Symptoms and other factors associated with time to diagnosis and stage of lung cancer: a prospective cohort study

Understanding ethnic inequalities in cancer diagnostic intervals: a cohort study of patients presenting suspected cancer symptoms to GPs in England

BACKGROUND

UK Asian and Black patients experience longer cancer diagnostic intervals - the period between initial symptomatic presentation in primary care and cancer diagnosis.

AIM

To determine whether the differences in diagnostic intervals are because of prolonged primary care, referral, or secondary care interval.

DESIGN AND SETTING

A cohort study was undertaken of 70 971 patients with seven cancers (breast, lung, prostate, colorectal, oesophagogastric, myeloma, ovarian) diagnosed after symptom presentation in English primary care.

METHOD

Data on symptom presentation and diagnosis were extracted from cancer registry-linked primary care and secondary care data. Primary interval was defined as the period between first primary care presentation and secondary care referral, referral interval as the period between referral and first secondary care appointment, and secondary care interval as the period between the first secondary care appointment and diagnosis. Accelerated failure time models were used to investigate ethnic differences across all four intervals.

RESULTS

Across all sites, the median diagnostic interval was 46 days, ranging from 13 days for breast cancer to 116 days for lung cancer. It was 14% longer for Black patients (adjusted time ratio [ATR] 1.14, 95% confidence interval [CI] = 1.05 to 1.25) and 13% longer for Asian patients (ATR 1.13, 95% CI = 1.03 to 1.23) compared with White patients. Site-specific analyses showed that, for myeloma, lung, prostate, and colorectal cancer, the secondary care interval was longer in Asian and Black patients, who also had a longer primary care interval in breast and colorectal cancer. There was little evidence of ethnic differences in referral interval.

CONCLUSION

This study found evidence of ethnic differences in diagnostic intervals, with prolonged secondary care intervals for four common cancers and prolonged primary care intervals for two. Although these differences are relatively modest, they are unjustified and may indicate shortcomings in healthcare delivery that disproportionately affect ethnic minorities.

Treatment delays in patients with lung cancer: a retrospective study conducted at the National Cancer Institute of Mexico between 2004 and 2021

IMPORTANCE

Lung cancer management involves navigating a complex pathway from symptom onset to treatment initiation, where delays can compromise outcomes.

OBJECTIVE

To identify the length of treatment intervals among Mexican lung cancer patients, compare treatment intervals to results from other countries, and identify determinants of delays.

DESIGN

Retrospective study collecting patient records and exploring the treatment interval in lung cancer.

SETTING

The study was conducted at Mexico's National Cancer Institute.

PARTICIPANTS

2645 lung cancer patients with a confirmed diagnosis between 2004 and 2021 were included in the analysis.

EXPOSURE

Social determinants of health.

MAIN OUTCOME

Treatment interval (from diagnosis to treatment).

RESULTS

Logistic regression models revealed significant associations between delays and various factors, including marital status, education, region, first symptom at presentation, treatment type, and political period. A comparison with international guidelines highlighted substantial delays in patients diagnosed at the Instituto Nacional de Cancerología and diagnosed externally.

CONCLUSIONS

Targeted interventions should consider patient characteristics to enhance care efficiency. Concerns should be raised about the observed increase in treatment intervals from 2014 and the associated impact on survival rates. There is an urgency for timely interventions, continuous research, and collaborative efforts to optimize care delivery and outcomes for lung cancer patients in Mexico.

The Role of the Interventional Radiologist in Stopping Bleeding in Cancer Patients

PURPOSE OF REVIEW

Malignancy-related hemorrhage is a complex and potentially life-threatening complication that requires a multidisciplinary approach. This review examines the role of endovascular interventions in achieving hemostasis when conservative measures fail, focusing on their indications, efficacy, and associated risks.

RECENT FINDINGS

Endovascular therapies have demonstrated high success rates in controlling hemorrhage from various malignancies. Bronchial artery embolization (BAE) effectively manages hemoptysis in lung cancer, though recurrence remains a challenge. Gastrointestinal tumor bleeding can be treated with targeted embolization, but ischemic complications require careful technique. Hematuria due to urinary and prostate malignancies responds well to superselective embolization, and uterine artery embolization (UAE) is a viable option for gynecologic malignancy-related bleeding. Emerging techniques, such as bronchial artery chemoembolization, show promise in improving long-term control. Endovascular interventions are a cornerstone in the management of malignancy-related hemorrhage, offering minimally invasive and effective hemostatic solutions. While recurrence and complications remain a concern, advancements in embolization techniques and materials continue to improve outcomes. A multidisciplinary approach is essential to optimizing patient care.

Outcomes for Emergency Presentations of Lung Cancer: A Scoping Review

BACKGROUND

Lung cancer is frequently detected during visits to the emergency department (ED). The ED is crucial for identifying likely cases of lung cancer and coordinating the subsequent care for these patients.

OBJECTIVES

This scoping review aims to explore the definitions of emergency presentations (EPs) of lung cancer, along with mortality rates, cancer stage, and treatments for patients diagnosed with lung cancer following an EP.

METHODS

We conducted a scoping review of the literature on EPs of lung cancer, identifying 27 relevant articles out of 1338 initially screened.

RESULTS

Most studies originated from the United Kingdom, collectively reporting over 270,000 EPs of lung cancer. The majority of included studies provided strong evidence. Key findings revealed higher mortality rates among patients diagnosed with lung cancer through emergency presentations, with a significant proportion presenting at advanced stages. Patients with EPs were less likely to undergo surgical removal or receive radiotherapy. Lastly, only 66.7% of the studies defined an EP, with great heterogeneity among EP definitions. Methodological differences precluded meta-analysis.

CONCLUSION

Despite methodological heterogeneity, our synthesis indicates that patients presenting acutely with undiagnosed lung cancer often present at advanced stages and experience high mortality rates. These findings underscore the need for further research to develop evidence-based interventions for improving outcomes among ED patients with suspected lung cancer.

Analysis of Diagnostic Delay and its Impact on Lung Cancer Survival: Results From the Spanish Thoracic Tumor Registry

BACKGROUND

Early detection is crucial to improve lung cancer survival rates. Delays in diagnosis might negatively impact the prognosis of the disease. This study aims to analyze the diagnostic delay in lung cancer patients and describe if there is an association between delay and survival.

METHODS

The data source used was the Thoracic Tumor Registry of the Spanish Lung Cancer Group. This analysis was restricted to lung cancer cases with information on the first date of consultation by symptoms and date of diagnosis. The delay was calculated as the number of days between the two dates. A descriptive analysis was performed, and ordinal logistic regressions were fitted with delay as the dependent variable. Kaplan-Meier survival analysis and Cox regression were performed.

RESULTS

22,755 lung cancer cases were included. Never smokers were 1.16 (95%CI: 1.06-1.27) times more likely to register longer delay than smokers. Stage 0-I-II cases had a 3.09 (95%CI: 2.88-3.32) higher risk of longer delay compared to III-IV stages. Overall, 5-year survival rate after diagnosis was 23.64% (95%CI: 22.88-24.41). In those categorized as having the shortest delay 5-year survival was 17.67% (95%CI: 16.31-19.07) and in the extreme delay it was 32.98% (95%CI: 31.28-34.69) (p<0.001). Adjusted mortality risk was higher in those with the shortest delay (HR 1.36, CI95%: 1.30-1.43) in comparison with the extreme delay.

CONCLUSIONS

Diagnostic delay is short among Spanish lung cancer patients, indicating a relatively quick diagnostic process. Extreme delays appear to be associated with higher survival rates, possibly attributed to slow-growing tumors, earlier stage at diagnosis or basically the natural history of this disease.

The effect of comorbidities on diagnostic interval for lung cancer in England: a cohort study using electronic health record data

BACKGROUND

Comorbid conditions may delay lung cancer diagnosis by placing demand on general practioners' time reducing the possibility of prompt cancer investigation ("competing demand conditions"), or by offering a plausible non-cancer explanation for signs/symptoms ("alternative explanation conditions").

METHOD

Patients in England born before 1955 and diagnosed with incident lung cancer between 1990 and 2019 were identified in the Clinical Practice Research Datalink and linked hospital admission and cancer registry data. Diagnostic interval was defined as time from first presentation in primary care with a relevant sign/symptom to the diagnosis date. 14 comorbidities were classified as ten "competing demand" and four "alternative explanation" conditions. Associations with diagnostic interval were investigated using multivariable linear regression models.

