Lung cancer stage-shift following a symptom awareness campaign

Transforming post pandemic cancer services

This paper outlines the impact of the COVID-19 pandemic on cancer services in the UK including screening, symptomatic diagnosis, treatment pathways and projections on clinical outcomes as a result of these care disruptions. A restoration of cancer services to pre-pandemic levels is not likely to mitigate this adverse impact, particularly with an ageing population and increased cancer burden. New cancer cases are projected to rise to over 500,000 per year by 2035, with over 4 million people living with and beyond cancer. This paper calls for a strategic transformation to prioritise effort on the basis of available datasets and evidence-in particular, to prioritise cancers where an earlier diagnosis is feasible and clinically useful with a focus on mortality benefit by preventing emergency presentations by harnessing data and analytics. This could be delivered by a focus on underperforming groups/areas to try and reduce inequity, linking near real-time datasets with clinical decision support systems at the primary and secondary care levels, promoting the use of novel technologies to improve patient uptake of services, screening and diagnosis, and finally, upskilling and cross-skilling healthcare workers to expand supply of diagnostic and screening services.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

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

BACKGROUND

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

RESEARCH QUESTION

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

STUDY DESIGN AND METHODS

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

RESULTS

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

INTERPRETATION

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

A comprehensive review of summer savory (Satureja hortensis L.): promising ingredient for production of functional foods

This review aims to measure the different aspects of summer savory including biological activity, medicinal properties, nutritional value, food application, prospective health benefits, and its use as an additive in broiler feed. Furthermore, toxicity related to this is also overviewed. Summer savory leaves are abundant in total phenolic compounds (rosmarinic acid and flavonoids) that have a powerful antioxidant impact. Rosmarinic (α-O-caffeoyl-3,4-dihydroxy-phenyl lactic) acid has been identified in summer savory as a main component. According to phytochemical investigations, tannins, volatile oils, sterols, acids, gums, pyrocatechol, phenolic compounds, mucilage, and pyrocatechol are the primary compounds of Satureja species. Summer savory extract shows considerable biological potential in antioxidant, cytotoxic, and antibacterial assays. Regarding antioxidant activity, summer savory extract displays an inhibitory effect on lipid peroxidation. Summer savory also has Fe (III) reductive and free radical scavenging properties and contains minerals and vitamins. Summer savory has important biological properties, including antimicrobial activity and antioxidant activity, and protective effects against Jurkat T Cells, Alzheimer's disease, cancer, infection, cardiovascular diseases, diabetes, and cholesterol. The leaves and stems of this plant are employed in the food, feed, and pharmacological industries due to their antioxidant properties and substantial nutritional content. Conclusively, summer savory is widely considered beneficial for human health due to its versatile properties and medicinal use.

Impact of low-dose computed tomography screening on lung cancer incidence and outcomes

PURPOSE OF REVIEW

To review findings from clinical trials of lung cancer screening (LCS), assess contemporary issues with implementation in clinical practice, and review emerging strategies to increase the uptake and efficiency of LCS.

RECENT FINDINGS

In 2013, the USPSTF recommended annual screening for individuals aged 55-80 years and currently smoke or quit within the past 15 years based on reduced mortality from lung cancer with annual low-dose computed tomography (LDCT) screening in the National Lung Screening Trial. Subsequent trials have demonstrated similar mortality outcomes in individuals with lower pack-year smoking histories. These findings, coupled with evidence for disparities in screening eligibility by race, resulted in updated guidelines by USPSTF to broaden eligibility criteria for screening. Despite this body of evidence, implementation in the United States has been suboptimal with fewer than 20% of eligible individuals receiving a screen. Barriers to efficient implementation are multifactorial and include patient, clinician, and system-level factors.

SUMMARY

Multiple randomized trials have established that annual LCS reduces mortality from lung cancer; however, several areas of uncertainty exist on the effectiveness of annual LDCT. Ongoing research is examining approaches to improve the uptake and efficiency of LCS, such as the use of risk-prediction models and biomarkers for identification of high-risk individuals.

Clinical and chest radiographic features of missed lung cancer and their association with patient outcomes

PURPOSE

To examine clinical and chest radiographic features of missed lung cancer (MLC) and explore their association with patient outcomes.

METHODS

We retrospectively reviewed chest radiographs obtained at least six months before lung cancer (LC) diagnosis in 95 patients to identify the first positive chest radiograph showing MLC. We assessed chest radiographic features of MLC and their association with patient outcomes.

