated for three different datasets. J Clin Epidemiol 2012; 65:669-78. [PMID: 22459430 DOI: 10.1016/j.jclinepi.2011.12.006] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 12/09/2011] [Accepted: 12/13/2011] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To test the theory of a U-shaped association between time from the first presentation of symptoms in primary care to the diagnosis (the diagnostic interval) and mortality after diagnosis of colorectal cancer (CRC). STUDY DESIGN AND SETTING Three population-based studies in Denmark and the United Kingdom using data from general practitioner's questionnaires, interviewer-administered patient questionnaires, and primary care records, respectively. RESULTS Despite variations in the potential selection and information bias when using different methods of identifying the date of first presentation, the association between the length of the diagnostic interval and 5-year mortality rate after the diagnosis of CRC was the same for all three types of data: displaying a U-shaped association with decreasing and subsequently increasing mortality with longer diagnostic intervals. CONCLUSION Unknown confounding and in particular confounding by indication is likely to explain the counterintuitive findings of higher mortality among patients with very short diagnostic intervals, but cannot explain the increasing mortality with longer diagnostic intervals. The results support the theory that longer diagnostic intervals cause higher mortality in patients with CRC.
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Tørring ML, Frydenberg M, Hansen RP, Olesen F, Hamilton W, Vedsted P. Time to diagnosis and mortality in colorectal cancer: a cohort study in primary care. Br J Cancer 2011; 104:934-40. [PMID: 21364593 PMCID: PMC3065288 DOI: 10.1038/bjc.2011.60] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background: The relationship between the diagnostic interval and mortality from colorectal cancer (CRC) is unclear. This association was examined by taking account of important confounding factors at the time of first presentation of symptoms in primary care. Methods: A total of 268 patients with CRC were included in a prospective, population-based study in a Danish county. The diagnostic interval was defined as the time from first presentation of symptoms until diagnosis. We analysed patients separately according to the general practitioner's interpretation of symptoms. Logistic regression was used to estimate 3-year mortality odds ratios as a function of the diagnostic interval using restricted cubic splines and adjusting for tumour site, comorbidity, age, and sex. Results: In patients presenting with symptoms suggestive of cancer or any other serious illness, the risk of dying within 3 years decreased with diagnostic intervals up to 5 weeks and then increased (P=0.002). In patients presenting with vague symptoms, the association was reverse, although not statistically significant. Conclusion: Detecting cancer in primary care is two sided: aimed at expediting ill patients while preventing healthy people from going to hospital. This likely explains the counterintuitive findings; but it does not explain the increasing mortality with longer diagnostic intervals. Thus, this study provides evidence for the hypothesis that the length of the diagnostic interval affects mortality in CRC patients.
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Affiliation(s)
- M L Tørring
- The Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, School of Public Health, Aarhus University, Bartholin Allé 2, DK-8000 Aarhus C, Denmark.
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Sharma C, Eltawil KM, Renfrew PD, Walsh MJ, Molinari M. Advances in diagnosis, treatment and palliation of pancreatic carcinoma: 1990-2010. World J Gastroenterol 2011; 17:867-97. [PMID: 21412497 PMCID: PMC3051138 DOI: 10.3748/wjg.v17.i7.867] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Revised: 12/08/2010] [Accepted: 12/15/2010] [Indexed: 02/06/2023] Open
Abstract
Several advances in genetics, diagnosis and palliation of pancreatic cancer (PC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. PC is relatively common as it is the fourth leading cause of cancer related mortality. Most patients present with obstructive jaundice, epigastric or back pain, weight loss and anorexia. Despite improvements in diagnostic modalities, the majority of cases are still detected in advanced stages. The only curative treatment for PC remains surgical resection. No more than 20% of patients are candidates for surgery at the time of diagnosis and survival remains quite poor as adjuvant therapies are not very effective. A small percentage of patients with borderline non-resectable PC might benefit from neo-adjuvant chemoradiation therapy enabling them to undergo resection; however, randomized controlled studies are needed to prove the benefits of this strategy. Patients with unresectable PC benefit from palliative interventions such as biliary decompression and celiac plexus block. Further clinical trials to evaluate new chemo and radiation protocols as well as identification of genetic markers for PC are needed to improve the overall survival of patients affected by PC, as the current overall 5-year survival rate of patients affected by PC is still less than 5%. The aim of this article is to review the most recent high quality literature on this topic.
