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Wiering B, Lyratzopoulos G, Hamilton W, Campbell J, Abel G. Concordance with urgent referral guidelines in patients presenting with any of six 'alarm' features of possible cancer: a retrospective cohort study using linked primary care records. BMJ Qual Saf 2022; 31:579-589. [PMID: 34607914 PMCID: PMC9304100 DOI: 10.1136/bmjqs-2021-013425] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 09/02/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Clinical guidelines advise GPs in England which patients warrant an urgent referral for suspected cancer. This study assessed how often GPs follow the guidelines, whether certain patients are less likely to be referred, and how many patients were diagnosed with cancer within 1 year of non-referral. METHODS We used linked primary care (Clinical Practice Research Datalink), secondary care (Hospital Episode Statistics) and cancer registration data. Patients presenting with haematuria, breast lump, dysphagia, iron-deficiency anaemia, post-menopausal or rectal bleeding for the first time during 2014-2015 were included (for ages where guidelines recommend urgent referral). Logistic regression was used to investigate whether receiving a referral was associated with feature type and patient characteristics. Cancer incidence (based on recorded diagnoses in cancer registry data within 1 year of presentation) was compared between those receiving and those not receiving referrals. RESULTS 48 715 patients were included, of which 40% (n=19 670) received an urgent referral within 14 days of presentation, varying by feature from 17% (dysphagia) to 68% (breast lump). Young patients (18-24 vs 55-64 years; adjusted OR 0.20, 95% CI 0.10 to 0.42, p<0.001) and those with comorbidities (4 vs 0 comorbidities; adjusted OR 0.87, 95% CI 0.80 to 0.94, p<0.001) were less likely to receive a referral. Associations between patient characteristics and referrals differed across features: among patients presenting with anaemia, breast lump or haematuria, those with multi-morbidity, and additionally for breast lump, more deprived patients were less likely to receive a referral. Of 29 045 patients not receiving a referral, 3.6% (1047) were diagnosed with cancer within 1 year, ranging from 2.8% for rectal bleeding to 9.5% for anaemia. CONCLUSIONS Guideline recommendations for action are not followed for the majority of patients presenting with common possible cancer features. A significant number of these patients developed cancer within 1 year of their consultation, indicating scope for improvement in the diagnostic process.
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Affiliation(s)
- Bianca Wiering
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes Group, Department of Behavioral Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Willie Hamilton
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - John Campbell
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Gary Abel
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
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Pedersen LH, Erdmann F, Aalborg GL, Hjalgrim LL, Larsen HB, Schmiegelow K, Winther JF, Dalton SO. Socioeconomic position and prediagnostic health care contacts in children with cancer in Denmark: a nationwide register study. BMC Cancer 2021; 21:1104. [PMID: 34649500 PMCID: PMC8518314 DOI: 10.1186/s12885-021-08837-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 09/30/2021] [Indexed: 11/28/2022] Open
Abstract
Background While underlying mechanisms and pathways of social inequalities in cancer survival have been extensively examined in adults, this is less so for children with cancer. Hypothesized mechanisms include prediagnostic utilization of and navigation through the health care system, which may differ by socioeconomic resources of the families. In this nationwide register-based study we investigated the association between measures of family socioeconomic position in relation to prediagnostic health care contacts and stage of disease at diagnosis in children with cancer in Denmark. Methods We identified all children diagnosed with a cancer at ages 0–15 years in 1998–2016 (N = 3043) from the Danish Childhood Cancer Registry. We obtained comprehensive information on measures of socioeconomic position, parental health and prediagnostic contacts to both general practitioners and hospitals 24 months prior to diagnosis from various national registries. We fitted multivariable conditional logistic regression models for the association of family socioeconomic and health-related variables with firstly, frequent health care contacts and secondly, advanced stage. Results We found higher odds ratios (OR) of frequent both overall and emergency health care contacts in the last 3 months before diagnosis in children from households with short parental education and mixed affiliation to work market, when compared to children with high family socioeconomic position. Further, children of parents with depression or of non-Western origin, respectively, had higher OR for frequent overall and emergency contacts. We found no association between socioeconomic position, parental health and stage of disease. Conclusion Families with socioeconomic disadvantage, non-Western origin or depression more frequently utilize prediagnostic health care services, both generally and in the acute setting, indicating that some disadvantaged families may struggle to navigate the health care system when their child is sick. Reassuringly, this was not reflected in disparities in stage at diagnosis. In order to improve the diagnostic process and potentially reduce health care contacts, attention and support should be given to families with a high number of health care contacts over a short period of time. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08837-x.
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Affiliation(s)
- Line Hjøllund Pedersen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark. .,Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark.
| | - Friederike Erdmann
- Division of Childhood Cancer Epidemiology, Institute for Medical Biostatistics, Epidemiology and Informatics (IMBEI), Johannes Gutenberg University Mainz, Mainz, Germany
| | - Gitte Lerche Aalborg
- Statistics and Data Analysis, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Lisa Lyngsie Hjalgrim
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Hanne Bækgaard Larsen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Susanne Oksbjerg Dalton
- Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Oncology & Palliative Care, Zealand University Hospital, Naestved, Denmark
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Pedersen LH, Wahlberg A, Cordt M, Schmiegelow K, Dalton SO, Larsen HB. Parent's perspectives of the pathway to diagnosis of childhood cancer: a matter of diagnostic triage. BMC Health Serv Res 2020; 20:969. [PMID: 33092610 PMCID: PMC7584100 DOI: 10.1186/s12913-020-05821-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 10/14/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Early diagnosis is crucial for the treatment of childhood cancer as it in some cases can prevent progression of disease and improve prognoses. However, childhood cancer can be difficult to diagnose and barriers to early diagnosis are multifactorial. New knowledge about factors influencing the pathway to diagnosis contribute to a deeper understanding of the mechanisms that influence this time span. Qualitative research in the field is sparse but can be expected to lead to additional useful insights that could contribute to efforts shorten time to diagnosis. The purpose of this study was to explore parents' experiences of the pathway to diagnosis in the time between their noticing bodily or behavioural changes and their child's diagnosis. METHODS The study is a qualitative interview study carried out in large Danish hospital. Thirty-two interviews with a total of 46 parents of children with cancer were included for analysis. The children were diagnosed with haematological cancers (n = 17), solid tumours (n = 9) or brain tumours (n = 6). Data were analysed applying the theoretical model of pathways to treatment and an inductive-deductive approach. A revised 'diagnostic triage' model was developed and validated by member checking. RESULTS The pathway to diagnosis was influenced by various factors which we present as consistent parts of a new diagnostic triage model. Each factor impacts the level of urgency assigned to bodily and behavioural changes by parents, general practitioners and specialists. The model of diagnostic triage was developed and validated to understand mechanisms influencing time from the point parents notice changes in their child to diagnosis. The model identifies dynamic movement between parental triage in everyday life and professional triage in a healthcare system, both affecting appraisal and case escalation according to: 1) the nature of bodily and behavioural changes, 2) parental intuition, 3) social relations, 4) professional-child-parent interaction, and 5) specialist-child-parent interaction. CONCLUSIONS Diagnostic triage is a model which explains mechanisms that shape the pathway to diagnosis. It is a contribution aimed at supporting the clinical diagnostic process, that ultimately could ensure more timely testing, referral and diagnosis, and also a novel theoretical framework for future research on diagnostic pathways.
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Affiliation(s)
| | - Ayo Wahlberg
- Department of Anthropology, University of Copenhagen, Copenhagen, Denmark
| | - Marie Cordt
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Susanne Oksbjerg Dalton
- Danish Cancer Society Research Centre, Survivorship and Inequality in Cancer, Danish Cancer Society, Copenhagen, Denmark.,Department of Clinical Oncology & Palliative Care, Zealand University Hospital, Naestved, Denmark
| | - Hanne Bækgaard Larsen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
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Hultstrand C, Coe AB, Lilja M, Hajdarevic S. GPs' perspectives of the patient encounter - in the context of standardized cancer patient pathways. Scand J Prim Health Care 2020; 38:238-247. [PMID: 32314634 PMCID: PMC8570742 DOI: 10.1080/02813432.2020.1753388] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective: We aim to explore how GPs assign meanings and act upon patients' symptoms in primary care encounters in the context of standardized cancer patient pathways (CPPs).Design, setting and subjects: Thirteen individual interviews were conducted with GPs, at primary healthcare centers (n = 4) in one county in northern Sweden. Interviews were analyzed using grounded theory method. The results were then linked to symbolic interactionism.Main outcome measures: GPs' perspectives about assigning meanings to patients' presented symptoms and perception about CPPs.Results: In the encounter, GPs engaged in two simultaneous interactions, one with patients' symptoms - and the other with CPPs. The core category Disentangling patients' care trajectory consists of three categories, interpreted as GPs' strategies developed to assign meaning to symptoms. These strategies are carried out not in a straightforward manner but rather in a conflicting way, illuminating the complexity of GPs' daily work.Conclusions: Interacting with patients is vital for assigning meaning to presented symptoms. However, nowadays GPs are not only required to interact with patients, they are also required to interact with CPPs. These standardized routines might create pressure and demands on GPs, especially for those experiencing a lack of information about CPPs. Beside of carrying out the challenging patient/person-centered dialogues and interpreting presented symptoms, GPs also need to link the interpreted symptoms to CPPs. Therefore, it is essential that GPs are given opportunities at their workplaces to continuously be informed and be supported in order to practice CPPs and thereby optimize trajectories for patients undergoing cancer diagnostics.Key points Current awareness: • GPs deliberation about patients' trajectories is a complex process, often dealing with vague symptoms. How CPPs influence this process within the encounter has not been studied. Main statements: • GPs in our study were involved in two simultaneous interactions, one with patients' symptoms in the encounter - and the other with CPPs within the healthcare organization. • Symbolic interactionism helped capture how GPs deliberated about conflicting and paradoxical aspects of the encounter, in terms of balancing two contradictory ways of action that GPs face when providing patient/person-centered care and linking to CPPs. • Based on our results, primary care needs support from healthcare organizations to build capacity about CPPs and how to use them.
