Are GPs under-investigating older patients presenting with symptoms of ovarian cancer? Observational study using General Practice Research Database

Time to Diagnosis and Treatment for Ovarian Cancer and Associations with Outcomes: A Systematic Review

Background: Ovarian cancer is commonly diagnosed symptomatically at an advanced stage. Better survival for early disease suggests improving diagnostic pathways may increase survival. This study examines literature assessing diagnostic intervals and their association with clinical and psychological outcomes. Methods: Medline, EMBASE, and EmCare databases were searched for studies including quantitative measures of at least one interval, published between January 1, 2000 and August 9, 2022. Interval measures and associations (interval, outcomes, analytic strategy) were synthesized. Risk of bias of association studies was assessed using the Aarhus Checklist and ROBINS-E tool. Results: In total, 65 papers (20 association studies) were included and 26 unique intervals were identified. Interval estimates varied widely and were impacted by summary statistic used (mean or median) and group focused on. Of Aarhus-defined intervals, patient (symptom to presentation, n = 23; range [median]: 7-168 days) and diagnostic (presentation to diagnosis, n = 22; range [median]: 7-270 days) were most common. Nineteen association studies examined survival or stage outcomes with most, including five low risk-of-bias studies, finding no association. Conclusions: Studies reporting intervals for ovarian cancer diagnosis are limited by inconsistent definitions and reporting. Greater utilization of the Aarhus statement to define intervals and appropriate analytic methods is needed to strengthen findings from future studies.

Factors affecting the decision to investigate older adults with potential cancer symptoms: a systematic review

BACKGROUND

Older age and frailty increase the risk of morbidity and mortality from cancer surgery and intolerance of chemotherapy and radiotherapy. The effect of old age on diagnostic intervals is unknown; however, older adults need a balanced approach to the diagnosis and management of cancer symptoms, considering the benefits of early diagnosis, patient preferences, and the likely prognosis of a cancer.

AIM

To examine the association between older age and diagnostic processes for cancer, and the specific factors that affect diagnosis.

DESIGN AND SETTING

A systematic literature review.

METHOD

Electronic databases were searched for studies of patients aged >65 years presenting with cancer symptoms to primary care considering diagnostic decisions. Studies were analysed using thematic synthesis and according to the Synthesis Without Meta-analysis guidelines.

RESULTS

Data from 54 studies with 230 729 participants were included. The majority of studies suggested an association between increasing age and prolonged diagnostic interval or deferral of a decision to investigate cancer symptoms. Thematic synthesis highlighted three important factors that resulted in uncertainty in decisions involving older adults: presence of frailty, comorbidities, and cognitive impairment. Data suggested patients wished to be involved in decision making, but the presence of cognitive impairment and the need for additional time within a consultation were significant barriers.

CONCLUSION

This systematic review has highlighted uncertainty in the management of older adults with cancer symptoms. Patients and their family wished to be involved in these decisions. Given the uncertainty regarding optimum management of this group of patients, a shared decision-making approach is important.

Exploring Older Women's Attitudes to and Experience of Treatment for Advanced Ovarian Cancer: A Qualitative Phenomenological Study

Simple Summary

Older women with ovarian cancer often receive less anti-cancer treatment than younger women despite evidence showing they may benefit from similar levels of treatment. Little is known, however, about older women’s preferences toward chemotherapy and treatment experience. We aimed to understand the lived experience of older women with ovarian cancer undergoing chemotherapy though interviews and focus groups. Participants expressed a strong desire to undergo full treatment to improve survival for themselves and for their families. Women did not see their age as a reason to have less intensive treatment. Despite feeling overwhelmed with information and daily tasks due to fatigue, participants did not want cancer to interfere with their daily lives. Women felt distressed by logistical issues with transportation and communication between healthcare providers; however, they still felt positive about their care experience and desire for treatment. Older women may benefit from additional help to support effective communication around treatment preferences.

Abstract

Older women with ovarian cancer more often receive less intensive treatment and early discontinuation compared to younger women. There is little understanding of older women’s treatment experience and whether this contributes to declining intensive treatment. We aimed to explore the lived experience of older patients with advanced ovarian cancer undergoing chemotherapy, their treatment preferences and treatment burden. We conducted a phenomenological qualitative study with 15 women who had completed at least three cycles of first-line chemotherapy for advanced epithelial ovarian cancer, aged 65 years or older at the first cycle, at one tertiary cancer centre. We conducted interviews and focus groups and analysed the transcripts using inductive thematic analysis. Women reported a strong preference for active treatment despite treatment burden and toxicities. Participants undertook treatment to lengthen their lives for themselves and their families. Participants did not see age as a barrier to treatment. Patients expressed determination not to let cancer interfere with daily life. Women felt overwhelmed with information and struggled with daily tasks due to fatigue. Logistical issues, such as transportation and ineffective communication between healthcare providers, caused substantial distress. Despite these logistical burdens and toxicities, participants were positive about their care experience and desire for anticancer treatment. Older women may benefit from additional support to facilitate effective communication during the early stages of treatment.

