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Lykkegaard J, Olsen JK, Wehberg S, Jarbøl DE. The durability of previous examinations for cancer: Danish nationwide cohort study. Scand J Prim Health Care 2024; 42:246-253. [PMID: 38251839 PMCID: PMC11003324 DOI: 10.1080/02813432.2024.2305942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 01/10/2024] [Indexed: 01/23/2024] Open
Abstract
OBJECTIVE Patients previously examined for cancer with a negative result may present in general practice with ongoing or new symptoms or signs suggestive of cancer. This paper explores the potential existence of a relatively safe period for cancer occurrence after receiving negative examination results for specific types of cancer, including lung (CT thorax), upper gastrointestinal (gastroscopy), colorectal (colonoscopy), bladder (cystoscopy), and breast (clinical mammography). DESIGN Register-based time-to-event analyses. SETTING Denmark. SUBJECTS All 3.3 million citizens aged 30-85 years who on January first, 2017, had not previously been diagnosed with the specific type of cancer were categorized based on the time since their most recent examination. MAIN OUTCOME MEASURES Using 1-year follow-up, we calculated the age- and sex-adjusted hazard ratios of being diagnosed with the related cancer, with non-examined individuals as reference. Negative examination results were defined as the absence of a cancer diagnosis within 6 months following the examination. RESULTS Previous negative examination results were common, also among those diagnosed with cancer during follow-up. For 10 years after a negative colonoscopy the risk of diagnosing a colorectal cancer was nearly halved. However, already 1 year after a clinical mammography and 2 years after a CT thorax the risk of diagnosing the related cancers was significantly higher among those with a previous negative result compared to non-examined individuals. CONCLUSION This study did not identify a post-examination period in which the cancer risk, compared to non-examined individuals, was sufficiently low to confidently rule out any of the investigated cancers.
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Affiliation(s)
- Jesper Lykkegaard
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jonas Kanstrup Olsen
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Sonja Wehberg
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Dorte Ejg Jarbøl
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Carlile O, Briggs A, Henderson AD, Butler-Cole BF, Tazare J, Tomlinson LA, Marks M, Jit M, Lin LY, Bates C, Parry J, Bacon SC, Dillingham I, Dennison WA, Costello RE, Walker AJ, Hulme W, Goldacre B, Mehrkar A, MacKenna B, Herrett E, Eggo RM. Impact of long COVID on health-related quality-of-life: an OpenSAFELY population cohort study using patient-reported outcome measures (OpenPROMPT). THE LANCET REGIONAL HEALTH. EUROPE 2024; 40:100908. [PMID: 38689605 PMCID: PMC11059448 DOI: 10.1016/j.lanepe.2024.100908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/22/2024] [Accepted: 04/04/2024] [Indexed: 05/02/2024]
Abstract
Background Long COVID is a major problem affecting patient health, the health service, and the workforce. To optimise the design of future interventions against COVID-19, and to better plan and allocate health resources, it is critical to quantify the health and economic burden of this novel condition. We aimed to evaluate and estimate the differences in health impacts of long COVID across sociodemographic categories and quantify this in Quality-Adjusted Life-Years (QALYs), widely used measures across health systems. Methods With the approval of NHS England, we utilised OpenPROMPT, a UK cohort study measuring the impact of long COVID on health-related quality-of-life (HRQoL). OpenPROMPT invited responses to Patient Reported Outcome Measures (PROMs) using a smartphone application and recruited between November 2022 and October 2023. We used the validated EuroQol EQ-5D questionnaire with the UK Value Set to develop disutility scores (1-utility) for respondents with and without Long COVID using linear mixed models, and we calculated subsequent Quality-Adjusted Life-Months (QALMs) for long COVID. Findings The total OpenPROMPT cohort consisted of 7575 individuals who consented to data collection, with which we used data from 6070 participants who completed a baseline research questionnaire where 24.6% self-reported long COVID. In multivariable regressions, long COVID had a consistent impact on HRQoL, showing a higher likelihood or odds of reporting loss in quality-of-life (Odds Ratio (OR): 4.7, 95% CI: 3.72-5.93) compared with people who did not report long COVID. Reporting a disability was the largest predictor of losses of HRQoL (OR: 17.7, 95% CI: 10.37-30.33) across survey responses. Self-reported long COVID was associated with an 0.37 QALM loss. Interpretation We found substantial impacts on quality-of-life due to long COVID, representing a major burden on patients and the health service. We highlight the need for continued support and research for long COVID, as HRQoL scores compared unfavourably to patients with conditions such as multiple sclerosis, heart failure, and renal disease. Funding This research was supported by the National Institute for Health and Care Research (NIHR) (OpenPROMPT: COV-LT2-0073).
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Affiliation(s)
- Oliver Carlile
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Andrew Briggs
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | | | - Ben F.C. Butler-Cole
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - John Tazare
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Laurie A. Tomlinson
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Michael Marks
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Hospital for Tropical Diseases, University College London Hospital, London, WC1E 6JD, UK
- Division of Infection and Immunity, University College London, London, WC1E 6BT, UK
| | - Mark Jit
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Liang-Yu Lin
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Chris Bates
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | - John Parry
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | - Sebastian C.J. Bacon
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Iain Dillingham
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | | | - Ruth E. Costello
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Alex J. Walker
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - William Hulme
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Ben Goldacre
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Amir Mehrkar
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Brian MacKenna
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Emily Herrett
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Rosalind M. Eggo
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Marković A, Grujičić D, Živković Radojević M, Milošević-Djordjević O. Measurement of chromosomal instability and level of DNA damage in peripheral blood mononuclear cells of endometrial cancer patients. Mutagenesis 2024; 39:172-180. [PMID: 38267363 DOI: 10.1093/mutage/geae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/23/2024] [Indexed: 01/26/2024] Open
Abstract
Endometrial cancer is one of the most common invasive gynecologic malignancies in developed countries. The aim of this study was to evaluate chromosomal instability and level of DNA damage in peripheral blood mononuclear cells (PBMCs) of newly diagnosed endometrial cancer patients in relation to health status (diagnosis), age, histological grade of cancer, residence, smoking, number of pregnancies, miscarriages, and abortions. The analyzed sample consisted of 60 individuals, 30 endometrial cancer patients with an average age of 64.37 ± 7.08, and 30 healthy control women with an average age of 60.23 ± 11.55. Chromosomal instability was evaluated by the cytokinesis-block micronucleus (CBMN) assay, and the level of DNA damage by the single-cell gel electrophoresis (comet) assay in PBMCs. The average frequencies of micronuclei (MNi), nucleoplasmic bridges (NPBs) as well as nuclear buds (NBUDs) were significantly higher in cancer patients compared to controls (P < .0005). There was no difference in the nuclear division index (NDI) among the analyzed samples. The comet assay showed that the patients had a significantly increased genetic damage index (GDI) compared with controls (P < .0005). Using linear regression analysis, we found that health status (diagnosis) had the strongest influence on the MN frequency as well as GDI (P < .0005). Our results indicated that there is a high level of genetic damage in both the level of DNA and the level of chromosomes in the PBMCs of newly diagnosed patients with endometrial cancer, where the frequency and level of damage were significantly affected by health status, grade of cancer, residence, number of pregnancies, miscarriages, and abortions.
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Affiliation(s)
- Aleksandra Marković
- Faculty of Science, Department of Biology and Ecology, University of Kragujevac, 34 000 Kragujevac, Serbia
| | - Darko Grujičić
- Faculty of Science, Department of Biology and Ecology, University of Kragujevac, 34 000 Kragujevac, Serbia
| | - Marija Živković Radojević
- Radiotherapy Department, University Clinical Centre, Centre for Radiation Oncology, 34 000 Kragujevac, Serbia
- Faculty of Medical Sciences, Department of Clinical Oncology, University of Kragujevac, 34 000 Kragujevac, Serbia
| | - Olivera Milošević-Djordjević
- Faculty of Science, Department of Biology and Ecology, University of Kragujevac, 34 000 Kragujevac, Serbia
- Faculty of Medical Sciences, Department of Genetics, University of Kragujevac, 34 000 Kragujevac, Serbia
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Hajdarevic S, Högberg C, Marzo-Castillejo M, Siliņa V, Sawicka-Powierza J, Esteva M, Koskela T, Petek D, Contreras-Martos S, Mangione M, Ožvačić Adžić Z, Asenova R, Gašparović Babić S, Brekke M, Buczkowski K, Buono N, Çifçili SS, Dinant GJ, Doorn B, Hoffman RD, Kuodza G, Murchie P, Pilv L, Puia A, Rapalavicius A, Smyrnakis E, Weltermann B, Harris M. Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis. A qualitative study. BJGP Open 2023; 7:BJGPO.2023.0029. [PMID: 37380218 DOI: 10.3399/bjgpo.2023.0029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/30/2023] [Accepted: 06/06/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND While primary care physicians (PCPs) play a key role in cancer detection, they can find cancer diagnosis challenging, and some patients have considerable delays between presentation and onward referral. AIM To explore European PCPs' experiences and views on cases where they considered that they had been slow to think of, or act on, a possible cancer diagnosis. DESIGN & SETTING A multicentre European qualitative study, based on an online survey with open-ended questions, asking PCPs for their narratives about cases when they had missed a diagnosis of cancer. METHOD Using maximum variation sampling, PCPs in 23 European countries were asked to describe what happened in a case where they were slow to think of a cancer diagnosis, and for their views on why it happened. Thematic analysis was used to analyse the data. RESULTS A total of 158 PCPs completed the questionnaire. The main themes were as follows: patients' descriptions did not suggest cancer; distracting factors reduced PCPs' cancer suspicions; patients' hesitancy delayed the diagnosis; system factors not facilitating timely diagnosis; PCPs felt that they had acted wrongly; and problems with communicating adequately. CONCLUSION The study identified six overarching themes that need to be addressed. Doing so should reduce morbidity and mortality in the small proportion of patients who have a significant, avoidable delay in their cancer diagnosis. The 'Swiss cheese' model of accident causation showed how the themes related to each other.
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Affiliation(s)
- Senada Hajdarevic
- Department of Nursing, Umeå University, Umeå, Sweden
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden
| | - Cecilia Högberg
- Department of Public Health and Clinical Medicine, Education and Development Östersund, Unit of Research, Umeå University, Umeå, Sweden
| | - Mercè Marzo-Castillejo
- Research Support Unit Metropolitana Sud, University Institute for Primary Health Care Research IDIAPJordi Gol, Catalan Health Institute, Barcelona, Spain
| | - Vija Siliņa
- Department of Family Medicine, Riga Stradiņš University, Riga, Latvia
| | | | - Magadalena Esteva
- Majorca Primary Care Department, Spain
- Balearic Islands Health Research Institute (IdISBa), Balearic Islands, Spain
| | - Tuomas Koskela
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Center of General Practice,Tampere University Hospital, Tampere, Finland
| | - Davorina Petek
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Sara Contreras-Martos
- Research Support Unit Metropolitana Sud, University Institute for Primary Health Care Research IDIAPJordi Gol, Catalan Health Institute, Barcelona, Spain
| | | | - Zlata Ožvačić Adžić
- Department of Family Medicine, University of Zagreb, School of Medicine, Zagreb, Croatia
- Health Center Zagreb-Centar, Zagreb, Croatia
| | - Radost Asenova
- Department Urology and General Practice, Medical University of Plovdiv, Plovdiv, Bulgaria
| | | | - Mette Brekke
- Department of Health and Society, General Practice Research Unit, University of Oslo, Oslo, Norway
| | | | - Nicola Buono
- Department of General Practice, National Society of Medical Education in General Practice (SNaMID), Caserta, Italy
| | | | - Geert-Jan Dinant
- Department of General Practice, Maastricht University, Maastricht, The Netherlands
| | - Babette Doorn
- Department of General Practice, Maastricht University, Maastricht, The Netherlands
| | - Robert D Hoffman
- Department of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Family Medicine, Maccabi Healthcare Services, Southern District, Israel
| | - George Kuodza
- Department of Family Medicine and Outpatient Care, Medical Faculty #2, Uzhhorod National University, Uzhgorod, Ukraine
| | - Peter Murchie
- Centre of Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Liina Pilv
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Aida Puia
- Department of Family Medicine, University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Aurimas Rapalavicius
- Family Medicine Department, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Emmanouil Smyrnakis
- Laboratory of Primary Health Care, General Practice and Health Services Research, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Michael Harris
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
- College of Medicine & Health, University of Exeter, Exeter, UK
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González-Esquerré J, Karlsberg S, Winters S, Paling S. Faster Diagnosis and Treatment for Cancer: Assessing Patient Pathways Using a Panel Regression Analysis of the English National Cancer Registration Data. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1730-1737. [PMID: 37741449 DOI: 10.1016/j.jval.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/28/2023] [Accepted: 09/13/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVES Timely treatment is crucial for patients with cancer, affecting both their experience and outcomes. This study examined events that shorten or extend cancer pathways. METHODS A cohort of breast, lower gastrointestinal, lung, and prostate cancers diagnosed between 2015 and 2016 in England were identified using cancer registration data. This was linked to Hospital Episode Statistic data, Cancer Waiting Times data, and specialized treatment data sets to highlight key events and dates in the pathways of 236 205 patients. Our fixed-effects panel regression included straight-to-test first appointments, multiple tests on the same day, number of multidisciplinary team meetings, appointment cancellations, trust fixed effects, and patient factors, including sex, ethnicity, index of multiple deprivations, age, comorbidities, stage, and route to diagnosis. RESULTS Patients with straight-to-test, multiple tests on the same day, and who were discussed in a single multidisciplinary team meeting waited a shorter time for treatment (-5, -4, and -7 days, respectively). Cancelled appointments and attending multiple providers were associated with longer pathways (+11 and +9 days). CONCLUSIONS Our findings highlight specific areas in which redesigning cancer pathways and transfers between hospitals could potentially lead to less waiting time for treatment, and suggest that policies aimed at reducing cancellations, by patients or hospitals, have the potential to improve waiting times.