RESULTS

Complete data were available for 11870 lung cancer patients. In adjusted analyses diagnostic interval was longer for patients with "alternative explanation" conditions, by 31 and 74 days in patients with one and ≥2 conditions respectively versus those with none. Number of "competing demand" conditions did not remain in the final adjusted regression model for diagnostic interval.

CONCLUSIONS

Conditions offering alternative explanations for lung cancer symptoms are associated with increased diagnostic intervals. Clinical guidelines should incorporate the impact of alternative and competing causes upon delayed diagnosis.

Examination of Firefighting as an Occupational Exposure Criteria for Lung Cancer Screening

PURPOSE

Firefighting is known to be carcinogenic to humans. However, current lung cancer screening guidelines do not account for occupational exposure. We hypothesize that firefighting is an independent risk factor associated with the development of high-risk lung nodules on low-dose CT (LDCT).

METHODS

Members of a firefighter's union underwent LDCT at a single institution between April 2022 and June 2023 within a lung cancer screening program. Results were interpreted by designated chest radiologists and reported using the Lung-RADS scoring system. Demographic and radiographic data were recorded, and summary statistics are reported.

RESULTS

1347 individuals underwent lung cancer screening, with a median age of 51 years (IQR 42-58), including 56 (4.2%) females. Overall, 899 (66.7%) were never smokers, 345 (25.6%) were former smokers, and 103 (7.7%) were current smokers. There were 41 firefighters (3.0%) who had high-risk (Lung-RADS 3 or 4) nodules requiring intervention or surveillance, of which 21 (1.5%) were Lung-RADS 3 and 20 (1.5%) that were Lung-RADS 4. Of the firefighters with high-risk nodules, only 6 (14.6%) were eligible for LDCT based on current screening guidelines. There were 7 high-risk nodules (0.5%) that required procedural intervention, 6 (85.7%) of which were from the non-screening eligible cohort. There were also 20 never-smoking firefighters (57.1%) with high-risk nodules that were non-screening eligible.

CONCLUSION

Firefighting, even in the absence of smoking history, may be associated with the development of high-risk lung nodules on LDCT. Carefully selected occupational exposures should be considered in the development of future lung cancer screening guidelines.

Income differences in time to colon cancer diagnosis

INTRODUCTION

People with low income have worse outcomes throughout the cancer care continuum; however, little is known about income and the diagnostic interval. We described diagnostic pathways by neighborhood income and investigated the association between income and the diagnostic interval.

METHODS

This was a retrospective cohort study of colon cancer patients diagnosed 2007-2019 in Ontario using routinely collected data. The diagnostic interval was defined as the number of days from the first colon cancer encounter to diagnosis. Asymptomatic pathways were defined as first encounter with a colonoscopy or guaiac fecal occult blood test not occurring in the emergency department and were examined separately from symptomatic pathways. Quantile regression was used to determine the association between neighborhood income quintile and the conditional 50th and 90th percentile diagnostic interval controlling for age, sex, rural residence, and year of diagnosis.

RESULTS

A total of 64,303 colon cancer patients were included. Patients residing in the lowest income neighborhoods were more likely to be diagnosed through symptomatic pathways and in the emergency department. Living in low-income neighborhoods was associated with longer 50th and 90th-percentile symptomatic diagnostic intervals compared to patients living in the highest income neighborhoods. For example, the 90th percentile diagnostic interval was 15 days (95% CI 6-23) longer in patients living in the lowest income neighborhoods compared to the highest.

CONCLUSION

These findings reveal income inequities during the diagnostic phase of colon cancer. Future work should determine pathways to reducing inequalities along the diagnostic interval and evaluate screening and diagnostic assessment programs from an equity perspective.

Nonspecific Signs and/or Symptoms of Cancer: A Retrospective, Observational Analysis from a Secondary Care, US Community Oncology Dataset

To help determine the unmet need for improved diagnostic tools to evaluate patients with nonspecific signs and/or symptoms (NSSS) and suspicion of cancer, we examined patient characteristics, diagnostic journey, and cancer incidence of patients with NSSS within The US Oncology Network (The Network), a secondary care community oncology setting. This retrospective, observational cohort study included patients aged ≥40 years with ≥1 NSSS in their problem list at their first visit within The Network (the index date) between 1 January 2016 and 31 December 2020. Patients were followed longitudinally with electronic health record data for initial cancer diagnosis, new noncancer diagnosis, death, end of study observation period, or 12 months, whichever occurred first. Of 103,984 patients eligible for inclusion, 96,722 presented with only 1 NSSS at index date; 6537/103,984 (6.3%) were diagnosed with 1 primary cancer within 12 months after the index date; 3825/6537 (58.5%) with hematologic malignancy, and 2712/6537 (41.5%) with solid tumor. Among patients diagnosed with cancer (n = 6774), the median time to cancer diagnosis after their first visit within The Network was 5.13 weeks. This study provides a real-world perspective on cancer incidence in patients with NSSS referred to a secondary care setting and highlights the unmet need for improved diagnostic tools to improve cancer outcomes.

[Severe hemoptysis in the onco-hematology patient]

In France, even though it occurs only exceptionally in cases of hemopathy, severe hemoptysis in cancer is the leading cause of hemoptysis. Without adequate treatment, in-hospital mortality exceeds 60%, even reaching 100% at 6 months. The management of severe hemoptysis should be discussed with the oncologist. Aside from situations of threatening hemoptysis, in which bronchoscopy should be performed immediately, CT angiography is an essential means of localizing the bleeding and determining the causes and the vascular mechanisms involved. In more than 90% of cases, hemoptysis is linked to systemic bronchial or non-bronchial hypervascularization, whereas in fewer than 5%, it is associated with pulmonary arterial origin or, exceptionally, with damage to the alveolar-capillary barrier. The most severely ill patients must be treated in intensive care in centers equipped with interventional radiology, thoracic surgery and, ideally, with interventional bronchoscopy. Interventional radiology is the first-line symptomatic treatment. In over 80% of cases, bronchial arteriography with embolization allows immediate control. Emergency surgery should be avoided, as it is associated with significant mortality. Appropriate and adequate care reduces hospital mortality to 30%, enabling patients to benefit from the most recent, survival-prolonging treatments.

An Interventional Radiologist's Guide to Lung Cancer

Lung cancer continues to be the third leading cause of cancer and the leading cause of cancer deaths. As the field of interventional oncology continues to grow, interventional radiologists are increasingly treating lung cancer patients. Involvement begins with tissue diagnosis for which biomarkers and immunohistochemistry are used to guide selective and advanced medical therapies. An interventional radiologist must be aware of the rationale behind tissue diagnosis and techniques to minimize biopsy complications. Staging is an important part of tumor board conversations and drives treatment pathways. Surgical therapy remains the gold standard for early-stage disease but with an aging population the need for less invasive treatments such as radiation therapy and ablation continue to grow. The interventionalist must be aware of the indications, techniques, and pre- and posttherapy managements for percutaneous ablation. Endovascular therapy is broadly divided into therapeutic treatment of lung cancer, which is gaining traction, and treatment of lung cancer complications such as hemoptysis. This review aims to provide a good basis for interventional radiologists treating lung cancer patients.

Guideline concordance for timely chest imaging after new presentations of dyspnoea or haemoptysis in primary care: a retrospective cohort study

BACKGROUND

Guidelines recommend urgent chest X-ray for newly presenting dyspnoea or haemoptysis but there is little evidence about their implementation.

METHODS

We analysed linked primary care and hospital imaging data for patients aged 30+ years newly presenting with dyspnoea or haemoptysis in primary care during April 2012 to March 2017. We examined guideline-concordant management, defined as General Practitioner-ordered chest X-ray/CT carried out within 2 weeks of symptomatic presentation, and variation by sociodemographic characteristic and relevant medical history using logistic regression. Additionally, among patients diagnosed with cancer we described time to diagnosis, diagnostic route and stage at diagnosis by guideline-concordant status.