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Siefert ML. Fatigue, Pain, and Functional Status During Outpatient Chemotherapy. Oncol Nurs Forum 2010; 37:E114-23. [DOI: 10.1188/10.onf.114-123] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Gellad ZF, Almirall D, Provenzale D, Fisher DA. Time from positive screening fecal occult blood test to colonoscopy and risk of neoplasia. Dig Dis Sci 2009; 54:2497-502. [PMID: 19093199 PMCID: PMC3726721 DOI: 10.1007/s10620-008-0653-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Accepted: 11/21/2008] [Indexed: 12/18/2022]
Abstract
There is no guideline defining the optimal time from a positive screening fecal occult blood test to follow-up colonoscopy. We reviewed records of 231 consecutive primary care patients who received a colonoscopy within 18 months of a positive fecal occult blood test. We examined the relationship between time to colonoscopy and risk of neoplasia on colonoscopy using a logistic regression analysis adjusting for potential confounders such as age, race, and gender. The mean time to colonoscopy was 236 days. Longer time to colonoscopy (OR = 1.10, P = 0.01) and older age (OR 1.04, P = 0.01) were associated with higher odds of neoplasia. The association of time with advanced neoplasia was positive, but not statistically significant (OR 1.07, P = 0.14). In this study, a longer interval to colonoscopy after fecal occult blood test was associated with an increased risk of neoplasia. Determining the optimal interval for follow-up is desirable and will require larger studies.
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Affiliation(s)
- Ziad F. Gellad
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center,Department of Medicine, Division of Gastroenterology, Duke University Medical Center
| | - Daniel Almirall
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center,Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham NC
| | - Dawn Provenzale
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center,Department of Medicine, Division of Gastroenterology, Duke University Medical Center
| | - Deborah A. Fisher
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center,Department of Medicine, Division of Gastroenterology, Duke University Medical Center
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Iversen LH, Antonsen S, Laurberg S, Lautrup MD. Therapeutic delay reduces survival of rectal cancer but not of colonic cancer. Br J Surg 2009; 96:1183-9. [DOI: 10.1002/bjs.6700] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Background
The relationship between therapeutic delay and long-term survival from colorectal cancer is unclear. This association was examined prospectively among patients with colorectal cancer in Denmark.
Methods
A total of 740 patients with colorectal cancer were included in a prospective, population-based study in three Danish counties from 1 January 2001 to 31 July 2002. Delay was determined by self-report during a standardized interview. Cox proportional hazards regression was used to compute the hazard ratio (HR) associated with delay, while adjusting for age, sex and co-morbidity, and also for urgency of surgery in patients with colonic cancer.
Results
For rectal cancer only, a time span of at least 60 days from the onset of symptoms until treatment (total therapeutic delay) was associated with a 69 per cent higher risk of mortality compared with a total therapeutic delay of less than 60 days (HR 1·69 (95 per cent confidence interval 1·01 to 2·83)). Provider delay (interval from first physician contact until treatment) and hospital delay (interval from referral to a hospital until treatment) of at least 60 days had no impact on survival from colorectal cancer.
Conclusion
A total therapeutic delay of at least 60 days was a negative prognostic factor for long-term survival from rectal cancer.