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Affiliation(s)
| | - Sarah Karlsberg
- Economics & Strategic Analysis, NHS England, London, England, UK
| | - Sam Winters
- National Cancer Registration and Analysis Service, NHS England, London, England, UK
| | - Steven Paling
- Economics & Strategic Analysis, NHS England, London, England, UK
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Whitfield E, White B, Denaxas S, Barclay ME, Renzi C, Lyratzopoulos G. A taxonomy of early diagnosis research to guide study design and funding prioritisation. Br J Cancer 2023; 129:1527-1534. [PMID: 37794179 PMCID: PMC10645731 DOI: 10.1038/s41416-023-02450-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 09/12/2023] [Accepted: 09/20/2023] [Indexed: 10/06/2023] Open
Abstract
Researchers and research funders aiming to improve diagnosis seek to identify if, when, where, and how earlier diagnosis is possible. This has led to the propagation of research studies using a wide range of methodologies and data sources to explore diagnostic processes. Many such studies use electronic health record data and focus on cancer diagnosis. Based on this literature, we propose a taxonomy to guide the design and support the synthesis of early diagnosis research, focusing on five key questions: Do healthcare use patterns suggest earlier diagnosis could be possible? How does the diagnostic process begin? How do patients progress from presentation to diagnosis? How long does the diagnostic process take? Could anything have been done differently to reach the correct diagnosis sooner? We define families of diagnostic research study designs addressing each of these questions and appraise their unique or complementary contributions and limitations. We identify three further questions on relationships between the families and their relevance for examining patient group inequalities, supported with examples from the cancer literature. Although exemplified through cancer as a disease model, we recognise the framework is also applicable to non-neoplastic disease. The proposed framework can guide future study design and research funding prioritisation.
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Affiliation(s)
- Emma Whitfield
- ECHO (Epidemiology of Cancer Healthcare & Outcomes), Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, UCL (University College London), 1-19 Torrington Place, London, WC1E 7HB, UK.
- Institute of Health Informatics, UCL, London, UK.
| | - Becky White
- ECHO (Epidemiology of Cancer Healthcare & Outcomes), Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, UCL (University College London), 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Spiros Denaxas
- Institute of Health Informatics, UCL, London, UK
- British Heart Foundation Data Science Centre, London, UK
- Health Data Research UK, London, UK
- UCL Hospitals Biomedical Research Centre, London, UK
| | - Matthew E Barclay
- ECHO (Epidemiology of Cancer Healthcare & Outcomes), Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, UCL (University College London), 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Cristina Renzi
- ECHO (Epidemiology of Cancer Healthcare & Outcomes), Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, UCL (University College London), 1-19 Torrington Place, London, WC1E 7HB, UK
- Faculty of Medicine, University Vita-Salute San Raffaele, Milan, Italy
| | - Georgios Lyratzopoulos
- ECHO (Epidemiology of Cancer Healthcare & Outcomes), Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, UCL (University College London), 1-19 Torrington Place, London, WC1E 7HB, UK
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Cranfield BM, Abel GA, Swann R, Moore SF, McPhail S, Rubin GP, Lyratzopoulos G. Pre-Referral Primary Care Blood Tests and Symptom Presentation before Cancer Diagnosis: National Cancer Diagnosis Audit Data. Cancers (Basel) 2023; 15:3587. [PMID: 37509248 PMCID: PMC10377509 DOI: 10.3390/cancers15143587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Blood tests can support the diagnostic process in primary care. Understanding how symptomatic presentations are associated with blood test use in patients subsequently diagnosed with cancer can help to benchmark current practices and guide interventions. METHODS English National Cancer Diagnosis Audit data on 39,751 patients with incident cancer in 2018 were analysed. The frequency of four generic (full blood count, urea and electrolytes, liver function tests, and inflammatory markers) and five organ-specific (cancer biomarkers (PSA or CA125), serum protein electrophoresis, ferritin, bone profile, and amylase) blood tests was described for a total of 83 presenting symptoms. The adjusted analysis explored variation in blood test use by the symptom-positive predictive value (PPV) group. RESULTS There was a large variation in generic blood test use by presenting symptoms, being higher in patients subsequently diagnosed with cancer who presented with nonspecific symptoms (e.g., fatigue 81% or loss of appetite 79%), and lower in those who presented with alarm symptoms (e.g., breast lump 3% or skin lesion 1%). Serum protein electrophoresis (reflecting suspicion of multiple myeloma) was most frequently used in cancer patients who presented with back pain (18%), and amylase measurement (reflecting suspicion of pancreatic cancer) was used in those who presented with upper abdominal pain (14%). Prostate-specific antigen (PSA) use was greatest in men with cancer who presented with lower urinary tract symptoms (88%), and CA125 in women with cancer who presented with abdominal distention (53%). Symptoms with PPV values between 2.00-2.99% were associated with greater test use (64%) compared with 52% and 51% in symptoms with PPVs in the 0.01-0.99 or 1.00-1.99% range and compared with 42% and 31% in symptoms with PPVs in either the 3.00-4.99 or ≥5% range (p < 0.001). CONCLUSIONS Generic blood test use reflects the PPV of presenting symptoms, and the use of organ-specific tests is greater in patients with symptomatic presentations with known associations with certain cancer sites. There are opportunities for greater blood test use in patients presenting with symptoms that do not meet referral thresholds (i.e., <3% PPV for cancer) where information gain to support referral decisions is likely greatest. The findings benchmark blood test use in cancer patients, highlighting opportunities for increasing use.
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Affiliation(s)
- Ben M. Cranfield
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK;
| | - Gary A. Abel
- University of Exeter Medical School, St Luke’s Campus, Exeter EX1 2HZ, UK
| | - Ruth Swann
- National Disease Registration Service, NHS England, Leeds LS1 4AP, UK
- Cancer Research UK, London E20 1JQ, UK
| | - Sarah F. Moore
- University of Exeter Medical School, St Luke’s Campus, Exeter EX1 2HZ, UK
| | - Sean McPhail
- National Disease Registration Service, NHS England, Leeds LS1 4AP, UK
| | - Greg P. Rubin
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE1 4LP, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK;
- National Disease Registration Service, NHS England, Leeds LS1 4AP, UK
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Boswell L, Harris J, Ip A, Russell J, Black GB, Whitaker KL. Assessing awareness of blood cancer symptoms and barriers to symptomatic presentation: measure development and results from a population survey in the UK. BMC Cancer 2023; 23:633. [PMID: 37415106 PMCID: PMC10324260 DOI: 10.1186/s12885-023-11149-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 07/04/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Low levels of cancer awareness may contribute to delays in seeking medical help and subsequent delays in diagnosis. For blood cancer this may be a particularly prominent problem due to the high prevalence of undifferentiated symptoms such as bodily pain, weakness, nausea and weight loss, resulting in low symptom awareness. The delay is exacerbated by the dismissal of similar symptoms which are often interpreted as mild disease, resulting in multiple consultations prior to diagnosis. This study describes the development of a Cancer Awareness Measure for Blood Cancer (Blood CAM) and presents results from a population-representative survey using the measure. METHODS A rapid systematic review identified constructs relevant to blood cancer. Items were taken from previous awareness measures and other literature and reviewed by expert groups including health care professionals and patients. Cognitive interviews were conducted with ten members of the public to check comprehension and clarity. A total sample of 434 participants completed the survey at Time 1 and n = 302 at Time 2 (two weeks later). RESULTS Internal reliability was high across the different constructs included in the questionnaire (> 0.70) and test-retest reliability was moderate to good (0.49-0.79). The most commonly recognised blood cancer symptoms were unexplained weight loss (68.9%) and unexplained bleeding (64.9%) and the least commonly recognised symptoms were night sweats (31.3%) breathlessness and rash/itchy skin (both 44%). In terms of symptom experience, fatigue was the most commonly reported symptom (26.7%) followed by night sweats (25.4%). Exploratory factor analysis of barriers to presenting at primary care revealed three distinct categories of barriers; emotional, external/practical and service/healthcare professional related. Service and emotional barriers were most common. CONCLUSIONS We developed a valid and reliable tool to assess blood cancer awareness and showed variable awareness of blood cancer symptoms which can help target public health campaigns. We also incorporated additional measures (e.g. confidence to re-consult, ability to understand symptoms) that could be used to tailor public messaging for blood cancer and for other harder to suspect and diagnose cancers.
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Affiliation(s)
- Laura Boswell
- School of Health Sciences, University of Surrey, Guildford, UK
| | - Jenny Harris
- School of Health Sciences, University of Surrey, Guildford, UK
| | - Athena Ip
- School of Health Sciences, University of Surrey, Guildford, UK
| | - Jessica Russell
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Georgia B Black
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- Department of Applied Health Research, University College London, London, UK
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Rak O, Urban D, Perlman S, Ziv-Baran T, Katorza E. Fast vs. Regular Track for Lung and Pancreatic Cancer Diagnosis-Time from Initial Finding to Final Diagnosis and Patient Survival. J Med Syst 2023; 47:48. [PMID: 37060494 DOI: 10.1007/s10916-023-01939-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 03/16/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND Health systems around the world have begun implementing unique tracks to expedite diagnosis and improve survival of patients with suspected cancers. This study aimed to compare characteristics and survival between patients diagnosed by way of fast and regular diagnostic tracks. METHODS A historical cohort study of patients (age ≥ 18) diagnosed with lung or pancreatic cancers between 09/2017 and 03/2020 on a fast diagnostic track and treated in a tertiary hospital versus a random sample of patients with the same cancer types who began treatment in the hospital over the same period of time after being diagnosed utilizing the regular track in the community. RESULTS The study included 336 patients (108 fast-track diagnostics, 228 regular track diagnostics). Advanced stages III-IV at diagnosis were more likely in the fast-track group (94.4% vs. 81.1%, p = 0.001). The median time from initial cancer suspicion to diagnosis was 21 days (IQR 14-37) for the fast-track vs. 31 days (IQR 18-51) for the regular track (p < 0.001). During the follow-up period, 56 patients from the fast-track and 131 patients from the regular track died. No significant difference was found in the median survival time between the fast and regular tracks, whether from the onset of symptoms, diagnosis, or treatment initiation. CONCLUSION Patients referred to the fast-track were more likely to be diagnosed at a further advanced stage of their cancer. The fast-track shortened the time until diagnosis and treatment but no difference was found in median survival between the tracks, perhaps due to late referral and high fatality rates.
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Affiliation(s)
- Orit Rak
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Center for Fast Diagnosis of Cancer, Sheba Medical Center, Ramat Gan, Israel
| | - Damien Urban
- Center for Fast Diagnosis of Cancer, Sheba Medical Center, Ramat Gan, Israel
| | - Saritte Perlman
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tomer Ziv-Baran
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Eldad Katorza
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan, Israel
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10
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Black GB, Boswell L, Harris J, Whitaker KL. What causes delays in diagnosing blood cancers? A rapid review of the evidence. Prim Health Care Res Dev 2023; 24:e26. [PMID: 37039465 PMCID: PMC10156470 DOI: 10.1017/s1463423623000129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 04/12/2023] Open
Abstract
OBJECTIVE We undertook a rapid review of literature relating to the diagnosis of blood cancers, to find out what factors contribute to delays in diagnosis, including symptom recognition, appraisal and help-seeking behaviours. METHODS We used rapid review methodology following Tricco et al. to synthesise current literature from two electronic databases. We searched for studies about symptom appraisal help-seeking for all blood cancers published between 2001 and 2021, written in English. RESULTS Fifteen studies were included in the review, of which 10 were published in the United Kingdom. We found a number of factors associated with delays in blood cancer diagnosis. These included patient factors such as gender, age and ethnicity, as well as health system factors such as poor communication and seeing a locum clinician in primary care. A narrative synthesis of the evidence produced four types of symptom interpretation by patients: (1) symptoms compatible with normal state of health, (2) event-linked problems, (3) mild or chronic illness and (4) non-specific unwell state. These four interpretations were linked to different help-seeking behaviours. After seeking help, patients often experienced delays due to healthcare professionals' (HCPs') non-serious interpretation of symptoms, misleading blood tests, discontinuity of care and other barriers in the diagnostic pathway. CONCLUSION Blood cancers are difficult to diagnose due to non-specific heterogeneous symptoms, and this is reflected in how those symptoms are interpreted by patients and managed by HCPs. It is important to understand how different interpretations affect delays in help-seeking, and what HCPs can do to support timely follow-up for patients.
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Affiliation(s)
- Georgia B. Black
- Reader in Applied Health Research, Wolfson Institute of Population Health,
Queen Mary University of London, London,
UK
| | - Laura Boswell
- PhD student, School of Health Sciences, University of
Surrey, Guildford, UK
| | - Jenny Harris
- Senior Lecturer in Cancer Care, School of Health Sciences,
University of Surrey, Guildford,
UK
| | - Katriina L. Whitaker
- Professor of Psychology and Lead for Cancer Care, School of Health
Sciences, University of Surrey, Guildford,
UK
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11
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Black GB, Lyratzopoulos G, Vincent CA, Fulop NJ, Nicholson BD. Early diagnosis of cancer: systems approach to support clinicians in primary care. BMJ 2023; 380:e071225. [PMID: 36758989 DOI: 10.1136/bmj-2022-071225] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- Georgia B Black
- Department of Applied Health Research, University College London, London, UK
| | - Georgios Lyratzopoulos
- ECHO (Epidemiology of Cancer Healthcare and Outcomes), Department of Behavioural Science and Health, University College London, UK
| | - Charles A Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
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12
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Cranfield BM, Koo MM, Abel GA, Swann R, McPhail S, Rubin GP, Lyratzopoulos G. Primary care blood tests before cancer diagnosis: National Cancer Diagnosis Audit data. Br J Gen Pract 2023; 73:e95-e103. [PMID: 36253112 PMCID: PMC9591015 DOI: 10.3399/bjgp.2022.0265] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/07/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Blood tests can support the diagnostic process in patients with cancer but how often they are used is unclear. AIM To explore use of common blood tests before cancer diagnosis in primary care. DESIGN AND SETTING English National Cancer Diagnosis Audit data on 39 752 patients with cancer diagnosed in 2018. METHOD Common blood test use (full blood count [FBC], urea and electrolytes [U&E], and liver function tests [LFTs]), variation by patient and symptom group, and associations with the primary care interval and the diagnostic interval were assessed. RESULTS At least one common blood test was used in 41% (n = 16 427/39 752) of patients subsequently diagnosed with cancer. Among tested patients, (n = 16 427), FBC was used in 95% (n = 15 540), U&E in 89% (n = 14 555), and LFTs in 76% (n = 12 414). Blood testing was less common in females (adjusted odds ratio versus males: 0.92, 95% confidence interval [CI] = 0.87 to 0.98) and Black and minority ethnic patients (0.89, 95% CI = 0.82 to 0.97 versus White), and more common in older patients (1.12, 95% CI = 1.06 to 1.18 for ≥70 years versus 50-69 years). Test use varied greatly by cancer site (melanoma 2% [ n = 55/2297]; leukaemia 84% [ n = 552/661]). Fewer patients presenting with alarm symptoms alone were tested (24% [ n = 3341/13 778]) than those with non-alarm symptoms alone (50% [ n = 8223/16 487]). Median primary care interval and diagnostic interval were longer in tested than non-tested patients (primary care interval: 10 versus 0 days; diagnostic interval: 49 versus 32 days, respectively, P<0.001 for both), including among tested patients with alarm symptoms (primary care interval: 4 versus 0 days; diagnostic interval: 41 versus 22 days). CONCLUSION Two-fifths of patients subsequently diagnosed with cancer have primary care blood tests as part of their diagnostic process. Given variable test use, research is needed on the clinical context in which blood tests are ordered.