RESULTS

Seventy-five (78.9%) patients (39 men, 36 women; mean age, 64.5 ± 10.5 years) had MLC. The median diagnostic delay was 31.3 months (6.6-128.0 months). The median MLC size was 16 mm (5-57 mm), and 54.7%, 68.0%, and 74.7% of MLC were in the left lung, the middle/lower zones, and the outer two-thirds of the lung, respectively. MLC exhibited a round/oval shape, partly/poorly defined margin, irregular/spiculated border, a density less than the aortic knob, and anatomical superimposition in 57.3%, 77.3%, 61.3%, 85.3%, and 88.0% of cases, respectively. Thirty-five (46.7%) patients had stage III + IV LC at diagnosis. Thirty-one (41.3%) patients died. MLC in the inner one-third of the lung, exhibiting a density equal to/greater than the aortic knob, or superimposed by midline structures was significantly associated with stage III + IV LC at diagnosis. The 3-year all-cause mortality significantly increased when MLC was in the upper zone, superimposed by pulmonary vessels, superimposed by pulmonary vessels plus ribs, or superimposed by pulmonary vessels plus in the inner one-third of the lung.

CONCLUSION

MLC with some radiographic features pertaining to their location, density, and superimposed structures was found to portend a worse outcome.

Barriers to early diagnosis of cervical cancer: a mixed-method study in Côte d'Ivoire, West Africa

BACKGROUND

Cervical cancer, a major public health problem in many developing countries, is usually associated with a poor survival related to an advanced disease at diagnosis. In Côte d'Ivoire and other developing countries with high cervical cancer prevalence, little is known about factors associated with advanced cervical cancer stages in a context of limited access to screening services.

METHODS

From May to July 2019, we conducted a cross-sectional study using a mixed, quantitative and qualitative method. Information on socio-demographic and history of the disease was extracted from a rapid case ascertainement study performed by the cancer registry of Côte d'Ivoire that enrolled all women diagnosed with cervical cancer between July 2018 and June 2019. In-depth semi-structured interviews were conducted among a subset of these women (12 women) and six healthcare providers to further capture barriers to early cervical cancer diagnosis. Factors associated with an advanced stage III, IV (according to FIGO classification) were estimated by a logistic regression model. Qualitative data were analyzed using a thematic analysis technique guided by the treatment pathway model and triangulated with quantitative data.

RESULTS

In total, 95 women with cervical cancer [median age = 51 (IQR 42-59)] years, were included. Among them, 18.9% were living with HIV and only 9.5% were covered by a health insurance. The majority (71.5%) were diagnosed with advanced cervical cancer. Being HIV-uninfected (aOR = 5.4; [1.6-17.8], p = 0.006) and being uninsured (aOR = 13.1; [2.0-85.5], p = 0.007) were independently associated with advanced cervical cancer in multivariable analysis. Qualitative data raised additional factors potentially related to advanced cervical cancer stages at diagnosis, including the lack of patient information on cervical cancer by healthcare providers and inadequate national awareness and screening campaigns.

CONCLUSION

In a context of challenges in access to systematic cervical cancer screening in Côte d'Ivoire, access to health insurance or integrated healthcare program appear to be key determinants of early diagnosis of cervical cancer.

Recent Trends in Biosensing and Diagnostic Methods for Novel Cancer Biomarkers

Cancer is one of the major public health issues in the world. It has become the second leading cause of death, with approximately 75% of cancer deaths transpiring in low- or middle-income countries. It causes a heavy global economic cost estimated at more than a trillion dollars per year. The most common cancers are breast, colon, rectum, prostate, and lung cancers. Many of these cancers can be treated effectively and cured if detected at the primary stage. Nowadays, around 50% of cancers are detected at late stages, leading to serious health complications and death. Early diagnosis of cancer diseases substantially increases the efficient treatment and high chances of survival. Biosensors are one of the potential screening methodologies useful in the early screening of cancer biomarkers. This review summarizes the recent findings about novel cancer biomarkers and their advantages over traditional biomarkers, and novel biosensing and diagnostic methods for them; thus, this review may be helpful in the early recognition and monitoring of treatment response of various human cancers.

Pre- and post-intervention survey on lung cancer awareness among adults in selected communities in KwaZulu-Natal, South Africa: A quasi-experimental study

Background

Lung cancer remains the number one cause of cancer mortality estimated at 1.8 million deaths. There are limited studies in resource poor countries regarding knowledge, attitudes and practices towards lung cancer.