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Affiliation(s)
- L H Iversen
- Department of Surgery P, Aarhus University Hospital THG, Århus Denmark
| | - S Antonsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Århus Denmark
| | - S Laurberg
- Department of Surgery P, Aarhus University Hospital THG, Århus Denmark
| | - M D Lautrup
- Department of Surgery P, Aarhus University Hospital THG, Århus Denmark
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Duration of symptoms, stage at diagnosis and relative survival in colon and rectal cancer. Eur J Cancer 2009; 45:2383-90. [PMID: 19356923 DOI: 10.1016/j.ejca.2009.03.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Revised: 03/08/2009] [Accepted: 03/12/2009] [Indexed: 12/15/2022]
Abstract
In colorectal cancer, the relation between duration of symptoms and stage at presentation and prognosis is not yet settled. All 1263 patients treated for colorectal cancer at Levanger Hospital, 1980-2004, and 2892 patients treated in Norway during 2004 were included. The association between symptom duration as an explanatory variable and tumour stage as a dependent variable was analysed using a proportional odds logistic regression model. Known duration of symptoms was divided into four categories: <1 week, 1-8 weeks, 2-6 months and >6 months. There was an inverse relationship between symptom duration and colon cancer TNM-stage, OR=0.73 (95% CI 0.63-0.84), p<0.001 (Levanger Hospital) and 0.84 (0.75-0.95), p=0.004 (Norway 2004), where the OR is per category of symptom duration. Duration of symptoms were also inversely associated with T-stage, N-stage and M-stage in colon cancer. These relationships were not found for rectal cancer. In colon cancer the relative five-year survival for the four intervals of symptom duration was 44%, 39%, 54% and 66%, p<0.001, in Levanger, 1980-2004, and four-year survival was 46%, 62%, 75% and 74%, p<0.001, in Norway 2004, respectively. For rectal cancer survival was not dependent on symptom duration. In a multivariate analysis of relative survival of patients with colon cancer, duration of symptoms was associated with survival independent of tumour differentiation and TNM-stage. Increasing duration of symptoms was positively associated with less advanced disease and better survival in colon cancer, but not in rectal cancer.
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[Implication of late diagnosis for survival of patients with colorectal carcinoma]. VOJNOSANIT PREGL 2009; 66:135-40. [PMID: 19281125 DOI: 10.2298/vsp0902135z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIM Colorectal cancer (CRC) is one of the most frequent diseases and early diagnosis has a potential role to improve survival. The aim of this study was to analyze influence of delay in diagnosis on survival in patiens with colorectal cancer. METHODS A total of 119 patients with pathohystological diagnosis of CRC were included in the study. They were operated at our Department for Surgery from 2000 to 2002. They were divided into two groups according to the duration of symptoms: early operated patients - EOP (symptoms were presented for 3 months) and late operated patients - LOP (duration of symptoms was more than 3 months). Follow-up period was 5 year. RESULTS Weight loss, intermittent abdominal pain and anorexia were more frequent in LOP (p < 0.01). Young age, blood in stool, and tumor localized in rectum were dominant characteristics in EOP (p < 0.05). Overall delay in diagnosis was 2.19 +/- 0.79 months in EOP and 11.37 +/- 5.68 months in LOP. There was highly statistically significant difference between these two groups (p < 0.01). Overall survival was 44.75%. Five years survival was 65.9% in the group of EOP and 26.5% in the group of LOP (chi2 = 28.16, p < 0.01) Weight loss was dominant characteristics in the patients who did not survive five years (chi2 = 14.26, p < 0.01). A period of 2 months in delay in diagnosis is "cut-off' value in prediction of death (sensitivity of 75.5% and specificity of 90.3%). CONCLUSION A delay in diagnosis and stage of the disease are highly significant factors of patients with CRC survival. In everyday medical practice higher importance should be put on weight loss, intermittent abdominal pain, change in bowel habits, as well as on syderopenic anaemia.