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Affiliation(s)
| | | | - Gary A Abel
- University of Exeter Medical School, St Luke's Campus, Exeter
| | - Ruth Swann
- National Disease Registration Service, NHS Digital, Leeds, and Cancer Research UK, London
| | - Sean McPhail
- National Disease Registration Service, NHS Digital, Leeds
| | - Greg P Rubin
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne
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13
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White B, Renzi C, Barclay M, Lyratzopoulos G. Underlying cancer risk among patients with fatigue and other vague symptoms: a population-based cohort study in primary care. Br J Gen Pract 2023; 73:e75-e87. [PMID: 36702593 PMCID: PMC9888575 DOI: 10.3399/bjgp.2022.0371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/17/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Presenting to primary care with fatigue is associated with slightly increased cancer risk, although it is unknown how this varies in the presence of other 'vague' symptoms. AIM To quantify cancer risk in patients with fatigue who present with other 'vague' symptoms in the absence of 'alarm' symptoms for cancer. DESIGN AND SETTING Cohort study of patients presenting in UK primary care with new-onset fatigue during 2007-2015, using Clinical Practice Research Datalink data linked to national cancer registration data. METHOD Patients presenting with fatigue without co-occurring alarm symptoms or anaemia were identified, who were further characterised as having co-occurrence of 19 other 'vague' potential cancer symptoms. Sex- and age-specific 9-month cancer risk for each fatigue-vague symptom cohort were calculated. RESULTS Of 285 382 patients presenting with new-onset fatigue, 84% (n = 239 846) did not have co-occurring alarm symptoms or anaemia. Of these, 38% (n = 90 828) presented with ≥1 of 19 vague symptoms for cancer. Cancer risk exceeded 3% in older males with fatigue combined with any of the vague symptoms studied. The age at which risk exceeded 3% was 59 years for fatigue-weight loss, 65 years for fatigue-abdominal pain, 67 years for fatigue-constipation, and 67 years for fatigue-other upper gastrointestinal symptoms. For females, risk exceeded 3% only in older patients with fatigue-weight loss (from 65 years), fatigue-abdominal pain (from 79 years), or fatigue-abdominal bloating (from 80 years). CONCLUSION In the absence of alarm symptoms or anaemia, fatigue combined with specific vague presenting symptoms, alongside patient age and sex, can guide clinical decisions about referral for suspected cancer.
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Affiliation(s)
- Becky White
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, UK
| | - Cristina Renzi
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, UK, and associate professor, Faculty of Medicine, University Vita-Salute San Raffaele, Milan, Italy
| | - Matthew Barclay
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, UK
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14
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Aboelkhir HAB, Elomri A, ElMekkawy TY, Kerbache L, Elakkad MS, Al-Ansari A, Aboumarzouk OM, El Omri A. A Bibliometric Analysis and Visualization of Decision Support Systems for Healthcare Referral Strategies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16952. [PMID: 36554837 PMCID: PMC9778793 DOI: 10.3390/ijerph192416952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/24/2022] [Accepted: 11/14/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND The referral process is an important research focus because of the potential consequences of delays, especially for patients with serious medical conditions that need immediate care, such as those with metastatic cancer. Thus, a systematic literature review of recent and influential manuscripts is critical to understanding the current methods and future directions in order to improve the referral process. METHODS A hybrid bibliometric-structured review was conducted using both quantitative and qualitative methodologies. Searches were conducted of three databases, Web of Science, Scopus, and PubMed, in addition to the references from the eligible papers. The papers were considered to be eligible if they were relevant English articles or reviews that were published from January 2010 to June 2021. The searches were conducted using three groups of keywords, and bibliometric analysis was performed, followed by content analysis. RESULTS A total of 163 papers that were published in impactful journals between January 2010 and June 2021 were selected. These papers were then reviewed, analyzed, and categorized as follows: descriptive analysis (n = 77), cause and effect (n = 12), interventions (n = 50), and quality management (n = 24). Six future research directions were identified. CONCLUSIONS Minimal attention was given to the study of the primary referral of blood cancer cases versus those with solid cancer types, which is a gap that future studies should address. More research is needed in order to optimize the referral process, specifically for suspected hematological cancer patients.
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Affiliation(s)
| | - Adel Elomri
- College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Tarek Y. ElMekkawy
- Department of Mechanical and Industrial Engineering, College of Engineering, Qatar University, Doha 2713, Qatar
| | - Laoucine Kerbache
- College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Mohamed S. Elakkad
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Abdulla Al-Ansari
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Omar M. Aboumarzouk
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
- College of Medicine, QU-Health, Qatar University, Doha 2713, Qatar
- School of Medicine, Dentistry and Nursing, The University of Glasgow, Glasgow G12 8QQ, UK
| | - Abdelfatteh El Omri
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
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15
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Barr CE, Njoku K, Jones ER, Crosbie EJ. Serum CA125 and HE4 as Biomarkers for the Detection of Endometrial Cancer and Associated High-Risk Features. Diagnostics (Basel) 2022; 12:diagnostics12112834. [PMID: 36428894 PMCID: PMC9689358 DOI: 10.3390/diagnostics12112834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022] Open
Abstract
Early detection of endometrial cancer improves survival. Non-invasive diagnostic biomarkers would improve triage of symptomatic women for investigations. This study aimed to determine the diagnostic accuracy of serum Cancer Antigen 125 (CA125) and Human Epididymis 4 (HE4) for endometrial cancer and associated high-risk features. Serum samples from women investigated for gynaecological symptoms or diagnosed with endometrial cancer were analysed for CA125 and HE4. Conventional diagnostic metrics were calculated. In total, 755 women were included; 397 had endometrial cancer. Serum CA125 and HE4 were significantly elevated in cases compared with controls (both p < 0.001), and with pathological markers of disease severity (p < 0.05). A combination of CA125 and HE4 detected endometrial cancer with an area under the curve (AUC) of 0.77 (95% CI: 0.74−0.81). In a model with body mass index (BMI) and parity, HE4 predicted endometrial cancer in pre-menopausal women with an AUC of 0.91 [sensitivity = 84.5%, specificity = 80.9% (p < 0.001)]. In women with abnormal ultrasound, HE4 ≥ 77 pmol/L improved specificity compared with imaging alone [68.6% (95% CI: 75.0−83.6) vs. 34.4% (95% CI: 27.1−42.3), respectively], but at a cost to sensitivity. HE4 ≥ 77 pmol/L improved the detection of myometrial invasion ≥50% in women with stage I disease compared with magnetic resonance imaging (MRI) alone [sensitivity = 100% (95% CI: 54.1−100)]. CA125 ≥ 35 U/mL did not add to imaging. HE4 is a good predictor of poor prognostic features which could assist staging investigations.
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Affiliation(s)
- Chloe E. Barr
- Manchester Academic Health Science Centre, Division of Gynaecology, Manchester NHS Foundation Trust, Manchester M13 9WL, UK
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Kelechi Njoku
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Eleanor R. Jones
- Manchester Academic Health Science Centre, Division of Gynaecology, Manchester NHS Foundation Trust, Manchester M13 9WL, UK
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Emma J. Crosbie
- Manchester Academic Health Science Centre, Division of Gynaecology, Manchester NHS Foundation Trust, Manchester M13 9WL, UK
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
- Correspondence: ; Tel.: +44-161-701-6942
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16
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Hultstrand C, Hörnsten C, Lilja M, Coe A, Fjällström P, Hajdarevic S. The association between sociodemographic factors and time to diagnosis for colorectal cancer in northern Sweden. Eur J Cancer Care (Engl) 2022; 31:e13687. [PMID: 35970596 PMCID: PMC9787547 DOI: 10.1111/ecc.13687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 06/29/2022] [Accepted: 08/02/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES This study examined whether sociodemographic factors, including distance to hospital, were associated with differences in the diagnostic interval and the treatment interval for colorectal cancer in northern Sweden. METHODS Data were retrieved from the Swedish cancer register on patients (n = 446) diagnosed in three northern regions during 2017-2018, then linked to data from Statistics Sweden and medical records. Also, Google maps was used to map the distance between patients' place of residence and nearest hospital. The different time intervals were analysed using Mann-Whitney U-test and Cox regression. RESULTS Differences in time to diagnosis were found between groups for income and distance to hospital, favouring those with higher income and shorter distance. The unadjusted regression analysis showed higher income to be associated with more rapid diagnosis (HR 1.004, CI 1.001-1.007). This association remained in the fully adjusted model for income (HR 1.004, CI 1.000-1.008), but not for distance. No differences between sociodemographic groups were found in the treatment interval. CONCLUSION Higher income and shorter distance to hospital were in the unadjusted models associated with shorter time to diagnosis for patients with CRC in northern Sweden. The association remained for income when adjusting for other variables even though the difference was small.
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Affiliation(s)
- Cecilia Hultstrand
- Department of NursingUmeå UniversityUmeåSweden,Department of Public Health and Clinical Medicine, Family MedicineUmeå UniversityUmeåSweden
| | | | - Mikael Lilja
- Department of Public Health and Clinical Medicine, Unit of Research, Education, and DevelopmentÖstersund Hospital, Umeå UniversityUmeåSweden
| | | | | | - Senada Hajdarevic
- Department of NursingUmeå UniversityUmeåSweden,Department of Public Health and Clinical Medicine, Family MedicineUmeå UniversityUmeåSweden
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17
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Saab MM, McCarthy M, O'Driscoll M, Sahm LJ, Leahy-Warren P, Noonan B, FitzGerald S, O'Malley M, Lyons N, Burns HE, Kennedy U, Lyng Á, Hegarty J. A systematic review of interventions to recognise, refer and diagnose patients with lung cancer symptoms. NPJ Prim Care Respir Med 2022; 32:42. [PMID: 36258020 PMCID: PMC9579201 DOI: 10.1038/s41533-022-00312-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/06/2022] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Mohamad M Saab
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland.
| | - Megan McCarthy
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Michelle O'Driscoll
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Laura J Sahm
- School of Pharmacy, University College Cork, Cork, Ireland
| | - Patricia Leahy-Warren
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Brendan Noonan
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Serena FitzGerald
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Maria O'Malley
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Noreen Lyons
- Rapid Access Lung Clinic, Cork University Hospital, Cork, Ireland
| | - Heather E Burns
- National Cancer Control Programme, Health Services Executive, Dublin, Ireland
| | - Una Kennedy
- National Cancer Control Programme, Health Services Executive, Dublin, Ireland
| | - Áine Lyng
- National Cancer Control Programme, Health Services Executive, Dublin, Ireland
| | - Josephine Hegarty
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
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18
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Martins T, Abel G, Ukoumunne OC, Mounce LTA, Price S, Lyratzopoulos G, Chinegwundoh F, Hamilton W. Ethnic inequalities in routes to diagnosis of cancer: a population-based UK cohort study. Br J Cancer 2022; 127:863-871. [PMID: 35661833 PMCID: PMC9427836 DOI: 10.1038/s41416-022-01847-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 04/08/2022] [Accepted: 05/06/2022] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND UK Asian and Black ethnic groups have poorer outcomes for some cancers and are less likely to report a positive care experience than their White counterparts. This study investigated ethnic differences in the route to diagnosis (RTD) to identify areas in patients' cancer journeys where inequalities lie, and targeted intervention might have optimum impact. METHODS We analysed data of 243,825 patients with 10 cancers (2006-2016) from the RTD project linked to primary care data. Crude and adjusted proportions of patients diagnosed via six routes (emergency, elective GP referral, two-week wait (2WW), screen-detected, hospital, and Other routes) were calculated by ethnicity. Adjusted odds ratios (including two-way interactions between cancer and age, sex, IMD, and ethnicity) determined cancer-specific differences in RTD by ethnicity. RESULTS Across the 10 cancers studied, most patients were diagnosed via 2WW (36.4%), elective GP referral (23.2%), emergency (18.2%), hospital routes (10.3%), and screening (8.61%). Patients of Other ethnic group had the highest proportion of diagnosis via the emergency route, followed by White patients. Asian and Black group were more likely to be GP-referred, with the Black and Mixed groups also more likely to follow the 2WW route. However, there were notable cancer-specific differences in the RTD by ethnicity. CONCLUSION Our findings suggest that, where inequalities exist, the adverse cancer outcomes among Asian and Black patients are unlikely to be arising solely from a poorer diagnostic process.
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Affiliation(s)
- Tanimola Martins
- College of Medicine and Health, University of Exeter, College House, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK.
| | - Gary Abel
- College of Medicine and Health, University of Exeter, College House, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK
| | - Obioha C Ukoumunne
- National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter, Exeter, UK
| | - Luke T A Mounce
- College of Medicine and Health, University of Exeter, College House, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK
| | - Sarah Price
- College of Medicine and Health, University of Exeter, College House, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Frank Chinegwundoh
- Barts Health NHS Trust & Department of Health Sciences, University of London, London, UK
| | - William Hamilton
- College of Medicine and Health, University of Exeter, College House, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK
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19
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White B, Rafiq M, Gonzalez-Izquierdo A, Hamilton W, Price S, Lyratzopoulos G. Risk of cancer following primary care presentation with fatigue: a population-based cohort study of a quarter of a million patients. Br J Cancer 2022; 126:1627-1636. [PMID: 35181753 PMCID: PMC9130200 DOI: 10.1038/s41416-022-01733-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 01/12/2022] [Accepted: 02/01/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The management of adults presenting with fatigue presents a diagnostic challenge, particularly regarding possible underlying cancer. METHODS Using electronic health records, we examined cancer risk in patients presenting to primary care with new-onset fatigue in England during 2007-2013, compared to general population estimates. We examined variation by age, sex, deprivation, and time following presentation. FINDINGS Of 250,606 patients presenting with fatigue, 12-month cancer risk exceeded 3% in men aged 65 and over and women aged 80 and over, and 6% in men aged 80 and over. Nearly half (47%) of cancers were diagnosed within 3 months from first fatigue presentation. Site-specific cancer risk was higher than the general population for most cancers studied, with greatest relative increases for leukaemia, pancreatic and brain cancers. CONCLUSIONS In older patients, new-onset fatigue is associated with cancer risk exceeding current thresholds for urgent specialist referral. Future research should consider how risk is modified by the presence or absence of other signs and symptoms. Excess cancer risk wanes rapidly after 3 months, which could inform the duration of a 'safety-netting' period. Fatigue presentation is not strongly predictive of any single cancer, although certain cancers are over-represented; this knowledge can help prioritise diagnostic strategies.