Objective

This study aimed to assess the effects of a lung cancer awareness intervention in selected communities in KwaZulu- Natal, South Africa.

Materials and Methods

A quasi-experimental study design was conducted in the selected communities in KwaZulu-Natal. A community intervention was administered in the communities after a baseline survey. The intervention effects were assessed a month after implementation.

Results

There were statistical differences in the mean age (p<0.001) and proportion of males and females (p<0.001) at baseline and post-intervention. There were no differences in terms of smoking status (p=0.958), however, there was a reduction in the number of cigarettes smoked per day (p<0.001) and the number of packs smoked per week (p=0.026). The mean knowledge score increased from 41.8% (95% CI 35.7 - 47.9) at baseline to 59.9 (95% CI 53.8 - 66.0) post-intervention (p<0.001). The proportion of participants who were aware that lung cancer can be detected early increased from 46.5% (95% CI 39.1 - 53.9) at baseline to 81.1% (95% CI 71.7 - 87.9) post-intervention (p<0.001). The intervention had a statistically significant effect (aOR 4.370, 95% CI 1.477-12.928) on the level of lung cancer knowledge in the selected communities (p<0.001).

Conclusions

Interventions increasing the recognition of signs and symptoms, focusing on the importance of early detection and health seeking behaviour (including screening), smoking cessation, and addressing the perceived health system barriers are required.

Stage Migration and Lung Cancer Incidence After Initiation of Low-Dose Computed Tomography Screening

INTRODUCTION

Despite evidence from clinical trials of favorable shifts in cancer stage and improvements in lung cancer-specific mortality, the effectiveness of lung cancer screening (LCS) in clinical practice has not been clearly revealed.

METHODS

We performed a multicenter cohort study of patients diagnosed with a primary lung cancer between January 1, 2014, and September 30, 2019, at one of four U.S. health care systems. The primary outcome variables were cancer stage distribution and annual age-adjusted lung cancer incidence. The primary exposure variable was receipt of at least one low-dose computed tomography for LCS before cancer diagnosis.

RESULTS

A total of 3678 individuals were diagnosed with an incident lung cancer during the study period; 404 (11%) of these patients were diagnosed after initiation of LCS. As screening volume increased, the proportion of patients diagnosed with lung cancer after LCS initiation also rose from 0% in the first quartile of 2014 to 20% in the third quartile of 2019. LCS did not result in a significant change in the overall incidence of lung cancer (average annual percentage change [AAPC]: -0.8 [95% confidence interval (CI): -4.7 to 3.2]) between 2014 and 2018. Stage-specific incidence rates increased for stage I cancer (AAPC = 8.0 [95% CI: 0.8-15.7]) and declined for stage IV disease (AAPC = -6.0 [95% CI: -11.2 to -0.5]).

CONCLUSIONS

Implementation of LCS at four diverse health care systems has resulted in a favorable shift to a higher incidence of stage I cancer with an associated decline in stage IV disease. Overall lung cancer incidence did not increase, suggesting a limited impact of overdiagnosis.

Underlying reasons for post-mortem diagnosed lung cancer cases - A robust retrospective comparative study from Hungary (HULC study)

Objective

The Hungarian Undiagnosed Lung Cancer (HULC) study aimed to explore the potential reasons for missed LC (lung cancer) diagnosis by comparing healthcare and socio-economic data among patients with post-mortem diagnosed LC with those who were diagnosed with LC during their lives.

Methods

This nationwide, retrospective study used the databases of the Hungarian Central Statistical Office (HCSO) and National Health Insurance Fund (NHIF) to identify patients who died between January 1, 2019 and December 31, 2019 and were diagnosed with lung cancer post-mortem (population A) or during their lifetime (population B). Patient characteristics, socio-economic factors, and healthcare resource utilization (HCRU) data were compared between the diagnosed and undiagnosed patient population.

Results

During the study period, 8,435 patients were identified from the HCSO database with LC as the cause of death, of whom 1,203 (14.24%) had no LC-related ICD (International Classification of Diseases) code records in the NHIF database during their lives (post-mortem diagnosed LC population). Post-mortem diagnosed LC patients were significantly older than patients diagnosed while still alive (mean age 71.20 vs. 68.69 years, p<0.001), with a more pronounced age difference among female patients (difference: 4.57 years, p<0.001), and had significantly fewer GP (General Practitioner) and specialist visits, X-ray and CT scans within 7 to 24 months and 6 months before death, although the differences in GP and specialist visits within 7-24 months did not seem clinically relevant. Patients diagnosed with LC while still alive were more likely to be married (47.62% vs. 33.49%), had higher educational attainment, and had more children, than patients diagnosed with LC post-mortem.