RESULTS

In total, 22 560/162 161 (13.9%) patients with dyspnoea and 4022/8120 (49.5%) patients with haemoptysis received guideline-concordant imaging within the recommended 2-week period. Patients with recent chest imaging pre-presentation were much less likely to receive imaging (adjusted OR 0.16, 95% CI 0.14-0.18 for dyspnoea, and adjusted OR 0.09, 95% CI 0.06-0.11 for haemoptysis). History of chronic obstructive pulmonary disease/asthma was also associated with lower odds of guideline concordance (dyspnoea: OR 0.234, 95% CI 0.225-0.242 and haemoptysis: 0.88, 0.79-0.97). Guideline-concordant imaging was lower among dyspnoea presenters with prior heart failure; current or ex-smokers; and those in more socioeconomically disadvantaged groups.The likelihood of lung cancer diagnosis within 12 months was greater among the guideline-concordant imaging group (dyspnoea: 1.1% vs 0.6%; haemoptysis: 3.5% vs 2.7%).

CONCLUSION

The likelihood of receiving urgent imaging concords with the risk of subsequent cancer diagnosis. Nevertheless, large proportions of dyspnoea and haemoptysis presenters do not receive prompt chest imaging despite being eligible, indicating opportunities for earlier lung cancer diagnosis.

Anticipated time to seek medical advice for possible lung cancer symptoms and barriers to timely presentation in Palestine: a national cross-sectional study

BACKGROUND

Lung cancer (LC) has poor survival outcomes mainly due to diagnosis at late stages. This study explored the anticipated time to seek medical advice for possible LC symptoms and barriers to early presentation in Palestine.

METHODS

This cross-sectional study recruited adult participants from hospitals, primary healthcare centers, and public spaces of 11 governorates using convenience sampling. A modified, translated-into-Arabic version of the validated LC awareness measure was used to assess LC symptom awareness, the time needed to seek medical advice and barriers to early presentation.

RESULTS

A total of 4762 participants were included. The proportion that would immediately seek medical advice for possible LC symptoms varied according to the symptoms' nature. For respiratory symptoms, this ranged from 15.0% for 'painful cough' to 37.0% for 'coughing up blood'. For non-respiratory symptoms, this ranged from '4.2% for 'unexplained loss of appetite' to 13.8% for 'changes in the shape of fingers or nails'. Participants with good LC symptom awareness were more likely to seek medical advice within a week of recognizing most LC symptoms. About 13.0% would delay their visit to see a doctor after recognizing an LC symptom. The most reported barriers were emotional with 'disliking the visit to healthcare facilities' (59.8%) as the leading barrier.

CONCLUSION

LC respiratory symptoms were more likely to prompt early seeking of medical advice. Good LC symptom awareness was associated with a higher likelihood of help-seeking within a week. Educational interventions are needed to promote LC awareness and address the perceived barriers to early presentation in low-resource settings, such as Palestine.

The presenting symptom signatures of incident cancer: evidence from the English 2018 National Cancer Diagnosis Audit

BACKGROUND

Understanding relationships between presenting symptoms and subsequently diagnosed cancers can inform symptom awareness campaigns and investigation strategies.

METHODS

We used English National Cancer Diagnosis Audit 2018 data for 55,122 newly diagnosed patients, and examined the relative frequency of presenting symptoms by cancer site, and of cancer sites by presenting symptom.

RESULTS

Among 38 cancer sites (16 cancer groups), three classes were apparent: cancers with a dominant single presenting symptom (e.g. melanoma); cancers with diverse presenting symptoms (e.g. pancreatic); and cancers that are often asymptomatically detected (e.g. chronic lymphocytic leukaemia). Among 83 symptoms (13 symptom groups), two classes were apparent: symptoms chiefly relating to cancers of the same body system (e.g. certain respiratory symptoms mostly relating to respiratory cancers); and symptoms with a diverse cancer site case-mix (e.g. fatigue). The cancer site case-mix of certain symptoms varied by sex.

CONCLUSION

We detailed associations between presenting symptoms and cancer sites in a large, representative population-based sample of cancer patients. The findings can guide choice of symptoms for inclusion in awareness campaigns, and diagnostic investigation strategies post-presentation when cancer is suspected. They can inform the updating of clinical practice recommendations for specialist referral encompassing a broader range of cancer sites per symptom.

Clinical Trials for Oral, Inhaled and Intravenous Drug Delivery System for Lung Cancer and Emerging Nanomedicine-Based Approaches

Lung cancer is one of the most common malignant tumors worldwide and is characterized by high morbidity and mortality rates and a poor prognosis. It is the leading cause of cancer-related death in the United States and worldwide. Most patients with lung cancer are treated with chemotherapy, radiotherapy, or surgery; however, effective treatment options remain limited. In this review, we aim to provide an overview of clinical trials, ranging from Phase I to III, conducted on drug delivery systems for lung cancer treatment. The trials included oral, inhaled, and intravenous administration of therapeutics. Furthermore, the study also talks about the evolving paradigm of targeted therapy and immunotherapy providing promising directions for personalized treatment. In addition, we summarize the best results and limitations of these drug delivery systems and discuss the potential capacity of nanomedicine.

Socioeconomic position and the pre-diagnostic interval among patients diagnosed with head and neck squamous cell carcinoma - a population-based study from DAHANCA

BACKGROUND

The socioeconomic differences in survival are pronounced for patients diagnosed with head and neck cancer; disease stage at diagnosis is suggested to be a main driver of this association. This nationwide, population-based study investigates socioeconomic differences in the pre-diagnostic interval and disease stage at diagnosis.

MATERIAL AND METHODS

Information on patient-reported symptoms, symptom onset and disease-specific factors was obtained from the nationwide population-based Danish Head and Neck Cancer Group (DAHANCA) database for patients diagnosed with head and neck squamous cell carcinoma between 2008 and 2019 in Denmark. Socioeconomic position (SEP) was measured by individual-level education, income and cohabitation status obtained from administrative registers. Socioeconomic differences in the interval from symptom onset to diagnosis were investigated in general linear models with 95% confidence intervals (CIs); overall and by subsite, symptom and comorbidity score. Consultation patterns prior to diagnosis were examined using methods for change-point detection. Associations with advanced-stage disease were estimated in logistic regression models.

RESULTS

Patients with low, medium and high SEP had a similar interval from patient-reported symptom onset to diagnosis of 10 weeks. Although this interval varied according to primary symptom and anatomical subsite, no apparent socioeconomic differences were observed within these subgroups. Aligned with the patient-reported symptom onset, a distinct increase in consultation rates was observed at 9 weeks (95% CI [7.3; 10.7]) for patients with low SEP and 7 weeks (95% CI [4.8; 9.2]) for patients with high SEP, with overlapping CIs. Patients with low compared to high SEP had increased odds for advanced-stage glottic and oral cavity squamous cell carcinoma. For the remaining subsites the association varied according to SEP-indicator and TNM-edition.

CONCLUSION

The interval from symptom onset to diagnosis and consultation patterns were similar across SEP groups. Still, socioeconomic differences in stage at diagnosis were observed for some - but not all - subsites.

Pre-diagnostic prescribing patterns in dyspnoea patients with as-yet-undiagnosed lung cancer: A longitudinal study of linked primary care and cancer registry data

INTRODUCTION

Patients with as-yet undiagnosed lung cancer (LC) can present to primary care with non-specific symptoms such as dyspnoea, often in the context of pre-existing chronic obstructive pulmonary disease (COPD). Related medication prescriptions pre-diagnosis might represent opportunities for earlier diagnosis, but UK evidence is limited. Consequently, we explored prescribing patterns of relevant medications in patients who presented with dyspnoea in primary care and were subsequently diagnosed with LC.

METHOD

Linked primary care (Clinical Practice Research Datalink) and National Cancer Registry data were used to identify 5434 patients with incident LC within a year of a dyspnoea presentation in primary care between 2006 and 2016. Primary care prescriptions relevant to dyspnoea management were examined: antibiotics, inhaled medications, oral steroids, and opioid analgesics. Poisson regression models estimated monthly prescribing rates during the year pre-diagnosis. Variation by COPD status (52 % pre-existing, 36 % COPD-free, 12 % new-onset) was examined. Inflection points were identified indicating when prescribing rates changed from the background rate.

RESULTS

63 % of patients received 1 or more relevant prescriptions 1-12 months pre-diagnosis. Pre-existing COPD patients were most prescribed inhaled medications. COPD-free and new-onset COPD patients were most prescribed antibiotics. Most patients received 2 or more relevant prescriptions. Monthly prescribing rates of all medications increased towards time of diagnosis in all patient groups and were highest in pre-existing COPD patients. Increases in prescribing activity were observed earliest in pre-existing COPD patients 5 months pre-diagnosis for inhaled medications, antibiotics, and steroids, CONCLUSION: Results indicate that a diagnostic window of appreciable length exists for potential earlier LC diagnosis in some patients. Lung cancer diagnosis may be delayed if early symptoms are misattributed to COPD or other benign conditions.