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Redondo M, Rivas-Ruiz F, Guzman-Soler MC, Labajos C. Monitoring indicators of health care quality by means of a hospital register of tumours. J Eval Clin Pract 2008; 14:1026-30. [PMID: 19019095 DOI: 10.1111/j.1365-2753.2007.00937.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
RATIONALE Hospital registers of tumours provide, on a continuous basis, information on differences in patterns of neoplasias and the results of the treatment strategies employed. OBJECTIVE In view of the scant publications on measures of health care quality in hospital tumour registers, the aim of our paper is to present the outcome of a study to monitor the results related to health care quality in oncology. METHODS Data are presented for cases recorded at the Hospital Costa del Sol over a period of 8 years. The sources of information are fundamentally the patient's medical record and the database of the Pathology Department. RESULTS A high proportion of patients (mean 50%, range 45-68%) were admitted to the hospital by the Emergency Department; there was a notably long delay between the appearance of the first symptoms and the occasion of the first hospital visit (median 65 days; range 60-75 days). Particularly striking was the corresponding delay for breast cancer patients, in most cases superior to 3 months. As was the case for the percentage of admissions by the Emergency Department, most of the indicators evaluated in this study present a significant improvement compared with the initial years of the Hospital Register of Tumours. Thus, non anatomic-pathological diagnoses represented around 7% (range 3-13%), while 43% of patients (range 28-57%) were given adjuvant treatment in the form of radiation therapy or chemotherapy. In 40% of cases (range 20-50%), the tumour stage was included in the clinical record by the doctor who was treating the patient (in the remaining cases, these data were recorded by the Tumour Registry); the date of appearance of the first symptoms was included in the medical record in 65% of cases (range 54-80%). According to the stage classification, the following 5-year survival rates were recorded: (I) 98%, (II) 94%, (III) 69% and (IV) 39% for breast cancer; (I) 93%, (II) 83%, (III) 68% and (IV) 12% for cancer of the colon; and (I) 100%, (II) 94%, (III) 79% and (IV) 53% for prostate cancer. CONCLUSION The high percentage of patients admitted by the Emergency Department and the long delay between the appearance of the first symptoms reflect the deficient attention paid to this problem by patients and by primary health care services. Our results suggest that the Hospital Register of Tumours could constitute an excellent tool for monitoring the quality of health care systems for oncological patients.
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Affiliation(s)
- Maximino Redondo
- Research Unit, Hospital Costa del Sol, Marbella, Malálaga, Spain.
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Pérez G, Porta M, Borrell C, Casamitjana M, Bonfill X, Bolibar I, Fernández E. Interval from diagnosis to treatment onset for six major cancers in Catalonia, Spain. ACTA ACUST UNITED AC 2008; 32:267-75. [PMID: 18789609 DOI: 10.1016/j.cdp.2008.05.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Targets set by health care organizations on time intervals between cancer diagnosis and treatment often go unmet. The objective of the study was to analyse the interval from diagnosis to treatment onset, and related factors, in the six most incident cancers in Catalonia (Spain), a developed European region with universal free access to health care. METHODS Twenty-two hospitals contributed 1023 incident cancer patients (198 lung, 253 colorectal, 95 prostate, 109 urinary bladder, 266 breast, 102 endometrial). Information was gathered from hospital medical records. The dependent variable was the length of the diagnosis to treatment interval (DTI). Independent variables were age, sex, disease stage, hospital level, mode of admission to hospital, and type of physician seen before admission. Multivariate-adjusted odds ratios were calculated by unconditional logistic regression for each cancer site. RESULTS The median DTI (in days) was 39 for lung cancer, 25 for colorectal, 108 for prostate, 69 for bladder, 35 for breast and 40 for endometrial cancer. In prostate and bladder cancers, over 78% of patients showed a DTI >30 days, while in colorectal the figure was 42%. Disseminated stage (distant metastases) was associated with a lower DTI in all sites. Patients admitted to third-level hospitals and with an elective admission were more likely to have a DTI >30 days. CONCLUSIONS In Catalonia, a substantial proportion of cancer patients experience treatment delays that may impact negatively on psychological well-being, quality of life, and probably survival as well.
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Affiliation(s)
- Glòria Pérez
- Agència de Salut Pública de Barcelona, Barcelona, Spain; Universitat Pompeu Fabra, Catalonia, Spain.