Conclusions

Post-mortem diagnosed lung cancer accounts for 14.24% of total lung cancer mortality in Hungary. This study provides valuable insights into patient characteristics, socio-economic factors, and HCRU data potentially associated with a high risk of lung cancer misdiagnosis.

Early-stage lung cancer associated with higher frequency of chest x-ray up to three years prior to diagnosis

OBJECTIVES

Symptom awareness campaigns have contributed to improved early detection of lung cancer. Previous research suggests that this may have been achieved partly by diagnosing lung cancer in those who were not experiencing symptoms of their cancer. This study aimed to explore the relationship between frequency of chest x-ray in the three years prior to diagnosis and stage at diagnosis.

SETTINGS

Lung cancer service in a UK teaching hospital.

PARTICIPANTS

Patients diagnosed with lung cancer between 2010 and 2013 were identified. The number of chest x-rays for each patient in the three years prior to diagnosis was recorded. Statistical analysis of chest x-ray frequency comparing patients with early- and late-stage disease was performed.

RESULTS

One-thousand seven-hundred fifty patients were included - 589 (33.7%) with stage I/II and 1,161 (66.3%) with stage III/IV disease. All patients had at least one chest x-ray in the six months prior to diagnosis. Those with early-stage disease had more chest x-rays in this period (1.32 vs 1.15 radiographs per patient, P = 0.009). In the period 36 months to six months prior to lung cancer diagnosis, this disparity was even greater (1.70 vs 0.92, radiographs per patient, P < 0.001).

CONCLUSIONS

Increased rates of chest x-ray are likely to contribute to earlier detection. Given the known symptom lead time many patients diagnosed through chest x-ray may not have been experiencing symptoms caused by their cancer. The number of chest x-rays performed could reflect patient and/or clinician behaviours in response to symptoms.

Early Diagnosis and Lung Cancer Screening

Lung cancer remains the most significant cause of cancer death, accounting for about 20% of all cancer-related mortality. A significant reason for this is delayed diagnosis, either due to lack of symptoms in early-stage disease or presentation with non-specific symptoms common with a broad range of alternative diagnoses. More is needed in terms of increasing public awareness, providing adequate healthcare professional education and implementing clinical pathways that improve the earlier diagnosis of symptomatic lung cancer. Low-dose computed tomography screening of high-risk, asymptomatic populations has been shown to reduce lung cancer mortality, with focus now shifting towards how best to implement lung cancer screening on a wider scale in a safe, efficient and cost-effective manner. For maximum benefit, efforts must be made to optimise uptake, especially among high-risk populations with significant socioeconomic deprivation, as well as successfully incorporate tobacco-dependency treatment. Quality assured programme management will be critical to minimising screening-related harms and adequately managing incidental findings. By undertaking the above, there can be optimism that lung cancer outcomes can be improved significantly in the near future.

An International Consensus on Actions to Improve Lung Cancer Survival: A Modified Delphi Method Among Clinical Experts in the International Cancer Benchmarking Partnership

BACKGROUND

Research from the International Cancer Benchmarking Partnership (ICBP) demonstrates that international variation in lung cancer survival persists, particularly within early stage disease. There is a lack of international consensus on the critical contributing components to variation in lung cancer outcomes and the steps needed to optimise lung cancer services. These are needed to improve the quality of options for and equitable access to treatment, and ultimately improve survival.

METHODS

Semi-structured interviews were conducted with 9 key informants from ICBP countries. An international clinical network representing 6 ICBP countries (Australia, Canada, Denmark, England, Ireland, New Zealand, Northern Ireland, Scotland & Wales) was established to share local clinical insights and examples of best practice. Using a modified Delphi consensus model, network members suggested and rated recommendations to optimise the management of lung cancer. Calls to Action were developed via Delphi voting as the most crucial recommendations, with Good Practice Points included to support their implementation.

RESULTS

Five Calls to Action and thirteen Good Practice Points applicable to high income, comparable countries were developed and achieved 100% consensus. Calls to Action include (1) Implement cost-effective, clinically efficacious, and equitable lung cancer screening initiatives; (2) Ensure diagnosis of lung cancer within 30 days of referral; (3) Develop Thoracic Centres of Excellence; (4) Undertake an international audit of lung cancer care; and (5) Recognise improvements in lung cancer care and outcomes as a priority in cancer policy.