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

BACKGROUND

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

RESEARCH QUESTION

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

STUDY DESIGN AND METHODS

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

RESULTS

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

INTERPRETATION

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

Best analgesia control in pancreatic adenocarcinoma study: justification and feasibility of a randomised trial of early EUS-CPN versus standard care-a prospective observational study (The BAC-PAC study)

INTRODUCTION

Limited and conflicting trial data is available on the efficacy of Endoscopic Ultrasound-guided Coeliac Plexus Neurolysis (EUS-CPN). This study aimed to assess the feasibility, justification and to inform design considerations of a randomised trial of early EUS-CPN versus standard care.

METHODS

This was a questionnaire-based prospective observational study of patients with inoperable pancreatic adenocarcinoma who were self-reporting their performance status, pain levels, analgesic use, quality of life (QoL) and healthcare resource use, on a monthly basis.

RESULTS

Over a total period of twelve months 143 patients were screened for eligibility, of which 56 met the criteria. In total, 12 (21%) patients were recruited. The median survival from the first record of pain was 5.2 (IQR 2.46-5.9) months. In total, 80% of the questionnaires were completed. The median Visual Analogue Score for pain was 2.6 (0.8-5.1) and the median daily morphine dose was 36 (20-48) mg.

DISCUSSION

Recruitment rates remained low throughout this study. Despite these limitations, overall, this study supports the justification of trial administering endoscopic analgesia. However, uncertainties remain with regards to its feasibility. In a future trial, data collection procedures need to minimise burden to patients. Further observational research with a larger sample size, longer follow-up and refined procedures is required.

Household donations of time and money in response to a health shock

Donations play a critical role in supporting the provision of public goods, yet how donating behaviour changes in response to health shocks is poorly understood. We investigate how the household's joint decision to donate time (volunteer) and money changes following a health shock. Using data from the United States Panel Study of Income Dynamics, and a within-household design that captures the dynamics of a post-health shock response, we find no overall change in the probability of households donating money but an overall reduction in the probability of donating time following a health shock. This is driven by a significant shift from donating both money and time to donating only money after a health shock. The shift away from donating time occurs for both the individual who experienced the health shock and their spouse, though the reduction is greater for the spouse. We examine the role of labour market responses to health shocks in explaining donating behaviour and find that consistent with the added worker effect, spouses of those who experience a health shock increase their work hours, constraining their time available for volunteering.

Lung cancer in never smokers (LCINS): development of a UK national research strategy

INTRODUCTION

Lung cancer in never smokers (LCINS) accounts for 15% of lung cancers diagnosed in the UK, making it the 8th most common cancer. There are few robust studies specific to the LCINS population making data surrounding the incidence and mortality of LCINS incomplete, leaving many gaps in our understanding of the needs of this population.

METHODS

To address a lack of research in this important area, the UK National Cancer Research Institute Lung Study Group (NCRI-LSG) undertook a national survey and hosted a research strategy day to define key research priorities. A wide cross section of stakeholders, including patient advocates, the charitable sector, basic and translational researchers, and multi-disciplinary healthcare professionals contributed highlighting their research priorities.

RESULTS

One-hundred twenty-seven surveys were completed (52 by patients/patient advocates) prior to the strategy day. These identified themes for expert review presentations and subsequent workshop discussions at the national research strategy day, which registered 190 attendees (50 patients/patient advocates). The four key themes that emerged to form the basis of a research strategy for LCINS are (1) Raising awareness, (2) Risk assessment and early detection, (3) Disease biology, (4) Living with and beyond.

CONCLUSION

This paper summarises current evidence and important gaps in our knowledge related to LCINS. We present recommendations for a national research strategy aimed at improving outcomes for patients.

Identification of Potent Inhibitors Targeting EGFR and HER3 for Effective Treatment of Chemoresistance in Non-Small Cell Lung Cancer

Non-small cell lung cancer (NSCLC) is the most common form of lung cancer. Despite the existence of various therapeutic options, NSCLC is still a major health concern due to its aggressive nature and high mutation rate. Consequently, HER3 has been selected as a target protein along with EGFR because of its limited tyrosine kinase activity and ability to activate PI3/AKT pathway responsible for therapy failure. We herein used a BioSolveIT suite to identify potent inhibitors of EGFR and HER3. The schematic process involves screening of databases for constructing compound library comprising of 903 synthetic compounds (602 for EGFR and 301 for HER3) followed by pharmacophore modeling. The best docked poses of compounds with the druggable binding site of respective proteins were selected according to pharmacophore designed by SeeSAR version 12.1.0. Subsequently, preclinical analysis was performed via an online server SwissADME and potent inhibitors were selected. Compound 4k and 4m were the most potent inhibitors of EGFR while 7x effectively inhibited the binding site of HER3. The binding energies of 4k, 4m, and 7x were -7.7, -6.3 and -5.7 kcal/mol, respectively. Collectively, 4k, 4m and 7x showed favorable interactions with the most druggable binding sites of their respective proteins. Finally, in silico pre-clinical testing by SwissADME validated the non-toxic nature of compounds 4k, 4m and 7x providing a promising treatment option for chemoresistant NSCLC.

Endovascular Management of Life-Threatening Hemoptysis in Primary Lung Cancer: A Retrospective Study

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of endovascular treatment of hemoptysis caused by primary lung cancer.

METHODS

We conducted a single-center retrospective study (2005-2021), including patients who underwent thoracic embolization for life-threatening hemoptysis complication of lung cancer. Exclusion criteria were hemoptysis caused by a benign lung tumor or by a lung metastasis of a primary non-lung tumor. Depending on the origin of the bleeding, determined by CT-angiography, systemic arteries were treated with microspheres or coils, and pulmonary arteries with coils, plugs or covered stents. Outcomes were assessed from patients' medical records in April 2022. Primary endpoints were clinical success at one month and at one year. Secondary endpoints were incidence of complications, 1 year overall survival, and relative risk of recurrence of hemoptysis. Survival was compared with a log-rank test.

RESULTS

Sixty-two patients underwent 68 systemic artery embolizations and 14 pulmonary artery procedures. Clinical success defined as cessation of hemoptysis without any recurrence was 81% at one month and 74% at one year. Three major complications occurred: spinal cord ischemia, stroke, and acute pancreatitis. 5% of patient died from hemoptysis. One-year overall survival was 29% and was significantly higher in patients without hemoptysis recurrence when compared to patients with recurring hemoptysis (p = 0.021). In univariate analysis, recurrence of hemoptysis at one year was associated with massive hemoptysis (RR = 2.50; p = 0.044) and with tumor cavitation (RR = 2.51; p = 0.033).

CONCLUSION

Endovascular treatment for primary lung cancer-related hemoptysis is effective but not uneventful.

Are There Ethnic Differences in Recorded Features among Patients Subsequently Diagnosed with Cancer? An English Longitudinal Data-Linked Study

We investigated ethnic differences in the presenting features recorded in primary care before cancer diagnosis.

METHODS

English population-based cancer-registry-linked primary care data were analysed. We identified the coded features of six cancers (breast, lung, prostate, colorectal, oesophagogastric, and myeloma) in the year pre-diagnosis. Logistic regression models investigated ethnic differences in first-incident cancer features, adjusted for age, sex, smoking status, deprivation, and comorbidity.

RESULTS

Of 130,944 patients, 92% were White. In total, 188,487 incident features were recorded in the year pre-diagnosis, with 48% (89,531) as sole features. Compared with White patients, Asian and Black patients with breast, colorectal, and prostate cancer were more likely than White patients to have multiple features; the opposite was seen for the Black and Other ethnic groups with lung or prostate cancer. The proportion with relevant recorded features was broadly similar by ethnicity, with notable cancer-specific exceptions. Asian and Black patients were more likely to have low-risk features (e.g., cough, upper abdominal pain) recorded. Non-White patients were less likely to have alarm features.

CONCLUSION

The degree to which these differences reflect disease, patient or healthcare factors is unclear. Further research examining the predictive value of cancer features in ethnic minority groups and their association with cancer outcomes is needed.