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Affiliation(s)
- Cecilia Hultstrand
- Department of Nursing, Umeå University, Umeå, Sweden;
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden;
- CONTACT Cecilia Hultstrand Department of Nursing, Umeå University, Umeå, SE-901 87, Sweden
| | | | - Mikael Lilja
- Department of Public Health and Clinical Medicine, Unit of Research, Education, and Development, Östersund Hospital, Umeå University, Umeå, Sweden
| | - Senada Hajdarevic
- Department of Nursing, Umeå University, Umeå, Sweden;
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden;
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Murray MJ, Ruffle A, Lowis S, Howell L, Shanmugavadivel D, Dommett R, Gamble A, Shenton G, Nicholson J. Delphi method to identify expert opinion to support children's cancer referral guidelines. Arch Dis Child 2020; 105:241-246. [PMID: 31420330 DOI: 10.1136/archdischild-2019-317235] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/16/2019] [Accepted: 08/02/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND The National Institute for Health and Care Excellence (NICE) guidance for referral of children with suspected cancer was first published in 2005 and updated in 2015. The updated version relied on sparse primary care evidence and published without input from key stakeholders, for example, acute general paediatricians and paediatric haematologists/oncologists. This led to a document that fell short as a practical guide for referring physicians managing children with potentially life-threatening conditions. Following discussions between the Children's Cancer and Leukaemia Group (CCLG, the UK multidisciplinary professional body for healthcare professionals caring for children with cancer) and NICE, it was agreed that a practical supplement should be produced for the 2015 guidance. A prerequisite was evidence gathering from tertiary care to balance the existing primary care evidence, and a Delphi consensus method was therefore convened. METHODS A CCLG NICE Guidance Committee formulated 25 draft statements for review. The CCLG emailed its paediatric haematologist/oncologist membership (n=179) and 88 responded (49%). To achieve consensus, statements required ≥70% agreement from ≥60% of actual respondents, from the denominator (n=88). RESULTS Fifteen of 25 original statements were accepted at the first round of voting. Three of 25 statements where >50% did not support were rejected outright. One statement could not be revised without replicating a previously accepted statement. The six remaining statements were revised and a second round of voting undertaken; all six revised statements were accepted. Overall, 21 of 25 statements (84%) met consensus criteria. CONCLUSIONS This expert opinion should help streamline suspected cancer referral in children and help optimise subsequent outcomes.
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Affiliation(s)
- Matthew J Murray
- Department of Paediatric Haematology and Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Amy Ruffle
- Department of Paediatric Haematology and Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stephen Lowis
- Department of Paediatric Haematology and Oncology, Bristol Royal Hospital for Children, Bristol, Bristol, UK
| | - Lisa Howell
- Department of Paediatric Haematology and Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, Liverpool, UK
| | | | - Rachel Dommett
- Department of Paediatric Haematology and Oncology, Bristol Royal Hospital for Children, Bristol, Bristol, UK
| | - Ashley Gamble
- Children's Cancer and Leukaemia Group, Leicester, UK
| | - Geoff Shenton
- Paediatric Haematology, Great North Children's Hospital, Newcastle-upon-Tyne, UK
| | - James Nicholson
- Department of Paediatric Haematology and Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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6
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Dommett RM, Pring H, Cargill J, Beynon P, Cameron A, Cox R, Nechowska A, Wint A, Stevens MCG. Achieving a timely diagnosis for teenagers and young adults with cancer: the ACE "too young to get cancer?" study. BMC Cancer 2019; 19:616. [PMID: 31234813 PMCID: PMC6591830 DOI: 10.1186/s12885-019-5776-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 05/30/2019] [Indexed: 02/03/2023] Open
Abstract
Background Time to diagnosis (TTD) concerns teenagers and young adults (TYA) with cancer and may affect outcome. Methods Healthcare records from 105 TYA in a regional cancer service were assessed to document events from 1st symptom to treatment start. Detailed pathway construction was possible for 104 patients and allowed a multidisciplinary panel review of each pathway with assessment of good practice and lessons for the future. Results 1st presentation was to primary care in 86, and 93% consulted in primary care before diagnosis. Routes to Diagnosis were 45% via urgent 2 Week Wait pathways and 38% as emergency referrals. Total Interval (time from 1st presentation to treatment start) was median 63 (range 1–559) days, varying within/between diagnoses. Patient interval (time from 1st symptom to 1st presentation) was longest for lymphoma, carcinoma and bone tumour (medians: 9, 12, 20 days). Overall, time in primary care was short (median 3, range 0–537 days) compared to secondary care (median 29, range 0–195 days) and longest for lymphoma, carcinoma, brain/CNS (medians: 10, 15, 16 days). Specialist Care interval (time from 1st specialist visit to treatment start) was longest for bone, brain/CNS, lymphoma, carcinoma (medians: 30, 33, 36, 48 days). 40% pathways were rated as showing good/best practice but 16% were less than satisfactory. Continued safety-netting/support was identified from primary care but analysis suggested opportunities for improvement in transition through secondary care. Conclusions Previous reports of prolonged TTD have focused on delay in referral from primary care but this study suggests that this might be reduced by optimising management in secondary care.
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Affiliation(s)
- Rachel M Dommett
- South West TYA Cancer Service, Bristol Haematology Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Horfield Road, Bristol, BS2 8ED, UK.,Department of Paediatric Haematology Oncology & BMT, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Hannah Pring
- South West TYA Cancer Service, Bristol Haematology Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Horfield Road, Bristol, BS2 8ED, UK
| | - Jamie Cargill
- South West TYA Cancer Service, Bristol Haematology Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Horfield Road, Bristol, BS2 8ED, UK
| | - Paul Beynon
- South West TYA Cancer Service, Bristol Haematology Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Horfield Road, Bristol, BS2 8ED, UK
| | - Alison Cameron
- South West TYA Cancer Service, Bristol Haematology Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Horfield Road, Bristol, BS2 8ED, UK
| | - Rachel Cox
- Department of Paediatric Haematology Oncology & BMT, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Aoife Nechowska
- South West TYA Cancer Service, Bristol Haematology Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Horfield Road, Bristol, BS2 8ED, UK
| | - Alison Wint
- Macmillan GP and NHS Bristol, North Somerset & South Gloucestershire CCG, Bristol, UK
| | - Michael C G Stevens
- South West TYA Cancer Service, Bristol Haematology Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Horfield Road, Bristol, BS2 8ED, UK. .,Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
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7
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Benchimol EI, Smeeth L, Guttmann A, Harron K, Moher D, Petersen I, Sørensen HT, Januel JM, von Elm E, Langan SM. La déclaration RECORD (Reporting of Studies Conducted Using Observational Routinely Collected Health Data) : directives pour la communication des études réalisées à partir de données de santé collectées en routine. CMAJ 2019; 191:E216-E230. [PMID: 30803952 PMCID: PMC6389451 DOI: 10.1503/cmaj.181309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Eric I Benchimol
- Institut de recherche du Centre hospitalier pour enfants de l'est de l'Ontario (Benchimol) ; Département de pédiatrie (Benchimol), Université d'Ottawa ; École d'épidémiologie et de santé publique (Benchimol, Moher), Université d'Ottawa, Ottawa, Ont. ; ICES (Benchimol, Guttmann), Toronto, Ont. ; London School of Hygiene and Tropical Medicine (Smeeth, Harron, Langan), Londres, Royaume-Uni ; Department of Paediatrics (Guttmann), The Hospital for Sick Children; Institute of Health Policy, Management and Evaluation (Guttmann), University of Toronto, Toronto, Ont. ; Institut de recherche de l'Hôpital d'Ottawa (Moher), Ottawa, Ont. ; Département de soins primaires et santé publique (Petersen), University College London, Londres, Royaume-Uni ; Département d'épidémiologie clinique (Sørensen), université d'Aarhus, Aarhus, Danemark ; Management des organisations de santé (EA 7348 MOS) (Januel), Institut du Management, École des hautes études en santé publique, Rennes, France ; Chaire d'excellence en Management de la santé (Januel), Université Sorbonne Paris Cité, Paris, France ; Cochrane Suisse (von Elm), Institut universitaire de médecine sociale et préventive, Université de Lausanne, Lausanne, Suisse
| | - Liam Smeeth
- Institut de recherche du Centre hospitalier pour enfants de l'est de l'Ontario (Benchimol) ; Département de pédiatrie (Benchimol), Université d'Ottawa ; École d'épidémiologie et de santé publique (Benchimol, Moher), Université d'Ottawa, Ottawa, Ont. ; ICES (Benchimol, Guttmann), Toronto, Ont. ; London School of Hygiene and Tropical Medicine (Smeeth, Harron, Langan), Londres, Royaume-Uni ; Department of Paediatrics (Guttmann), The Hospital for Sick Children; Institute of Health Policy, Management and Evaluation (Guttmann), University of Toronto, Toronto, Ont. ; Institut de recherche de l'Hôpital d'Ottawa (Moher), Ottawa, Ont. ; Département de soins primaires et santé publique (Petersen), University College London, Londres, Royaume-Uni ; Département d'épidémiologie clinique (Sørensen), université d'Aarhus, Aarhus, Danemark ; Management des organisations de santé (EA 7348 MOS) (Januel), Institut du Management, École des hautes études en santé publique, Rennes, France ; Chaire d'excellence en Management de la santé (Januel), Université Sorbonne Paris Cité, Paris, France ; Cochrane Suisse (von Elm), Institut universitaire de médecine sociale et préventive, Université de Lausanne, Lausanne, Suisse
| | - Astrid Guttmann
- Institut de recherche du Centre hospitalier pour enfants de l'est de l'Ontario (Benchimol) ; Département de pédiatrie (Benchimol), Université d'Ottawa ; École d'épidémiologie et de santé publique (Benchimol, Moher), Université d'Ottawa, Ottawa, Ont. ; ICES (Benchimol, Guttmann), Toronto, Ont. ; London School of Hygiene and Tropical Medicine (Smeeth, Harron, Langan), Londres, Royaume-Uni ; Department of Paediatrics (Guttmann), The Hospital for Sick Children; Institute of Health Policy, Management and Evaluation (Guttmann), University of Toronto, Toronto, Ont. ; Institut de recherche de l'Hôpital d'Ottawa (Moher), Ottawa, Ont. ; Département de soins primaires et santé publique (Petersen), University College London, Londres, Royaume-Uni ; Département d'épidémiologie clinique (Sørensen), université d'Aarhus, Aarhus, Danemark ; Management des organisations de santé (EA 7348 MOS) (Januel), Institut du Management, École des hautes études en santé publique, Rennes, France ; Chaire d'excellence en Management de la santé (Januel), Université Sorbonne Paris Cité, Paris, France ; Cochrane Suisse (von Elm), Institut universitaire de médecine sociale et préventive, Université de Lausanne, Lausanne, Suisse
| | - Katie Harron