Under-Treatment of Older Patients with Newly Diagnosed Epithelial Ovarian Cancer Remains an Issue

Older women with ovarian cancer have disproportionately poorer survival outcomes than their younger counterparts and receive less treatment. In order to understand where the gaps lie in the treatment of older patients, studies incorporating more detailed assessment of baseline characteristics and treatment delivery beyond the scope of most cancer registries are required. We aimed to assess the proportion of women over the age of 65 who are offered and receive standard of care for first-line ovarian cancer at two UK NHS Cancer Centres over a 5-year period (December 2009 to August 2015). Standard of care treatment was defined as a combination of cytoreductive surgery and if indicated platinum-based chemotherapy (combination or single-agent). Sixty-five percent of patients aged 65 and above received standard of care treatment. Increasing age was associated with lower rates of receiving standard of care (35% > 80 years old versus 78% of 65-69-year-olds, p = 0.000). Older women were less likely to complete the planned chemotherapy course (p = 0.034). The oldest women continue to receive lower rates of standard care compared to younger women. Once adjusted for Federation of Gynaecology and Obstetrics (FIGO) stage, Eastern Cooperative Oncology Group (ECOG) performance status and first-line treatment received, age was no longer an independent risk factor for poorer overall survival. Optimisation of vulnerable patients utilising a comprehensive geriatric assessment and directed interventions to facilitate the delivery of standard of care treatment could help narrow the survival discrepancy between the oldest patients and their younger counterparts.

Associations of perceived poor societal treatment among the oldest-old

BACKGROUND

Previous studies of perceived ageism among older people have focused on younger age groups with the respondents' mean age far below 80.

OBJECTIVE

To explore the perceptions of poor societal treatment of older people among home-dwelling people aged 75-100+ and how their perceptions are associated with demographic characteristics, health, functioning, and wellbeing.

METHODS

In the Helsinki Aging Study, a random sample of 2,917 home-dwelling people aged 75-104 received a postal questionnaire inquiring about their health, wellbeing and experiences. The response rate was 74%. We asked: 'How in your opinion are older people treated in Finland?' (well/moderately/poorly) and categorized the respondents according to their responses. A multivariable forward stepwise ordered logistic regression model was used to determine the independent associations of the variables on the ordinal level of perceptions of treatment.

RESULTS

Of the participants, 1,653 responded to the index item. Of these, only 13% thought that older people are treated well in society, and 66% and 21% were of the opinion that older people are treated moderately or poorly in society, respectively. Perceived poor societal treatment was more common among women, the younger respondents, and those with lower incomes, as well as family caregivers and those with lower self-rated health and lower psychological wellbeing. Those who were able to walk outside unassisted and those with a regular hobby perceived poor societal treatment more often.

CONCLUSIONS

Several demographic factors, self-rated health, psychological wellbeing and better functioning were associated with perceptions of poor treatment among the oldest-old.

Randomised feasibility trial and embedded qualitative process evaluation of a new intervention to facilitate the involvement of older patients with multimorbidity in decision-making about their healthcare during general practice consultations: the VOLITION study protocol

BACKGROUND

The number of older people with multiple health problems is increasing worldwide. This creates a strain on clinicians and the health service when delivering clinical care to this patient group, who themselves carry a large treatment burden. Despite shared decision-making being acknowledged by healthcare organisations as a priority feature of clinical care, older patients with multimorbidity are less often involved in decision-making when compared with younger patients, with some evidence suggesting associated health inequalities. Interventions aimed at facilitating shared decision-making between doctors and patients are outdated in their assessments of today's older patient population who need support in prioritising complex care needs in order to maximise quality of life and day-to-day function.

AIMS

To undertake feasibility testing of an intervention ('VOLITION') aimed at facilitating the involvement of older patients with more than one long-term health problem in shared decision-making about their healthcare during GP consultations.To inform the design of a fully powered trial to assess intervention effectiveness.

METHODS

This study is a cluster randomised controlled feasibility trial with qualitative process evaluation interviews. Participants are patients, aged 65 years and above with more than one long-term health problem (multimorbidity), and the GPs that they consult with. This study aims to recruit 6 GP practices, 18 GPs and 180 patients. The intervention comprises two components: (i) a half-day training workshop for GPs in shared decision-making; and (ii) a leaflet for patients that facilitate their engagement with shared decision-making. Intervention implementation will take 2 weeks (to complete delivery of both patient and GP components), and follow-up duration will be 12 weeks (from index consultation and commencement of data collection to final case note review and process evaluation interview). The trial will run from 01/01/20 to 31/01/21; 1 year 31 days.

DISCUSSION

Shared decision-making for older people with multimorbidity in general practice is under-researched. Emerging clinical guidelines advise a patient-centred approach, to reduce treatment burden and focus on quality of life alongside disease control. The systematic development, testing and evaluation of an intervention is warranted and timely. This study will test the feasibility of implementing a new intervention in UK general practice for future evaluation as a part of routine care.

TRIAL REGISTRATION

CLINICAL TRIALS.GOV registration number NCT03786315, registered 24/12/18.

Interventions for involving older patients with multi-morbidity in decision-making during primary care consultations

BACKGROUND

Older patients with multiple health problems (multi-morbidity) value being involved in decision-making about their health care. However, they are less frequently involved than younger patients. To maximise quality of life, day-to-day function, and patient safety, older patients require support to identify unmet healthcare needs and to prioritise treatment options.

OBJECTIVES

To assess the effects of interventions for older patients with multi-morbidity aiming to involve them in decision-making about their health care during primary care consultations.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; all years to August 2018), in the Cochrane Library; MEDLINE (OvidSP) (1966 to August 2018); Embase (OvidSP) (1988 to August 2018); PsycINFO (OvidSP) (1806 to August 2018); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (Ovid) (1982 to September 2008), then in Ebsco (2009 to August 2018); Centre for Reviews and Dissemination Databases (Database of Abstracts and Reviews of Effects (DARE)) (all years to August 2018); the Health Technology Assessment (HTA) Database (all years to August 2018); the Ongoing Reviews Database (all years to August 2018); and Dissertation Abstracts International (1861 to August 2018).

SELECTION CRITERIA

We sought randomised controlled trials (RCTs), cluster-RCTs, and quasi-RCTs of interventions to involve patients in decision-making about their health care versus usual care/control/another intervention, for patients aged 65 years and older with multi-morbidity in primary care.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Meta-analysis was not possible; therefore we prepared a narrative synthesis.