Symptoms and signs of lung cancer prior to diagnosis: case-control study using electronic health records from ambulatory care within a large US-based tertiary care centre

OBJECTIVE

Lung cancer is the most common cause of cancer-related death in the USA. While most patients are diagnosed following symptomatic presentation, no studies have compared symptoms and physical examination signs at or prior to diagnosis from electronic health records (EHRs) in the USA. We aimed to identify symptoms and signs in patients prior to diagnosis in EHR data.

DESIGN

Case-control study.

SETTING

Ambulatory care clinics at a large tertiary care academic health centre in the USA.

PARTICIPANTS, OUTCOMES

We studied 698 primary lung cancer cases in adults diagnosed between 1 January 2012 and 31 December 2019, and 6841 controls matched by age, sex, smoking status and type of clinic. Coded and free-text data from the EHR were extracted from 2 years prior to diagnosis date for cases and index date for controls. Univariate and multivariable conditional logistic regression were used to identify symptoms and signs associated with lung cancer at time of diagnosis, and 1, 3, 6 and 12 months before the diagnosis/index dates.

RESULTS

Eleven symptoms and signs recorded during the study period were associated with a significantly higher chance of being a lung cancer case in multivariable analyses. Of these, seven were significantly associated with lung cancer 6 months prior to diagnosis: haemoptysis (OR 3.2, 95% CI 1.9 to 5.3), cough (OR 3.1, 95% CI 2.4 to 4.0), chest crackles or wheeze (OR 3.1, 95% CI 2.3 to 4.1), bone pain (OR 2.7, 95% CI 2.1 to 3.6), back pain (OR 2.5, 95% CI 1.9 to 3.2), weight loss (OR 2.1, 95% CI 1.5 to 2.8) and fatigue (OR 1.6, 95% CI 1.3 to 2.1).

CONCLUSIONS

Patients diagnosed with lung cancer appear to have symptoms and signs recorded in the EHR that distinguish them from similar matched patients in ambulatory care, often 6 months or more before diagnosis. These findings suggest opportunities to improve the diagnostic process for lung cancer.

Systematic review of the literature on the occurrence and characteristics of dyspnea in oncology patients

BACKGROUND

Dyspnea is a common and distressing symptom for oncology patients.However, dyspnea is not well-characterized and often underestimated by clinicians. This systematic review summarizes the prevalence, intensity, distress, and impact of dyspnea in oncology patients and identifies research gaps.

METHODS

A search of all of the relevant databases was done from 2009 to May 2022. A qualitative synthesis of the extant literature was performed using established guidelines.

RESULTS

One hundred-seventeen studies met inclusion criteria. Weighted grand mean prevalence of dyspnea in patients with advanced cancer was 58.0%. Intensity of dyspnea was most common dimension evaluated, followed by the impact and distress. Depression and anxiety were the most common symptoms that co-occurred with dyspnea.

CONCLUSION

Numerous methodologic challenges were evident across studies. Future studies need to use valid and reliable measures; evaluate the impact of dyspnea; and determine biomarkers for dyspnea.

Navigating patient journey in early diagnosis of lung cancer in India

Lung cancer (LC) is one of the leading causes of cancer deaths worldwide. In India, the incidence of LC is increasing rapidly, and a majority of the patients are diagnosed at advanced stages of the disease when treatment is less likely to be effective. Recent therapeutic developments have significantly improved survival outcomes in patients with LC. Prompt specialist referral remains critical for early diagnosis for improved patient survival. In the Indian scenario, distinguishing LC from benign and endemic medical conditions such as tuberculosis can pose a challenge. Hence, awareness regarding the red flags-signs and symptoms that warrant further investigations and referral-is vital. This review is an effort toward encouraging general physicians to maintain a high index of clinical suspicion for those at risk of developing LC and assisting them in refering patients with concerning symptoms to specialists or multidisciplinary teams as early as possible.

What are the similarities and differences in lung cancer symptom appraisal and help-seeking according to smoking status? A qualitative study with lung cancer patients

OBJECTIVE

Lung cancer in never-smokers represents a growing proportion of patients. The relationship between smoking status, symptom appraisal and help-seeking behaviour is complex. Little is known about cancer symptom-related health behaviours according to smoking status. The aim of the study was to explore lung cancer patients' experiences of a lung cancer diagnosis, identifying differences by smoking history.

METHOD

This was a qualitative study involving telephone interviews with 40 lung cancer patients (20 never smokers, 11 former smokers and 9 current smokers). We used framework analysis to analyse the data using the Common Sense Model of Illness Self-Regulation as a theoretical framework, developed after initial analysis.

RESULTS

All patients were likely to delay seeking help for symptoms in primary care regardless of smoking history, but for different reasons. Smoking history was instrumental to how individuals perceived and responded to early symptoms of lung cancer. Differences in interpretation and coping responses to new symptoms seemed to be caused by the higher presence of comorbidities due to smoking, and perceptions of the current state of health. Individuals with a smoking history reported acting with urgency in seeking help and follow up, whereas patients who experienced low levels of concern were more easily reassured by clinicians, resulting in delays.

CONCLUSIONS

Never and former smokers perceive, interpret, and respond to symptoms of lung cancer differently to smokers. However, few people attribute their lung symptoms to cancer initially, even with a smoking history. Interventions that drive increased urgency and vigilance in never smokers may be effective.

How Timely Is Diagnosis of Lung Cancer? Cohort Study of Individuals with Lung Cancer Presenting in Ambulatory Care in the United States

The diagnosis of lung cancer in ambulatory settings is often challenging due to non-specific clinical presentation, but there are currently no clinical quality measures (CQMs) in the United States used to identify areas for practice improvement in diagnosis. We describe the pre-diagnostic time intervals among a retrospective cohort of 711 patients identified with primary lung cancer from 2012-2019 from ambulatory care clinics in Seattle, Washington USA. Electronic health record data were extracted for two years prior to diagnosis, and Natural Language Processing (NLP) applied to identify symptoms/signs from free text clinical fields. Time points were defined for initial symptomatic presentation, chest imaging, specialist consultation, diagnostic confirmation, and treatment initiation. Median and interquartile ranges (IQR) were calculated for intervals spanning these time points. The mean age of the cohort was 67.3 years, 54.1% had Stage III or IV disease and the majority were diagnosed after clinical presentation (94.5%) rather than screening (5.5%). Median intervals from first recorded symptoms/signs to diagnosis was 570 days (IQR 273-691), from chest CT or chest X-ray imaging to diagnosis 43 days (IQR 11-240), specialist consultation to diagnosis 72 days (IQR 13-456), and from diagnosis to treatment initiation 7 days (IQR 0-36). Symptoms/signs associated with lung cancer can be identified over a year prior to diagnosis using NLP, highlighting the need for CQMs to improve timeliness of diagnosis.

Lung cancer prediction using machine learning on data from a symptom e-questionnaire for never smokers, formers smokers and current smokers

PURPOSE

The aim of the present study was to investigate the predictive ability for lung cancer of symptoms reported in an adaptive e-questionnaire, separately for never smokers, former smokers, and current smokers.

PATIENTS AND METHODS

Consecutive patients referred for suspected lung cancer were recruited between September 2014 and November 2015 from the lung clinic at the Karolinska University Hospital, Stockholm, Sweden. A total of 504 patients were later diagnosed with lung cancer (n = 310) or no cancer (n = 194). All participants answered an adaptive e-questionnaire with a maximum of 342 items, covering background variables and symptoms/sensations suspected to be associated with lung cancer. Stochastic gradient boosting, stratified on smoking status, was used to train and test a model for predicting the presence of lung cancer.

RESULTS

Among never smokers, 17 predictors contributed to predicting lung cancer with 82% of the patients being correctly classified, compared with 26 predictors with an accuracy of 77% among current smokers and 36 predictors with an accuracy of 63% among former smokers. Age, sex, and education level were the most important predictors in all models.

CONCLUSION

Methods or tools to assess the likelihood of lung cancer based on smoking status and to prioritize investigative and treatment measures among all patients seeking care with diffuse symptoms are much needed. Our study presents risk assessment models for patients with different smoking status that may be developed into clinical risk assessment tools that can help clinicians in assessing a patient's risk of having lung cancer.