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Affiliation(s)
- Becky White
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, London, UK.
| | - Meena Rafiq
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, London, UK
| | - Arturo Gonzalez-Izquierdo
- Institute of Health Informatics, Faculty of Population Health Sciences, University College London, London, UK
| | - Willie Hamilton
- University of Exeter Medical School, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK
| | - Sarah Price
- University of Exeter Medical School, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, London, UK
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Crosbie EJ, Kitson SJ, McAlpine JN, Mukhopadhyay A, Powell ME, Singh N. Endometrial cancer. Lancet 2022; 399:1412-1428. [PMID: 35397864 DOI: 10.1016/s0140-6736(22)00323-3] [Citation(s) in RCA: 307] [Impact Index Per Article: 153.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/26/2022] [Accepted: 02/03/2022] [Indexed: 12/21/2022]
Abstract
Endometrial cancer is the most common gynaecological cancer in high income countries and its incidence is rising globally. Although an ageing population and fewer benign hysterectomies have contributed to this trend, the growing prevalence of obesity is the major underlying cause. Obesity poses challenges for diagnosis and treatment and more research is needed to offer primary prevention to high-risk women and to optimise endometrial cancer survivorship. Early presentation with postmenopausal bleeding ensures most endometrial cancers are cured by hysterectomy but those with advanced disease have a poor prognosis. Minimally invasive surgical staging and sentinel-lymph-node biopsy provides a low morbidity alternative to historical surgical management without compromising oncological outcomes. Adjuvant radiotherapy reduces loco-regional recurrence in intermediate-risk and high-risk cases. Advances in our understanding of the molecular biology of endometrial cancer have paved the way for targeted chemotherapeutic strategies, and clinical trials will establish their benefit in adjuvant, advanced, and recurrent disease settings in the coming years.
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Affiliation(s)
- Emma J Crosbie
- Gynaecological Oncology Research Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary's Hospital, Manchester, UK; Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
| | - Sarah J Kitson
- Gynaecological Oncology Research Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary's Hospital, Manchester, UK
| | - Jessica N McAlpine
- Department of Obstetrics and Gynaecology, Division of Gynecologic Oncology, University of British Columbia and BC Cancer, Vancouver, BC, Canada
| | - Asima Mukhopadhyay
- Kolkata Gynecological Oncology Trials and Translational Research Group, Chittaranjan National Cancer Institute, Kolkata, India; Department of Gynaecological Oncology, James Cook University Hospital, Middlesbrough, UK; Department of Gynaecological Oncology, Newcastle University, Newcastle upon Tyne, UK
| | - Melanie E Powell
- Department of Clinical Oncology, Barts and The London NHS Trust, London, UK
| | - Naveena Singh
- Department of Anatomic Pathology, Vancouver General Hospital, Vancouver, BC, Canada
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21
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White B, Renzi C, Rafiq M, Abel GA, Jensen H, Lyratzopoulos G. Does changing healthcare use signal opportunities for earlier detection of cancer? A review of studies using information from electronic patient records. Cancer Epidemiol 2022; 76:102072. [PMID: 34876377 PMCID: PMC8785122 DOI: 10.1016/j.canep.2021.102072] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/10/2021] [Accepted: 11/14/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND It has been proposed that changes in healthcare use before cancer diagnosis could signal opportunities for quicker detection, but systematic appreciation of such evidence is lacking. We reviewed studies examining pre-diagnostic changes in healthcare utilisation (e.g. rates of GP or hospital consultations, prescriptions or diagnostic tests) among patients subsequently diagnosed with cancer. METHODS We identified studies through Pubmed searches complemented by expert elicitation. We extracted information on the earliest time point when diagnosis could have been possible for at least some cancers, together with variation in the length of such 'diagnostic windows' by tumour and patient characteristics. RESULTS Across twenty-eight studies, changes in healthcare use were observable at least six months pre-diagnosis for many common cancers, and potentially even earlier for colorectal cancer, multiple myeloma and brain tumours. Early changes were also identified for brain and colon cancer sub-sites. CONCLUSION Changing healthcare utilisation patterns before diagnosis indicate that future improvements in diagnostic technologies or services could help to shorten diagnostic intervals for cancer. There is greatest potential for quicker diagnosis for certain cancer types and patient groups, which can inform priorities for the development of decision support tools.
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Affiliation(s)
- Becky White
- ECHO (Epidemiology of Cancer Healthcare and Outcomes, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IEHC)), University College London, Gower Street, London WC1E 6BT, UK.
| | - Cristina Renzi
- ECHO (Epidemiology of Cancer Healthcare and Outcomes, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IEHC)), University College London, Gower Street, London WC1E 6BT, UK
| | - Meena Rafiq
- ECHO (Epidemiology of Cancer Healthcare and Outcomes, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IEHC)), University College London, Gower Street, London WC1E 6BT, UK
| | - Gary A Abel
- University of Exeter Medical School, St Luke's Campus, Magdalen Road, Exeter EX1 2LU, UK
| | - Henry Jensen
- Research Unit for General Practice, Bartholins Allé 2, 8000 Aarhus C, Denmark
| | - Georgios Lyratzopoulos
- ECHO (Epidemiology of Cancer Healthcare and Outcomes, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IEHC)), University College London, Gower Street, London WC1E 6BT, UK
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22
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Harrison H, Usher-Smith JA, Li L, Roberts L, Lin Z, Thompson RE, Rossi SH, Stewart GD, Walter FM, Griffin S, Zhou Y. Risk prediction models for symptomatic patients with bladder and kidney cancer: a systematic review. Br J Gen Pract 2022; 72:e11-e18. [PMID: 34844922 PMCID: PMC8714528 DOI: 10.3399/bjgp.2021.0319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/25/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Timely diagnosis of bladder and kidney cancer is key to improving clinical outcomes. Given the challenges of early diagnosis, models incorporating clinical symptoms and signs may be helpful to primary care clinicians when triaging at-risk patients. AIM To identify and compare published models that use clinical signs and symptoms to predict the risk of undiagnosed prevalent bladder or kidney cancer. DESIGN AND SETTING Systematic review. METHOD A search identified primary research reporting or validating models predicting the risk of bladder or kidney cancer in MEDLINE and EMBASE. After screening identified studies for inclusion, data were extracted onto a standardised form. The risk models were classified using TRIPOD guidelines and evaluated using the PROBAST assessment tool. RESULTS The search identified 20 661 articles. Twenty studies (29 models) were identified through screening. All the models included haematuria (visible, non-visible, or unspecified), and seven included additional signs and symptoms (such as abdominal pain). The models combined clinical features with other factors (including demographic factors and urinary biomarkers) to predict the risk of undiagnosed prevalent cancer. Several models (n = 13) with good discrimination (area under the receiver operating curve >0.8) were identified; however, only eight had been externally validated. All of the studies had either high or unclear risk of bias. CONCLUSION Models were identified that could be used in primary care to guide referrals, with potential to identify lower-risk patients with visible haematuria and to stratify individuals who present with non-visible haematuria. However, before application in general practice, external validations in appropriate populations are required.
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Affiliation(s)
- Hannah Harrison
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Lanxin Li
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge
| | - Lydia Roberts
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge
| | - Zhiyuan Lin
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge
| | - Rachel E Thompson
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge
| | - Sabrina H Rossi
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge
| | - Fiona M Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, and director, Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Simon Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Yin Zhou
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
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23
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Zhou Y, Walter FM, Mounce L, Abel GA, Singh H, Hamilton W, Stewart GD, Lyratzopoulos G. Identifying opportunities for timely diagnosis of bladder and renal cancer via abnormal blood tests: a longitudinal linked data study. Br J Gen Pract 2022; 72:e19-e25. [PMID: 34903517 PMCID: PMC8714503 DOI: 10.3399/bjgp.2021.0282] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/14/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Understanding pre-diagnostic test use could reveal diagnostic windows where more timely evaluation for cancer may be indicated. AIM To examine pre-diagnostic patterns of results of abnormal blood tests in patients with bladder and renal cancer. DESIGN AND SETTING A retrospective cohort study using primary care and cancer registry data on patients with bladder and renal cancer who were diagnosed between April 2012 and December 2015 in England. METHOD The rates of patients with a first abnormal result in the year before cancer diagnosis, for 'generic' (full blood count components, inflammatory markers, and calcium) and 'organ-specific' blood tests (creatinine and liver function test components) that may lead to subsequent detection of incidental cancers, were examined. Poisson regression was used to detect the month during which the cohort's rate of each abnormal test started to increase from baseline. The proportion of patients with a test found in the first half of the diagnostic window was examined, as these 'early' tests might represent opportunities where further evaluation could be initiated. RESULTS Data from 4533 patients with bladder and renal cancer were analysed. The monthly rate of patients with a first abnormal test increased towards the time of cancer diagnosis. Abnormalities of both generic (for example, high inflammatory markers) and organ-specific tests (for example, high creatinine) started to increase from 6-8 months pre-diagnosis, with 25%-40% of these patients having an abnormal test in the 'early half' of the diagnostic window. CONCLUSION Population-level signals of bladder and renal cancer can be observed in abnormalities in commonly performed primary care blood tests up to 8 months before diagnosis, indicating the potential for earlier diagnosis in some patients.
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Affiliation(s)
- Yin Zhou
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Fiona M Walter
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK; professor of primary care cancer research, Wolfson Institute of Population Health, Queen Mary University London, London, UK
| | - Luke Mounce
- University of Exeter Medical School, Exeter, UK
| | - Gary A Abel
- University of Exeter Medical School, Exeter, UK
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, TX, US; Baylor College of Medicine, Houston, TX, US
| | | | - Grant D Stewart
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
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24
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Jeffery HE, Gillespie AM, Macdonald M. Evaluation of women referred to the two-week wait gynaecology clinic with suspected ovarian cancer. Eur J Obstet Gynecol Reprod Biol 2021; 266:145-149. [PMID: 34653919 DOI: 10.1016/j.ejogrb.2021.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/24/2021] [Accepted: 09/29/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Ovarian cancer is the leading cause of death from gynaecological cancer in the UK, making early diagnosis key. The two-week wait pathway aims to facilitate rapid referrals from primary to secondary care for suspected cancer thus increasing rates of early diagnosis. The objective of this study was to evaluate referrals made via the two-week wait pathway for suspected ovarian cancer. STUDY DESIGN A retrospective analysis of 215 women referred on the two-week wait pathway to a tertiary centre in the United Kingdom with suspected ovarian cancer in 2018. RESULTS Only 16% of women referred were subsequently diagnosed with gynaecological malignancy. Of those diagnosed with ovarian cancer, 78% had late stage disease at diagnosis. Pre-menopausal women made up 29% of those referred, but only 6% of those diagnosed with cancer. CONCLUSION Despite its goal of increasing early stage diagnosis of cancer, the majority of women referred via the two-week wait pathway do not have cancer, and the majority of those who do are referred with late stage disease. These results highlight the need for an effective screening programme for ovarian cancer.
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Affiliation(s)
- H E Jeffery
- Department of Obstetrics and Gynaecology, Sheffield Teaching Hospital NHS Foundation Trust, Royal Hallamshire Hospital, Glossop Road, Broomhall, Sheffield S10 2JF, United Kingdom.
| | - A M Gillespie
- Department of Gynaecological Oncology, Sheffield Teaching Hospital NHS Foundation Trust, Royal Hallamshire Hospital, Glossop Road, Broomhall, Sheffield S10 2JF, United Kingdom.
| | - M Macdonald
- Department of Gynaecological Oncology, Sheffield Teaching Hospital NHS Foundation Trust, Royal Hallamshire Hospital, Glossop Road, Broomhall, Sheffield S10 2JF, United Kingdom.
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25
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Medina-Lara A, Grigore B, Lewis R, Peters J, Price S, Landa P, Robinson S, Neal R, Hamilton W, Spencer AE. Cancer diagnostic tools to aid decision-making in primary care: mixed-methods systematic reviews and cost-effectiveness analysis. Health Technol Assess 2021; 24:1-332. [PMID: 33252328 DOI: 10.3310/hta24660] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Tools based on diagnostic prediction models are available to help general practitioners diagnose cancer. It is unclear whether or not tools expedite diagnosis or affect patient quality of life and/or survival. OBJECTIVES The objectives were to evaluate the evidence on the validation, clinical effectiveness, cost-effectiveness, and availability and use of cancer diagnostic tools in primary care. METHODS Two systematic reviews were conducted to examine the clinical effectiveness (review 1) and the development, validation and accuracy (review 2) of diagnostic prediction models for aiding general practitioners in cancer diagnosis. Bibliographic searches were conducted on MEDLINE, MEDLINE In-Process, EMBASE, Cochrane Library and Web of Science) in May 2017, with updated searches conducted in November 2018. A decision-analytic model explored the tools' clinical effectiveness and cost-effectiveness in colorectal cancer. The model compared patient outcomes and costs between strategies that included the use of the tools and those that did not, using the NHS perspective. We surveyed 4600 general practitioners in randomly selected UK practices to determine the proportions of general practices and general practitioners with access to, and using, cancer decision support tools. Association between access to these tools and practice-level cancer diagnostic indicators was explored. RESULTS Systematic review 1 - five studies, of different design and quality, reporting on three diagnostic tools, were included. We found no evidence that using the tools was associated with better outcomes. Systematic review 2 - 43 studies were included, reporting on prediction models, in various stages of development, for 14 cancer sites (including multiple cancers). Most studies relate to QCancer® (ClinRisk Ltd, Leeds, UK) and risk assessment tools. DECISION MODEL In the absence of studies reporting their clinical outcomes, QCancer and risk assessment tools were evaluated against faecal immunochemical testing. A linked data approach was used, which translates diagnostic accuracy into time to diagnosis and treatment, and stage at diagnosis. Given the current lack of evidence, the model showed that the cost-effectiveness of diagnostic tools in colorectal cancer relies on demonstrating patient survival benefits. Sensitivity of faecal immunochemical testing and specificity of QCancer and risk assessment tools in a low-risk population were the key uncertain parameters. SURVEY Practitioner- and practice-level response rates were 10.3% (476/4600) and 23.3% (227/975), respectively. Cancer decision support tools were available in 83 out of 227 practices (36.6%, 95% confidence interval 30.3% to 43.1%), and were likely to be used in 38 out of 227 practices (16.7%, 95% confidence interval 12.1% to 22.2%). The mean 2-week-wait referral rate did not differ between practices that do and practices that do not have access to QCancer or risk assessment tools (mean difference of 1.8 referrals per 100,000 referrals, 95% confidence interval -6.7 to 10.3 referrals per 100,000 referrals). LIMITATIONS There is little good-quality evidence on the clinical effectiveness and cost-effectiveness of diagnostic tools. Many diagnostic prediction models are limited by a lack of external validation. There are limited data on current UK practice and clinical outcomes of diagnostic strategies, and there is no evidence on the quality-of-life outcomes of diagnostic results. The survey was limited by low response rates. CONCLUSION The evidence base on the tools is limited. Research on how general practitioners interact with the tools may help to identify barriers to implementation and uptake, and the potential for clinical effectiveness. FUTURE WORK Continued model validation is recommended, especially for risk assessment tools. Assessment of the tools' impact on time to diagnosis and treatment, stage at diagnosis, and health outcomes is also recommended, as is further work to understand how tools are used in general practitioner consultations. STUDY REGISTRATION This study is registered as PROSPERO CRD42017068373 and CRD42017068375. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology programme and will be published in full in Health Technology Assessment; Vol. 24, No. 66. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Antonieta Medina-Lara
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Bogdan Grigore
- Exeter Test Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Ruth Lewis
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Jaime Peters
- Exeter Test Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Sarah Price
- Primary Care Diagnostics, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Paolo Landa
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Sophie Robinson
- Peninsula Technology Assessment Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Richard Neal
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - William Hamilton
- Primary Care Diagnostics, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Anne E Spencer
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
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26
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Cancer detection via primary care urgent referral and association with practice characteristics: a retrospective cross-sectional study in England from 2009/2010 to 2018/2019. Br J Gen Pract 2021; 71:e826-e835. [PMID: 34544690 PMCID: PMC8463132 DOI: 10.3399/bjgp.2020.1030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 05/17/2021] [Indexed: 11/17/2022] Open
Abstract
Background There is substantial variation in the use of urgent suspected cancer referral (2-week wait [2WW]) between practices. Aim To examine the change in use of 2WW referrals in England over 10 years (2009/2010 to 2018/2019) and the practice and population factors associated with cancer detection. Design and setting Retrospective cross-sectional study of English general practices and their 2WW referral and Cancer Waiting Times database detection data (all cancers other than non-melanoma skin cancers) from 2009/2010 to 2018/2019. Method A retrospective study conducted using descriptive statistics of changes over 10 years in 2WW referral data. Yearly linear regression models were used to determine the association between cancer detection rates and quintiles of practice and population characteristics. Predicted cancer detection rates were calculated, as well as the difference between lowest to highest quintiles. Results Over the 10 years studied there were 14.89 million 2WW referrals (2.24 million in 2018/2019), and 2.68 million new cancer diagnoses, of which 1.26 million were detected following 2WW. The detection rate increased from 41% to 52% over the time period. In 2018/2019 an additional 66 172 cancers were detected via 2WW compared with 2009/2010. Higher cancer detection via 2WW referrals was associated with larger practices and those with younger GPs. From 2016/2017 onwards more deprived practice populations were associated with decreased cancer detection. Conclusion From 2009/2010 to 2018/2019 2WW referrals increased on average by 10% year on year. The most consistent association with higher cancer detection was found for larger practices and those with younger GPs, though these differences became attenuated over time. The more recent association between increased practice deprivation and lower cancer detection is a cause for concern. The COVID-19 pandemic has led to significant impacts on 2WW referral activity and the impact on patient outcomes will need to be studied.