- Institut de recherche du Centre hospitalier pour enfants de l'est de l'Ontario (Benchimol) ; Département de pédiatrie (Benchimol), Université d'Ottawa ; École d'épidémiologie et de santé publique (Benchimol, Moher), Université d'Ottawa, Ottawa, Ont. ; ICES (Benchimol, Guttmann), Toronto, Ont. ; London School of Hygiene and Tropical Medicine (Smeeth, Harron, Langan), Londres, Royaume-Uni ; Department of Paediatrics (Guttmann), The Hospital for Sick Children; Institute of Health Policy, Management and Evaluation (Guttmann), University of Toronto, Toronto, Ont. ; Institut de recherche de l'Hôpital d'Ottawa (Moher), Ottawa, Ont. ; Département de soins primaires et santé publique (Petersen), University College London, Londres, Royaume-Uni ; Département d'épidémiologie clinique (Sørensen), université d'Aarhus, Aarhus, Danemark ; Management des organisations de santé (EA 7348 MOS) (Januel), Institut du Management, École des hautes études en santé publique, Rennes, France ; Chaire d'excellence en Management de la santé (Januel), Université Sorbonne Paris Cité, Paris, France ; Cochrane Suisse (von Elm), Institut universitaire de médecine sociale et préventive, Université de Lausanne, Lausanne, Suisse
| | - David Moher
- Institut de recherche du Centre hospitalier pour enfants de l'est de l'Ontario (Benchimol) ; Département de pédiatrie (Benchimol), Université d'Ottawa ; École d'épidémiologie et de santé publique (Benchimol, Moher), Université d'Ottawa, Ottawa, Ont. ; ICES (Benchimol, Guttmann), Toronto, Ont. ; London School of Hygiene and Tropical Medicine (Smeeth, Harron, Langan), Londres, Royaume-Uni ; Department of Paediatrics (Guttmann), The Hospital for Sick Children; Institute of Health Policy, Management and Evaluation (Guttmann), University of Toronto, Toronto, Ont. ; Institut de recherche de l'Hôpital d'Ottawa (Moher), Ottawa, Ont. ; Département de soins primaires et santé publique (Petersen), University College London, Londres, Royaume-Uni ; Département d'épidémiologie clinique (Sørensen), université d'Aarhus, Aarhus, Danemark ; Management des organisations de santé (EA 7348 MOS) (Januel), Institut du Management, École des hautes études en santé publique, Rennes, France ; Chaire d'excellence en Management de la santé (Januel), Université Sorbonne Paris Cité, Paris, France ; Cochrane Suisse (von Elm), Institut universitaire de médecine sociale et préventive, Université de Lausanne, Lausanne, Suisse
| | - Irene Petersen
- Institut de recherche du Centre hospitalier pour enfants de l'est de l'Ontario (Benchimol) ; Département de pédiatrie (Benchimol), Université d'Ottawa ; École d'épidémiologie et de santé publique (Benchimol, Moher), Université d'Ottawa, Ottawa, Ont. ; ICES (Benchimol, Guttmann), Toronto, Ont. ; London School of Hygiene and Tropical Medicine (Smeeth, Harron, Langan), Londres, Royaume-Uni ; Department of Paediatrics (Guttmann), The Hospital for Sick Children; Institute of Health Policy, Management and Evaluation (Guttmann), University of Toronto, Toronto, Ont. ; Institut de recherche de l'Hôpital d'Ottawa (Moher), Ottawa, Ont. ; Département de soins primaires et santé publique (Petersen), University College London, Londres, Royaume-Uni ; Département d'épidémiologie clinique (Sørensen), université d'Aarhus, Aarhus, Danemark ; Management des organisations de santé (EA 7348 MOS) (Januel), Institut du Management, École des hautes études en santé publique, Rennes, France ; Chaire d'excellence en Management de la santé (Januel), Université Sorbonne Paris Cité, Paris, France ; Cochrane Suisse (von Elm), Institut universitaire de médecine sociale et préventive, Université de Lausanne, Lausanne, Suisse
| | - Henrik T Sørensen
- Institut de recherche du Centre hospitalier pour enfants de l'est de l'Ontario (Benchimol) ; Département de pédiatrie (Benchimol), Université d'Ottawa ; École d'épidémiologie et de santé publique (Benchimol, Moher), Université d'Ottawa, Ottawa, Ont. ; ICES (Benchimol, Guttmann), Toronto, Ont. ; London School of Hygiene and Tropical Medicine (Smeeth, Harron, Langan), Londres, Royaume-Uni ; Department of Paediatrics (Guttmann), The Hospital for Sick Children; Institute of Health Policy, Management and Evaluation (Guttmann), University of Toronto, Toronto, Ont. ; Institut de recherche de l'Hôpital d'Ottawa (Moher), Ottawa, Ont. ; Département de soins primaires et santé publique (Petersen), University College London, Londres, Royaume-Uni ; Département d'épidémiologie clinique (Sørensen), université d'Aarhus, Aarhus, Danemark ; Management des organisations de santé (EA 7348 MOS) (Januel), Institut du Management, École des hautes études en santé publique, Rennes, France ; Chaire d'excellence en Management de la santé (Januel), Université Sorbonne Paris Cité, Paris, France ; Cochrane Suisse (von Elm), Institut universitaire de médecine sociale et préventive, Université de Lausanne, Lausanne, Suisse
| | - Jean-Marie Januel
- Institut de recherche du Centre hospitalier pour enfants de l'est de l'Ontario (Benchimol) ; Département de pédiatrie (Benchimol), Université d'Ottawa ; École d'épidémiologie et de santé publique (Benchimol, Moher), Université d'Ottawa, Ottawa, Ont. ; ICES (Benchimol, Guttmann), Toronto, Ont. ; London School of Hygiene and Tropical Medicine (Smeeth, Harron, Langan), Londres, Royaume-Uni ; Department of Paediatrics (Guttmann), The Hospital for Sick Children; Institute of Health Policy, Management and Evaluation (Guttmann), University of Toronto, Toronto, Ont. ; Institut de recherche de l'Hôpital d'Ottawa (Moher), Ottawa, Ont. ; Département de soins primaires et santé publique (Petersen), University College London, Londres, Royaume-Uni ; Département d'épidémiologie clinique (Sørensen), université d'Aarhus, Aarhus, Danemark ; Management des organisations de santé (EA 7348 MOS) (Januel), Institut du Management, École des hautes études en santé publique, Rennes, France ; Chaire d'excellence en Management de la santé (Januel), Université Sorbonne Paris Cité, Paris, France ; Cochrane Suisse (von Elm), Institut universitaire de médecine sociale et préventive, Université de Lausanne, Lausanne, Suisse
| | - Erik von Elm
- Institut de recherche du Centre hospitalier pour enfants de l'est de l'Ontario (Benchimol) ; Département de pédiatrie (Benchimol), Université d'Ottawa ; École d'épidémiologie et de santé publique (Benchimol, Moher), Université d'Ottawa, Ottawa, Ont. ; ICES (Benchimol, Guttmann), Toronto, Ont. ; London School of Hygiene and Tropical Medicine (Smeeth, Harron, Langan), Londres, Royaume-Uni ; Department of Paediatrics (Guttmann), The Hospital for Sick Children; Institute of Health Policy, Management and Evaluation (Guttmann), University of Toronto, Toronto, Ont. ; Institut de recherche de l'Hôpital d'Ottawa (Moher), Ottawa, Ont. ; Département de soins primaires et santé publique (Petersen), University College London, Londres, Royaume-Uni ; Département d'épidémiologie clinique (Sørensen), université d'Aarhus, Aarhus, Danemark ; Management des organisations de santé (EA 7348 MOS) (Januel), Institut du Management, École des hautes études en santé publique, Rennes, France ; Chaire d'excellence en Management de la santé (Januel), Université Sorbonne Paris Cité, Paris, France ; Cochrane Suisse (von Elm), Institut universitaire de médecine sociale et préventive, Université de Lausanne, Lausanne, Suisse
| | - Sinéad M Langan
- Institut de recherche du Centre hospitalier pour enfants de l'est de l'Ontario (Benchimol) ; Département de pédiatrie (Benchimol), Université d'Ottawa ; École d'épidémiologie et de santé publique (Benchimol, Moher), Université d'Ottawa, Ottawa, Ont. ; ICES (Benchimol, Guttmann), Toronto, Ont. ; London School of Hygiene and Tropical Medicine (Smeeth, Harron, Langan), Londres, Royaume-Uni ; Department of Paediatrics (Guttmann), The Hospital for Sick Children; Institute of Health Policy, Management and Evaluation (Guttmann), University of Toronto, Toronto, Ont. ; Institut de recherche de l'Hôpital d'Ottawa (Moher), Ottawa, Ont. ; Département de soins primaires et santé publique (Petersen), University College London, Londres, Royaume-Uni ; Département d'épidémiologie clinique (Sørensen), université d'Aarhus, Aarhus, Danemark ; Management des organisations de santé (EA 7348 MOS) (Januel), Institut du Management, École des hautes études en santé publique, Rennes, France ; Chaire d'excellence en Management de la santé (Januel), Université Sorbonne Paris Cité, Paris, France ; Cochrane Suisse (von Elm), Institut universitaire de médecine sociale et préventive, Université de Lausanne, Lausanne, Suisse
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8
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Lima BDCD, Silva LFD, Góes FGB, Ribeiro MTS, Alves LL. The therapeutic pathway of families of children with cancer: difficulties faced in this journey. ACTA ACUST UNITED AC 2018; 39:e20180004. [PMID: 30365758 DOI: 10.1590/1983-1447.2018.20180004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 07/02/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To know the difficulties faced by families in the therapeutic pathway of children with cancer. METHOD Qualitative, descriptive and exploratory research, with a quantitative approach, performed from March to November 2016, through face-to-face semi-structured interviews, with 21 relatives of children undergoing oncological treatment at a federal university hospital in Rio de Janeiro, whose data were submitted to content analysis. RESULTS The difficulties of these families traverse the identification and investigation by health professionals regarding the signs and symptoms of children as well as the passage of relatives through various health services until diagnostic confirmation. FINAL CONSIDERATIONS The early diagnosis of childhood cancer depends on actions from health and teaching institutions for the appropriate investigation of the disease by professionals, including the nurse who works with risk classification in emergency departments and in primary care, besides the appropriate operation of the reference and counter-reference system of the health system.
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Affiliation(s)
| | - Liliane Faria da Silva
- Universidade Federal Fluminense (UFF). Escola de Enfermagem. Departamento de Enfermagem Materno-infantil e Psiquiátrica. Niterói, Rio de Janeiro, Brasil
| | - Fernanda Garcia Bezerra Góes
- Universidade Federal Fluminense (UFF). Escola de Enfermagem. Departamento de Enfermagem de Rio das Ostras. Rio das Ostras, Rio de Janeiro, Brasil
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9
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Ewing M, Naredi P, Zhang C, Månsson J. Diagnostic profile characteristics of cancer patients with frequent consultations in primary care before diagnosis: a case-control study. Fam Pract 2018; 35:559-566. [PMID: 29546418 DOI: 10.1093/fampra/cmy012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Many patients with common cancers are late diagnosed. OBJECTIVES Identify consultation profiles and clinical features in patients with the seven most common cancers, who had consulted a general practitioner (GP) frequently before their cancer diagnosis. METHODS A case-control study was conducted in Region Västra Götaland, Sweden. A total of 2570 patients, diagnosed in 2011 with prostate, breast, colorectal, lung, gynaecological and skin cancers including malignant melanoma, and 9424 controls were selected from the Swedish Cancer Register and a regional health care database. Diagnostic codes [International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10)] from primary care for patients with ≥4 GP consultations registered in the year before cancer diagnosis were collected. Likelihood ratios (LRs) were calculated for variables associated with the different cancers. RESULTS Fifty-six percent of the patients had consulted a GP four or more times in the year before cancer diagnosis. Alarm symptoms or signs represented 60% of the codes with the highest LR, but only 40% of the 10 most prevalent codes. Breast lump had the highest LR, 11.9 [95% confidence interval (CI) 8.0-17.8]; abnormalities of plasma proteins had an LR of 5.0 (95% CI 3.0-8.2) and abnormal serum enzyme levels had an LR of 4.6 (95% CI 3.6-5.9). Early clinical features associated with cancer had been registered already at the first two GP consultations. CONCLUSION One out of six clinical features associated with cancer were presented by cancer patients with four or more pre-referral consultations already at the two first consultations. These early clinical features that were focal and had benign characteristics might have been missed diagnostic opportunities.