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Abstract
Gastric cancer is one of the most common cancers and the second most common cause of cancer deaths worldwide. Apart from Japan, where screening programmes have resulted in early diagnosis in asymptomatic patients, in most countries the diagnosis of gastric cancers is invariably made on account on dyspeptic and alarm symptoms, which may also be of prognostic significance when reported by the patient at diagnosis. However, their use as selection criteria for endoscopy seems to be inconsistent since alarm symptoms are not sufficiently sensitive to detect malignancies. In fact, the overall prevalence of these symptoms in dyspeptic patients is high, while the prevalence of gastro-intestinal cancer is very low. Moreover, symptoms of early stage cancer may be indistinguishable from those of benign dyspepsia, while the presence of alarm symptoms may imply an advanced and often inoperable disease. The features of dyspeptic and alarm symptoms may reflect the pathology of the tumour and be of prognostic value in suggesting site, stage and aggressiveness of cancer. Alarm symptoms in gastric cancer are independently related to survival and an increased number, as well as specific alarm symptoms, are closely correlated to the risk of death.Dysphagia, weight loss and a palpable abdominal mass appear to be major independent prognostic factors in gastric cancer, while gastro-intestinal bleeding, vomiting and also duration of symptoms, do not seem to have a relevant prognostic impact on survival in gastric cancer.
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Relationship of diagnostic and therapeutic delay with survival in colorectal cancer: a review. Eur J Cancer 2007; 43:2467-78. [PMID: 17931854 DOI: 10.1016/j.ejca.2007.08.023] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2007] [Accepted: 08/22/2007] [Indexed: 12/23/2022]
Abstract
BACKGROUND Early diagnosis of colorectal cancer before the onset of symptoms improves survival. Once symptoms have occurred, however, the effect of delay on survival is unclear. We review here evidence on the relationship of diagnostic and therapeutic delay with survival in colorectal cancer. METHODS We conducted a systematic of Medline, Embase, Cancerlit and the Cochrane Database of Systematic Reviews to identify publications published between 1962 and 2006 dealing with delay, survival and colon cancer. A meta-analysis was performed based on the calculation of the relative risk (RR) and on a model of random effects. RESULTS We identified 40 studies, representing 20,440 patients. Fourteen studies were excluded due to excessively restricted samples (e.g. exclusion of patients with intestinal obstruction, with tumours at stage C or D at the time of diagnosis, or who died 1-3 months after surgery); or because they studied only a portion of the delay. Of the 26 remaining studies, 20 showed no association between delay and survival. In contrast, four studies showed that delay was a factor contributing to better prognosis, and two showed that it contributed to poorer prognosis. There was no association between delay and survival when the colon and rectum were considered separately, when a multivariate analysis was performed, and when the effects of tumour stage and degree of differentiation were taken into account. To perform a meta-analysis, 18 additional studies were excluded, since the published articles did not specify the absolute numbers. In the remaining eight studies, the combined relative risk (RR) of delay was 0.92 (confidence interval (CI) 95%: 0.87-0.97). CONCLUSIONS The results of the review suggest that there is no association between diagnostic and therapeutic delay and survival in colorectal cancer patients. Colon and rectum should be assessed separately, and it is necessary to adjust for other relevant variables such as tumour stage.
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Porta M, Pumarega J, Ferrer-Armengou O, López T, Alguacil J, Malats N, Fernàndez E. Timing of blood extraction in epidemiologic and proteomic studies: results and proposals from the PANKRAS II Study. Eur J Epidemiol 2007; 22:577-88. [PMID: 17636417 DOI: 10.1007/s10654-007-9149-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2007] [Accepted: 05/29/2007] [Indexed: 12/22/2022]
Abstract
There are no consensus guidelines or standards for epidemiologic and '-omics' studies using blood biomarkers on how to report the timing of extraction of blood samples. However, disease-induced changes in blood concentrations of exogenous and endogenous compounds may bias studies. The aim of the present report is to describe the timing of blood collection with respect to a variety of relevant clinical events in the PANKRAS II Study, and to suggest ways to display graphically the quantitative information. Subjects were 167 incident cases of exocrine pancreatic cancer prospectively recruited in five teaching hospitals in eastern Spain. Over 80% of patients had blood extracted during the first 6 months since onset of cancer symptoms, and 82% within the first month of admission to a study hospital. Over 80% of cases had blood drawn after an ultrasound, a CT scan or an ERCP, 25% after a laparotomy, and 37% after treatment onset. All three intervals from blood extraction to diagnosis, to treatment onset and to interview had a median of 0 days, and 88% of cases had blood drawn within 2 weeks of diagnosis. Over 72% of cases had concentrations of total lipids in the medium, normal range. Results suggest ways to report intervals involving blood biomarkers and may contribute to develop consensus guidelines and standards on the collection of blood samples in epidemiologic and '-omics' research.