CONCLUSION

The recommendations presented are the voice of an expert international lung cancer clinical network, and signpost key considerations for policymakers in countries within the ICBP but also in other comparable high-income countries. These define a roadmap to help align and focus efforts in improving outcomes and management of lung cancer patients globally.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

Low Rates of Lung and Colorectal Cancer Screening Uptake Among a Safety-net Emergency Department Population

Introduction

A suspected diagnosis of cancer through an emergency department (ED) visit is associated with poor clinical outcomes. The purpose of this study was to explore the rate at which ED patients attend cancer screenings for lung, colorectal (CRC), and breast cancers based on national guidelines set forth by the United States Preventive Services Task Force (USPSTF).

Methods

This was a prospective cohort study. Patients were randomly approached in the Eskenazi Hospital ED between August 2019–February 2020 and were surveyed to determine whether they would be eligible and had attended lung, CRC, and breast cancer screenings, as well as their awareness of lung cancer screening with low-dose computed tomography (LDCT). Patients who were English-speaking and ≥18 years old, and who were not critically ill or intoxicated or being seen for acute decompensated psychiatric illness were offered enrollment. Enrolled subjects were surveyed to determine eligibility for lung, colorectal, and breast cancer screenings based on guidelines set by the USPSTF. No cancer screenings were actually done during the ED visit.

Results

A total of 500 patients were enrolled in this study. More participants were female (54.4%), and a majority were Black (53.0%). Most participants had both insurance (80.2%) and access to primary care (62.8%). Among the entire cohort, 63.0% identified as smokers, and 62.2% (140/225) of the 50- to 80-year-old participants qualified for lung cancer screening. No patients were screened for lung cancer in this cohort (0/225). Only 0.6% (3/500) were aware that LDCT was the preferred method for screening. Based on pack years, 35.5% (32/90) of the patients who were 40–49 years old and 6.7% (6/90) of those 30–39 years old would eventually qualify for screening. Regarding CRC screening, 43.6% (218/500) of the entire cohort was eligible. However, of those patients only 54% (118/218) had been screened. Comparatively, 77.7% (87/112) of the eligible females had been screened for breast cancer, but only 54.5% (61/112) had been screened in the prior two years.

Conclusion

Many ED patients are not screened for lung/colorectal/breast cancers even though many are eligible and have reported access to primary care. This study demonstrates an opportunity and a need to address cancer screening in the ED.

Primary care system factors and clinical decision-making in patients that could have lung cancer: A vignette study in five balkan region countries

Introduction

Lung cancer is the leading cause of cancer death, with wide variations in national survival rates. This study compares primary care system factors and primary care practitioners’ (PCPs’) clinical decision-making for a vignette of a patient that could have lung cancer in five Balkan region countries (Slovenia, Croatia, Bulgaria, Greece, Romania).

Methods

PCPs participated in an online questionnaire that asked for demographic data, practice characteristics, and information on health system factors. Participants were also asked to make clinical decisions in a vignette of a patient with possible lung cancer.

Results

The survey was completed by 475 PCPs. There were significant national differences in PCPs’ direct access to investigations, particularly to advanced imaging. PCPs from Bulgaria, Greece, and Romania were more likely to organise relevant investigations. The highest specialist referral rates were in Bulgaria and Romania. PCPs in Bulgaria were less likely to have access to clinical guidelines, and PCPs from Slovenia and Croatia were more likely to have access to a cancer fast-track specialist appointment system. The PCPs’ country had a significant effect on their likelihood of investigating or referring the patient.

Conclusions

There are large differences between Balkan region countries in PCPs’ levels of direct access to investigations. When faced with a vignette of a patient with the possibility of having lung cancer, their investigation and referral rates vary considerably. To reduce diagnostic delay in lung cancer, direct PCP access to advanced imaging, availability of relevant clinical guidelines, and fast-track referral systems are needed.

Associations between general practice characteristics and chest X-ray rate: an observational study

BACKGROUND

Chest X-ray (CXR) is the first-line test for lung cancer in many settings. Previous research has suggested that higher utilisation of CXR is associated with improved outcomes.

AIM

To explore the associations between characteristics of general practices and frequency of investigation with CXR.

DESIGN AND SETTING

Retrospective observational study of English general practices.

METHOD

A database was constructed of English general practices containing number of CXRs requested and data on practices for 2018, including patient and staff demographics, smoking prevalence, deprivation, and patient satisfaction indicators. Mixed-effects Poisson modelling was used to account for variation because of chance and to estimate the amount of remaining variation that could be attributed to practice and population characteristics.