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Affiliation(s)
- Marcela Ewing
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Naredi
- Department of Surgery, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Jörgen Månsson
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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10
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Friis Abrahamsen C, Ahrensberg JM, Vedsted P. Utilisation of primary care before a childhood cancer diagnosis: do socioeconomic factors matter?: A Danish nationwide population-based matched cohort study. BMJ Open 2018; 8:e023569. [PMID: 30121615 PMCID: PMC6104784 DOI: 10.1136/bmjopen-2018-023569] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Early diagnosis of childhood cancer is critical. Nevertheless, little is known about the potential role of inequality. This study aims to describe the use of primary care 2 years before a childhood cancer diagnosis and to investigate whether socioeconomic factors influence the use of consultations and diagnostic tests in primary care. DESIGN A national population-based matched cohort study. SETTING AND PARTICIPANTS This study uses observational data from four Danish nationwide registers. All children aged 0-15 diagnosed with cancer during 2008-2015 were included (n=1386). Each case was matched based on gender and age with 10 references (n=13 860). PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was additional rates for consultations and for invoiced diagnostic tests for children with cancer according to parental socioeconomic factors. Furthermore, we estimated the association between socioeconomic factors and frequent use of consultations, defined as at least four consultations, and the odds of receiving a diagnostic test within 3 months of diagnosis. RESULTS Children with cancer from families with high income had 1.46 (95% CI 1.23 to 1.69) additional consultations 3 months before diagnosis, whereas children from families with low income had 1.85 (95% CI 1.60 to 2.11) additional consultations. The highest odds of frequent use of consultations was observed among children from low-income families (OR: 1.94, 95% CI 1.24 to 3.03). A higher odds of receiving an invoiced diagnostic test was seen for children from families with mid-educational level (OR: 1.46, 95% CI 1.09 to 1.95). CONCLUSION We found a socioeconomic gradient in the use of general practice before a childhood cancer diagnosis. This suggests that social inequalities exist in the pattern of healthcare utilisation in general practice.
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Affiliation(s)
| | - Jette Møller Ahrensberg
- Department of Clinical Medicine, Research Center for Emergency Medicine, Aarhus University, Aarhus, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
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11
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Chu TPC, Shah A, Walker D, Coleman MP. How Do Biological Characteristics of Primary Intracranial Tumors Affect Their Clinical Presentation in Children and Young Adults? J Child Neurol 2018; 33:503-511. [PMID: 29724124 DOI: 10.1177/0883073818767562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We demonstrated the pattern in presentation of primary intracranial tumors in a population-based cohort of patients aged 0-24 years identified from the National Cancer Registry for England, using linked medical records from primary care and hospitals. We used generalized additive models to estimate temporal changes in presentation rates. Borderline and malignant tumors presented at a similar rate in primary care (6.4 and 6.6 consultations per 100 patients each month) and in hospital (3.4 and 3.6). Benign tumors presented earlier but less frequently (rate = 4.4 and rate ratio = 0.75, 95% CI = 0.60-0.93, in primary care; rate = 2.6 and rate ratio = 0.83, 95% CI = 0.77-0.89, in hospital). Many tumors began presenting shortly before their diagnosis, but less aggressive tumors were likely to present earlier in primary care. Earlier detection of less aggressive tumors in primary care may reduce the risk of complications and morbidity among survivors.
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Affiliation(s)
- Thomas P C Chu
- 1 Cancer Survival Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anjali Shah
- 2 Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - David Walker
- 3 Children's Brain Tumour Research Centre, University of Nottingham, Nottingham, United Kingdom
| | - Michel P Coleman
- 1 Cancer Survival Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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12
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Carberry AR, Hanson K, Flannery A, Fischer M, Gehlbach J, Diamond C, Wald ER. Diagnostic Error in Pediatric Cancer. Clin Pediatr (Phila) 2018; 57:11-18. [PMID: 28478722 DOI: 10.1177/0009922816687325] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to ( a) determine the frequency of diagnostic errors in pediatric cancer, ( b) categorize errors, and ( c) underscore themes associated with misdiagnosis. This is a retrospective cohort study at a tertiary children's hospital of 265 patients with new oncologic diagnoses. The diagnostic error rate was 28%. Compared with those with no diagnostic error, those in whom there was an error were more likely to have ( a) more visits before diagnosis ( P < .001), ( b) not been seen in an acute care setting ( P = .03), ( c) inappropriate treatment ( P < .001), and ( d) misinterpreted laboratory studies or imaging ( P < .001). Themes in diagnostic errors were lack of appropriate evaluation for persistent symptoms (47%), failure to recognize signs and symptoms suggestive of malignancy (45%), and misinterpretation of tests (8%). Clinicians should consider diagnostic evaluation for multiple visits for the same complaint or a constellation of signs and symptoms suggestive of malignancy.
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Affiliation(s)
| | - Keith Hanson
- 2 University of Illinois College of Medicine at Peoria, Peoria, IL, USA
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13
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Chu TPC, Shah A, Walker D, Coleman MP. Where are the opportunities for an earlier diagnosis of primary intracranial tumours in children and young adults? Eur J Paediatr Neurol 2017; 21:388-395. [PMID: 27840025 PMCID: PMC6152901 DOI: 10.1016/j.ejpn.2016.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/21/2016] [Accepted: 10/20/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Childhood brain tumours have some of the longest time to diagnosis. A timely diagnosis may have a role in reducing anxiety in waiting for a diagnosis and subsequent morbidity and mortality. We investigated where the opportunities for an earlier diagnosis were, and for which anatomical locations this strategy will most likely to be effective. METHODS A record-linkage cohort study of patients diagnosed aged 0-24 years with a primary intracranial tumour between 1989 and 2006 in England, using records from the National Cancer Registry linked to hospital admission records from Hospital Episode Statistics (HES, 1997-2006) and primary care consultation records from Clinical Practice Research Datalink (CPRD, 1989-2006). Relevant neurological presentations were extracted from HES and CPRD. Temporal changes in presentation rates were estimated in generalised additive models. RESULTS Frequency of presentation began to increase six months before diagnosis in primary care and three months before diagnosis in hospital. Supratentorial and midline tumours had the longest presentation history before diagnosis. Peri-ventricular tumours presented frequently in hospital (rate ratio = 1.29 vs supratentorial tumours; 95% CI = 1.12-1.48) or as an emergency (1.24; 1.01-1.51), and in primary care (1.12; 0.62-1.85). CONCLUSIONS Opportunities for an earlier diagnosis are greater in supratentorial, midline or cranial nerve tumours, which have a longer presentation history than peri-ventricular, cerebellar or brainstem tumours. Common features before diagnosis include headache, convulsions, and growth or endocrine disorders. Focal neurological deficits are uncommon and emerge late in the pre-diagnosis period.
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Affiliation(s)
- Thomas P C Chu
- Cancer Research UK Cancer Survival Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.
| | - Anjali Shah
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford OX3 7LD, United Kingdom
| | - David Walker
- Children's Brain Tumour Research Centre, University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, United Kingdom
| | - Michel P Coleman
- Cancer Research UK Cancer Survival Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
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14
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Abstract
Much time, effort and investment goes into the diagnosis of symptomatic cancer, with the expectation that this approach brings clinical benefits. This investment of resources has been particularly noticeable in the UK, which has, for several years, appeared near the bottom of international league tables for cancer survival in economically developed countries. In this Review, we examine expedited diagnosis of cancer from four perspectives. The first relates to the potential for clinical benefits of expedited diagnosis of symptomatic cancer. Limited evidence from clinical trials is available, but the considerable observational evidence suggests benefits can be obtained from this approach. The second perspective considers how expedited diagnosis can be achieved. We concentrate on data from the UK, where extensive awareness campaigns have been conducted, and initiatives in the primary-care setting, including clinical decision support, have all occurred during a period of considerable national policy change. The third section considers the most appropriate patients for cancer investigations, and the possible community settings for identification of such patients; UK national guidance for selection of patients for investigation is discussed. Finally, the health economics of expedited diagnosis are reviewed, although few studies provide definitive evidence on this topic.
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Affiliation(s)
- Willie Hamilton
- University of Exeter, College House, St Luke's Campus, Exeter EX2 4TE, UK
| | - Fiona M Walter
- Department of Public Health &Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Greg Rubin
- School of Medicine, Pharmacy and Health, Wolfson Building, Queen's Campus, University of Durham, Stockton-on-Tees TS17 6BH, UK
| | - Richard D Neal
- North Wales Centre for Primary Care Research, Bangor University, Gwenfro Unit 5, Wrexham Technology Park, Wrexham LL13 7YP, UK
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15
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Clarke RT, Van den Bruel A, Bankhead C, Mitchell CD, Phillips B, Thompson MJ. Clinical presentation of childhood leukaemia: a systematic review and meta-analysis. Arch Dis Child 2016; 101:894-901. [PMID: 27647842 DOI: 10.1136/archdischild-2016-311251] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 07/17/2016] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Leukaemia is the most common cancer of childhood, accounting for a third of cases. In order to assist clinicians in its early detection, we systematically reviewed all existing data on its clinical presentation and estimated the frequency of signs and symptoms presenting at or prior to diagnosis. DESIGN We searched MEDLINE and EMBASE for all studies describing presenting features of leukaemia in children (0-18 years) without date or language restriction, and, when appropriate, meta-analysed data from the included studies. RESULTS We screened 12 303 abstracts for eligibility and included 33 studies (n=3084) in the analysis. All were cohort studies without control groups. 95 presenting signs and symptoms were identified and ranked according to frequency. Five features were present in >50% of children: hepatomegaly (64%), splenomegaly (61%), pallor (54%), fever (53%) and bruising (52%). An additional eight features were present in a third to a half of children: recurrent infections (49%), fatigue (46%), limb pain (43%), hepatosplenomegaly (42%), bruising/petechiae (42%), lymphadenopathy (41%), bleeding tendency (38%) and rash (35%). 6% of children were asymptomatic on diagnosis. CONCLUSIONS Over 50% of children with leukaemia have palpable livers, palpable spleens, pallor, fever or bruising on diagnosis. Abdominal symptoms such as anorexia, weight loss, abdominal pain and abdominal distension are common. Musculoskeletal symptoms such as limp and joint pain also feature prominently. Children with unexplained illness require a thorough history and focused clinical examination, which should include abdominal palpation, palpation for lymphadenopathy and careful scrutiny of the skin. Occurrence of multiple symptoms and signs should alert clinicians to possible leukaemia.