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Affiliation(s)
- Miquel Porta
- Clinical & Molecular Epidemiology of Cancer Unit, Institut Municipal d'Investigació Mèdica, Universitat Autònoma de Barcelona, Carrer del Dr. Aiguader 88, 08003 Barcelona, Catalonia, Spain.
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Suzuki H, Gotoda T, Sasako M, Saito D. Detection of early gastric cancer: misunderstanding the role of mass screening. Gastric Cancer 2007; 9:315-9. [PMID: 17235635 DOI: 10.1007/s10120-006-0399-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2006] [Accepted: 08/30/2006] [Indexed: 02/07/2023]
Abstract
BACKGROUND The proportion of early gastric cancer (EGC) increased from 15% during the 1960s to 50% recently, leading to a remarkable improvement of the 5-year survival rate of gastric cancer patients from 40% to 70%. This has been attributed to mass screening together with extended lymphadenectomy. However, more and more patients with EGC are diagnosed outside of mass screening. The aim of this study was to determine whether patients are symptomatic at the time of early detection and the method of tumor detection. METHODS From 2001 to 2003, a total of 1226 patients (male/female 2.2 : 1.0, age 26-95 years) with EGC were treated at the National Cancer Center Hospital, Tokyo. We reviewed their medical records. RESULTS Of these 1226 patients, 512 (41.8%) were symptomatic, and 714 (58.2%) reported no symptoms. Among the symptomatic patients, 468 (91.4%) were examined at outpatient clinics, 39 (7.6%) by private health assessment clinics, and 5 (1.0%) by mass screening. In total, 91.6% of the symptomatic patients directly underwent esophagogastro-duodenoscopy (EGD). Of the asymptomatic patients, 320 (44.8%) were examined at outpatient clinics, 306 (42.9%) by private health assessment clinics, and 88 (12.3%) by mass screening. EGD was the initial assessment in 67.8% and radiography in 32.2% of asymptomatic patients. CONCLUSION Most patients with EGC were detected outside of mass screening. This suggests that the Japanese public and physicians are well aware of the risk of gastric cancer and the importance of early detection. The effect of mass screening is misunderstood.
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Affiliation(s)
- Haruhisa Suzuki
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
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Abstract
PURPOSE Reports of the relationship between length of delay before diagnosis of rectal cancer and stage of the disease have been mixed. The present study documented the magnitude and medical ramifications of delay in diagnosing rectal cancer. METHODS One hundred twenty patients who had been recently diagnosed with rectal cancer provided information regarding history of symptoms and initial perceptions of those symptoms. Patients also estimated the time elapsed from onset of symptoms until their first consultation with a physician, as well as time elapsed from consultation until the diagnosis of rectal cancer was made. Stage information was gathered from patient charts. RESULTS For 106 of the patients, the first sign of rectal cancer was in the form of symptoms, and the most common first symptom was rectal bleeding. For the remaining 14 patients, their cancer was first discovered through routine examination. Over 75 percent of patients with symptoms did not initially believe that they were caused by cancer or any other serious problem, and over 50 percent attributed their symptoms to hemorrhoids. There was a clear trend, albeit statistically nonsignificant, toward worsening disease with longer delays. Median delay times in weeks were Stage I (10.0 weeks), Stage II (14.0 weeks), Stage III (18.5 weeks), and Stage IV (26.0 weeks). CONCLUSIONS Delayed diagnosis for rectal cancer remains a significant problem, with instances of delay attributable to both patient and physician. Delayed diagnosis can result in more serious disease and, when attributable to the physician, can result in damaged trust and sometimes legal action.