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Holtedahl K, Borgquist L, Donker GA, Buntinx F, Weller D, Campbell C, Månsson J, Hammersley V, Braaten T, Parajuli R. Symptoms and signs of colorectal cancer, with differences between proximal and distal colon cancer: a prospective cohort study of diagnostic accuracy in primary care. BMC FAMILY PRACTICE 2021; 22:148. [PMID: 34238248 PMCID: PMC8268573 DOI: 10.1186/s12875-021-01452-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 05/05/2021] [Indexed: 12/24/2022]
Abstract
Background In an abdominal symptom study in primary care in six European countries, 511 cases of cancer were recorded prospectively among 61,802 patients 16 years and older in Norway, Denmark, Sweden, Netherlands, Belgium and Scotland. Colorectal cancer is one of the main types of cancer associated with abdominal symptoms; hence, an in-depth subgroup analysis of the 94 colorectal cancers was carried out in order to study variation in symptom presentation among cancers in different anatomical locations. Method Initial data capture was by completion of standardised forms containing closed questions about symptoms recorded during the consultation. Follow-up data were provided by the GP after diagnosis, based on medical record data made after the consultation. GPs also provided free text comments about the diagnostic procedure for individual patients. Fisher’s exact test was used to analyse differences between groups. Results Almost all symptoms recorded could indicate colorectal cancer. ‘Rectal bleeding’ had a specificity of 99.4% and a PPV of 4.0%. Faecal occult blood in stool (FOBT) or anaemia may indicate gastrointestinal bleeding: when these symptoms and signs were combined, sensitivity reached 57.5%, with 69.2% for cancer in the distal colon. For proximal colon cancers, none of 18 patients had ‘Rectal bleeding’ at the initial consultation, but three of the 18 did so at a later consultation. ‘Abdominal pain, lower part’, ‘Constipation’ and ‘Distended abdomen, bloating’ were less specific and also less sensitive than ‘Rectal bleeding’, and with PPV between 0.7% and 1.9%. Conclusions Apart from rectal bleeding, single symptoms did not reach the PPV 3% NICE threshold. However, supplementary information such as a positive FOBT or persistent symptoms may revise the PPV upwards. If a colorectal cancer is suspected by the GP despite few symptoms, the total clinical picture may still reach the NICE PPV threshold of 3% and justify a specific referral. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01452-6.
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Affiliation(s)
- Knut Holtedahl
- Department of Community Medicine, UiT The Arctic University of Norway, 9037, Breivika, Tromsø, Norway.
| | - Lars Borgquist
- Department of Health, Medicine and Caring Sciences, Linköping University, 58183, Linköping, Sweden
| | - Gé A Donker
- Netherlands Institute of Health Services Research, Otterstraat 118, Utrecht, 3513, the Netherlands
| | - Frank Buntinx
- Department of General Practice, KU Leuven, Oude Markt 13, 3000, Leuven, Belgium.,Maastricht University, P.O. Box 616, Maastricht, 6200, The Netherlands
| | - David Weller
- Usher Institute of Population Health Sciences and Medical Informatics, University of Edinburgh, Edinburgh, EH8 9AG, UK
| | - Christine Campbell
- Usher Institute of Population Health Sciences and Medical Informatics, University of Edinburgh, Edinburgh, EH8 9AG, UK
| | - Jörgen Månsson
- Department of Public Health and Community Medicine/Primary Health Care, University of Gothenburg, Box 100, 40530, Gothenburgh, Sweden
| | - Victoria Hammersley
- Usher Institute of Population Health Sciences and Medical Informatics, University of Edinburgh, Edinburgh, EH8 9AG, UK
| | - Tonje Braaten
- Department of Community Medicine, UiT The Arctic University of Norway, 9037, Breivika, Tromsø, Norway
| | - Ranjan Parajuli
- Faculty of Nursing and Health Sciences, Nord University, P.O.Box 1490, 8049, Bodø, Norway
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28
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Describing the potential of non-specific symptoms-based pathways for diagnosing less common cancers. Br J Gen Pract 2021; 71:e846-e853. [PMID: 34097639 PMCID: PMC8463131 DOI: 10.3399/bjgp.2020.1108] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/07/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Although less common cancers account for over half of all cancer diagnoses in England, their relative scarcity and complex presentation, often with non-specific symptoms, means that patients often experience multiple primary care consultations, longer times to diagnosis and poorer clinical outcomes. An urgent referral pathway for non-specific symptoms, the Multidisciplinary Diagnostic Centre (MDC), may address this problem. AIM To examine the less common cancers identified during the MDC pilots and consider if such an approach improves the diagnosis of these cancers. DESIGN AND SETTING A service evaluation of five MDC pilot projects in England to 31st March 2019. METHOD Data items were collected by pilot sites in near-real time, based mainly on the English cancer outcomes and services dataset, with additional project specific items. Simple descriptive and comparative statistics were used, including chi-squared tests for proportions and t-tests for means where appropriate. RESULTS From 5,134 referrals, 378 cancers were diagnosed, of which 218 (58%) were less common. Over 30 different less common tumour types were diagnosed within this cohort. 23% of MDC patients with less common cancers had ≥3 more GP consultations before referral and, at programme level, a median time of 57 days was recorded from GP urgent referral to treatment for these tumour types. CONCLUSION A non-specific symptomatic referral route diagnoses a broad range of less common cancers, and can support primary care case management for patients with symptoms of possible cancer that do not qualify for a site-specific urgent referral.
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29
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Martínez MT, Montón-Bueno J, Simon S, Ortega B, Moragon S, Roselló S, Insa A, Navarro J, Sanmartín A, Julve A, Buch E, Peña A, Franco J, Martínez-Jabaloyas J, Marco J, Forner MJ, Cano A, Silvestre A, Teruel A, Lluch A, Cervantes A, Chirivella Gonzalez I. Ten-year assessment of a cancer fast-track programme to connect primary care with oncology: reducing time from initial symptoms to diagnosis and treatment initiation. ESMO Open 2021; 6:100148. [PMID: 33989988 PMCID: PMC8136438 DOI: 10.1016/j.esmoop.2021.100148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 11/07/2022] Open
Abstract
Background Cancer is the second leading cause of mortality worldwide. Integrating different levels of care by implementing screening programmes, extending diagnostic tools and applying therapeutic advances may increase survival. We implemented a cancer fast-track programme (CFP) to shorten the time between suspected cancer symptoms, diagnosis and therapy initiation. Patients and methods Descriptive data were collected from the 10 years since the CFP was implemented (2009-2019) at the Clinico-Malvarrosa Health Department in Valencia, Spain. General practitioners (GPs), an oncology coordinator and 11 specialists designed guidelines for GP patient referral to the CFP, including criteria for breast, digestive, gynaecological, lung, urological, dermatological, head and neck, and soft tissue cancers. Patients with enlarged lymph nodes and constitutional symptoms were also considered. On identifying patients with suspected cancer, GPs sent a case proposal to the oncology coordinator. If criteria were met, an appointment was quickly made with the patient. We analysed the timeline of each stage of the process. Results A total of 4493 suspected cancer cases were submitted to the CFP, of whom 4019 were seen by the corresponding specialist. Cancer was confirmed in 1098 (27.3%) patients: breast cancer in 33%, urological cancers in 22%, gastrointestinal cancer in 19% and lung cancer in 15%. The median time from submission to cancer testing was 11 days, and diagnosis was reached in a median of 19 days. Treatment was started at a median of 34 days from diagnosis. Conclusions The findings of this study show that the interval from GP patient referral to specialist testing, cancer diagnosis and start of therapy can be reduced. Implementation of the CFP enabled most patients to begin curative intended treatment, and required only minimal resources in our setting. Our CFP easily connects GPs and hospital specialists. Our CFP shortens assessment time in patients with suspected cancer, adding to quality care. Our CFP decreases emotional stress in patients without cancer.
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Affiliation(s)
- M T Martínez
- Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - J Montón-Bueno
- Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - S Simon
- Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - B Ortega
- Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - S Moragon
- Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - S Roselló
- Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain; Instituto de Salud Carlos III, CIBERONC, Madrid, Spain
| | - A Insa
- Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - J Navarro
- Management Department, Hospital Clínico Universitario de Valencia, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain; CIBERESP (CIBER de Epidemiología y Salud Pública), Centro Nacional de Epidemiología del Instituto de Salud Carlos III, Madrid, Spain
| | - A Sanmartín
- Management Department, Hospital Clínico Universitario de Valencia, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - A Julve
- Department of Radiodiagnosis, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - E Buch
- Department of Surgery, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - A Peña
- Department of Medicine Digestive, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - J Franco
- Department of Pneumology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - J Martínez-Jabaloyas
- Department of Urology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - J Marco
- Department of Otolaryngology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - M J Forner
- Department of Internal Medicine, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - A Cano
- Department of Gynecology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - A Silvestre
- Department of Traumatology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - A Teruel
- Department of Hematology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - A Lluch
- Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - A Cervantes
- Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain; Instituto de Salud Carlos III, CIBERONC, Madrid, Spain.
| | - I Chirivella Gonzalez
- Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain.
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Smith CF, Kristensen BM, Andersen RS, Hobbs FR, Ziebland S, Nicholson BD. GPs' use of gut feelings when assessing cancer risk: a qualitative study in UK primary care. Br J Gen Pract 2021; 71:e356-e363. [PMID: 33753347 PMCID: PMC7997673 DOI: 10.3399/bjgp21x714269] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/01/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The use of gut feelings to guide clinical decision making in primary care has been frequently described but is not considered a legitimate reason for cancer referral. AIM To explore the role that gut feeling plays in clinical decision making in primary care. DESIGN AND SETTING Qualitative interview study with 19 GPs in Oxfordshire, UK. METHOD GPs who had referred patients to a cancer pathway based on a gut feeling as a referral criterion were invited to participate. Interviews were conducted between November 2019 and January 2020, and transcripts were analysed using the one sheet of paper method. RESULTS Gut feeling was seen as an essential part of decision making that facilitated appropriate and timely care. GPs distanced their gut feelings from descriptions that could be seen as unscientific, describing successful use as reliant on experience and clinical knowledge. This was especially true for patients who fell within a 'grey area' where clinical guidelines did not match the GP's assessment of cancer risk, either because the guidance inadequately represented or did not include the patient's presentation. GPs sought to legitimise their gut feelings by gathering objective clinical evidence, careful examination of referral procedures, and consultation with colleagues. CONCLUSION GPs described their gut feelings as important to decision making in primary care and a necessary addition to clinical guidance. The steps taken to legitimise their gut feelings matched that expected in good clinical practice.
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Affiliation(s)
| | - Benedikte Møller Kristensen
- Research Unit for General Practice, Department of Public Health, Aarhus University and University of Copenhagen, Denmark
| | - Rikke Sand Andersen
- Institute for Public Health - General Practice, University of Southern Denmark, Odense, Denmark
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Sheringham J, Kuhn I, Burt J. The use of experimental vignette studies to identify drivers of variations in the delivery of health care: a scoping review. BMC Med Res Methodol 2021; 21:81. [PMID: 33888077 PMCID: PMC8061048 DOI: 10.1186/s12874-021-01247-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 02/23/2021] [Indexed: 11/10/2022] Open
Abstract
Background Identifying how unwarranted variations in healthcare delivery arise is challenging. Experimental vignette studies can help, by isolating and manipulating potential drivers of differences in care. There is a lack of methodological and practical guidance on how to design and conduct these studies robustly. The aim of this study was to locate, methodologically assess, and synthesise the contribution of experimental vignette studies to the identification of drivers of unwarranted variations in healthcare delivery. Methods We used a scoping review approach. We searched MEDLINE, Embase, Web of Science and CINAHL databases (2007–2019) using terms relating to vignettes and variations in healthcare. We screened title/abstracts and full text to identify studies using experimental vignettes to examine drivers of variations in healthcare delivery. Included papers were assessed against a methodological framework synthesised from vignette study design recommendations within and beyond healthcare. Results We located 21 eligible studies. Study participants were almost exclusively clinicians (18/21). Vignettes were delivered via text (n = 6), pictures (n = 6), video (n = 6) or interactively, using face-to-face, telephone or online simulated consultations (n = 3). Few studies evaluated the credibility of vignettes, and many had flaws in their wider study design. Ten were of good methodological quality. Studies contributed to understanding variations in care, most commonly by testing hypotheses that could not be examined directly using real patients. Conclusions Experimental vignette studies can be an important methodological tool for identifying how unwarranted variations in care can arise. Flaws in study design or conduct can limit their credibility or produce biased results. Their full potential has yet to be realised. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01247-4.