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Affiliation(s)
- Rachel T Clarke
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ann Van den Bruel
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare Bankhead
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher D Mitchell
- Department of Paediatric Oncology/Haematology, Children's Hospital, John Radcliffe, Oxford, UK
| | - Bob Phillips
- Department of Paediatric Oncology/Haematology, Leeds General Infirmary, Leeds, UK
| | - Matthew J Thompson
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK Department of Family Medicine, University of Washington, Seattle, USA
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Benchimol EI, Smeeth L, Guttmann A, Harron K, Hemkens LG, Moher D, Petersen I, Sørensen HT, von Elm E, Langan SM. [The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2016; 115-116:33-48. [PMID: 27837958 PMCID: PMC5330542 DOI: 10.1016/j.zefq.2016.07.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 07/18/2016] [Indexed: 12/17/2022]
Abstract
Zunehmend werden routinemäßig gesammelte Gesundheitsdaten, die zu administrativen und klinischen Zwecken und ohne spezifische, a priori festgelegte Forschungsziele erhoben wurden, auch für die Forschung eingesetzt. Die rasche Entwicklung und Verfügbarkeit dieser Daten machten Probleme deutlich, die in den bestehenden Berichts-Leitlinien, wie dem STROBE-Statement (Strengthening the Reporting of Observational Studies in Epidemiology) nicht behandelt werden. Das RECORD-Statement (REporting of studies Conducted using Observational Routinely-collected health Data) wurde entwickelt, um diese Lücken zu schließen. RECORD ist als Erweiterung des STROBE-Statements gedacht, um Punkte abzudecken, die spezifisch sind beim Berichten von Beobachtungsstudien, die routinemäßig gesammelte Gesundheitsdaten verwenden. RECORD besteht aus einer Checkliste von 13 Punkten mit Bezug zu Titel, Abstract, Einleitung, Methoden-, Ergebnis- und Diskussionsteil von Artikeln sowie zu anderen Informationen, die in Forschungsberichten dieser Art enthalten sein sollten. Dieses Dokument enthält die Checkliste sowie Erläuterungen und weitere Erklärungen, um die Verwendung der Checkliste zu verbessern. Beispiele für ein gutes Berichten der einzelnen Punkte der RECORD-Checkliste sind ebenfalls in diesem Dokument enthalten. Dieses Dokument sowie die zugehörige Website und ein Forum (http://www.record-statement.org) werden die Umsetzung und das Verständnis von RECORD verbessern. Autoren, Redakteure von Fachzeitschriften und Peer-Reviewer können die Transparenz beim Berichten von Forschungsergebnissen erhöhen, indem sie RECORD anwenden.
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Affiliation(s)
- Eric I Benchimol
- Children's Hospital of Eastern Ontario Research Institute, Department of Pediatrics and School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada.
| | - Liam Smeeth
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Astrid Guttmann
- Institute for Clinical Evaluative Sciences, Toronto, Canada; Hospital for Sick Children, Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Katie Harron
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lars G Hemkens
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Switzerland
| | - David Moher
- Ottawa Hospital Research Institute, Ottawa, Canada, and School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, Canada
| | - Irene Petersen
- Department of Primary Care and Population Health, University College London (UCL), London, United Kingdom
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Erik von Elm
- Cochrane Switzerland, Institute of Social and Preventive Medicine, University Medical Centre Lausanne, Lausanne, Switzerland
| | - Sinéad M Langan
- London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Oyinlola JO, Campbell J, Kousoulis AA. Is real world evidence influencing practice? A systematic review of CPRD research in NICE guidances. BMC Health Serv Res 2016; 16:299. [PMID: 27456701 PMCID: PMC4960862 DOI: 10.1186/s12913-016-1562-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 07/20/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND There is currently limited evidence regarding the extent Real World Evidence (RWE) has directly impacted the health and social care systems. The aim of this review is to identify national guidelines or guidances published in England from 2000 onwards which have referenced studies using the governmental primary care data provider the Clinical Practice Research Datalink (CPRD). METHODS The methodology recommended by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed. Four databases were searched and documents of interest were identified through a search algorithm containing keywords relevant to CPRD. A search diary was maintained with the inclusion/exclusion decisions which were performed by two independent reviewers. RESULTS Twenty-five guidance documents were included in the final review (following screening and assessment for eligibility), referencing 43 different CPRD/GPRD studies, all published since 2007. The documents covered 12 disease areas, with the majority (N =7) relevant to diseases of the Central Nervous system (CNS). The 43 studies provided evidence of disease epidemiology, incidence/prevalence, pharmacoepidemiology, pharmacovigilance and health utilisation. CONCLUSIONS A slow uptake of RWE in clinical and therapeutic guidelines (as provided by UK governmental structures) was noticed. However, there seems to be an increasing trend in the use of healthcare system data to inform clinical practice, especially as the real world validity of clinical trials is being questioned. In order to accommodate this increasing demand and meet the paradigm shift expected, organisations need to work together to enable or improve data access, undertake translational and relevant research and establish sources of reliable evidence.
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Affiliation(s)
- Jessie O. Oyinlola
- Clinical Practice Research Datalink (CPRD), Medicines and Healthcare products Regulatory Agency, 151 Buckingham Palace Road, Victoria London, SW1W 9SZ UK
| | - Jennifer Campbell
- Clinical Practice Research Datalink (CPRD), Medicines and Healthcare products Regulatory Agency, 151 Buckingham Palace Road, Victoria London, SW1W 9SZ UK
| | - Antonis A. Kousoulis
- Clinical Practice Research Datalink (CPRD), Medicines and Healthcare products Regulatory Agency, 151 Buckingham Palace Road, Victoria London, SW1W 9SZ UK
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Ewing M, Naredi P, Nemes S, Zhang C, Månsson J. Increased consultation frequency in primary care, a risk marker for cancer: a case-control study. Scand J Prim Health Care 2016; 34:205-12. [PMID: 27189513 PMCID: PMC4977944 DOI: 10.1080/02813432.2016.1183692] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To identify early diagnostic profiles such as diagnostic codes and consultation patterns of cancer patients in primary care one year prior to cancer diagnosis. DESIGN Total population-based case-control study. SETTING AND SUBJECTS 4562 cancer patients and 17,979 controls matched by age, sex, and primary care unit. Data were collected from the Swedish Cancer Register and the Regional Healthcare Database. METHOD We identified cancer patients in the Västra Götaland Region of Sweden diagnosed in 2011 with prostate, breast, colorectal, lung, gynaecological, and skin cancers including malignant melanoma. We studied the symptoms and diagnoses identified by diagnostic codes during a diagnostic interval of 12 months before the cancer diagnosis. MAIN OUTCOME MEASURES Consultation frequency, symptom density by cancer type, prevalence and odds ratios (OR) for the diagnostic codes in the cancer population as a whole. RESULTS The diagnostic codes with the highest OR were unspecified lump in breast, neoplasm of uncertain behaviour, and abnormal serum enzyme levels. The codes with the highest prevalence were hyperplasia of prostate, other skin changes and abdominal and pelvic pain. The frequency of diagnostic codes and consultations in primary care rose in tandem 50 days before diagnosis for breast and gynaecological cancer, 60 days for malignant melanoma and skin cancer, 80 days for prostate cancer and 100 days for colorectal and lung cancer. CONCLUSION Eighty-seven percent of patients with the most common cancers consulted a general practitioner (GP) a year before their diagnosis. An increase in consultation frequency and presentation of any symptom should raise the GP's suspicion of cancer. Key points Knowledge about the prevalence of early symptoms and other clinical signs in cancer patients in primary care remains insufficient. • Eighty-seven percent of the patients with the seven most common cancers consulted a general practitioner 12 months prior to cancer diagnosis. • Both the frequency of consultation and the number of symptoms and diseases expressed in diagnostic codes rose in tandem 50-100 days before the cancer diagnosis. • Unless it is caused by a previously known disease, an increased consultation rate for any symptom should result in a swift investigation or referral from primary care to confirm or exclude cancer.
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Affiliation(s)
- Marcela Ewing
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
- CONTACT Marcela Ewing Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Naredi
- Department of Surgery, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
| | | | - Chenyang Zhang
- Regional Cancer Center West, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jörgen Månsson
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
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19
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Primary Care Use before Cancer Diagnosis in Adolescents and Young Adults - A Nationwide Register Study. PLoS One 2016; 11:e0155933. [PMID: 27203083 PMCID: PMC4874574 DOI: 10.1371/journal.pone.0155933] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 05/06/2016] [Indexed: 01/07/2023] Open
Abstract
Introduction Survival rates of cancer patients have generally improved in recent years. However, children and older adults seem to have experienced more significant clinical benefits than adolescents and young adults (AYAs). Previous studies suggest a prolonged diagnostic pathway in AYAs, but little is known about their pre-diagnostic healthcare use. This study investigates the use of primary care among AYAs during the two years preceding a cancer diagnosis. Methods The study is a retrospective population-based matched cohort study using Danish nationwide registry data. All persons diagnosed with cancer during 2002–2011 in the age group 15–39 years were included (N = 12,306); each participant was matched on gender, age and general practice with 10 randomly selected references (N = 123,060). The use of primary healthcare services (face-to-face contacts, blood tests and psychometric tests) was measured during the two years preceding the diagnosis (index date), and collected data were analysed in a negative binomial regression model. Results The cases generally increased their use of primary care already from 8 months before a cancer diagnosis, whereas a similar trend was not found for controls. The increase was observed for all cancer types, but it started at different times: 17 months before a diagnosis of CNS tumour, 12 months before a diagnosis of soft tissue sarcoma, 9 months before a diagnosis of lymphoma, 5–6 months before a diagnosis of leukaemia, bone tumour or GCT, and 3 months before a diagnosis of malignant melanoma. Conclusion The use of primary care among AYAs increase several months before a cancer diagnosis. The diagnostic intervals are generally short for malignant melanomas and long for brain tumours. A prolonged diagnostic pathway may indicate non-specific or vague symptomatology and low awareness of cancer among AYAs primary-care personnel. The findings suggest potential of faster cancer diagnosis in AYAs.