MAIN RESULTS

We included three studies involving 1879 participants: two RCTs and one cluster-RCT. Interventions consisted of: · patient workshop and individual coaching using behaviour change techniques; · individual patient coaching utilising cognitive-behavioural therapy and motivational interviewing; and · holistic patient review, multi-disciplinary practitioner training, and organisational change. No studies reported the primary outcome 'patient involvement in decision-making' or the primary adverse outcome 'less patient involvement as a result of the intervention'. Comparing interventions (patient workshop and individual coaching, holistic patient review plus practitioner training, and organisational change) to usual care: we are uncertain whether interventions had any effect on patient reports of high self-rated health (risk ratio (RR) 1.40, 95% confidence interval (CI) 0.36 to 5.49; very low-certainty evidence) or on patient enablement (mean difference (MD) 0.60, 95% CI -9.23 to 10.43; very low-certainty evidence) compared with usual care. Interventions probably had no effect on health-related quality of life (adjusted difference in means 0.00, 95% CI -0.02 to 0.02; moderate-certainty evidence) or on medication adherence (MD 0.06, 95% CI -0.05 to 0.17; moderate-certainty evidence) but probably improved the number of patients discussing their priorities (adjusted odds ratio 1.85, 95% CI 1.44 to 2.38; moderate-certainty evidence) and probably increased the number of nurse consultations (incident rate ratio from adjusted multi-level Poisson model 1.37, 95% CI 1.17 to 1.61; moderate-certainty evidence) compared with usual care. Practitioner outcomes were not measured. Interventions were not reported to adversely affect rates of participant death or anxiety, emergency department attendance, or hospital admission compared with usual care. Comparing interventions (patient workshop and coaching, individual patient coaching) to attention-control conditions: we are uncertain whether interventions affect patient-reported high self-rated health (RR 0.38, 95% CI 0.15 to 1.00, favouring attention control, with very low-certainty evidence; RR 2.17, 95% CI 0.85 to 5.52, favouring the intervention, with very low-certainty evidence). We are uncertain whether interventions affect patient enablement and engagement by increasing either patient activation (MD 1.20, 95% CI -8.21 to 10.61; very low-certainty evidence) or self-efficacy (MD 0.29, 95% CI -0.21 to 0.79; very low-certainty evidence); or whether interventions affect the number of general practice visits (MD 0.51, 95% CI -0.34 to 1.36; very low-certainty evidence), compared to attention-control conditions. The intervention may however lead to more patient-reported changes in management of their health conditions (RR 1.82, 95% CI 1.35 to 2.44; low-certainty evidence). Practitioner outcomes were not measured. Interventions were not reported to adversely affect emergency department attendance nor hospital admission when compared with attention control. Comparing one form of intervention with another: not measured. There was 'unclear' risk across studies for performance bias, detection bias, and reporting bias; however, no aspects were 'high' risk. Evidence was downgraded via GRADE, most often because of 'small sample size' and 'evidence from a single study'.

AUTHORS' CONCLUSIONS

Limited available evidence does not allow a robust conclusion regarding the objectives of this review. Whilst patient involvement in decision-making is seen as a key mechanism for improving care, it is rarely examined as an intervention and was not measured by included studies. Consistency in design, analysis, and evaluation of interventions would enable a greater likelihood of robust conclusions in future reviews.

Contrasting effects of comorbidities on emergency colon cancer diagnosis: a longitudinal data-linkage study in England

BACKGROUND

One in three colon cancers are diagnosed as an emergency, which is associated with worse cancer outcomes. Chronic conditions (comorbidities) affect large proportions of adults and they might influence the risk of emergency presentations (EP).

METHODS

We aimed to evaluate the effect of specific pre-existing comorbidities on the risk of colon cancer being diagnosed following an EP rather than through non-emergency routes. The cohort study included 5745 colon cancer patients diagnosed in England 2005-2010, with individually-linked cancer registry, primary and secondary care data. In addition to multivariable analyses we also used potential-outcomes methods.

RESULTS

Colon cancer patients with comorbidities consulted their GP more frequently with cancer symptoms during the pre-diagnostic year, compared with non-comorbid cancer patients. EP occurred more frequently in patients with 'serious' or complex comorbidities (diabetes, cardiac and respiratory diseases) diagnosed/treated in hospital during the years pre-cancer diagnosis (43% EP in comorbid versus 27% in non-comorbid individuals; multivariable analysis Odds Ratio (OR), controlling for socio-demographic factors and symptoms: men OR = 2.40; 95% CI 2.0-2.9 and women OR = 1.98; 95% CI 1.6-2.4. Among women younger than 60, gynaecological (OR = 3.41; 95% CI 1.2-9.9) or recent onset gastro-intestinal conditions (OR = 2.84; 95% CI 1.1-7.7) increased the risk of EP. In contrast, primary care visits for hypertension monitoring decreased EPs for both genders.

CONCLUSIONS

Patients with comorbidities have a greater risk of being diagnosed with cancer as an emergency, although they consult more frequently with cancer symptoms during the year pre-cancer diagnosis. This suggests that comorbidities may interfere with diagnostic reasoning or investigations due to 'competing demands' or because they provide 'alternative explanations'. In contrast, the management of chronic risk factors such as hypertension may offer opportunities for earlier diagnosis. Interventions are needed to support the diagnostic process in comorbid patients. Appropriate guidelines and diagnostic services to support the evaluation of new or changing symptoms in comorbid patients may be useful.

Patient and primary care delays in the diagnostic pathway of gynaecological cancers: a systematic review of influencing factors

BACKGROUND

Gynaecological cancers are the second most common female cancer type, with survival rates in the UK lower than in many comparable countries. A potentially important factor in the UK's poorer cancer outcomes is diagnostic delay; gynaecological cancers are the cancer type most likely to be affected by less timely diagnosis.