RESULTS

There was substantial variation in GP CXR rates (median 34 per 1000 patients, interquartile range 26-43). Only 18% of between-practice variance in CXR rate was accounted for by recorded characteristics. Higher practice scores for continuity and communication skills, and higher proportions of smokers, Asian and mixed ethnic groups, and patients aged >65 years were associated with increased CXR rates. Higher patient satisfaction scores for access and greater proportions of male patients and patients of Black ethnicity were associated with lower CXR rates.

CONCLUSION

Substantial variation was found in CXR rates beyond that expected by chance, which could not be accounted for by practices' recorded characteristics. As other research has indicated that increasing CXR rates can lead to earlier detection, supporting practices that currently investigate infrequently could be an effective strategy to improve lung cancer outcomes.

Promoting early diagnosis and recovering from the COVID-19 pandemic in lung cancer through public awareness campaigns: learning from patient and public insight work

COVID-19 has had a devastating impact on outcomes in lung cancer leading to later stage presentation, less curative treatment and higher mortality. This has amplified the existing problem of late-stage presentation in lung cancer and is a call to arms for a multifaceted strategy to address this, including public awareness campaigns to promote healthcare review in patients with persistent chest symptoms. We report the learning from patient and public insight work from across the North of England exploring the barriers to seeking healthcare review with persistent chest symptoms. Members of the public described how a lack of importance is placed on the common symptoms of lung cancer and a feeling of being unworthy of review by healthcare professionals. They would feel motivated to seek review by dispelling the nihilism of lung cancer and would be able to take action more easily by removing the logistical hassle in the process. We propose a four-pillar framework (validation–endorsement–motivation–action) for developing the content of any public awareness campaigns promoting early diagnosis of lung cancer based on the findings of this comprehensive insight work. All providers and commissioners must work together to overcome the perceived and real barriers to patients with persistent chest symptoms.

Knowledge of ovarian cancer symptoms among women in Palestine: a national cross-sectional study

INTRODUCTION

Ovarian cancer (OC) is often diagnosed at advanced stages. This study aimed to assess the Palestinian women's knowledge about OC symptoms and determine the factors associated with having good knowledge.

METHODS

A cross-sectional study was conducted from July 2019 to March 2020 in the two main areas of Palestine: the West Bank and Jerusalem as well as the Gaza Strip. A translated-into-Arabic version of the validated OC awareness measure (OCAM) was utilized for data collection. Stratified convenience sampling was used to recruit adult women attending hospitals, primary healthcare centers, and public spaces at 11 governorates. The knowledge level was categorized into three categories based on the number of symptoms recognized: poor (0 to 4), fair (5 to 8), and good (9 to 11).

RESULTS

Of 6095 approached, 5618 participants completed the Arabic OCAM (response rate = 92.1%).A total of 5411 questionnaires were included in the analysis: 2278 from the Gaza Strip and 3133 from the West Bank and Jerusalem. Participants living in the West Bank and Jerusalem were older, of higher monthly income, and with more chronic diseases than those living in the Gaza Strip. The most frequently identified symptoms were 'extreme generalized fatigue' (n = 3821, 70.6%), 'unexplained weight loss' (n = 3607, 66.7%), and 'increased abdominal size on most days' (n = 3252, 60.1%). On the other hand, the least recognized symptoms were 'feeling full persistently' (n = 1553, 28.7%) and 'difficulty eating on most days' (n = 1971, 36.4%). Only 943 participants (17.4%) displayed good knowledge of OC symptoms. Participants from the Gaza Strip had a higher likelihood than participants from the West Bank and Jerusalem to have a good level of knowledge (21.0% vs. 14.8%). Being married, knowing someone with cancer, and visiting hospitals were all associated with a higher likelihood of having good knowledge level. However, living in the West Bank and Jerusalem was associated with a lower likelihood of having good knowledge.

CONCLUSION

The overall knowledge of OC symptoms in this study was low. Educational interventions are needed to improve Palestinian women's knowledge about OC symptoms.

An evaluation of a national mass media campaign to raise public awareness of possible lung cancer symptoms in England in 2016 and 2017

BACKGROUND

A two-phase 'respiratory symptoms' mass media campaign was conducted in 2016 and 2017 in England raising awareness of cough and worsening shortness of breath as symptoms warranting a general practitioner (GP) visit.