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20
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Benchimol EI, Smeeth L, Guttmann A, Harron K, Moher D, Petersen I, Sørensen HT, von Elm E, Langan SM. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med 2015; 12:e1001885. [PMID: 26440803 PMCID: PMC4595218 DOI: 10.1371/journal.pmed.1001885] [Citation(s) in RCA: 2712] [Impact Index Per Article: 301.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Routinely collected health data, obtained for administrative and clinical purposes without specific a priori research goals, are increasingly used for research. The rapid evolution and availability of these data have revealed issues not addressed by existing reporting guidelines, such as Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). The REporting of studies Conducted using Observational Routinely collected health Data (RECORD) statement was created to fill these gaps. RECORD was created as an extension to the STROBE statement to address reporting items specific to observational studies using routinely collected health data. RECORD consists of a checklist of 13 items related to the title, abstract, introduction, methods, results, and discussion section of articles, and other information required for inclusion in such research reports. This document contains the checklist and explanatory and elaboration information to enhance the use of the checklist. Examples of good reporting for each RECORD checklist item are also included herein. This document, as well as the accompanying website and message board (http://www.record-statement.org), will enhance the implementation and understanding of RECORD. Through implementation of RECORD, authors, journals editors, and peer reviewers can encourage transparency of research reporting.
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Affiliation(s)
- Eric I. Benchimol
- Children’s Hospital of Eastern Ontario Research Institute, Department of Pediatrics and School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Liam Smeeth
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Astrid Guttmann
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Hospital for Sick Children, Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Katie Harron
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David Moher
- Ottawa Hospital Research Institute, Ottawa, Canada, and School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | - Irene Petersen
- Department of Primary Care and Population Health, University College London, London, United Kingdom
| | | | - Erik von Elm
- Cochrane Switzerland, Institute of Social and Preventive Medicine, University of Lausanne, Lausanne, Switzerland
| | - Sinéad M. Langan
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Rubin G, Berendsen A, Crawford SM, Dommett R, Earle C, Emery J, Fahey T, Grassi L, Grunfeld E, Gupta S, Hamilton W, Hiom S, Hunter D, Lyratzopoulos G, Macleod U, Mason R, Mitchell G, Neal RD, Peake M, Roland M, Seifert B, Sisler J, Sussman J, Taplin S, Vedsted P, Voruganti T, Walter F, Wardle J, Watson E, Weller D, Wender R, Whelan J, Whitlock J, Wilkinson C, de Wit N, Zimmermann C. The expanding role of primary care in cancer control. Lancet Oncol 2015; 16:1231-72. [PMID: 26431866 DOI: 10.1016/s1470-2045(15)00205-3] [Citation(s) in RCA: 355] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 07/25/2015] [Accepted: 07/27/2015] [Indexed: 12/21/2022]
Abstract
The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.
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Affiliation(s)
- Greg Rubin
- School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK.
| | - Annette Berendsen
- Department of General Practice, University of Groningen, Groningen, Netherlands
| | | | - Rachel Dommett
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Craig Earle
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Jon Emery
- Department of General Practice, University of Melbourne, Melbourne, VIC, Australia
| | - Tom Fahey
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Luigi Grassi
- Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy
| | - Eva Grunfeld
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Sumit Gupta
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | | | | | - David Hunter
- School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK
| | | | - Una Macleod
- Hull-York Medical School, University of Hull, Hull, UK
| | - Robert Mason
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Geoffrey Mitchell
- Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, QLD, Australia
| | - Richard D Neal
- North Wales Centre for Primary Care Research, Bangor University, Bangor, Wales
| | | | - Martin Roland
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Bohumil Seifert
- Department of General Practice, Charles University, Prague, Czech Republic
| | - Jeff Sisler
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Stephen Taplin
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Peter Vedsted
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Teja Voruganti
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Fiona Walter
- Department of General Practice, University of Groningen, Groningen, Netherlands
| | - Jane Wardle
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Eila Watson
- Department of Clinical Health Care, Oxford Brookes University, Oxford, UK
| | - David Weller
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Jeremy Whelan
- Research Department of Oncology, University College London, London, UK
| | - James Whitlock
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research, Bangor University, Bangor, Wales
| | - Niek de Wit
- Department of General Practice, University Medical Center Utrecht, Utrecht, Netherlands
| | - Camilla Zimmermann
- Division of Medical Oncology and Haematology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Gupta S, Gibson P, Pole JD, Sutradhar R, Sung L, Guttmann A. Predictors of diagnostic interval and associations with outcome in acute lymphoblastic leukemia. Pediatr Blood Cancer 2015; 62:957-63. [PMID: 25586065 DOI: 10.1002/pbc.25402] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 11/27/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Little is known about diagnostic interval lengths in childhood cancer, their predictors or impact upon survival. To date, studies have relied on questionnaires or chart abstraction. We aimed to construct and validate a diagnostic interval measure using health services data among children with acute lymphoblastic leukemia (ALL) in order to determine predictors of prolonged intervals and associations with event-free survival (EFS). PROCEDURE All children with ALL diagnosed 1995-2011 (N = 1,541) in Ontario, Canada were linked to population-based health administrative databases. Healthcare claims prior to diagnosis were used to define healthcare episodes. Diagnostic intervals (time between first episode with diagnostic code a priori classified as consistent with underlying ALL, and diagnosis) were validated by correlation with a chart abstraction-based measure. RESULTS Intervals were generally short (median 2 days, IQR 1-3). Predictors of longer intervals included having general primary care physicians versus pediatricians (odds ratio 1.60, 95%CI 1.04-2.47; P = 0.03). While prolonged diagnostic intervals were associated with superior EFS (hazard ratio 0.71, 95%CI 0.52-0.98; P = 0.04), this was explained by confounding by disease biology. CONCLUSIONS Health administrative data can be used to measure diagnostic intervals in ALL and potentially other pediatric malignant and non-malignant diseases. Diagnostic intervals were short and a marker of disease severity rather than independent predictors of outcome. These findings may be used to address caregiver guilt and caution against "early diagnosis" benchmarks not based in evidence. Future studies should examine the impact of diagnostic interval length in other conditions, but should account for potential confounding by disease severity.
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Affiliation(s)
- Sumit Gupta
- Division of Haematology/Oncology and Program in Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Canada
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23
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Din NU, Ukoumunne OC, Rubin G, Hamilton W, Carter B, Stapley S, Neal RD. Age and Gender Variations in Cancer Diagnostic Intervals in 15 Cancers: Analysis of Data from the UK Clinical Practice Research Datalink. PLoS One 2015; 10:e0127717. [PMID: 25978414 PMCID: PMC4433335 DOI: 10.1371/journal.pone.0127717] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 03/21/2015] [Indexed: 12/11/2022] Open
Abstract
Background Time from symptomatic presentation to cancer diagnosis (diagnostic interval) is an important, and modifiable, part of the patient’s cancer pathway, and can be affected by various factors such as age, gender and type of presenting symptoms. The aim of this study was to quantify the relationships of diagnostic interval with these variables in 15 cancers diagnosed between 2007 and 2010 using routinely collected data from the Clinical Practice Research Datalink (CPRD) in the UK. Methods Symptom lists for each cancer were prepared from the literature and by consensus amongst the clinician researchers, which were then categorised into either NICE qualifying (NICE) or not (non-NICE) based on NICE Urgent Referral Guidelines for Suspected Cancer criteria. Multivariable linear regression models were fitted to examine the relationship between diagnostic interval (outcome) and the predictors: age, gender and symptom type. Results 18,618 newly diagnosed cancer patients aged ≥40 who had a recorded symptom in the preceding year were included in the analysis. Mean diagnostic interval was greater for older patients in four disease sites (difference in days per 10 year increase in age; 95% CI): bladder (10.3; 5.5 to 15.1; P<0.001), kidney (11.0; 3.4 to 18.6; P=0.004), leukaemia (18.5; 8.8 to 28.1; P<0.001) and lung (10.1; 6.7 to 13.4; P<0.001). There was also evidence of longer diagnostic interval in older patients with colorectal cancer (P<0.001). However, we found that mean diagnostic interval was shorter with increasing age in two cancers: gastric (-5.9; -11.7 to -0.2; P=0.04) and pancreatic (-6.0; -11.2 to -0.7; P=0.03). Diagnostic interval was longer for females in six of the gender non-specific cancers (mean difference in days; 95% CI): bladder (12.2; 0.8 to 23.6; P=0.04), colorectal (10.4; 4.3 to 16.5; P=0.001), gastric (14.3; 1.1 to 27.6; P=0.03), head and neck (31.3; 6.2 to 56.5; P=0.02), lung (8.0; 1.2 to 14.9; P=0.02), and lymphoma (19.2; 3.8 to 34.7; P=0.01). Evidence of longer diagnostic interval was found for patients presenting with non-NICE symptoms in 10 of 15 cancers (mean difference in days; 95% CI): bladder (62.9; 48.7 to 77.2; P<0.001), breast (115.1; 105.9 to 124.3; P<0.001), cervical (60.3; 31.6 to 89.0; P<0.001), colorectal (25.8; 19.6 to 31.9; P<0.001), gastric (24.1; 3.4 to 44.8; P=0.02), kidney (22.1; 4.5 to 39.7; P=0.01), oesophageal (67.0; 42.1 to 92.0; P<0.001), pancreatic (48.6; 28.1 to 69.1; P<0.001), testicular (36.7; 17.0 to 56.4; P< 0.001), and endometrial (73.8; 60.3 to 87.3; P<0.001). Pooled analysis across all cancers demonstrated highly significant evidence of differences overall showing longer diagnostic intervals with increasing age (7.8 days; 6.4 to 9.1; P<0.001); for females (8.9 days; 5.5 to 12.2; P<0.001); and in non-NICE symptoms (27.7 days; 23.9 to 31.5; P<0.001). Conclusions We found age and gender-specific inequalities in time to diagnosis for some but not all cancer sites studied. Whilst these need further explanation, these findings can inform the development and evaluation of interventions intended to achieve timely diagnosis and improved cancer outcomes, such as to provide equity across all age and gender groupings.