AIM

To examine current evidence for factors that contribute to patient and primary care delays in the diagnostic pathway of gynaecological cancer.

DESIGN AND SETTING

A systematic review of the available literature.

METHOD

PRISMA guidelines were followed. MEDLINE and Embase databases and the Cochrane Library were searched using three terms: primary care; gynaecological cancer; and delay. Citation lists of all identified articles were searched. Two authors independently screened the titles, abstracts, and full texts of publications. Data extraction was performed by one author and quality assured by a second reviewer in a 20% sample of selected articles. Synthesis was narrative.

RESULTS

A total of 1253 references was identified, of which 37 met the inclusion criteria. Factors associated with delayed diagnosis were categorised as either patient factors (patient demographics, symptoms or knowledge, and presentation to the GP) or primary care factors (doctor factors: patient demographics, symptoms or knowledge, and referral process); and system factors (such as limited access to investigations).

CONCLUSION

Delayed diagnosis in the patient and primary care intervals of the diagnostic journey of gynaecological cancer is complex and multifactorial. This review identifies areas of future research that could lead to interventions to enable prompter diagnosis of gynaecological cancers.

Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes

INTRODUCTION

Lung cancer survival is low and comparatively poor in the UK. Patients with symptoms suggestive of lung cancer commonly consult primary care, but it is unclear how general practitioners (GPs) distinguish which patients require further investigation. This study examined how patients' clinical and sociodemographic characteristics influence GPs' decisions to initiate lung cancer investigations.

METHODS

A factorial experiment was conducted among a national sample of 227 English GPs using vignettes presented as simulated consultations. A multimedia-interactive website simulated key features of consultations using actors ('patients'). GP participants made management decisions online for six 'patients', whose sociodemographic characteristics systematically varied across three levels of cancer risk. In low-risk vignettes, investigation (ie, chest X-ray ordered, computerised tomography scan or respiratory consultant referral) was not indicated; in medium-risk vignettes, investigation could be appropriate; in high-risk vignettes, investigation was definitely indicated. Each 'patient' had two lung cancer-related symptoms: one volunteered and another elicited if GPs asked. Variations in investigation likelihood were examined using multilevel logistic regression.

RESULTS

GPs decided to investigate lung cancer in 74% (1000/1348) of vignettes. Investigation likelihood did not increase with cancer risk. Investigations were more likely when GPs requested information on symptoms that 'patients' had but did not volunteer (adjusted OR (AOR)=3.18; 95% CI 2.27 to 4.70). However, GPs omitted to seek this information in 42% (570/1348) of cases. GPs were less likely to investigate older than younger 'patients' (AOR=0.52; 95% CI 0.39 to 0.7) and black 'patients' than white (AOR=0.68; 95% CI 0.48 to 0.95).

CONCLUSIONS

GPs were not more likely to investigate 'patients' with high-risk than low-risk cancer symptoms. Furthermore, they did not investigate everyone with the same symptoms equally. Insufficient data gathering could be responsible for missed opportunities in diagnosis.

Older patients and their GPs: shared decision making in enhancing trust

BACKGROUND

Older patients differ from younger patients in their perceptions of trust in doctors; their sense of shared decision making is particularly associated with their trust in the GP. Enhancing trust and improving shared decision making are thought to have positive health outcomes. Older patients are sometimes reported as being less frequently involved in decisions about their health care, however, and in having more unmet healthcare needs than younger patients.

AIM

This study explored older patients' trust in their GPs and their perceptions of shared decision making.

DESIGN AND SETTING

Qualitative methods were used. Systematic sampling identified 20 participants, aged ≥65 years, from three GP surgeries in Devon, UK.

METHOD

A constant comparative approach was applied to thematic analysis of transcribed interviews.

RESULTS

All participants valued feeling involved in decisions but differed regarding how they felt involved. Trust influenced preferences for shared decision making: a trusted GP 'ally', to competently manage participants' increasing health-information requirements throughout the vulnerable ageing process, was important. Trust was affected by factors contributing to the facilitation of involvement. GP characteristics, communication skills, consultation duration, and continuity of care were common themes.

CONCLUSION

Although limited geographically and subsequently by ethnic group, the present sample allows for reasonable transferability of the study to other UK populations. A range of factors are highlighted for consideration when planning primary healthcare delivery: to facilitate the optimal involvement of older patients in decisions about their health care, while enhancing their trust in the GP; to help minimise potential health inequalities for this patient group.

Improving outcomes for older women with gynaecological malignancies

The incidence of most gynaecological malignancies rises significantly with increasing age. With an ageing population, the proportion of women over the age of 65 with cancer is expected to rise substantially over the next decade. Unfortunately, survival outcomes are much poorer in older patients and evidence suggests that older women with gynaecological cancers are less likely to receive current standard of care treatment options. Despite this, older women are under-represented in practice changing clinical studies. The evidence for efficacy and tolerability is therefore extrapolated from a younger; often more fit population and applied to in every day clinical practice to older patients with co-morbidities. There has been significant progress in the development of geriatric assessment in oncology to predict treatment outcomes and tolerability however there is still no clear evidence that undertaking a geriatric assessment improves patient outcomes. Clinical trials focusing on treating older patients are urgently required. In this review, we discuss the evidence for treatment of gynaecological cancers as well as methods of assessing older patients for therapy. Potential biomarkers of ageing are also summarised.

An Association of Cancer Physicians' strategy for improving services and outcomes for cancer patients

The Association of Cancer Physicians in the United Kingdom has developed a strategy to improve outcomes for cancer patients and identified the goals and commitments of the Association and its members.