A systematic review of interventions to recognise, refer and diagnose patients with lung cancer symptoms

Patients with lung cancer (LC) often experience delay between symptom onset and treatment. Primary healthcare professionals (HCPs) can help facilitate early diagnosis of LC through recognising early signs and symptoms and making appropriate referrals. This systematic review describes the effect of interventions aimed at helping HCPs recognise and refer individuals with symptoms suggestive of LC. Seven studies were synthesised narratively. Outcomes were categorised into: Diagnostic intervals; referral and diagnosis patterns; stage distribution at diagnosis; and time interval from diagnosis to treatment. Rapid access pathways and continuing medical education for general practitioners can help reduce LC diagnostic and treatment delay. Awareness campaigns and HCP education can help inform primary HCPs about referral pathways. However, campaigns did not significantly impact LC referral rates or reduce diagnostic intervals. Disease outcomes, such as LC stage at diagnosis, recurrence, and survival were seldom measured. Review findings highlight the need for longitudinal, powered, and controlled studies.

Protocol for a feasibility study of a cancer symptom awareness campaign to support the rapid diagnostic centre referral pathway in a socioeconomically deprived area: Targeted Intensive Community-based campaign To Optimise Cancer awareness (TIC-TOC)

INTRODUCTION

Rapid diagnostic centres (RDCs) are being implemented across the UK to accelerate the assessment of vague suspected cancer symptoms. Targeted behavioural interventions are needed to augment RDCs that serve socioeconomically deprived populations who are disproportionately affected by cancer, have lower cancer symptom awareness and are less likely to seek help for cancer symptoms. The aim of this study is to assess the feasibility and acceptability of delivering and evaluating a community-based vague cancer symptom awareness intervention in an area of high socioeconomic deprivation.

METHODS AND ANALYSIS

Intervention materials and messages were coproduced with local stakeholders in Cwm Taf Morgannwg, Wales. Cancer champions will be trained to deliver intervention messages and distribute intervention materials using broadcast media (eg, local radio), printed media (eg, branded pharmacy bags, posters, leaflets), social media (eg, Facebook) and attending local community events. A cross-sectional questionnaire will include self-reported patient interval (time between noticing symptoms to contacting the general practitioner), cancer symptom recognition, cancer beliefs and barriers to presentation, awareness of campaign messages, healthcare resource use, generic quality of life and individual and area-level deprivation indicators. Consent rates and proportion of missing data for patient questionnaires (n=189) attending RDCs will be measured. Qualitative interviews and focus groups will assess intervention acceptability and barriers/facilitators to delivery.

ETHICS AND DISSEMINATION

Ethical approval for this study was given by the London-West London & GTAC Research Ethics (21/LO/0402). This project will inform a potential future controlled study to assess intervention effectiveness in reducing the patient interval for vague cancer symptoms. The results will be critical to informing national policy and practice regarding behavioural interventions to support RDCs in highly deprived populations.

Who are the patients being offered the faecal immunochemical test in routine English general practice, and for what symptoms? A prospective descriptive study

OBJECTIVES

The faecal immunochemical test (FIT) was introduced to triage patients with lower-risk symptoms of colorectal cancer (CRC) in English primary care in 2018. While there is growing evidence on its utility to triage patients in this setting, evidence is still limited on how official FIT guidance is being used, for which patients and for what symptoms. We aimed to investigate the use of FIT in primary care practice for lower-risk patients who did not immediately meet criteria for urgent referral.

DESIGN

A prospective, descriptive study of symptomatic patients offered a FIT in primary care between January and June 2020.

SETTING

East of England general practices.

PARTICIPANTS

Consenting patients (aged ≥40 years) who were seen by their general practitioners (GPs) with symptoms of possible CRC for whom a FIT was requested. We excluded patients receiving a FIT for asymptomatic screening purposes, or patients deemed by GPs as lacking capacity for informed consent. Data were obtained via patient questionnaire, medical and laboratory records.

PRIMARY AND SECONDARY OUTCOME MEASURES

FIT results (10 µg Hb/g faeces defined a positive result); patient sociodemographic and clinical characteristics; patient-reported and GP-recorded symptoms, symptom severity and symptom agreement between patient and GP (% and kappa statistics).

RESULTS

Complete data were available for 310 patients, median age 70 (IQR 61-77) years, 53% female and 23% FIT positive. Patients most commonly reported change in bowel habit (69%) and fatigue (57%), while GPs most commonly recorded abdominal pain (25%) and change in bowel habit (24%). Symptom agreement ranged from 44% (fatigue) to 80% (unexplained weight loss). Kappa agreement was universally low across symptoms.

CONCLUSION

Almost a quarter of this primary care cohort of symptomatic patients with FIT testing were found to be positive. However, there was low agreement between patient-reported and GP-recorded symptoms. This may impact cancer risk assessment and optimal patient management in primary care.

Simple diagnosis of cancer by detecting CEA and CYFRA 21-1 in saliva using electronic sensors

One way of early diagnosis of cancer is by detecting the biomarkers that get introduced into easily accessible body fluids. We report the development of portable and rapid electronic biosensors for quantitative detection of two secretive cancer biomarkers-Carcinoembryonic antigen (CEA) and Cytokeratin fragment 19 (CYFRA 21-1). The reduced graphene oxide (rGO)/ melamine (MEL)/antibodies/ bovine serum albumin (BSA) based devices were tested for 1 pg/mL to 800 ng/mL of CEA and CYFRA 21-1. The responses of the sensors ranged from 7.14 to 59.1% and from 6.18 to 64% for 1 pg/mL to 800 ng/mL CEA and CYFRA 21-1 respectively. A read-out circuit was assembled to develop a portable prototype which was used to assess the concentrations of the two antigens present in saliva samples of 14 subjects. The prototype could accurately discriminate between 9 oral squamous cell carcinoma patients and 5 healthy controls.

Public Health Messaging and Strategies to Promote "SWIFT" Lung Cancer Detection: a Qualitative Study Among High-Risk Individuals

Lung cancer (LC) is the most common cancer and the leading cause of cancer mortality globally. A positive association between LC incidence and socioeconomic deprivation exists. High-risk individuals are less likely to be aware of LC and to correctly appraise LC symptoms and seek medical help accordingly. This qualitative study explored strategies to promote early detection of LC among at-risk individuals living in high-incidence areas in Ireland. Five semi-structured focus groups were conducted with 46 individuals. Data were collected face-to-face in community centres and organisations in high-incidence areas in two Irish counties and analysed using inductive qualitative content analysis. Participants believed that there was insufficient information regarding LC and recommended promoting LC awareness at a young rather than old age. They favoured public health messages that are Simple, clear, and honest; Worded positively; Incorporating a shock element; Featuring a celebrity, healthcare professional, or survivor; and Targeted (SWIFT). Most participants reported becoming immune to messages on cigarette packaging and recommended using a combination of broadcast and print media within national government-run campaigns to promote LC awareness and early detection. Study findings suggest that promoting LC awareness, help-seeking, early presentation, and diagnosis can be achieved by developing and testing targeted interventions. Promoting LC awareness requires a multi-sectoral policy network, or a whole systems approach. Such approaches ought to consider the multifactorial drivers of LC risk behaviours; involve coordinated, collective actions across various stakeholders; operate across multiple agencies; and take a life course perspective.

Morbidity and measures of the diagnostic process in primary care for patients subsequently diagnosed with cancer

BACKGROUND

There is uncertainty regarding how pre-existing conditions (morbidities) may influence the primary care investigation and management of individuals subsequently diagnosed with cancer.

METHODS

We identified morbidities using information from both primary and secondary care records among 11,716 patients included in the English National Cancer Diagnosis Audit (NCDA) 2014. We examined variation in 5 measures of the diagnostic process (the primary care interval, diagnostic interval, number of pre-referral consultations, use of primary care-led investigations, and referral type) by both primary care- and hospital records-derived measures of morbidity.

RESULTS

Morbidity prevalence recorded before cancer diagnosis was almost threefold greater using the primary care (75%) vs secondary care-derived measure (28%). After adjustment, there was limited variation in the primary care interval and the number of pre-referral consultations by either definition of morbidity. Patients with more severe morbidities were less likely to have had a primary care-led investigation before cancer diagnosis compared with those without any morbidity (adjusted odds ratio, OR [95% confidence interval]: 0.72 [0.60-0.86] for Charlson score 3+ vs 0; joint P < 0.001). Patients with multiple primary care-recorded conditions or a Charlson score of 3+ were more likely to have diagnostic intervals exceeding 60 days (aOR: 1.26 [1.10-1.45] and 1.19 [>1.00-1.41], respectively), and more likely to receive an emergency referral (aOR: 1.60 [1.26-2.02] and 1.61 [1.26-2.06], respectively).