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Affiliation(s)
- Nafees U. Din
- North Wales Centre for Primary Care Research, College of Health and Behavioural Sciences, Bangor University, Wrexham, United Kingdom
- * E-mail:
| | - Obioha C. Ukoumunne
- NIHR CLAHRC South West Peninsula, University of Exeter Medical School, Exeter, United Kingdom
| | - Greg Rubin
- School of Medicine, Pharmacy and Health, Wolfson Research Institute, Durham University, Durham, United Kingdom
| | | | - Ben Carter
- Institute of Primary Care & Public Health, Cardiff School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Sal Stapley
- University of Exeter Medical School, Exeter, United Kingdom
| | - Richard D. Neal
- North Wales Centre for Primary Care Research, College of Health and Behavioural Sciences, Bangor University, Wrexham, United Kingdom
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Toftegaard BS, Bro F, Vedsted P. A geographical cluster randomised stepped wedge study of continuing medical education and cancer diagnosis in general practice. Implement Sci 2014; 9:159. [PMID: 25377520 PMCID: PMC4229614 DOI: 10.1186/s13012-014-0159-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 10/16/2014] [Indexed: 01/07/2023] Open
Abstract
Background Denmark has inferior cancer survival rates compared with many European countries. The main reason for this is suggested to be late diagnosis at advanced cancer stages. Cancer diagnostic work-up begins in general practice in 85% of all cancer cases. Thus, general practitioners (GPs) play a key role in the diagnostic process. The latest Danish Cancer Plan included continuing medical education (CME) on early cancer diagnosis in general practice to improve early diagnosis. This dual aims of this protocol are, first, to describe the conceptualisation, operationalisation and implementation of the CME and, second, to describe the study design and outcomes chosen to evaluate the effects of the CME. Methods/Design The intervention is a CME in early cancer diagnosis targeting individual GPs. It was developed by a step-wise approach. Barriers for early cancer diagnosis at GP level were identified systematically and analysed using the behaviour system involving capability, opportunity and motivation described by Michie et al. The study will be designed as a geographical cluster randomised stepped wedge study. The study population counts 836 GPs from 417 general practices in the Central Denmark Region, geographically divided into eight clusters. GPs from each cluster will be invited to a CME meeting at a certain date three weeks apart. The primary outcomes will be primary care interval and GP referral rate on cancer suspicion. Data will be obtained from national registries, GP-completed forms on patients referred to cancer fast-track pathways and GP-completed online questionnaires before and after the intervention. Discussion To our knowledge, this will be the first study to measure the effect of a theory-based CME in early cancer diagnosis at three levels: GP knowledge and attitude, GP activity and patient outcomes. The achieved knowledge will contribute to the understanding of whether and how general practice’s ability to perform cancer diagnosis may be improved. Trial registration Registered as NCT02069470 on ClinicalTrials.gov. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0159-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Berit Skjødeberg Toftegaard
- Research Unit for General Practice, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark. .,Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark. .,Department of Public Health, Section for General Medical Practice, Bartholins Allé 2, DK-8000, Aarhus, Denmark.
| | - Flemming Bro
- Research Unit for General Practice, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark. .,Department of Public Health, Section for General Medical Practice, Bartholins Allé 2, DK-8000, Aarhus, Denmark.
| | - Peter Vedsted
- Research Unit for General Practice, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark. .,Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark. .,Department of Public Health, Section for General Medical Practice, Bartholins Allé 2, DK-8000, Aarhus, Denmark.
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Clarke RT, Jones CHD, Mitchell CD, Thompson MJ. 'Shouting from the roof tops': a qualitative study of how children with leukaemia are diagnosed in primary care. BMJ Open 2014; 4:e004640. [PMID: 24549167 PMCID: PMC3931998 DOI: 10.1136/bmjopen-2013-004640] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To investigate the prehospital presentation of paediatric leukaemia and identify the disease and non-disease related factors which facilitate or impede diagnosis. DESIGN Thematic analysis of qualitative semistructured interviews. SETTING One tertiary referral centre in Southern England. PARTICIPANTS 21 parents and 9 general practitioners (GPs) of 18 children (<18-year-old) with a new diagnosis of acute leukaemia. RESULTS The majority of children were first seen by GPs before the characteristic signs and symptoms of leukaemia had developed. In their absence, behavioural cues such as the child becoming apathetic or 'not themselves' often triggered parents to seek medical help. Most GPs were unclear about the nature and severity of the child's presentation: then, safety netting, thorough history-taking and examination, and reliance on contextual information about the parents or from prior hospital paediatrics experience were used to manage diagnostic uncertainty. The nature of the doctor-parent relationship helped and hindered the diagnostic pathway. GPs' prior perceptions of parents as being 'sensible' or 'worriers' influenced how gravely they treated parental concerns, with 'worriers' being taken less seriously. Some parents believed GPs failed to listen to their anxieties and discounted their expert knowledge of their child. Specific delay factors included lack of continuity of GP; some GPs' reluctance to take blood from children; and some parents feeling unable to voice effectively their concerns. CONCLUSIONS The presentation of paediatric leukaemia in primary care differs from that described in many hospital studies, with greater diversity and intermittency of symptoms, and the frequent absence of 'red flags' of serious illness. A wide range of non-disease related factors potentially delay the diagnosis of paediatric leukaemia, including tensions in the doctor-patient relationship and the doctors' cognitive biases. The identification and attempted modification of these factors may minimise diagnostic delay more successfully than raising awareness of 'red flags' of disease.
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Affiliation(s)
- Rachel T Clarke
- Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK
| | - Caroline HD Jones
- Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
| | - Christopher D Mitchell
- Department of Paediatric Oncology/Haematology, Children's Hospital, John Radcliffe, Oxford, UK
| | - Matthew J Thompson
- Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
- University of Washington, Seattle, Washington, USA
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Risk of childhood cancer with symptoms in primary care: a population-based case-control study. Br J Gen Pract 2014; 63:e22-9. [PMID: 23336454 DOI: 10.3399/bjgp13x660742] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Guidelines describing symptoms in children that should alert GPs to consider cancer have been developed, but without any supporting primary-care research. AIM To identify symptoms and signs in primary care that strongly increase the likelihood of childhood cancer, to assist GPs in selection of children for investigation. DESIGN AND SETTING A population-based case-control study in UK general practice. METHOD Using electronic primary care records from the UK General Practice Research Database, 1267 children aged 0-14 years diagnosed with childhood cancer were matched to 15 318 controls. Clinical features associated with subsequent diagnosis of cancer were identified using conditional logistic regression, and likelihood ratios and positive predictive values (PPVs) were estimated for each. RESULTS Twelve symptoms were associated with PPVs of ≥0.04%, which represents a greater than tenfold increase in prior probability. The six symptoms with the highest PPVs were pallor (odds ratio, OR = 84; PPV = 0.41% (95% confidence interval [CI] = 0.12% to 1.34%), head and neck masses (OR = 17; PPV = 0.30%; 95% CI = 0.10% to 0.84%), masses elsewhere (OR = 22; PPV = 0.11%; 95% CI = 0.06% to 0.20%), lymphadenopathy (OR = 10; PPV = 0.09%; 95% CI = 0.06% to 0.13%), symptoms/signs of abnormal movement (OR = 16; PPV = 0.08%; 95% CI = 0.04% to 0.14%), and bruising (OR = 12; PPV = 0·08%; 95% CI = 0.05% to 0.13%). When each of these 12 symptoms was combined singly with at least three consultations in a 3-month period, the probability of cancer was between 11 and 76 in 10 000. CONCLUSION Twelve features of childhood cancers were identified, each of which increased the risk of cancer at least tenfold. These symptoms, particularly when combined with multiple consultations, warrant careful evaluation in general practice.
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Lyratzopoulos G, Greenberg DC, Rubin GP, Abel GA, Walter FM, Neal RD. Advanced stage diagnosis of cancer: who is at greater risk? Expert Rev Anticancer Ther 2014; 12:993-6. [DOI: 10.1586/era.12.77] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Comparison of cancer diagnostic intervals before and after implementation of NICE guidelines: analysis of data from the UK General Practice Research Database. Br J Cancer 2013; 110:584-92. [PMID: 24366304 PMCID: PMC3915139 DOI: 10.1038/bjc.2013.791] [Citation(s) in RCA: 154] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 11/04/2013] [Accepted: 11/19/2013] [Indexed: 12/18/2022] Open
Abstract
Background: The primary aim was to use routine data to compare cancer diagnostic intervals before and after implementation of the 2005 NICE Referral Guidelines for Suspected Cancer. The secondary aim was to compare change in diagnostic intervals across different categories of presenting symptoms. Methods: Using data from the General Practice Research Database, we analysed patients with one of 15 cancers diagnosed in either 2001–2002 or 2007–2008. Putative symptom lists for each cancer were classified into whether or not they qualified for urgent referral under NICE guidelines. Diagnostic interval (duration from first presented symptom to date of diagnosis in primary care records) was compared between the two cohorts. Results: In total, 37 588 patients had a new diagnosis of cancer and of these 20 535 (54.6%) had a recorded symptom in the year prior to diagnosis and were included in the analysis. The overall mean diagnostic interval fell by 5.4 days (95% CI: 2.4–8.5; P<0.001) between 2001–2002 and 2007–2008. There was evidence of significant reductions for the following cancers: (mean, 95% confidence interval) kidney (20.4 days, −0.5 to 41.5; P=0.05), head and neck (21.2 days, 0.2–41.6; P=0.04), bladder (16.4 days, 6.6–26.5; P⩽0.001), colorectal (9.0 days, 3.2–14.8; P=0.002), oesophageal (13.1 days, 3.0–24.1; P=0.006) and pancreatic (12.6 days, 0.2–24.6; P=0.04). Patients who presented with NICE-qualifying symptoms had shorter diagnostic intervals than those who did not (all cancers in both cohorts). For the 2007–2008 cohort, the cancers with the shortest median diagnostic intervals were breast (26 days) and testicular (44 days); the highest were myeloma (156 days) and lung (112 days). The values for the 90th centiles of the distributions remain very high for some cancers. Tests of interaction provided little evidence of differences in change in mean diagnostic intervals between those who did and did not present with symptoms specifically cited in the NICE Guideline as requiring urgent referral. Conclusion: We suggest that the implementation of the 2005 NICE Guidelines may have contributed to this reduction in diagnostic intervals between 2001–2002 and 2007–2008. There remains considerable scope to achieve more timely cancer diagnosis, with the ultimate aim of improving cancer outcomes.
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Gibson F, Pearce S, Eden T, Glaser A, Hooker L, Whelan J, Kelly D. Young people describe their prediagnosis cancer experience. Psychooncology 2013; 22:2585-92. [PMID: 23784978 DOI: 10.1002/pon.3325] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 05/07/2013] [Accepted: 05/08/2013] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Young people often report a protracted journey to diagnosis and frequently report perceived delays. This study was undertaken to increase understanding of the self-reported prediagnosis experiences in young people with a non-haematological cancer, as close as possible to the time of diagnosis. METHODS Narrative interviews were conducted with 24 young people aged 16-24, 2-4 months from the diagnosis of a solid tumour. Data were analysed to identify whether prediagnosis narratives could be classified according to shared characteristics (typologies) to identify broader contextual issues concerning cancer, and cancer risk perceptions, in this age group. Case notes were also accessed to contextualize and confirm accounts. RESULTS The main themes, which included a group narrative concerning perspectives of delay, included the impact on an individual's everyday life by symptoms; the role that significant others in young peoples' lives played in the interpretation of symptom significance; the negotiation of entry into, and experiences of, generalist health care; entry into specialist care; and the threshold points that exemplified when events shifted and a diagnosis was eventually obtained. CONCLUSIONS The narratives reveal complex, and multidimensional explanations for delay with individual and contextual factors contributing. Insights were gained into preventable diagnostic delay; including investigations having been instigated, but not followed up. Each narrative also offered significant insights into how cancer symptoms should be considered within the context of young peoples' lives. This would help prevent signs and symptoms in this age group failing to trigger suspicion and not being treated seriously.