Age and Gender Variations in Cancer Diagnostic Intervals in 15 Cancers: Analysis of Data from the UK Clinical Practice Research Datalink

Background

Time from symptomatic presentation to cancer diagnosis (diagnostic interval) is an important, and modifiable, part of the patient’s cancer pathway, and can be affected by various factors such as age, gender and type of presenting symptoms. The aim of this study was to quantify the relationships of diagnostic interval with these variables in 15 cancers diagnosed between 2007 and 2010 using routinely collected data from the Clinical Practice Research Datalink (CPRD) in the UK.

Methods

Symptom lists for each cancer were prepared from the literature and by consensus amongst the clinician researchers, which were then categorised into either NICE qualifying (NICE) or not (non-NICE) based on NICE Urgent Referral Guidelines for Suspected Cancer criteria. Multivariable linear regression models were fitted to examine the relationship between diagnostic interval (outcome) and the predictors: age, gender and symptom type.

Results

18,618 newly diagnosed cancer patients aged ≥40 who had a recorded symptom in the preceding year were included in the analysis. Mean diagnostic interval was greater for older patients in four disease sites (difference in days per 10 year increase in age; 95% CI): bladder (10.3; 5.5 to 15.1; P<0.001), kidney (11.0; 3.4 to 18.6; P=0.004), leukaemia (18.5; 8.8 to 28.1; P<0.001) and lung (10.1; 6.7 to 13.4; P<0.001). There was also evidence of longer diagnostic interval in older patients with colorectal cancer (P<0.001). However, we found that mean diagnostic interval was shorter with increasing age in two cancers: gastric (-5.9; -11.7 to -0.2; P=0.04) and pancreatic (-6.0; -11.2 to -0.7; P=0.03). Diagnostic interval was longer for females in six of the gender non-specific cancers (mean difference in days; 95% CI): bladder (12.2; 0.8 to 23.6; P=0.04), colorectal (10.4; 4.3 to 16.5; P=0.001), gastric (14.3; 1.1 to 27.6; P=0.03), head and neck (31.3; 6.2 to 56.5; P=0.02), lung (8.0; 1.2 to 14.9; P=0.02), and lymphoma (19.2; 3.8 to 34.7; P=0.01). Evidence of longer diagnostic interval was found for patients presenting with non-NICE symptoms in 10 of 15 cancers (mean difference in days; 95% CI): bladder (62.9; 48.7 to 77.2; P<0.001), breast (115.1; 105.9 to 124.3; P<0.001), cervical (60.3; 31.6 to 89.0; P<0.001), colorectal (25.8; 19.6 to 31.9; P<0.001), gastric (24.1; 3.4 to 44.8; P=0.02), kidney (22.1; 4.5 to 39.7; P=0.01), oesophageal (67.0; 42.1 to 92.0; P<0.001), pancreatic (48.6; 28.1 to 69.1; P<0.001), testicular (36.7; 17.0 to 56.4; P< 0.001), and endometrial (73.8; 60.3 to 87.3; P<0.001). Pooled analysis across all cancers demonstrated highly significant evidence of differences overall showing longer diagnostic intervals with increasing age (7.8 days; 6.4 to 9.1; P<0.001); for females (8.9 days; 5.5 to 12.2; P<0.001); and in non-NICE symptoms (27.7 days; 23.9 to 31.5; P<0.001).

Conclusions

We found age and gender-specific inequalities in time to diagnosis for some but not all cancer sites studied. Whilst these need further explanation, these findings can inform the development and evaluation of interventions intended to achieve timely diagnosis and improved cancer outcomes, such as to provide equity across all age and gender groupings.

Factors influencing veterinarian referral to oncology specialists for treatment of dogs with lymphoma and osteosarcoma in Ontario, Canada

OBJECTIVE

To elucidate factors influencing practitioner decisions to refer dogs with cancer to veterinary oncology specialists.

DESIGN

Cross-sectional study.

SAMPLE

2,724 Ontario primary care companion animal veterinarians.

PROCEDURES

Practitioners were invited to participate in a survey involving clinical scenarios of canine cancer patients, offered online and in paper format from October 2010 through January 2011. Analyses identified factors associated with the decision to refer patients to veterinary oncology specialists.

RESULTS

1,071 (39.3%) veterinarians responded, of which 603 (56.3%) recommended referral for dogs with multicentric lymphoma and appendicular osteosarcoma. Most (893/1,059 [84.3%]) practiced within < 2 hours' drive of a specialty referral center, and most (981/1,047 [93.7%]) were completely confident in the oncology service. Few (230/1,056 [21.8%] to 349/1,056 [33.0%]) were experienced with use of chemotherapeutics, whereas more (627/1,051 [59.7%]) were experienced with amputation. Referral was associated with practitioner perception of patient health status (OR, 1.54; 95% confidence interval [CI], 1.15 to 2.07), the interaction between the client's bond with the dog and the client's financial status, practitioner experience with treating cancer (OR, 2.79; 95% CI, 1.63 to 4.77), how worthwhile practitioners considered treatment to be (OR, 1.66 to 3.09; 95% CI, 1.08 to 4.72), and confidence in the referral center (OR, 2.20; 95% CI, 1. 11 to 4.34).

CONCLUSIONS AND CLINICAL RELEVANCE

Several factors influenced practitioner decisions to refer dogs with lymphoma or osteosarcoma for specialty care. Understanding factors that influence these decisions may enable practitioners to appraise their referral decisions and ensure they act in the best interests of patients, clients, and the veterinary profession.