CONCLUSION

Among cancer cases with up to 2 morbidities, there was no evidence of differences in diagnostic processes and intervals in primary care but higher morbidity burden was associated with longer time to diagnosis and higher likelihood of emergency referral.

Stigma in Early-Stage Lung Cancer

BACKGROUND

The phenomenon of lung cancer stigma has been firmly established in the literature. However, studies have predominantly focused on patients with advanced disease, whose experiences may differ from patients with earlier stage, surgically resectable lung cancer and an improved prognosis.

PURPOSE

The objective of the study was to examine the stigma experienced in a Canadian population with early-stage, resectable lung cancer.

METHODS

Patients with newly diagnosed lung cancer were enrolled at a tertiary thoracic surgery clinic. The 25-item Lung Cancer Stigma Inventory (LCSI) was self-administered by patients to quantitatively measure experiences of lung cancer stigma. LCSI results informed the development of a semi-structured focus group and individual interviews.

RESULTS

Of the 53 participants completing the survey, 38 (72%) met established LCSI score threshold, indicating a clinically meaningful level of stigma. No significant relationship was found between total LCSI scores and any demographic variable. Analysis of qualitative data revealed multiple themes related to experiences of lung cancer stigma. The major themes were classified into four categories: impact of the association between lung cancer and smoking, societal attitudes and assumptions, personal choices in relation to diagnosis, and experiences related to care.

CONCLUSIONS

A surgical population of patients with predominantly early-stage lung cancer experienced lung cancer stigma at a high incidence and a level similar to previously studied populations with more advanced disease. The qualitative results support the quantitative findings that respondents experienced more internal stigma than either perceived stigma from others or constrained disclosure related to their diagnosis.

Primary healthcare professionals' perspectives on patient help-seeking for lung cancer warning signs and symptoms: a qualitative study

BACKGROUND

Lung cancer is the leading cause of cancer incidence and mortality worldwide. Prompt patient help-seeking for signs and symptoms suggestive of lung cancer is crucial for early referral, diagnosis, and survivorship. However, individuals with potential lung cancer symptoms tend to delay help-seeking. This qualitative study explored perceived barriers to patient help-seeking and strategies to enhance help-seeking for lung cancer warning signs and symptoms from the perspective of primary healthcare professionals.

METHODS

Semi-structured focus groups and individual interviews were conducted with 36 primary healthcare professionals. Data were collected via videoconferencing. Inductive thematic analysis was conducted.

RESULTS

The following two themes were created from the data: (i) perceived barriers to patient help-seeking for signs and symptoms of concern and (ii) facilitating early patient presentation for signs and symptoms of concern. Some participants believed that the high cost of a general practitioner visit, long waiting times, and previous bad experiences with the healthcare system would deter patients from seeking help for symptoms of lung cancer. Perceived patient-related barriers to help-seeking related to the different emotions associated with a potential cancer diagnosis as well as stigma, embarrassment, and guilt felt by smokers. Sociodemographic factors such as drug use, homelessness, living in rural areas, and being male and older were also perceived to impede patient help-seeking. The negative impact of the COVID-19 pandemic on cancer help-seeking also featured strongly. Participants recommended several strategies to enable patients to seek help for symptoms of concern including targeted educational campaigns focussing on symptoms (e.g., cough) rather than behaviours (e.g., smoking), accessible and free health services, and using patients' support networks.

CONCLUSIONS

Patient-related and healthcare system-related barriers to help-seeking for lung cancer warning signs and symptoms include cost of healthcare, cancer fear, and various sociodemographic factors. Participants suggested that increased awareness and early patient help-seeking for symptoms of concern could be achieved through targeted patient education, national campaigns, the use of community support networks, and free and accessible targeted screening services.

Awareness of Palestinians about lung cancer symptoms: a national cross-sectional study

BACKGROUND

The majority of lung cancer (LC) cases are diagnosed at an advanced stage. Poor awareness of LC symptoms is a contributor to late diagnosis. This study aimed to assess the awareness of LC symptoms among Palestinians, and to examine the factors associated with displaying good awareness.

METHODS

Participants were recruited from hospitals, primary healthcare centers and public spaces using convenience sampling. A translated-into-Arabic version of the validated LC awareness measure was used to assess recognition of 14 LC symptoms. One point was given for each recognized symptom. The total score was calculated and categorized based on the number of symptoms recognized: poor (0-4), fair (5-9), and good (10-14). Multivariable logistic regression was used to examine the association between participant characteristics and having good awareness. The multivariable analysis adjusted for age-group, gender, education, monthly income, occupation, residence, marital status, any chronic disease, knowing someone with cancer, smoking history, and site of data collection.

RESULTS

Of 5174 potential participants approached, 4817 completed the questionnaire (response rate = 93.1%) and 4762 were included in the final analysis. Of these, 2742 (56.9%) were from the West Bank and Jerusalem (WBJ) and 2020 (43.1%) were from the Gaza Strip. Participants from the WBJ were older, had higher monthly income but lower education, and suffered from more chronic diseases. The most recognized respiratory LC symptom was 'worsening in an existing cough'(n = 3884, 81.6%) while the least recognized was 'a cough that does not go away for two or three weeks'(n = 2951, 62.0%). The most recognized non-respiratory LC symptom was 'persistent tiredness or lack of energy'(n = 3205, 67.3%) while the least recognized was 'persistent shoulder pain'(n = 1170, 24.6%). A total of 2466 participants (51.8%) displayed good awareness of LC symptoms. Participants from both the Gaza Strip and the WBJ had similar likelihoods to have good awareness levels. Factors associated with a higher likelihood to display good awareness included female gender, having post-secondary education, being employed, knowing someone with cancer, and visiting hospitals and primary healthcare centers.

CONCLUSION

About half of the study participants displayed a good level of awareness of LC symptoms. Further improvement in public awareness of LC symptoms by educational interventions might reduce LC mortality by promoting early diagnosis.

Awareness of Palestinians about lung cancer symptoms: a national cross-sectional study

BACKGROUND

The majority of lung cancer (LC) cases are diagnosed at an advanced stage. Poor awareness of LC symptoms is a contributor to late diagnosis. This study aimed to assess the awareness of LC symptoms among Palestinians, and to examine the factors associated with displaying good awareness.

METHODS

Participants were recruited from hospitals, primary healthcare centers and public spaces using convenience sampling. A translated-into-Arabic version of the validated LC awareness measure was used to assess recognition of 14 LC symptoms. One point was given for each recognized symptom. The total score was calculated and categorized based on the number of symptoms recognized: poor (0-4), fair (5-9), and good (10-14). Multivariable logistic regression was used to examine the association between participant characteristics and having good awareness. The multivariable analysis adjusted for age-group, gender, education, monthly income, occupation, residence, marital status, any chronic disease, knowing someone with cancer, smoking history, and site of data collection.

RESULTS

Of 5174 potential participants approached, 4817 completed the questionnaire (response rate = 93.1%) and 4762 were included in the final analysis. Of these, 2742 (56.9%) were from the West Bank and Jerusalem (WBJ) and 2020 (43.1%) were from the Gaza Strip. Participants from the WBJ were older, had higher monthly income but lower education, and suffered from more chronic diseases. The most recognized respiratory LC symptom was 'worsening in an existing cough'(n = 3884, 81.6%) while the least recognized was 'a cough that does not go away for two or three weeks'(n = 2951, 62.0%). The most recognized non-respiratory LC symptom was 'persistent tiredness or lack of energy'(n = 3205, 67.3%) while the least recognized was 'persistent shoulder pain'(n = 1170, 24.6%). A total of 2466 participants (51.8%) displayed good awareness of LC symptoms. Participants from both the Gaza Strip and the WBJ had similar likelihoods to have good awareness levels. Factors associated with a higher likelihood to display good awareness included female gender, having post-secondary education, being employed, knowing someone with cancer, and visiting hospitals and primary healthcare centers.

CONCLUSION

About half of the study participants displayed a good level of awareness of LC symptoms. Further improvement in public awareness of LC symptoms by educational interventions might reduce LC mortality by promoting early diagnosis.