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Affiliation(s)
- Faith Gibson
- Children's Nursing, Great Ormond Street Hospital for Children NHS Foundation Trust and London South Bank University, London, UK
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Dommett RM, Redaniel MT, Stevens MCG, Hamilton W, Martin RM. Features of cancer in teenagers and young adults in primary care: a population-based nested case-control study. Br J Cancer 2013; 108:2329-33. [PMID: 23619924 PMCID: PMC3681013 DOI: 10.1038/bjc.2013.191] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Teenagers and young adults (TYA, 15-24 years) diagnosed with cancer report repeated visits to primary care before referral. We investigated associations of symptoms and consultation frequency in primary care with TYA cancers. METHODS Population-based, case-control study was carried out using data from the Clinical Practice Research Datalink (CPRD). A total of 1064 TYA diagnosed with cancer were matched to 13,206 controls. Symptoms independently associated with specific cancers were identified. Likelihood ratios (LRs) and positive predictive values (PPVs) were calculated. RESULTS In the 3 months before diagnosis, 397 (42.9%) cases consulted > or =4 times vs 593(11.5%) controls (odds ratio (OR): 12.1; 95% CI: 9.7, 15.1), yielding a PPV for any cancer of 0.018%. The LR of lymphoma with a head/neck mass was 434 (95% CI: 60, 3158), with a PPV of 0.5%. Corresponding figures in other cancers included - LR of leukaemia with lymphadenopathy (any site): 29 (95% CI: 8, 112), PPV 0.015%; LR of CNS tumour with seizure: 56 (95% CI: 19, 163), PPV 0.024%; and LR of sarcoma with lump/mass/swelling: 79 (95% CI: 24, 264), PPV 0.042%. CONCLUSION Teenagers and young adults with cancer consulted more frequently than controls in the 3 months before diagnosis. Primary care features of cancer match secondary care reports, but were of very low risk; nonetheless, some features increased the likelihood of cancer substantially and should be taken seriously when assessing TYA.
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Affiliation(s)
- R M Dommett
- School of Clinical Sciences, University of Bristol, Level 6 UHB Education Centre, Upper Maudlin Street, Bristol BS2 8AE, UK.
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Ahrensberg JM, Fenger-Grøn M, Vedsted P. Use of primary care during the year before childhood cancer diagnosis: a nationwide population-based matched comparative study. PLoS One 2013; 8:e59098. [PMID: 23554980 PMCID: PMC3595276 DOI: 10.1371/journal.pone.0059098] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 02/12/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Childhood cancer is rare and symptoms tend to be unspecific and vague. Using the utilization of health care services as a proxy for symptoms, the present study seeks to determine when early symptoms of childhood cancer are seen in general practice. METHODS A population-based matched comparative study was conducted using nationwide registry data. As cases, all children in Denmark below 16 years of age (N = 1,278) diagnosed with cancer (Jan 2002-Dec 2008) were included. As controls, 10 children per case matched on gender and date of birth (N = 12,780) were randomly selected. The utilization of primary health care services (daytime contacts, out-of-hours contacts and diagnostic procedures) during the year preceding diagnosis/index date was measured for cases and controls. RESULTS During the six months before diagnosis, children with cancer used primary care more than the control cohort. This excess use grew consistently and steadily towards the time of diagnosis with an IRR = 3.19 (95%CI: 2.99-3.39) (p<0.0001) during the last three months before diagnosis. Children with Central Nervous System (CNS) tumours had more contacts than other children during the entire study period. The use of practice-based diagnostic tests and the number of out-of-hours contacts began to increase four to five months before cancer diagnosis. CONCLUSIONS The study shows that excess health care use, a proxy for symptoms of childhood cancer, occurs months before the diagnosis is established. Children with lymphoma, bone tumour or other solid tumours had higher consultation rates than the controls in the last five months before diagnosis, whereas children with CNS tumour had higher consultation rates in all twelve months before diagnosis. More knowledge about early symptoms and the diagnostic pathway for childhood cancer would be clinically relevant.
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Childhood cancer and factors related to prolonged diagnostic intervals: a Danish population-based study. Br J Cancer 2013; 108:1280-7. [PMID: 23449354 PMCID: PMC3619273 DOI: 10.1038/bjc.2013.88] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background: Early diagnosis of childhood cancer provides hope for better prognoses. Shorter diagnostic intervals (DI) in primary care require better knowledge of the association between presenting symptoms, interpretation of symptoms and the wording of the referral letter. Methods: A Danish nationwide population-based study. Data on 550 children aged <15 years with an incident cancer diagnosis (January 2007–December 2010) were collected through questionnaires to parents (response rate=69%) and general practitioners (GPs) (response rate=87%). The DI from the first presentation in general practice until diagnosis was categorised as short or long based on quartiles. Associations between variables and long DIs were assessed using logistic regression. Results: The GPs interpreted symptoms as ‘vague' in 25.4%, ‘serious' in 50.0% and ‘alarm' in 19.0% of cases. Symptom interpretation varied by cancer type (P<0.001) and was associated with the DI (P<0.001). Vomiting was associated with a shorter DI for central nervous system (CNS) tumours, and pain with a longer DI for leukaemia. Referral letter wording was associated with DI (P<0.001); the shortest DIs were observed when cancer suspicion was raised in the letter. Conclusion: The GPs play an important role in recognising early signs of childhood cancer as their symptom interpretation and referral wording have a profound impact on the diagnostic process.
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Stapley S, Peters TJ, Neal RD, Rose PW, Walter FM, Hamilton W. The risk of oesophago-gastric cancer in symptomatic patients in primary care: a large case-control study using electronic records. Br J Cancer 2012; 108:25-31. [PMID: 23257895 PMCID: PMC3553533 DOI: 10.1038/bjc.2012.551] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: Over 15 000 new oesophago-gastric cancers are diagnosed annually in the United Kingdom, with most being advanced disease. We identified and quantified features of this cancer in primary care. Methods: Case–control study using electronic primary-care records of the UK patients aged ⩾40 years was performed. Cases with primary oesophago-gastric cancer were matched to controls on age, sex and practice. Putative features of cancer were identified in the year before diagnosis. Odds ratios (ORs) were calculated for these features using conditional logistic regression, and positive predictive values (PPVs) were calculated. Results: A total of 7471 cases and 32 877 controls were studied. Sixteen features were independently associated with oesophago-gastric cancer (all P<0.001): dysphagia, OR 139 (95% confidence interval 112–173); reflux, 5.7 (4.8–6.8); abdominal pain, 2.6 (2.3–3.0); epigastric pain, 8.8 (7.0–11.0); dyspepsia, 6 (5.1–7.1); nausea and/or vomiting, 4.9 (4.0–6.0); constipation, 1.5 (1.2–1.7); chest pain, 1.6 (1.4–1.9); weight loss, 8.9 (7.1–11.2); thrombocytosis, 2.4 (2.0–2.9); low haemoglobin, 2.4 (2.1–2.7); low MCV, 5.2 (4.2–6.4); high inflammatory markers, 1.7 (1.4–2.0); raised hepatic enzymes, 1.3 (1.2–1.5); high white cell count, 1.4 (1.2–1.7); and high cholesterol, 0.8 (0.7–0.8). The only PPV >5% in patients ⩾55 years was for dysphagia. In patients <55 years, all PPVs were <1%. Conclusion: Symptoms of oesophago-gastric cancer reported in secondary care were also important in primary care. The results should inform guidance and commissioning policy for upper GI endoscopy.
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Affiliation(s)
- S Stapley
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
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Presenting symptoms of children with cancer: a primary-care population-based study. Br J Gen Pract 2012; 62:e458-65. [PMID: 22781993 DOI: 10.3399/bjgp12x652319] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Knowledge of how children with cancer present in general practice is sparse. Timely referral from general practice is important to ensure early diagnosis. AIM To investigate the presenting symptoms and GPs' interpretations of symptoms of children with cancer. DESIGN AND SETTING A Danish nationwide population-based study including children (<15 years) with an incident cancer diagnosis (January 2007 to December 2010). METHOD A questionnaire on symptoms and their interpretation was mailed to GPs (n=363). Symptoms were classified according to the International Classification of Primary Care (ICPC)-2 classification. RESULTS GPs' response rate was 87% (315/363) and GPs were involved in the diagnostic process of 253 (80.3%) children. Symptoms were few (2.4 per child) and most fell into the category 'general and unspecified' (71.9%), apart from patients with tumours of the central nervous system (CNS), whose symptoms fell mostly in the category 'neurological' (for example, headache). Symptoms like pain, swelling/lump, or fatigue were reported in 25% of the patients and they were the most commonly reported symptoms. GPs interpreted children's symptoms as alarm symptoms in 20.2%, as serious (that is, not alarm) symptoms in 52.9%, and as vague symptoms in 26.9%. GPs' interpretation varied significantly by diagnosis (P<0.001). CONCLUSION Children with cancer presented with few symptoms in general practice, of which most were 'general and unspecified' symptoms. Only 20% presented alarm symptoms, while 27% presented vague and non-specific symptoms. This low level of alarm symptoms may influence the time from symptom presentation in general practice to final diagnosis.
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Evidence for under-diagnosis of childhood acute lymphoblastic leukaemia in poorer communities within Great Britain. Br J Cancer 2012; 106:1556-9. [PMID: 22472883 PMCID: PMC3341865 DOI: 10.1038/bjc.2012.102] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Recorded incidence of childhood acute lymphoblastic leukaemia tends to be lower in poorer communities. A ‘pre-emptive infection hypothesis’ proposes that some children with leukaemia die from infection without diagnosis of leukaemia. Various different blood abnormalities can occur in untreated leukaemia. Methods: Logistic regression was used to compare pre-treatment blood counts among children aged 1–13 years at recruitment to national clinical trials for acute lymphoblastic leukaemia during 1980–2002 (N=5601), grouped by address at diagnosis within Great Britain into quintiles of the 1991 Carstairs deprivation index. Children combining severe neutropenia (risk of serious infection) with relatively normal haemoglobin and platelet counts (lack of pallor and bleeding) were postulated to be at risk of dying from infection without leukaemia being suspected. A deficit of these children among diagnosed patients from poorer communities was predicted. Results: As predicted, there was a deficit of children at risk of non-diagnosis (two-sided Ptrend=0.004; N=2009), and an excess of children with pallor (Ptrend=0.045; N=5535) and bleeding (Ptrend=0.036; N=5541), among cases from poorer communities. Conclusion: Under-diagnosis in poorer communities may have contributed to socioeconomic variation in recorded childhood acute lymphoblastic leukaemia incidence within Great Britain, and elsewhere. Implications for clinical practice and epidemiological studies should be considered.
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