Clinical epidemiology of epithelial ovarian cancer in the UK

Epithelial ovarian cancer is the fifth commonest cancer among women and the leading cause of gynecological cancer death in the UK. Most women present with advanced disease, mainly because the nonspecific nature of the symptoms lead to diagnostic delays. Recent data have shown a fall in ovarian cancer mortality rates in the UK, but rates are still higher when compared to other European countries or the USA. In addition, surgeons in the UK achieve on average lower optimal surgical cytoreduction rates in patients with advanced ovarian cancer. Despite a wealth of information on epidemiological risk factors, the pathogenesis of epithelial ovarian cancer remains largely unknown. This review presents the most recent data on incidence, mortality, and survival for epithelial ovarian cancer in the UK. Time trends, trends by age, international comparisons, and regional variation in incidence, survival, and mortality are presented within the context of a major reorganization of cancer services that took place in the UK over 10 years ago. Centralization of cancer services has meant that women with ovarian cancer receive treatment in specialist Cancer Centers.

Metformin and the risk of endometrial cancer: a case-control analysis

OBJECTIVE

To explore the risk of endometrial cancer in relation to metformin and other antidiabetic drugs.

METHODS

We conducted a case-control analysis to explore the association between use of metformin and other antidiabetic drugs and the risk of endometrial cancer using the UK-based General Practice Research Database (GPRD). Cases were women with an incident diagnosis of endometrial cancer, and up to 6 controls per case were matched in age, sex, calendar time, general practice, and number of years of active history in the GPRD prior to the index date. Odds ratios (ORs) with 95% confidence intervals (95% CI) were calculated and results were adjusted by multivariate logistic regression analyses for BMI, smoking, a recorded diagnosis of diabetes mellitus, and diabetes duration.

RESULTS

A total of 2554 cases with incident endometrial cancer and 15,324 matched controls were identified. Ever use of metformin compared to never use of metformin was not associated with an altered risk of endometrial cancer (adj. OR 0.86, 95% CI 0.63-1.18). Stratified by exposure duration, neither long-term (≥25 prescriptions) use of metformin (adj. OR 0.79, 95% CI 0.54-1.17), nor long-term use of sulfonylureas (adj. OR 0.96, 95% CI 0.65-1.44), thiazolidinediones (≥15 prescriptions; adj. OR 1.22, 95% CI 0.67-2.21), or insulin (adj. OR 1.05 (0.79-1.82) was associated with the risk of endometrial cancer.

CONCLUSION

Use of metformin and other antidiabetic drugs were not associated with an altered risk of endometrial cancer.

Optimising use of electronic health records to describe the presentation of rheumatoid arthritis in primary care: a strategy for developing code lists

Background

Research using electronic health records (EHRs) relies heavily on coded clinical data. Due to variation in coding practices, it can be difficult to aggregate the codes for a condition in order to define cases. This paper describes a methodology to develop ‘indicator markers’ found in patients with early rheumatoid arthritis (RA); these are a broader range of codes which may allow a probabilistic case definition to use in cases where no diagnostic code is yet recorded.

Methods

We examined EHRs of 5,843 patients in the General Practice Research Database, aged ≥30y, with a first coded diagnosis of RA between 2005 and 2008. Lists of indicator markers for RA were developed initially by panels of clinicians drawing up code-lists and then modified based on scrutiny of available data. The prevalence of indicator markers, and their temporal relationship to RA codes, was examined in patients from 3y before to 14d after recorded RA diagnosis.

Findings

Indicator markers were common throughout EHRs of RA patients, with 83.5% having 2 or more markers. 34% of patients received a disease-specific prescription before RA was coded; 42% had a referral to rheumatology, and 63% had a test for rheumatoid factor. 65% had at least one joint symptom or sign recorded and in 44% this was at least 6-months before recorded RA diagnosis.

Conclusion

Indicator markers of RA may be valuable for case definition in cases which do not yet have a diagnostic code. The clinical diagnosis of RA is likely to occur some months before it is coded, shown by markers frequently occurring ≥6 months before recorded diagnosis. It is difficult to differentiate delay in diagnosis from delay in recording. Information concealed in free text may be required for the accurate identification of patients and to assess the quality of care in general practice.

Referral of elderly cancer patients to specialists: action proposals for general practitioners

BACKGROUND

Many studies have identified advanced age as a barrier to accessing specialized oncological care.

OBJECTIVES

To identify elements from the literature influencing general practitioners (GPs) in their decisions to refer elderly patients with cancer to oncology teams, and propose focused actions to improve referral processes.

METHODS

Eligible articles published up to July 2010 identifying factors associated with referral decisions for elderly cancer patients were selected. A quality assessment of each article was performed. All factors identified were considered for possible interventions classified by the Effective Practice and Organisation of Care (EPOC) taxonomy and development of recommendations for referral of elderly patients.

RESULTS

Thirty eligible articles were found with only 18 articles specifically exploring factors influencing physicians in the referral of their patients with cancer. Twelve focused on delay to treatment and only two uniquely on elderly patients. Patient age was the main factor associated with referral decisions, but this factor can influence GP's differently depending on the type of cancer. The small size of these studies, heterogeneity of study populations, and diversity of outcome measures used meant that compilation of guidelines based on high-quality evidence was not possible. However, organizational factors hindering decisions to refer are identified and highlighted as crucial for inclusion in intervention programs, specifically to reach GPs in smaller locations or with less experience in collaborating with specialists. For patient-related factors, professional and organizational interventions are necessary, aimed at both GPs and patients to update knowledge of the non-linear relationship between chronological age and a patient's ability to tolerate treatment.

CONCLUSIONS

First and foremost, this article highlights the scarcity of literature specific to elderly patients with cancer. It also identifies the public health need for better knowledge of the factors for referral of elderly patients. Focussed action proposals are presented to improve knowledge and consequently, optimize the referral process.