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Affiliation(s)
- Stephen L Ristvedt
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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Porta M, Fabregat X, Malats N, Guarner L, Carrato A, de Miguel A, Ruiz L, Jariod M, Costafreda S, Coll S, Alguacil J, Corominas JM, Solà R, Salas A, Real FX. Exocrine pancreatic cancer: symptoms at presentation and their relation to tumour site and stage. Clin Transl Oncol 2005; 7:189-97. [PMID: 15960930 DOI: 10.1007/bf02712816] [Citation(s) in RCA: 173] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The need to detect pancreatic cancer at earlier stages is undisputed. We recorded the signs and symptoms of patients presenting with exocrine pancreatic cancer and evaluated their association with clinical characteristics such as tumour site and disease stage. PATIENTS AND METHODS All patients (n = 185) with exocrine pancreatic cancer newly diagnosed at five general hospitals in Eastern Spain were prospectively recruited over 5 years. Symptoms were elicited through personal interviews and signs were recorded by the attending physician on admission. RESULTS At diagnosis, one third of tumours of the pancreas head were in stage I and another third in stage IV. None of the tumours of the body and tail were in stage I, and over 80% were in stage IV (p < 0.001) . At presentation, the most frequent symptoms were asthenia (86%), anorexia (85%), weight-loss (85%), abdominal pain (79%), and choluria (59%). Cholestatic symptoms were more common in tumours affecting only the pancreatic head (p < 0.001) . There was a clear trend toward more localized tumours with increasing numbers of cholestatic signs (p < 0.001) . Asthenia, anorexia and weight-loss were unrelated to stage. An increased symptom-to-diagnosis interval was associated with more advanced stage (p = 0.048). CONCLUSIONS Proper attention to signs and symptoms, especially cholestasis, may help identify patients with pancreatic cancer at an earlier stage. Results also provide a current picture of the semiology of pancreatic cancer which could be of use in studies on the potential of proteomic tests in the early detection of this neoplasm.
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Affiliation(s)
- Miquel Porta
- Unidad de Epidemiología Clinica y Molecular del Cáncer, Instituto Municipal de Investigación Médica, Universidad Autónoma de Barcelona, Carrer del Dr. Aiguader 80, 08005 Barcelona, Spain.
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Castells A, Marzo M, Bellas B, Amador FJ, Lanas A, Mascort JJ, Ferrándiz J, Alonso P, Piñol V, Fernández M, Bonfill X, Piqué JM. [Clinical guidelines for the prevention of colorectal cancer]. GASTROENTEROLOGIA Y HEPATOLOGIA 2005; 27:573-634. [PMID: 15574281 DOI: 10.1016/s0210-5705(03)70535-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Porta M, Fernandez E, Alguacil J. Semiology, proteomics, and the early detection of symptomatic cancer. J Clin Epidemiol 2003; 56:815-9. [PMID: 14505764 DOI: 10.1016/s0895-4356(03)00165-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
"Diagnostic delay," the duration of symptoms or the symptom to diagnosis interval (SDI), are highly complex variables that reflect the behavior of the patient and the attending physician, tumor biology and host-tumor interactions, the functioning of the health care system, and sociocultural norms. In addition to tumor stage, other variables mediate the relationship between duration of symptoms and survival; clinical and epidemiologic procedures to measure them must be improved. Largely at odds with clinical and common wisdom, decades of research have shown that often SDI is not associated with tumor stage and/or with survival from cancer. It would be relevant to increase evidence in support of the notion that, for each type of tumor, there is a positive relationship between the length of the presymptomatic and the symptomatic phases. SDI could then be used to classify tumors according to their likelihood of being detected early when still asymptomatic. Also, tumors could be classified according to the ratio of the median SDI to the median survival (SDI to survival ratio, SSR), which may estimate the relative likelihood for clinical lead-time bias. If adhering to rigorous methodologic standards, proteomic analyses of early-stage cancers might provide new insights into changes that occur in early phases of tumorigenesis. More real examples are needed of uses of pathologic and genomic data to study mechanisms through which SDI influences-or fails to influence-prognosis. The degree of correlation between proteomic patterns and classic semiology constitutes an area of interest in itself; their respective correlations with cancer prognosis should be assessed in properly designed epidemiologic studies.