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Affiliation(s)
- Jessica Sheringham
- Department of Applied Health Research, UCL, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - Isla Kuhn
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH, UK
| | - Jenni Burt
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH, UK
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Müller DMJ, De Swart ME, Ardon H, Barkhof F, Bello L, Berger MS, Bouwknegt W, Van den Brink WA, Conti Nibali M, Eijgelaar RS, Furtner J, Han SJ, Hervey-Jumper S, Idema AJS, Kiesel B, Kloet A, Mandonnet E, Robe PAJT, Rossi M, Sciortino T, Vandertop WP, Visser M, Wagemakers M, Widhalm G, Witte MG, De Witt Hamer PC. Timing of glioblastoma surgery and patient outcomes: a multicenter cohort study. Neurooncol Adv 2021; 3:vdab053. [PMID: 34056605 PMCID: PMC8156977 DOI: 10.1093/noajnl/vdab053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The impact of time-to-surgery on clinical outcome for patients with glioblastoma has not been determined. Any delay in treatment is perceived as detrimental, but guidelines do not specify acceptable timings. In this study, we relate the time to glioblastoma surgery with the extent of resection and residual tumor volume, performance change, and survival, and we explore the identification of patients for urgent surgery. Methods Adults with first-time surgery in 2012–2013 treated by 12 neuro-oncological teams were included in this study. We defined time-to-surgery as the number of days between the diagnostic MR scan and surgery. The relation between time-to-surgery and patient and tumor characteristics was explored in time-to-event analysis and proportional hazard models. Outcome according to time-to-surgery was analyzed by volumetric measurements, changes in performance status, and survival analysis with patient and tumor characteristics as modifiers. Results Included were 1033 patients of whom 729 had a resection and 304 a biopsy. The overall median time-to-surgery was 13 days. Surgery was within 3 days for 235 (23%) patients, and within a month for 889 (86%). The median volumetric doubling time was 22 days. Lower performance status (hazard ratio [HR] 0.942, 95% confidence interval [CI] 0.893–0.994) and larger tumor volume (HR 1.012, 95% CI 1.010–1.014) were independently associated with a shorter time-to-surgery. Extent of resection, residual tumor volume, postoperative performance change, and overall survival were not associated with time-to-surgery. Conclusions With current decision-making for urgent surgery in selected patients with glioblastoma and surgery typically within 1 month, we found equal extent of resection, residual tumor volume, performance status, and survival after longer times-to-surgery.
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Affiliation(s)
- Domenique M J Müller
- Amsterdam University Medical Centers, location VU University Medical Center, Neurosurgical Center Amsterdam, Amsterdam, Netherlands
| | - Merijn E De Swart
- Department of Surgery, Amsterdam University Medical Centers, location VU University Medical Center, Amsterdam, Netherlands
| | - Hilko Ardon
- Department of Neurosurgery, St Elisabeth Hospital, Tilburg, Netherlands
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, Netherlands.,Institutes of Neurology and Healthcare Engineering, UCL, London, UK
| | - Lorenzo Bello
- Department of Neurological Surgery, Humanitas Research Hospital Milano, Milan, Italy
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Wim Bouwknegt
- Department of Neurosurgery, Medical Center Slotervaart, Amsterdam, Netherlands
| | | | - Marco Conti Nibali
- Department of Neurological Surgery, Humanitas Research Hospital Milano, Milan, Italy
| | - Roelant S Eijgelaar
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Julia Furtner
- Department of Biomedical Imaging and image-guided Therapy, Medical University Vienna, Vienna, Austria
| | - Seunggu J Han
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Shawn Hervey-Jumper
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Albert J S Idema
- Department of Neurosurgery, Northwest Clinics, Alkmaar, Netherlands
| | - Barbara Kiesel
- Department of Neurological Surgery, Medical University Vienna, Vienna, Austria
| | - Alfred Kloet
- Department of Neurosurgery, Medical Center Haaglanden, the Hague, Netherlands
| | | | - Pierre A J T Robe
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marco Rossi
- Department of Neurological Surgery, Humanitas Research Hospital Milano, Milan, Italy
| | - Tommaso Sciortino
- Department of Neurological Surgery, Humanitas Research Hospital Milano, Milan, Italy
| | - W Peter Vandertop
- Amsterdam University Medical Centers, location VU University Medical Center, Neurosurgical Center Amsterdam, Amsterdam, Netherlands
| | - Martin Visser
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, Netherlands
| | - Michiel Wagemakers
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Georg Widhalm
- Department of Neurological Surgery, Medical University Vienna, Vienna, Austria
| | - Marnix G Witte
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Philip C De Witt Hamer
- Amsterdam University Medical Centers, location VU University Medical Center, Neurosurgical Center Amsterdam, Amsterdam, Netherlands
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Brice SN, Harper P, Crosby T, Gartner D, Arruda E, England T, Aspland E, Foley K. Factors influencing the delivery of cancer pathways: a summary of the literature. J Health Organ Manag 2021; 35:121-139. [PMID: 33818048 PMCID: PMC9136872 DOI: 10.1108/jhom-05-2020-0192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 10/16/2020] [Accepted: 01/27/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE The study aims to summarise the literature on cancer care pathways at the diagnostic and treatment phases. The objectives are to find factors influencing the delivery of cancer care pathways; to highlight any interrelating factors; to find gaps in the literature concerning areas of research; to summarise the strategies and recommendations implemented in the studies. DESIGN/METHODOLOGY/APPROACH The study used a qualitative approach and developed a causal loop diagram to summarise the current literature on cancer care pathways, from screening and diagnosis to treatment. A total of 46 papers was finally included in the analysis, which highlights the recurring themes in the literature. FINDINGS The study highlights the myriad areas of research applied to cancer care pathways. Factors influencing the delivery of cancer care pathways were classified into different albeit interrelated themes. These include access barriers to care, hospital emergency admissions, fast track diagnostics, delay in diagnosis, waiting time to treatment and strategies to increase system efficiency. ORIGINALITY/VALUE As far as the authors know, this is the first study to present a visual representation of the complex relationship between factors influencing the delivery of cancer care pathways.
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Affiliation(s)
| | - Paul Harper
- School of Mathematics
,
Cardiff University
, Cardiff,
UK
| | | | - Daniel Gartner
- School of Mathematics
,
Cardiff University
, Cardiff,
UK
| | - Edilson Arruda
- Department of Decision Analytics and Risk,
Southampton Business School
,
University of Southampton
, Southampton,
UK
- Alberto Luiz Coimbra Institute-Graduate School and Research in Engineering
,
Federal University of Rio de Janeiro
, Rio de Janeiro,
Brazil
| | - Tracey England
- Department of Decision Analytics and Risk,
Southampton Business School
,
University of Southampton
, Southampton,
UK
| | - Emma Aspland
- School of Mathematics
,
Cardiff University
, Cardiff,
UK
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Dolly SO, Jones G, Allchorne P, Wheeler D, Ali S, Mukadam Y, Zheng S, Rahman L, Sindhar J, Moss CL, Harari D, Van Hemelrijck M, Cunliffe A, De Michele LV. The effectiveness of the Guy's Rapid Diagnostic Clinic (RDC) in detecting cancer and serious conditions in vague symptom patients. Br J Cancer 2021; 124:1079-1087. [PMID: 33402736 PMCID: PMC7783491 DOI: 10.1038/s41416-020-01207-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 10/28/2020] [Accepted: 11/25/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Rapid Diagnostic Clinics (RDC) are being expanded nationally by NHS England. Guy's RDC established a pathway for GPs and internal referrals for patients with symptoms concerning for malignancy not suitable for a site-specific 2WW referral. However, little data assessing the effectiveness of RDC models are available in an English population. METHODS We evaluated all patients referred to Guy's RDC between December 2016 and June 2019 (n = 1341) to assess the rate of cancer diagnoses, frequency of benign conditions and effectiveness of the service. RESULTS There were 96 new cancer diagnoses (7.2%): lung (16%), haematological (13%) and colorectal (12%)-with stage IV being most frequent (40%). Median time to definitive cancer diagnosis was 28 days (IQR 15-47) and treatment 56 days (IQR 32-84). In all, 75% were suitable for treatment: surgery (26%), systemic (24%) and radiotherapy (14%). Over 180 serious non-neoplastic conditions were diagnosed (35.8%) of patients with no significant findings in two-third of patients (57.0%). CONCLUSIONS RDCs provide GPs with a streamlined pathway for patients with complex non-site-specific symptoms that can be challenging for primary care. The 7% rate of cancer diagnosis exceeds many 2WW pathways and a third of patients presented with significant non-cancer diagnoses, which justifies the need for rapid diagnostics. Rapid Diagnostic Centres (RDCs) are being rolled out nationally by NHS England and NHS Improvement as part of the NHS long-term plan. The aim is for a primary care referral pathway that streamlines diagnostics, patient journey, clinical outcomes and patient experience. This pilot study of 1341 patients provides an in-depth analysis of the largest single RDC in England. Cancer was diagnosed in 7% of patients and serious non-cancer conditions in 36%-justifying the RDC approach in vague symptom patients.
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Affiliation(s)
| | - Geraint Jones
- Guy's and St Thomas' NHS Foundation Trust (GSTT), Medical Oncology, London, UK
- South East London Cancer Alliance, London, UK
| | - Paula Allchorne
- Guy's and St Thomas' NHS Foundation Trust (GSTT), Medical Oncology, London, UK
| | - Daniel Wheeler
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Sunnyath Ali
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Yaseen Mukadam
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Sifan Zheng
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Loay Rahman
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Jan Sindhar
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Charlotte Louise Moss
- King's College London, School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research (TOUR), London, UK
| | - Danielle Harari
- Guy's and St Thomas' NHS Foundation Trust (GSTT), Medical Oncology, London, UK
- King's College London, Geriatric and Acute Medicine, Department of Ageing and Health, London, UK
| | - Mieke Van Hemelrijck
- King's College London, School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research (TOUR), London, UK
| | - Anthony Cunliffe
- Joint National Lead Macmillan GP Adviser and Joint Clinical Chair, South East London Cancer alliance, London, UK
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Zhou Y, Walter FM, Singh H, Hamilton W, Abel GA, Lyratzopoulos G. Prolonged Diagnostic Intervals as Marker of Missed Diagnostic Opportunities in Bladder and Kidney Cancer Patients with Alarm Features: A Longitudinal Linked Data Study. Cancers (Basel) 2021; 13:E156. [PMID: 33466406 PMCID: PMC7796444 DOI: 10.3390/cancers13010156] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In England, patients who meet National Institute for Health and Care Excellence (NICE) guideline criteria for suspected cancer should receive a specialist assessment within 14 days. We examined how quickly bladder and kidney cancer patients who met fast-track referral criteria were actually diagnosed. METHODS We used linked primary care and cancer registration data on bladder and kidney cancer patients who met fast-track referral criteria and examined the time from their first presentation with alarm features to diagnosis. Using logistic regression we examined factors most likely to be associated with non-timely diagnosis (defined as intervals exceeding 90 days), adjusting for age, sex and cancer type, positing that such occurrences represent missed opportunity for timely referral, possibly due to sub-optimal guideline adherence. RESULTS 28%, 42% and 31% of all urological cancer patients reported no, one or two or more relevant symptoms respectively in the year before diagnosis. Of the 2105 patients with alarm features warranting fast-track assessment, 1373 (65%) presented with unexplained haematuria, 382 (18%) with recurrent urinary tract infections (UTIs), 303 (14%) with visible haematuria, and 45 (2%) with an abdominal mass. 27% overall, and 24%, 45%, 18% and 27% of each group respectively, had a non-timely diagnosis. Presentation with recurrent UTI was associated with longest median diagnostic interval (median 83 days, IQR 43-151) and visible haematuria with the shortest (median 50 days, IQR 30-79). After adjustment, presentation with recurrent UTIs, being in the youngest or oldest age group, female sex, and diagnosis of kidney and upper tract urothelial cancer, were associated with greater odds of non-timely diagnosis. CONCLUSION More than a quarter of patients presenting with fast-track referral features did not achieve a timely diagnosis, suggesting inadequate guideline adherence for some patients. The findings highlight a substantial number of opportunities for expediting the diagnosis of patients with bladder or kidney cancers.
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Affiliation(s)
- Yin Zhou
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Worts’ Causeway, Cambridge CB1 8RN, UK;
| | - Fiona M. Walter
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Worts’ Causeway, Cambridge CB1 8RN, UK;
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX 77030, USA;
| | - William Hamilton
- College of Medicine and Health, University of Exeter Medical School (Primary Care), Exeter EX1 1TX, UK; (W.H.); (G.A.A.)
| | - Gary A. Abel
- College of Medicine and Health, University of Exeter Medical School (Primary Care), Exeter EX1 1TX, UK; (W.H.); (G.A.A.)
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, London WC1E 6BT, UK;
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Price S, Spencer A, Zhang X, Ball S, Lyratzopoulos G, Mujica-Mota R, Stapley S, Ukoumunne OC, Hamilton W. Trends in time to cancer diagnosis around the period of changing national guidance on referral of symptomatic patients: A serial cross-sectional study using UK electronic healthcare records from 2006-17. Cancer Epidemiol 2020; 69:101805. [PMID: 32919226 PMCID: PMC7480981 DOI: 10.1016/j.canep.2020.101805] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 07/24/2020] [Accepted: 08/25/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND UK primary-care referral guidance describes the signs, symptoms, and test results ("features") of undiagnosed cancer. Guidance revision in 2015 liberalised investigation by introducing more low-risk features. We studied adults with cancer whose features were in the 2005 guidance ("Old-NICE") or were introduced in the revision ("New-NICE"). We compared time to diagnosis between the groups, and its trend over 2006-2017. METHODS Clinical Practice Research Datalink records were analysed for adults with incident myeloma, breast, bladder, colorectal, lung, oesophageal, ovarian, pancreatic, prostate, stomach or uterine cancers in 1/1/2006-31/12/2017. Cancer-specific features in the year before diagnosis were used to create New-NICE and Old-NICE groups. Diagnostic interval was time between the index feature and diagnosis. Semiparametric varying-coefficient analyses compared diagnostic intervals between New-NICE and Old-NICE groups over 1/1/2006-31/12/2017. RESULTS Over all cancers (N = 83,935), median (interquartile range) Old-NICE diagnostic interval rose over 2006-2017, from 51 (20-132) to 64 (30-148) days, with increases in breast (15 vs 25 days), lung (103 vs 135 days), ovarian (65·5 vs 100 days), prostate (80 vs 93 days) and stomach (72·5 vs 102 days) cancers. Median New-NICE values were consistently longer (99, 40-212 in 2006 vs 103, 42-236 days in 2017) than Old-NICE values over all cancers. After guidance revision, New-NICE diagnostic intervals became shorter than Old-NICE values for colorectal cancer. CONCLUSIONS Despite improvements for colorectal cancer, scope remains to reduce diagnostic intervals for most cancers. Liberalised investigation requires protecting and enhancing cancer-diagnostic services to avoid their becoming a rate-limiting step in the diagnostic pathway.