Impact of age and comorbidity on non-small-cell lung cancer treatment in older veterans

PURPOSE

Because comorbidity affects cancer treatment outcomes, guidelines recommend considering comorbidity when making treatment decisions in older patients with lung cancer. Yet, it is unclear whether treatment is targeted to healthier older adults who might reasonably benefit.

PATIENTS AND METHODS

Receipt of first-line guideline-recommended treatment was assessed for 20,511 veterans age ≥ 65 years with non-small-cell lung cancer (NSCLC) in the Veterans Affairs (VA) Central Cancer Registry from 2003 to 2008. Patients were stratified by age (65 to 74, 75 to 84, ≥ 85 years), Charlson comorbidity index score (0, 1 to 3, ≥ 4), and American Joint Committee on Cancer stage (I to II, IIIA to IIIB, IIIB with malignant effusion to IV). Comorbidity and patient characteristics were obtained from VA claims and registry data. Multivariate analysis identified predictors of receipt of guideline-recommended treatment.

RESULTS

In all, 51% of patients with local, 35% with regional, and 27% with metastatic disease received guideline-recommended treatment. Treatment rates decreased more with advancing age than with worsening comorbidity for all stages, such that older patients with no comorbidity had lower rates than younger patients with severe comorbidity. For example, 50% of patients with local disease age 75 to 84 years with no comorbidity received surgery compared with 57% of patients age 65 to 74 years with severe comorbidity (P < .001). In multivariate analysis, age and histology remained strong negative predictors of treatment for all stages, whereas comorbidity and nonclinical factors had a minor effect.

CONCLUSION

Advancing age is a much stronger negative predictor of treatment receipt among older veterans with NSCLC than comorbidity. Individualized decisions that go beyond age and include comorbidity are needed to better target NSCLC treatments to older patients who may reasonably benefit.

Patient-reported symptoms and survival in ovarian cancer

OBJECTIVE

While the development of an index of clinical symptoms to use for the detection and diagnosis of ovarian cancer is under active investigation, the role of clinical symptoms in survival after the initial diagnosis is poorly understood. The aim of this study was to correlate the type and extent of clinical symptoms with survival outcomes in ovarian cancer.

METHODS

Medical records of 276 cases of primary epithelial ovarian, fallopian tube, and peritoneal cancers were evaluated. Thirty-one symptoms in 5 categories were cataloged. The significance of clinical symptoms in progression-free survival (PFS) and overall survival (OS) was evaluated.

RESULTS

Overall, 93.5% of ovarian cancer patients expressed at least 1 symptom at the time of initial diagnosis. The 3 most common symptoms were abdominal pain (40.6%), increased abdominal size (33.7%), and bloating (21.7%). In survival analysis, weight loss (16.3%), nausea/vomiting (13.4%), and lower extremity edema (6.5%) were significantly associated with both decreased PFS and OS (all, P < 0.05). In multivariate analysis, lower extremity edema remained the strongest significant symptom, associated with increased surgical mortality rate, decreased response rate to adjuvant chemotherapy after primary cytoreductive surgery, and diminished survival outcomes (median PFS, 4.9 vs 15.3 months, P < 0.0001; and median OS, 5.9 vs 49.1 months, P < 0.001). Multiple symptoms were associated with poor survival outcomes (individual number of symptom ≤1 vs 2 vs ≥3; median PFS, 26.8 vs 17.4 vs 11.7 months [P < 0.001]; and median OS, 70 vs 41.6 vs 37.2 months [P < 0.001]).

CONCLUSIONS

Lower extremity edema at initial diagnosis is a strong prognostic indicator of ovarian cancer patient.

Use of metformin and the risk of ovarian cancer: a case-control analysis

OBJECTIVE

To explore the association between use of metformin or other antidiabetic drugs and the risk of ovarian cancer.

METHODS

Using the UK-based General Practice Research Database, we conducted a case-control analysis to evaluate whether users of metformin or other antidiabetic drugs had an altered risk of ovarian cancer. Cases had an incident diagnosis of ovarian cancer, and up to 6 controls per case were matched on age, sex, calendar time, general practice, and number of years of active history in the GPRD prior to the index date. Results were further adjusted by multivariate logistic regression analyses for BMI, polycystic ovaries, endometriosis, use of estrogens or oral contraceptives, a history of hysterectomy, and smoking.

RESULTS

We identified 1611 case patients with a recorded diagnosis of ovarian cancer. Mean age ± SD was 61.2 ± 13.1 years at the time of cancer diagnosis. Long-term use (≥ 30 prescriptions) of metformin, but not of sulfonylureas, was associated with a tendency towards a reduced risk of ovarian cancer (OR 0.61, 95% CI 0.30-1.25 for metformin and 1.26, 95% CI 0.65-2.44 for sulfonylureas). Long-term use of insulin (≥ 40 prescriptions) was associated with a slightly increased risk for ovarian cancer (OR 2.29, 95% CI 1.13-4.65).

CONCLUSION

In this large epidemiological study long-term use of metformin, but not of sulfonylureas, was associated with a tendency towards a decreased risk of ovarian cancer. Long-term use of insulin was associated with an increased risk of ovarian cancer.

Using free text information to explore how and when GPs code a diagnosis of ovarian cancer: an observational study using primary care records of patients with ovarian cancer

BACKGROUND

Primary care databases provide a unique resource for healthcare research, but most researchers currently use only the Read codes for their studies, ignoring information in the free text, which is much harder to access.

OBJECTIVES

To investigate how much information on ovarian cancer diagnosis is 'hidden' in the free text and the time lag between a diagnosis being described in the text or in a hospital letter and the patient being given a Read code for that diagnosis.

