Which patients are not included in the English Cancer Waiting Times monitoring dataset, 2009-2013? Implications for use of the data in research

What can patient-reported experience measures tell us about the variation in patients' experience of prostate cancer care? A cross-sectional study using survey data from the National Prostate Cancer Audit in England

OBJECTIVES

A national survey aimed to measure how men with prostate cancer perceived their involvement in and decisions around their care immediately after diagnosis. This study aimed to describe any differences found by socio-demographic groups.

DESIGN

Cross-sectional study of men who were diagnosed with and treated for prostate cancer.

SETTING

The National Prostate Cancer Audit patient-reported experience measures (PREMs) survey in England.

PARTICIPANTS

Men diagnosed in 2014-2016, with non-metastatic prostate cancer, were surveyed. Responses from 32 796 men were individually linked to records from a national clinical audit and to administrative hospital data. Age, ethnicity, deprivation and disease risk classification were used to explore variation in responses to selected questions.

PRIMARY AND SECONDARY OUTCOME MEASURES

Responses to five questions from the PREMs survey: the proportion responding to the highest positive category was compared across the socio-demographic characteristics above.

RESULTS

When adjusted for other factors, older men were less likely than men under the age of 60 to feel side effects had been explained in a way they could understand (men 80+: relative risk (RR)=0.92, 95% CI 0.84 to 1.00), that their views were considered (RR=0.79, 95% CI 0.73 to 0.87) or that they were involved in decisions (RR=0.92, 95% CI 0.85 to 1.00). The latter was also apparent for men who were not white (black men: RR=0.89, 95% CI 0.82 to 0.98; Asian men: RR=0.85, 95% CI 0.75 to 0.96) and, to a lesser extent, for more deprived men.

CONCLUSIONS

The observed discrepancies highlight the need for more focus on initiatives to improve the experience of ethnic minority patients and those older than 60 years. The findings also argue for further validation of discriminatory instruments to help cancer care providers fully understand the variation in the experience of their patients.

Association between time-to-treatment and outcomes in non-small cell lung cancer: a systematic review

BACKGROUND

National targets for timely diagnosis and management of a potential cancer are driven in part by the perceived risk of disease progression during avoidable delays. However, it is unclear to what extent time-to-treatment impacts prognosis for patients with non-small cell lung cancer, with previous reviews reporting mixed or apparently paradoxical associations. This systematic review focuses on potential confounders in order to identify particular patient groups which may benefit most from timely delivery of care.

METHODS

Medline, EMBASE and Cochrane databases were searched for publications between January 2012 and October 2020, correlating timeliness in secondary care pathways to patient outcomes. The protocol is registered with PROSPERO (the International Prospective Register of Systematic Reviews; ID 99239). Prespecified factors (demographics, performance status, histology, stage and treatment) are examined through narrative synthesis.

RESULTS

Thirty-seven articles were included. All but two were observational. Timely care was generally associated with a worse prognosis in those with advanced stage disease (6/8 studies) but with better outcomes for patients with early-stage disease treated surgically (9/12 studies). In one study, patients with squamous cell carcinoma referred for stereotactic ablative radiotherapy benefited more from timely care, compared with patients with adenocarcinoma. One randomised controlled trial supported timeliness as being advantageous in those with stage I-IIIA disease.

CONCLUSION

There are limitations to the available evidence, but observed trends suggest timeliness to be of particular importance in surgical candidates. In more advanced disease, survival trends are likely outweighed by symptom burden, performance status or clinical urgency dictating timeliness of treatment.

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

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.

Can we assess Cancer Waiting Time targets with cancer survival? A population-based study of individually linked data from the National Cancer Waiting Times monitoring dataset in England, 2009-2013

BACKGROUND

Cancer Waiting Time targets have been integrated into successive cancer strategies as indicators of cancer care quality in England. These targets are reported in national statistics for all cancers combined, but there is mixed evidence of their benefits and it is unclear if meeting Cancer Waiting Time targets, as currently defined and published, is associated with improved survival for individual patients, and thus if survival is a good metric for judging the utility of the targets.

METHODS AND FINDINGS

We used individually-linked data from the National Cancer Waiting Times Monitoring Dataset (CWT), the cancer registry and other routinely collected datasets. The study population consisted of all adult patients diagnosed in England (2009-2013) with colorectal (164,890), lung (171,208) or ovarian (24,545) cancer, of whom 82%, 76%, and 77%, respectively, had a CWT matching record. The main outcome was one-year net survival for all matched patients by target attainment ('met/not met'). The time to each type of treatment for the 31-day and 62-day targets was estimated using multivariable analyses, adjusting for age, sex, tumour stage and deprivation. The two-week wait (TWW) from GP referral to specialist consultation and 31-day target from decision to treat to start of treatment were met for more than 95% of patients, but the 62-day target from GP referral to start of treatment was missed more often. There was little evidence of an association between meeting the TWW target and one-year net survival, but for the 31-day and 62-day targets, survival was worse for those for whom the targets were met (e.g. colorectal cancer: survival 89.1% (95%CI 88.9-89.4) for patients with 31-day target met, 96.9% (95%CI 96.1-91.7) for patients for whom it was not met). Time-to-treatment analyses showed that treatments recorded as palliative were given earlier in time, than treatments with potentially curative intent. There are possible limitations in the accuracy of the categorisation of treatment variables which do not allow for fully distinguishing, for example, between curative and palliative intent; and it is difficult in these data to assess the appropriateness of treatment by stage. These limitations in the nature of the data do not affect the survival estimates found, but do mean that it is not possible to separate those patients for whom the times between referral, decision to treat and start of treatment could actually have an impact on the clinical outcomes. This means that the use of these survival measures to evaluate the targets would be misleading.

CONCLUSIONS

Based on these individually-linked data, and for the cancers we looked at, we did not find that Cancer Waiting Time targets being met translates into improved one-year survival. Patients may benefit psychologically from limited waits which encourage timely treatment, but one-year survival is not a useful measure for evaluating Trust performance with regards to Cancer Waiting Time targets, which are not currently stratified by stage or treatment type. As such, the current composition of the data means target compliance needs further evaluation before being used for the assessment of clinical outcomes.