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Affiliation(s)
- Sarah Price
- University of Exeter Medical School, Room 1.20 College House, St Luke's Campus, University of Exeter, Exeter, Devon, EX1 2LU, UK.
| | - Anne Spencer
- Health Economics Group, University of Exeter, Exeter, UK.
| | - Xiaohui Zhang
- University of Exeter Business School, University of Exeter, Exeter, UK.
| | - Susan Ball
- National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula, University of Exeter, Exeter, UK.
| | | | | | - Sal Stapley
- University of Exeter Medical School, University of Exeter, Exeter, UK.
| | - Obioha C Ukoumunne
- National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula, University of Exeter, Exeter, UK.
| | - Willie Hamilton
- University of Exeter Medical School, University of Exeter, Exeter, UK.
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Grant R, Dowswell T, Tomlinson E, Brennan PM, Walter FM, Ben-Shlomo Y, Hunt DW, Bulbeck H, Kernohan A, Robinson T, Lawrie TA. Interventions to reduce the time to diagnosis of brain tumours. Cochrane Database Syst Rev 2020; 9:CD013564. [PMID: 32901926 PMCID: PMC8082957 DOI: 10.1002/14651858.cd013564.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Brain tumours are recognised as one of the most difficult cancers to diagnose because presenting symptoms, such as headache, cognitive symptoms, and seizures, may be more commonly attributable to other, more benign conditions. Interventions to reduce the time to diagnosis of brain tumours include national awareness initiatives, expedited pathways, and protocols to diagnose brain tumours, based on a person's presenting symptoms and signs; and interventions to reduce waiting times for brain imaging pathways. If such interventions reduce the time to diagnosis, it may make it less likely that people experience clinical deterioration, and different treatment options may be available. OBJECTIVES To systematically evaluate evidence on the effectiveness of interventions that may influence: symptomatic participants to present early (shortening the patient interval), thresholds for primary care referral (shortening the primary care interval), and time to imaging diagnosis (shortening the secondary care interval and diagnostic interval). To produce a brief economic commentary, summarising the economic evaluations relevant to these interventions. SEARCH METHODS For evidence on effectiveness, we searched CENTRAL, MEDLINE, and Embase from January 2000 to January 2020; Clinicaltrials.gov to May 2020, and conference proceedings from 2014 to 2018. For economic evidence, we searched the UK National Health Services Economic Evaluation Database from 2000 to December 2014. SELECTION CRITERIA We planned to include studies evaluating any active intervention that may influence the diagnostic pathway, e.g. clinical guidelines, direct access imaging, public health campaigns, educational initiatives, and other interventions that might lead to early identification of primary brain tumours. We planned to include randomised and non-randomised comparative studies. Included studies would include people of any age, with a presentation that might suggest a brain tumour. DATA COLLECTION AND ANALYSIS Two review authors independently assessed titles identified by the search strategy, and the full texts of potentially eligible studies. We resolved discrepancies through discussion or, if required, by consulting another review author. MAIN RESULTS We did not identify any studies for inclusion in this review. We excluded 115 studies. The main reason for exclusion of potentially eligible intervention studies was their study design, due to a lack of control groups. We found no economic evidence to inform a brief economic commentary on this topic. AUTHORS' CONCLUSIONS In this version of the review, we did not identify any studies that met the review inclusion criteria for either effectiveness or cost-effectiveness. Therefore, there is no evidence from good quality studies on the best strategies to reduce the time to diagnosis of brain tumours, despite the prioritisation of research on early diagnosis by the James Lind Alliance in 2015. This review highlights the need for research in this area.
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Affiliation(s)
- Robin Grant
- Edinburgh Centre for Neuro-Oncology (ECNO), Western General Hospital, Edinburgh, UK
| | - Therese Dowswell
- C/o Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - Eve Tomlinson
- Cochrane Gynaecological, Neuro-oncology and Orphan Cancers, 1st Floor Education Centre, Royal United Hospital, Bath, UK
| | - Paul M Brennan
- Translational Neurosurgery Department, Western General Hospital, Edinburgh, UK
| | - Fiona M Walter
- Public Health & Primary Care, University of Cambridge, Cambridge, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, Bristol, UK
| | - David William Hunt
- Foundation School/Dept of Clinical and Experimental Medicine, Royal Surrey County Hospital/University of Surrey, Guildford, UK
| | | | - Ashleigh Kernohan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tomos Robinson
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
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Affiliation(s)
- Knut Holtedahl
- Department of Community Medicine, UiT The Arctic University of Norway, Breivika, Norway
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Zhou Y, Abel GA, Hamilton W, Singh H, Walter FM, Lyratzopoulos G. Imaging activity possibly signalling missed diagnostic opportunities in bladder and kidney cancer: A longitudinal data-linkage study using primary care electronic health records. Cancer Epidemiol 2020; 66:101703. [PMID: 32334389 PMCID: PMC7294227 DOI: 10.1016/j.canep.2020.101703] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 02/13/2020] [Accepted: 03/12/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Sub-optimal use or interpretation of imaging investigations prior to diagnosis of certain cancers may be associated with less timely diagnosis, but pre-diagnostic imaging activity for urological cancer is unknown. METHOD We analysed linked data derived from primary and secondary care records and cancer registration to evaluate the use of clinically relevant imaging tests pre-diagnosis, in patients with bladder and kidney cancer diagnosed in 2012-15 in England. As pre-diagnostic imaging activity increased from background rate 8 months pre-diagnosis, we used logistic regression to determine factors associated with first imaging test occurring 4-8 months pre-diagnosis, considering that such instances may reflect possible missed opportunities for expediting the diagnosis. RESULTS 1963 patients with bladder or kidney cancer had at least one imaging test in the 8 months pre-diagnosis. 420 (21%) of patients had their first imaging test 4-8 months pre-diagnosis, that being ultrasound, CT and X-ray in 48%, 43% and 9% of those cases, respectively. Factors associated with greater risk of a first imaging test 4-8 months pre-diagnosis were kidney cancer, diagnosis at stages other than stage IV, first imaging having been an X-ray, test requested by GP and absence of haematuria before the imaging request. CONCLUSION About 1 in 5 patients with urological cancers receive relevant first imaging investigations 4-8 months prior to diagnosis, which may represent potential missed diagnostic opportunities for earlier diagnosis.
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Affiliation(s)
- Yin Zhou
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
| | - Gary A Abel
- College of Medicine and Health, University of Exeter Medical School (Primary Care), Exeter, UK
| | - William Hamilton
- College of Medicine and Health, University of Exeter Medical School (Primary Care), Exeter, UK
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Fiona M Walter
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, London, UK
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Association between use of urgent suspected cancer referral and mortality and stage at diagnosis: a 5-year national cohort study. Br J Gen Pract 2020; 70:e389-e398. [PMID: 32312762 PMCID: PMC7176359 DOI: 10.3399/bjgp20x709433] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/16/2019] [Indexed: 02/06/2023] Open
Abstract
Background There is considerable variation between GP practices in England in their use of urgent referral pathways for suspected cancer. Aim To determine the association between practice use of urgent referral and cancer stage at diagnosis and cancer patient mortality, for all cancers and the most common types of cancer (colorectal, lung, breast, and prostate). Design and setting National cohort study of 1.4 million patients diagnosed with cancer in England between 2011 and 2015. Method The cohort was stratified according to quintiles of urgent referral metrics. Cox proportional hazards regression was used to quantify risk of death, and logistic regression to calculate odds of late-stage (III/IV) versus early-stage (I/II) cancers in relation to referral quintiles and cancer type. Results Cancer patients from the highest referring practices had a lower hazard of death (hazard ratio [HR] = 0.96; 95% confidence interval [CI] = 0.95 to 0.97), with similar patterns for individual cancers: colorectal (HR = 0.95; CI = 0.93 to 0.97); lung (HR = 0.95; CI = 0.94 to 0.97); breast (HR = 0.96; CI = 0.93 to 0.99); and prostate (HR = 0.88; CI = 0.85 to 0.91). Similarly, for cancer patients from these practices, there were lower odds of late-stage diagnosis for individual cancer types, except for colorectal cancer. Conclusion Higher practice use of referrals for suspected cancer is associated with lower mortality for the four most common types of cancer. A significant proportion of the observed mortality reduction is likely due to earlier stage at diagnosis, except for colorectal cancer. This adds to evidence supporting the lowering of referral thresholds and consequent increased use of urgent referral for suspected cancer.
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Nicholson BD, Hamilton W, Koshiaris C, Oke JL, Hobbs FDR, Aveyard P. The association between unexpected weight loss and cancer diagnosis in primary care: a matched cohort analysis of 65,000 presentations. Br J Cancer 2020; 122:1848-1856. [PMID: 32291391 PMCID: PMC7283307 DOI: 10.1038/s41416-020-0829-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 01/27/2020] [Accepted: 02/19/2020] [Indexed: 02/06/2023] Open
Abstract
Background We aimed to understand the time period of cancer diagnosis and the cancer types detected in primary care patients with unexpected weight loss (UWL) to inform cancer guidelines. Methods This retrospective matched cohort study used cancer registry linked electronic health records from the UK’s Clinical Practice Research Datalink from between 2000 and 2014. Univariable and multivariable time-to-event analyses examined the association between UWL, and all cancers combined, cancer site and stage. Results In all, 63,973 patients had UWL recorded, of whom 1375 (2.2%) were diagnosed with cancer within 2 years (days-to-diagnosis: mean 181; median 80). Men with UWL (HR 3.28 (2.88–3.73)) and women (1.87 (1.68–2.08)) were more likely than comparators to be diagnosed with cancer within 3 months. The association was greatest in men aged ≥50 years and women ≥70 years. The commonest cancers were pancreas, cancer of unknown primary, gastro-oesophageal, lymphoma, hepatobiliary, lung, bowel and renal-tract. The majority were late-stage, but there was some evidence of association with stage II and stage III cancers. In the 3–24 months after presenting with UWL, cancer diagnosis was less likely than in comparators. Conclusion UWL recorded in primary care is associated with a broad range of cancer sites of early and late-stage.
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Affiliation(s)
- Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK.
| | | | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Jason L Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
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Cheewakriangkrai C, Kietpeerakool C, Charoenkwan K, Pattanittum P, John D, Aue‐aungkul A, Lumbiganon P. Health education interventions to promote early presentation and referral for women with symptoms of endometrial cancer. Cochrane Database Syst Rev 2020; 3:CD013253. [PMID: 32168393 PMCID: PMC7069600 DOI: 10.1002/14651858.cd013253.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Diagnosis of endometrial (womb) cancer is normally made at an early stage, as most women with the disease experience abnormal vaginal bleeding, which prompts them to seek medical advice. However, delays in presentation and referral can result in delay in diagnosis and management, which can lead to unfavourable treatment outcomes. This is particularly a problem for pre- and peri-menopausal women. Providing educational information to women and healthcare providers regarding symptoms relating to endometrial cancer may raise awareness of the disease and reduce delayed treatment. OBJECTIVES To assess the effectiveness of health education interventions targeting healthcare providers, or individuals, or both, to promote early presentation and referral for women with endometrial cancer symptoms. SEARCH METHODS We searched CENTRAL, MEDLINE and Embase. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of review articles. SELECTION CRITERIA We planned to include randomised controlled trials (RCTs), both individually randomised and cluster-RCTs. In the absence of RCTs we planned to include well-designed non-randomised studies (NRS) with a parallel comparison assessing the benefits of any type of health education interventions. DATA COLLECTION AND ANALYSIS Two review authors independently evaluated whether potentially relevant studies met the inclusion criteria for the review, but none were found. MAIN RESULTS A comprehensive search of the literature yielded the following results: CENTRAL (1022 references), MEDLINE (2874 references), and Embase (2820 references). After de-duplication, we screened titles and abstracts of 4880 references and excluded 4864 that did not meet the review inclusion criteria. Of the 16 references that potentially met the review inclusion, we excluded all 16 reports after reviewing the full texts. We did not identify any ongoing trials. AUTHORS' CONCLUSIONS There is currently an absence of evidence to indicate the effectiveness of health education interventions involving healthcare providers or individuals or both to promote early presentation and referral for women with endometrial cancer symptoms. High-quality RCTs are needed to assess whether health education interventions enhance early presentation and referral. If health education interventions can be shown to reduce treatment delays in endometrial cancer, further studies would be required to determine which interventions are most effective.
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Affiliation(s)
- Chalong Cheewakriangkrai
- Faculty of Medicine, Chiang Mai UniversityDepartment of Obstetrics and Gynecology110 Intawaroros RoadMuangChiang MaiThailand50200
| | - Chumnan Kietpeerakool
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Kittipat Charoenkwan
- Faculty of Medicine, Chiang Mai UniversityDepartment of Obstetrics and Gynecology110 Intawaroros RoadMuangChiang MaiThailand50200
| | - Porjai Pattanittum
- Khon Kaen UniversityDepartment of Epidemiology and Biostatistics, Public Health FacultyMitraparp RoadMueng DistrictKhon KaenKhon KaenThailand40002
| | | | - Apiwat Aue‐aungkul
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Pisake Lumbiganon
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
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Fraulob I, Davies EA. How do patients with malignant brain tumors experience general practice care and support? Qualitative analysis of English Cancer Patient Experience Survey (CPES) data. Neurooncol Pract 2019; 7:313-319. [PMID: 32528712 PMCID: PMC7274186 DOI: 10.1093/nop/npz062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background English Cancer Patient Experience Survey (CPES) data show patients with brain cancer report the least-positive experiences of general practice support. We aimed to understand these findings by identifying the issues described in qualitative survey feedback and suggest how care may be improved. Methods We reviewed 2699 qualitative comments made to open questions about what was good or might be improved about National Health Service care between 2010 and 2014. We identified 84 (3%) specific comments about general practice care and used open coding and framework analysis to develop a thematic framework. Results We identified 3 key themes and 12 subthemes: first, the experience of initial diagnosis by a general practitioner (GP), including apparent complexity of making the diagnosis, apparent slowness in referral for investigation, referral made by patient or family, delay in receiving scan results, and whether the GP quickly identified the problem and referred to a specialist; second, the experience of care and support from the general practice, including lack of supportive response from the GP, lack of follow-up care from the GP, lack of family involvement by the GP, lack of GP knowledge about management, and whether the GP responded in a supportive way to the diagnosis; and third, the experience of overall coordination in care, including lack of communication between the hospital and general practice and good communication about the care plan. Conclusion Qualitative responses from patients with brain cancer reveal their needs for better emotional and practical support within primary care. Suggestions include increasing the speed of initial referral for investigation, the depth of discussion about diagnostic difficulties, and developing coordinated care plans with cancer centers.