METHOD

A prospectively planned pre-post evaluation was done using routinely collected data on 15 metrics, including GP attendance, GP referral, emergency presentations, cancers diagnosed (five metrics), cancer stage, investigations (two metrics), outpatient attendances, inpatient admissions, major lung resections and 1-year survival. The primary analysis compared 2015 with 2017. Trends in metrics over the whole period were also considered. The effects of the campaign on awareness of lung cancer symptoms were evaluated using bespoke surveys.

RESULTS

There were small favourable statistically significant and clinically important changes over 2 years in 11 of the 15 metrics measured, including a 2.11% (95% confidence interval 1.02-3.20, p < 0.001) improvement in the percentage of lung cancers diagnosed at an early stage. However, these changes were not accompanied by increases in GP attendances. Furthermore, the time trends showed a gradual change in the metrics rather than steep changes occurring during or after the campaigns.

CONCLUSION

There were small positive changes in most metrics relating to lung cancer diagnosis after this campaign. However, the pattern over time challenges whether the improvements are wholly attributable to the campaign. Given the importance of education on cancer in its own right, raising awareness of symptoms should remain important. However further research is needed to maximise the effect on health outcomes.

Establishing scanning protocols for a CT lung cancer screening trial in the UK

OBJECTIVES

To develop a CT scanning protocol for lung cancer screening which achieved low radiation dose and a high level of objectively assessed image quality.

METHODS

An anthropomorphic chest phantom and a commercially available lung screening image quality phantom were scanned on a series of scan protocols from a previous UK lung screening pilot and on an alternative protocol. The chest phantom scans were used to assess the CT dose metrics on community-based mobile CT scanners and comparisons were made with published recommended doses. Scans of the image quality phantom were objectively assessed against the RSNA Quantitative Imaging Biomarkers Alliance (QIBA) recommendations. Protocol adjustments were made to ensure that the recommended dose and image quality levels were both achieved.

RESULTS

The alternative scan protocol yielded doses up to 72% lower than on the previously used protocols with a CTDIvol of 0.6mGy for the 55 kg equivalent phantom and 1.3mGy with an additional 6 cm of tissue equivalent material in place. Scans on the existing protocols failed on two of the QIBA image quality metrics (edge enhancement and 3D resolution aspect ratio). Following adjustments to the reconstruction parameters of the resulting image quality met all six QIBA recommendations. Radiologist review of phantom images with this scan protocol deemed them suitable for a lung screening trial.

CONCLUSIONS

Scan protocols yielding low radiation doses and high levels of objectively assessed image quality which meet published criteria can be established through the use of specific anthropomorphic and image quality phantoms, and are deliverable in community-based lung cancer screening.

ADVANCES IN KNOWLEDGE

Development of a standard methodology for establishing CT lung screening scanning protocolsUse of QIBA recommendations as objective image quality metricsStandardised lung phantoms are essential tools for setting up lung screening protocols.

A prospective cohort evaluation of the sensitivity and specificity of the chest X-ray for the detection of lung cancer in symptomatic adults

BACKGROUND

The accuracy of the chest x-ray (CXR) in the identification of lung cancer amongst symptomatic individuals is uncertain.

PURPOSE

To determine the diagnostic accuracy of the CXR for the detection of non-small cell carcinomas (NSCLC) and all primary intrathoracic malignancies.

METHODS

A prospective cohort study of consecutive CXR reports obtained within a primary care open access initiative. Eligibility criteria were symptoms specified by National Institute for Clinical Excellence as indicative of possible lung cancer and age over 50-yrs. A positive test was a CXR which led directly or indirectly to investigation with CT. The reference standards were malignancies observed within a one- or two-year post-test period.

RESULTS

8,948 CXR outcomes were evaluated. 496 positive studies led to a diagnosis of 101 patients with primary intrathoracic malignancy including 80 with NSCLC. Within two-years, a cumulative total of 168 patients with primary intrathoracic malignancies including 133 NSCLC were observed. The sensitivity and specificity for NSCLC were 76% (95 %CI 68-84) and 95% (95 %CI 95-96) within 1-year and 60% (95 %CI 52-69) and 95% (95 %CI 95-96) within 2-years. The 2-yr positive and negative likelihood ratios were 12.8 and 0.4. The results did not differ for NSCLC compared to all primary malignancies. Within this symptomatic population a negative test reduced the 2-year risk of lung cancer to 0.8%.

CONCLUSIONS

A positive test strongly increases the probability of malignancy whereas a negative test does not conclusively exclude the disease. The findings allow the risk of malignancy following a negative test to be estimated.