Defining timeliness in care for patients with lung cancer: a scoping review

OBJECTIVES

Early diagnosis and reducing the time taken to achieve each step of lung cancer care is essential. This scoping review aimed to examine time points and intervals used to measure timeliness and to critically assess how they are defined by existing studies of the care seeking pathway for lung cancer.

METHODS

This scoping review was guided by the methodological framework for scoping reviews by Arksey and O'Malley. MEDLINE, EMBASE, CINAHL and PsycINFO electronic databases were searched for articles published between 1999 and 2019. After duplicate removal, all publications went through title and abstract screening followed by full text review and inclusion of articles in the review against the selection criteria. A narrative synthesis describes the time points, intervals and measurement guidelines used by the included articles.

RESULTS

A total of 2113 articles were identified from the initial search. Finally, 68 articles were included for data charting process. Eight time points and 14 intervals were identified as the most common events researched by the articles. Eighteen different lung cancer care guidelines were used to benchmark intervals in the included articles; all were developed in Western countries. The British Thoracic Society guideline was the most frequently used guideline (20%). Western guidelines were used by the studies in Asian countries despite differences in the health system structure.

CONCLUSION

This review identified substantial variations in definitions of some of the intervals used to describe timeliness of care for lung cancer. The differences in healthcare delivery systems of Asian and Western countries, and between high-income countries and low-income-middle-income countries may suggest different sets of time points and intervals need to be developed.

Worse Prognosis in the Symptomatic Patients With Lung Cancer - Czech Multicentric Study

BACKGROUND/AIM

This study aimed at contributing to a better diagnosis of lung cancer by analyzing the patient's symptoms and their linkage to other characteristics.

PATIENTS AND METHODS

We analyzed the data of 3,322 patients from LUCAS (LUngCAncerfocuS) National Registry of the Czech Republic. Overall survival was assessed using the Kaplan-Meier method.

RESULTS

The most common symptoms were cough (47.5%), dyspnea (45.6%), pain (27.3%), and weight loss (25.7%). Among all patients, 16% were asymptomatic. We demonstrated the negative prognostic significance of increasing number of lung cancer symptoms, that was significant after adjustment for age, TNM stages, and performance status, and morphological types of the cancer.

CONCLUSION

Monitoring the severity and type of symptoms in patients with lung cancer can help in the diagnostics of the disease and the estimation of prognosis.

[Delay in the diagnosis and treatment of five types of cancer in two urban health centres]

OBJECTIVES

To assess the diagnostic (ID) and treatment (IT) intervals of the most prevalent cancers in patients attached to two health centres and to analyse the influence of sociodemographic, clinical and health system (HS) organisational factors.

DESIGN

Observational, retrospective, analytical cohort study. SITE: Primary care. Two urban health centres.

PARTICIPANTS

Three hundred sixty-five patients diagnosed with colorectal cancer (CRC), breast, lung, prostate or bladder cancer between 1/1/2012 and 31/12/2017.

MAIN MEASURES

The medians of ID and IT and the risk (OR) of ID and IT above those medians according to the above factors are compared. The contribution of each process step to ID is analysed.

RESULTS

Median ID was 92 days, maximum in prostate cancer (395 days) and minimum in lung (54 days). Factors associated with prolonged ID (OR>92 days) were female sex, CRC or prostate location, localised stage, index primary care (AP) consultation and outpatient diagnostic pathway. Prolonged IT (OR>56 days) was related to CRC or prostate location and outpatient diagnostic route. ID components with the greatest influence on delay were: Primary Care Interval (IAP), Secondary Care Delay (DAS) and Secondary Care Adjunctive Test Delay (DPAS). The contribution of IAP was highest in patients with CRC, lung and bladder.

CONCLUSIONS

ID and IT were 92 and 56 days respectively. The ID components with the highest contribution to delay were IAP, DAS and DPAS. Increasing diagnostic capacity in PC and organising specific diagnostic and treatment pathways would shorten these intervals and allow earlier detection.

Consultations for clinical features of possible cancer and associated urgent referrals before and during the COVID-19 pandemic: an observational cohort study from English primary care

Background

It remains unclear to what extent reductions in urgent referrals for suspected cancer during the COVID-19 pandemic were the result of fewer patients attending primary care compared to GPs referring fewer patients.

Methods

Cohort study including electronic health records data from 8,192,069 patients from 663 English practices. Weekly consultation rates, cumulative consultations and referrals were calculated for 28 clinical features from the NICE suspected cancer guidelines. Clinical feature consultation rate ratios (CRR) and urgent referral rate ratios (RRR) compared time periods in 2020 with 2019.

Findings

Consultations for cancer clinical features decreased by 24.19% (95% CI: 24.04–24.34%) between 2019 and 2020, particularly in the 6–12 weeks following the first national lockdown. Urgent referrals for clinical features decreased by 10.47% (95% CI: 9.82–11.12%) between 2019 and 2020. Overall, once patients consulted with primary care, GPs urgently referred a similar or greater proportion of patients compared to previous years.

Conclusion

Due to the significant fall in patients consulting with clinical features of cancer there was a lower than expected number of urgent referrals in 2020. Sustained efforts should be made throughout the pandemic to encourage the public to consult their GP with cancer clinical features.

Enabling patients in effective self-management of breathlessness in lung cancer: the neglected pillar of personalized medicine

Globally, engagement of patients in the self management of disease and symptom problems has become a health policy priority to improve health outcomes in cancer. Unfortunately, little attention has been focused on the provision of self-management support (SMS)in cancer and specifically for complex cancer symptoms such as breathlessness. Current management of breathlessness, which includes treatment of underlying disease, pharmacological agents to address comorbidities and opiates and anxiolytics to change perception and reduce the sense of breathing effort, is inadequate. In this perspective paper, we review the rationale and evidence for a structured, multicomponent SMS program in breathlessness including four components: breathing retraining, enhancing positive coping skills, optimizing exertional capacity and reducing symptom burden and health risks. The integration of SMS in routine lung cancer care is essential to improve breathlessness, reduce psychological distress, suffering and improve quality of life.

Unmet supportive care needs associated with quality of life for people with lung cancer: A systematic review of the evidence 2007-2020

INTRODUCTION

The aim of this review was to systematically examine the evidence on the relationship between quality of life (QoL) and unmet supportive care needs in patients with lung cancer.

METHODS

Six databases were searched for studies published since 2007. Studies were included if they measured QoL using a standardised tool and examined its association with unmet supportive care needs in lung cancer patients.

RESULTS

Six studies involving 562 patients were included. Nearly two thirds of the patients had been diagnosed with advanced cancer (Stage III or IV), and the majority had been diagnosed for less than 2 years. There was a negative association between QoL and unmet needs using two different measures (Supportive Care Needs Survey[SCNS] and Cancer Survivors Unmet Needs Survey [CaSUN]). In two studies, the relationship was limited to physical and/or psychological domains.

CONCLUSIONS

Unmet supportive care needs are associated with poorer QoL for people with lung cancer: The findings suggest that unmet physical and psychological needs may have the most impact on QoL and reflect the high symptom burden and psychological distress associated with lung cancer. Further work is needed to examine these relationships to identify the services and interventions that address the range of care needs across the disease trajectory.

Primary care use by men with symptoms of possible prostate cancer: A multi-method study with an ethnically diverse sample in London

OBJECTIVE

The objective of this study is to investigate primary care use by men with recent onset of lower urinary tract symptoms (LUTS) to identify differences in presentation and investigation that may explain ethnic inequality in prostate cancer outcomes.

METHODS

This is a multi-method study of men presenting LUTS to primary care. Two hundred seventy-four men completed a self-administered questionnaire, and 23 participated in face-to-face interviews. Regression analyses investigated ethnic differences in (a) the period between symptom onset and first primary care presentation (patient interval) and (b) the interval between first primary care presentation and investigation with prostate-specific antigen (PSA) and digital rectal examination (DRE). Interview data were analysed using thematic analysis.

RESULTS

Half (144, 53%) reported a solitary first symptom, although multiple first symptoms were also common, particularly in Asian and Black men. There was no difference between ethnicities in patient interval or time from presentation to investigation. However, Asian men were offered less PSA testing (odds ratio 0.39; 95% confidence interval 0.17-0.92; p = 0.03). Qualitative data revealed ethnic differences in general practitioners' offer of DRE and PSA testing and highlighted limitations in doctor-patient communication and safety netting.

CONCLUSION

Our study showed only small differences in primary care experiences, insufficient to explain ethnic inequalities in prostate cancer outcomes.