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Affiliation(s)
- Isabell Fraulob
- School of Population Health and Environmental Sciences, King's College London, UK
| | - Elizabeth A Davies
- Cancer Epidemiology, Population and Global Health, School of Cancer and Pharmaceutical Sciences, King's College London, UK
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Herbert A, Winters S, McPhail S, Elliss-Brookes L, Lyratzopoulos G, Abel GA. Population trends in emergency cancer diagnoses: The role of changing patient case-mix. Cancer Epidemiol 2019; 63:101574. [PMID: 31655434 PMCID: PMC6905147 DOI: 10.1016/j.canep.2019.101574] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 07/15/2019] [Accepted: 07/18/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Diagnosis of cancer through an emergency presentation is associated with worse clinical and patient experience outcomes. The proportion of patients with cancer who are diagnosed through emergency presentations has consequently been introduced as a routine cancer surveillance measure in England. Welcome reductions in this metric have been reported over more than a decade but whether reductions reflect true changes in how patients are diagnosed rather than the changing case-mix of incident cohorts in unknown. METHODS We analysed 'Routes to Diagnosis' data on cancer patients (2006-2015) and used logistic regression modelling to determine the contribution of changes in four case-mix variables (sex, age, deprivation, cancer site) to time-trends in emergency presentations. RESULTS Between 2006 and 2015 there was an absolute 4.7 percentage point reduction in emergency presentations (23.8%-19.2%). Changing distributions of the four case-mix variables explained 19.0% of this reduction, leaving 81.0% unexplained. Changes in cancer site case-mix alone explained 16.0% of the total reduction. CONCLUSION Changes in case-mix (particularly that of cancer sites) account for about a fifth of the overall reduction in emergency presentations. This would support the use of adjustment/standardisation of reported statistics to support their interpretation and help appreciate the influence of case-mix, particularly regarding cancer sites with changing incidence. However, most of the reduction in emergency presentations remains unaccounted for, and likely reflects genuine changes during the study period in how patients were being diagnosed.
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Affiliation(s)
- A Herbert
- MRC Integrative Epidemiology Unit Bristol Medical School University of Bristol Bristol UK; Epidemiology of Cancer and Healthcare Outcomes (ECHO) Group, Research Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London, UK
| | - S Winters
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, 6th Floor, Wellington House, 135-155 Waterloo Road, London, UK
| | - S McPhail
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, 6th Floor, Wellington House, 135-155 Waterloo Road, London, UK
| | - L Elliss-Brookes
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, 6th Floor, Wellington House, 135-155 Waterloo Road, London, UK
| | - G Lyratzopoulos
- Epidemiology of Cancer and Healthcare Outcomes (ECHO) Group, Research Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London, UK; National Cancer Registration and Analysis Service (NCRAS), Public Health England, 6th Floor, Wellington House, 135-155 Waterloo Road, London, UK; Cambridge Centre for Health Services Research, University of Cambridge Institute of Public Health, Forvie Site, Cambridge, UK.
| | - G A Abel
- University of Exeter Medical School, Exeter, UK
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Burton C, O'Neill L, Oliver P, Murchie P. Contribution of primary care organisation and specialist care provider to variation in GP referrals for suspected cancer: ecological analysis of national data. BMJ Qual Saf 2019; 29:296-303. [PMID: 31586938 DOI: 10.1136/bmjqs-2019-009469] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 07/12/2019] [Accepted: 09/13/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To examine how much of the variation between general practices in referral rates and cancer detection rates is attributable to local health services rather than the practices or their populations. DESIGN Ecological analysis of national data on fast-track referrals for suspected cancer from general practices. Data were analysed at the levels of general practice, primary care organisation (Clinical Commissioning Group) and secondary care provider (Acute Hospital Trust) level. Analysis of variation in detection rate was by multilevel linear and Poisson regression. SETTING 6379 group practices with data relating to more than 50 cancer cases diagnosed over the 5 years from 2013 to 2017. OUTCOMES Proportion of observed variation attributable to primary and secondary care organisations in standardised fast-track referral rate and in cancer detection rate before and after adjustment for practice characteristics. RESULTS Primary care organisation accounted for 21% of the variation between general practices in the standardised fast-track referral rate and 42% of the unadjusted variation in cancer detection rate. After adjusting for standardised fast-track referral rate, primary care organisation accounted for 31% of the variation in cancer detection rate (compared with 18% accounted for by practice characteristics). In areas where a hospital trust was the main provider for multiple primary care organisations, hospital trusts accounted for the majority of the variation attributable to local health services (between 63% and 69%). CONCLUSION This is the first large-scale finding that a substantial proportion of the variation between general practitioner practices in referrals is attributable to their local healthcare systems. Efforts to reduce variation need to focus not just on individual practices but on local diagnostic service provision and culture at the interface of primary and secondary care.
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Affiliation(s)
- Christopher Burton
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
| | - Luke O'Neill
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
| | - Phillip Oliver
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
| | - Peter Murchie
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Svanvik T, Marcickiewicz J, Sundfeldt K, Holmberg E, Strömberg U. Sociodemographic disparities in stage-specific incidences of endometrial cancer: a registry-based study in West Sweden, 1995-2016. Acta Oncol 2019; 58:845-851. [PMID: 30849264 DOI: 10.1080/0284186x.2019.1581947] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background: For a few types of cancer, lower socioeconomic status (SES) is associated with higher incidence, and for even more cancer types it is associated with having a less favorable tumor stage at diagnosis. For endometrial cancer (EC), however, there is no clear evidence of such associations with SES. There is a need for analysis of sociodemographic disparities in EC incidences according to stage at diagnosis, which may provide support for trying to improve early detection of EC. Material and methods: Stage-specific incidences of endometrioid and non-endometrioid endometrial carcinomas [EECs (∼90% of all EC cases) and NECs (∼10%)] were analyzed for the population of the Western Swedish Healthcare Region, taking into account year (1995-2016), age, educational level (low, intermediate and high), and immigrant status (Swedish-born, foreign-born). All EC cases were identified and data were obtained from population-based registries. Results: Stage distribution of diagnosed EECs differed significantly according to the educational level of patients who were aged between 50 and 74 years at diagnosis, but not in the case of younger or older patients. An analysis based on 3113 EEC cases aged 50-74 years at diagnosis revealed marked disparities in the stage-II to stage-IV EEC incidences but not in the stage-I EEC incidence. Compared to women with a high level of education, the incidence rate ratios of stage-I, stage-II and stage-III and -IV EEC in women with a low level of education were 1.00 (95% CI: 0.90-1.12), 1.65 (1.13-2.42), and 1.82 (1.33-2.49), respectively. For NEC, we found no such association. Conclusions: Elevated incidences of stage-II to stage-IV EEC in 50- to 74-year-old women with a low level of education suggest that there should be targeted health service trials aimed at improving awareness of EC. Well-targeted EC awareness programs might lead to considerable health benefits.
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Affiliation(s)
- Teresia Svanvik
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Janusz Marcickiewicz
- Regional Cancer Centre West, Gothenburg, Sweden
- Department of Obstetrics and Gynaecology, Halland Hospital, Varberg, Sweden
| | - Karin Sundfeldt
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Erik Holmberg
- Regional Cancer Centre West, Gothenburg, Sweden
- Department of Oncology, Institute of Clinical Sciences Sahlgrenska Academy University of Gothenburg, Gothenburg, Sweden
| | - Ulf Strömberg
- Research and Development, Region Halland, Halmstad, Sweden
- Health Metrics Unit, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Availability and use of cancer decision-support tools: a cross-sectional survey of UK primary care. Br J Gen Pract 2019; 69:e437-e443. [PMID: 31064743 PMCID: PMC6592323 DOI: 10.3399/bjgp19x703745] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 11/26/2018] [Indexed: 12/13/2022] Open
Abstract
Background Decision-support tools quantify the risk of undiagnosed cancer in symptomatic patients, and may help GPs when making referrals. Aim To quantify the availability and use of cancer decision-support tools (QCancer® and risk assessment tools) and to explore the association between tool availability and 2-week-wait (2WW) referrals for suspected cancer. Design and setting A cross-sectional postal survey in UK primary care. Methods Out of 975 UK randomly selected general practices, 4600 GPs and registrars were invited to participate. Outcome measures included the proportions of UK general practices where cancer decision-support tools are available and at least one GP uses the tool. Weighted least-squares linear regression with robust errors tested the association between tool availability and number of 2WW referrals, adjusting for practice size, sex, age, and Index of Multiple Deprivation. Results In total, 476 GPs in 227 practices responded (response rates: practitioner, 10.3%; practice, 23.3%). At the practice level, 83/227 (36.6%, 95% confidence interval [CI] = 30.3 to 43.1) practices had at least one GP or registrar with access to cancer decision-support tools. Tools were available and likely to be used in 38/227 (16.7%, 95% CI = 12.1 to 22.2) practices. In subgroup analyses of 172 English practices, there was no difference in mean 2WW referral rate between practices with tools and those without (mean adjusted difference in referrals per 100 000: 3.1, 95% CI = −5.5 to 11.7). Conclusion This is the first survey of cancer decision-support tool availability and use. It suggests that the tools are an underused resource in the UK. Given the cost of cancer investigation, a randomised controlled trial of such clinical decision-support aids would be appropriate.
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Stenman E, Palmér K, Rydén S, Sävblom C, Svensson I, Rose C, Ji J, Nilbert M, Sundquist J. Diagnostic spectrum and time intervals in Sweden's first diagnostic center for patients with nonspecific symptoms of cancer. Acta Oncol 2019; 58:296-305. [PMID: 30632871 DOI: 10.1080/0284186x.2018.1537506] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Fast-track referral is an increasingly used method for diagnostic evaluation of patients suspected of having cancer. This approach is challenging and not used as often for patients with only nonspecific symptoms. In order to expedite the diagnostics for these patients, we established Sweden's first Diagnostic Center (DC) focusing on outcomes related to diagnoses and diagnostic time intervals. MATERIAL AND METHODS The study was designed as a prospective cohort study. Patients aged ≥18 years who presented in primary care with nonspecific symptoms of a serious disease were eligible for referral to the DC after having completed an initial investigation. Acceptable diagnostic time intervals were defined to be a maximum of 15 days in primary care and 22 days at the DC. Diagnostic outcome, length of diagnostic time intervals and patient satisfaction were evaluated. RESULTS A total of 290 patients were included in the study. Cancer was diagnosed in 22.1%, other diseases in 64.1%, and no diagnosis was identified in 13.8% of these patients. Patients diagnosed with cancer were older, had shorter patient interval (time from first symptom to help-seeking), shorter DC-interval (time from referral decision in primary care to diagnosis) and showed a greater number of symptoms compared to patients with no diagnosis. The median primary care interval was 21 days and the median DC interval was 11 days. Few symptoms, no diagnosis, female sex, longer patient interval, and incomplete investigations were associated with prolonged diagnostic time intervals. Patient satisfaction was high; 86% of patients reported a positive degree of satisfaction with the diagnostic procedures. CONCLUSIONS We demonstrated that the DC concept is feasible with a diagnosis reached in 86.2% of the patients in addition to favorable diagnostic time intervals at the DC and a high degree of patient satisfaction.
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Affiliation(s)
- Emelie Stenman
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Karolina Palmér
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Stefan Rydén
- Regional Cancer Centre South, Region Skåne, Lund, Sweden
| | | | - Inga Svensson
- Central Hospital of Kristianstad, Region Skåne, Kristianstad, Sweden
| | - Carsten Rose
- CREATE Health, Faculty of Engineering LTH, Lund University, Lund, Sweden
| | - Jianguang Ji
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Mef Nilbert
- Institute of Clinical Sciences, Division of Oncology and Pathology, Lund University, Lund, Sweden
- Clinical Research Centre Copenhagen University Hospital, Hvidovre, Denmark
- Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Jan Sundquist
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
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Disease-related factors affecting timely lymphoma diagnosis: a qualitative study exploring patient experiences. Br J Gen Pract 2019; 69:e134-e145. [PMID: 30692091 PMCID: PMC6355261 DOI: 10.3399/bjgp19x701009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/24/2018] [Indexed: 11/21/2022] Open
Abstract
Background Expediting cancer diagnosis is widely perceived as one way to improve patient outcomes. Evidence indicates that lymphoma diagnosis is often delayed, yet understanding of issues influencing this is incomplete. Aim To explore patients’ and their relatives’ perceptions of disease-related factors affecting time to diagnosis of Hodgkin and non-Hodgkin lymphoma. Design and setting Qualitative UK study involving patients with indolent and aggressive lymphomas, and their relatives, from an established population-based cohort in the north of England. Method Semi-structured interviews with 35 patients and 15 of their relatives. Interviews were audiorecorded and transcribed, and qualitative descriptive analysis was undertaken. Results Participant accounts suggest that certain features of lymphoma can impact on patients’ and healthcare providers’ (HCPs) responses to disease onset. Three characteristics stand out: disease occurrence (rare), manifestation (varied), and investigative options (often inconclusive). Interviewees described how they, and some HCPs, lacked familiarity with lymphoma, seldom considering it a likely explanation for their symptoms. Symptoms reported were highly variable, frequently non-specific, and often initially thought to be associated with various benign, self-limiting causes. Blood tests and other investigations, while frequently able to detect abnormalities, did not reliably indicate malignancy. Interviewees reported the potential for improvements among HCPs in information gathering, communication of uncertainty, and re-presentation advice for non-resolving/progressive health changes. Conclusion This study demonstrates the complex characteristics of lymphoma, perceived by patients as prolonging time to diagnosis, often despite significant effort by themselves, their relatives, and HCPs to expedite this process. The findings also illustrate why simple solutions to delayed diagnosis of lymphoma are lacking.
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Affiliation(s)
- Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust Oxford, UK
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