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Affiliation(s)
- Miquel Porta
- Institut Municipal d'Investigació Mèdica, Carrer del Dr. Aiguader 80, Barcelona E-08003, Spain.
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Pita-Fernández S, Montero-Martinez C, Pértega-Diaz S, Verea-Hernando H. Relationship between delayed diagnosis and the degree of invasion and survival in lung cancer. J Clin Epidemiol 2003; 56:820-5. [PMID: 14505765 DOI: 10.1016/s0895-4356(03)00166-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES The aim of this study is to evaluate the relationship between the interval from first symptom to diagnosis (SDI) and the degree of invasion and survival in lung cancer. METHODS Three hundred seventy-eight patients with lung cancer were included. SDI was defined as the time calculated from the cytohistologic confirmation of the diagnosis of cancer and the first symptoms noted by the patient and attributed to cancer by the physician. The degree of invasion was determined by TNM classification. RESULTS The median SDI was 2.1 months, and did not correlate with stage. Survival decreased progressively according to TNM classification. Adjusting for age, sex, SDI and TNM, survival was influenced by age (RR=1.02) and by staging [Stage (Ib) RR=1.3; stage (IIIa) RR=2.6; stage (IIIb) RR=4.06; stage (IV) RR=7.5]. SDI was not found to affect survival (RR=1.01; 95% CI: 0.94-1.08). In the small cell group, SDI also failed to modify survival. CONCLUSIONS The results of this study indicate that SDI has no effect on the stage or survival of patients with lung cancer.
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Affiliation(s)
- Salvador Pita-Fernández
- Clinical Epidemiology and Biostatistics Unit, Complexo Hospitalario Universitario Juan Canalejo, Hotel de Pacientes 7a Planta, As Xubias de Arriba 84, 15006 A Coruña, Spain.
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Bu LM, Ji X, Han Y, Chen G, Wang ZH, Sun SH. Effect of sodium butyrate combined with chuanhuning on HCT-8 cell line proliferation. Shijie Huaren Xiaohua Zazhi 2003; 11:1193-1196. [DOI: 10.11569/wcjd.v11.i8.1193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To study the effect of sodium butyrate in combination with chuanhuning on HCT-8 cell line proliferation.
METHODS Inhibition of HCT-8 cell line by sodium butyric acid in combination with chuanhuning was detected by MTT assay and growth curve, and apoptosis was determined by morphological assay and flow cytometry (FCM). Apoptotic cells were observed electro- microscopically.
RESULTS Sodium butyric acid showed inhibitory effect on the proliferation of HCT-8 cell line in dose-dependent and time-dependent manner. The inhibitory rates were 15.7%, 20.3%, and 33.3% (P<0.01) in different groups. Differentiation and apoptosis were observed under electronic microscope. Sub-G1 peak was detected by FCM. Cell cycle was blocked in S phase. The apoptotic rate of combined group 1 were 23.5%, 48.6% at 24 h, and 48 h, and the apoptotic rate of combined group 2 were 30.8%, 54.2% at 24 h, and 48 h (P<0.01).
CONCLUSION Sodium butyric acid can induce apoptosis and differentiation of HCT-8 cells of human colorectal carcinoma, and inhibit proliferation of HCT-8 cells. Apoptotic rate was significantly increased when sodium butyric acid was combined with Chuanhuning.
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Affiliation(s)
- Li-Min Bu
- Department of Gastroenterology, General Hospital of Chinese PLA, Beijing Command, Beijing 100700, China
| | - Xin Ji
- Department of Gastroenterology, General Hospital of Chinese PLA, Beijing Command, Beijing 100700, China
| | - Ying Han
- Department of Gastroenterology, General Hospital of Chinese PLA, Beijing Command, Beijing 100700, China
| | - Gang Chen
- Beijing Military Medical College, Beijing 100700, China
| | - Zhi-Hong Wang
- Department of Gastroenterology, General Hospital of Chinese PLA, Beijing Command, Beijing 100700, China
| | - Shu-Hong Sun
- Chengde Medical College, Chengde 06700, Hebei Province, China
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