DESIGN

Anonymised free text records from the General Practice Research Database of 344 women with a Read code indicating ovarian cancer between 1 June 2002 and 31 May 2007 were used to compare the date at which the diagnosis was first coded with the date at which the diagnosis was recorded in the free text. Free text relating to a diagnosis was identified (a) from the date of coded diagnosis and (b) by searching for words relating to the ovary.

RESULTS

90% of cases had information relating to their ovary in the free text. 45% had text indicating a definite diagnosis of ovarian cancer. 22% had text confirming a diagnosis before the coded date; 10% over 4 weeks previously. Four patients did not have ovarian cancer and 10% had only ambiguous or suspected diagnoses associated with the ovarian cancer code.

CONCLUSIONS

There was a vast amount of extra information relating to diagnoses in the free text. Although in most cases text confirmed the coded diagnosis, it also showed that in some cases GPs do not code a definite diagnosis on the date that it is confirmed. For diseases which rely on hospital consultants for diagnosis, free text (particularly letters) is invaluable for accurate dating of diagnosis and referrals and also for identifying misclassified cases.

What does validation of cases in electronic record databases mean? The potential contribution of free text

Electronic health records are increasingly used for research. The definition of cases or endpoints often relies on the use of coded diagnostic data, using a pre-selected group of codes. Validation of these cases, as 'true' cases of the disease, is crucial. There are, however, ambiguities in what is meant by validation in the context of electronic records. Validation usually implies comparison of a definition against a gold standard of diagnosis and the ability to identify false negatives ('true' cases which were not detected) as well as false positives (detected cases which did not have the condition). We argue that two separate concepts of validation are often conflated in existing studies. Firstly, whether the GP thought the patient was suffering from a particular condition (which we term confirmation or internal validation) and secondly, whether the patient really had the condition (external validation). Few studies have the ability to detect false negatives who have not received a diagnostic code. Natural language processing is likely to open up the use of free text within the electronic record which will facilitate both the validation of the coded diagnosis and searching for false negatives.

Factors associated with trauma center use for elderly patients with trauma: a statewide analysis, 1999-2008

OBJECTIVES

To estimate the likelihood of trauma center admission for injured elderly patients with trauma, determine trends in trauma center admissions, and identify factors associated with trauma center use for elderly patients with trauma.

DESIGN

Retrospective analysis.

SETTING

Acute care hospitals in California.

PATIENTS

All patients hospitalized for acute traumatic injuries during the period from January 1, 1999, to December 31, 2008 (n = 430,081). Patients who had scheduled admissions for nonacute or minor trauma were excluded.

MAIN OUTCOME MEASURE

Likelihood of admission to level I or II trauma center was calculated according to age categories after adjusting for patient and system factors.

RESULTS

Of 430,081 patients admitted to California acute care hospitals for trauma-related diagnoses, 27% were older than 65 years. After adjusting for demographic, clinical, and system factors, compared with trauma patients aged 18-25 years, the odds of admission to a trauma center decreased with increasing age; patients aged 26-45 years had lower odds (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.71-0.80) of being admitted to a trauma center for their injuries than did patients 46-65 years of age (OR, 0.57; 95% CI, 0.54-0.60), patients 66-85 years of age (OR, 0.35; 95% CI, 0.30-0.41), and patients older than 85 years (OR, 0.30; 95% CI, 0.25-0.36). Similar patterns were found when stratifying the analysis by trauma type and severity. Living more than 50 miles away from a trauma center (OR, 0.03; 95% CI, 0.01-0.06) and lack of county trauma center (OR, 0.17; 95% CI, 0.09-0.35) were also predictors of not receiving trauma care.

CONCLUSION

Age and likelihood of admission to a trauma center for injured patients were observed to be inversely proportional after controlling for other factors. System-level factors play a major role in determining which injured patients receive trauma care.

Explaining variation in referral from primary to secondary care: cohort study

OBJECTIVES

To determine the extent to which referral for defined symptoms from primary care varies by age, sex, and social deprivation and whether any sociodemographic variations in referral differ according to the presence of national referral guidance and the potential of the symptoms to be life threatening.

DESIGN

Cohort study using individual patient data from the health improvement network database in primary care.

SETTING

United Kingdom.

PARTICIPANTS

5492 patients with postmenopausal bleeding, 23 121 with hip pain, and 101 212 with dyspepsia from 326 general practices, 2001-7.

MAIN OUTCOME MEASURES

Multivariable associations between odds of immediate referral for postmenopausal bleeding and age and social deprivation; hazard rates of referral for hip pain or dyspepsia and age, sex, and social deprivation. Analyses for dyspepsia were stratified for people aged less than and more than 55 years because referral guidance differs by age.

RESULTS

61.4% (3374/5492) of patients with postmenopausal bleeding, 17.4% (4019/23 121) with hip pain, and 13.8% (13 944/101 212) with dyspepsia were referred. The likelihood of referral for postmenopausal bleeding declined with increasing age: the adjusted odds ratio for patients aged 85 or more compared with those aged 55-64 was 0.39 (95% confidence interval 0.31 to 0.49). Patients aged 85 or more with hip pain were also less likely to be referred than those aged 55-64 (0.68, 0.57 to 0.81). Women were less likely than men to be referred for hip pain (hazard ratio 0.90, 95% confidence interval 0.84 to 0.96). More deprived patients with hip pain or dyspepsia (if aged <55) were less likely to be referred. Adjusted hazard ratios for those in the most deprived Townsend fifth compared with the least deprived were 0.72 (95% confidence interval 0.62 to 0.82) and 0.76 (0.68 to 0.85), respectively. No socioeconomic gradient was evident in referral for postmenopausal bleeding.

CONCLUSIONS

Inequalities in referral associated with socioeconomic circumstances were more likely to occur in the absence of both explicit guidance and potentially life threatening conditions, whereas inequalities with age were evident for all conditions.