Treatment patterns and survival outcomes for patients with non-small cell lung cancer in the UK in the preimmunology era: a REAL-Oncology database analysis from the I-O Optimise initiative

OBJECTIVES

To report characteristics, treatment and overall survival (OS) trends, by stage and pathology, of patients diagnosed with non-small cell lung cancer (NSCLC) at Leeds Teaching Hospital NHS Trust in 2007-2018.

DESIGN

Retrospective cohort study based on electronic medical records.

SETTING

Large NHS university hospital in Leeds.

PARTICIPANTS

3739 adult patients diagnosed with incident NSCLC from January 2007 to August 2017, followed up until March 2018.

MAIN OUTCOME MEASURES

Patient characteristics at diagnosis, treatment patterns and OS.

RESULTS

34.3% of patients with NSCLC were clinically diagnosed (without pathological confirmation). Among patients with known pathology, 45.2% had non-squamous cell carcinoma (NSQ) and 33.3% had squamous cell carcinoma (SQ). The proportion of patients diagnosed at stage I increased (16.4%-27.7% in 2010-2017); those diagnosed at stage IV decreased (57.0%-39.1%). Surgery was the most common initial treatment for patients with pathologically confirmed stage I NSCLC. Use of radiotherapy alone increased over time in patients with clinically diagnosed stage I NSCLC (39.1%-60.3%); chemoradiation increased in patients with stage IIIA NSQ (21.6%-33.3%) and SQ (24.2%-31.9%). Initial treatment with systemic anticancer therapy (SACT) increased in patients with stages IIIB-IV NSQ (49.0%-67.5%); the proportion of untreated patients decreased (30.6%-15.0%). Median OS improved for patients diagnosed with stage I NSQ and SQ and stage IIIA NSQ over time. Median OS for patients with stages IIIB-IV NSQ and SQ remained stable, <10% patients were alive 3 years after diagnosis. Median OS for clinically diagnosed stages IIIB-IV patients was 1.2 months in both periods.

CONCLUSIONS

OS for stage I and IIIA patients improved over time, likely due to increased use of stereotactic ablative radiation, surgery (stage I) and chemoradiation (stage IIIA). Conversely, OS outcomes remained poor for stage IIIB-IV patients despite increasing use of SACT for NSQ. Many patients with advanced-stage disease remained untreated.

Feasibility and acceptability of a community pharmacy referral service for suspected lung cancer symptoms

BACKGROUND

Lung cancer survival rates in the UK are among the lowest in Europe, principally due to late-stage diagnosis. Alternative routes to earlier diagnosis of lung cancer are needed in socioeconomically deprived communities that are disproportionately affected by poor lung cancer outcomes. We assessed the feasibility and acceptability of a community-based pharmacy referral service to encourage earlier symptomatic referral for chest X-rays.

METHODS

Seventeen community pharmacies located in a deprived area of Wales participated between March 2019 and March 2020. Stakeholder interviews were conducted with four patients, seven pharmacy professionals and one general practitioner. Four focus groups were conducted, including one with healthcare professionals (n=6) and three with members of the public who were current and former smokers (n=13). Quantitative data regarding patient characteristics and clinical outcomes were collected from hospital records and patient referral questionnaires completed by pharmacists and analysed using descriptive statistics. Qualitative data sets were analysed thematically and triangulated.

RESULTS

Twelve patients used the pharmacy referral service, all of whom were male. Average length of the pharmacy consultation was 13 min, with a mean 3 days to accessing chest X-rays in secondary care. Patients experienced a mean 46-day wait for results, with no lung cancer detected. Participants found the service to be acceptable and considered the pharmacy element to be broadly feasible. Perceived barriers included low awareness of the service and concerns about the role and capacity of pharmacists to deliver the service. Facilitators included perceived approachability and accessibility of pharmacists. A well-publicised, multifaceted awareness campaign was recommended.

CONCLUSIONS

A community pharmacy referral service for lung symptoms was considered an acceptable alternative pathway to symptomatic diagnosis of lung cancer in deprived communities. Wider implementation of the service would require workforce capacity and training to be addressed to ensure optimum utilisation and promotion of the service.

Efficacy and toxicity hypofractionated radiotherapy for centrally located non-small cell lung cancer

Aim:

Centrally located early-stage non-small cell lung cancer in patients who are unfit for surgery are treated with fractionated radiotherapy. We present the outcomes of a moderately hypofractionated accelerated dose regimen of 50 Gy in 15 fractions from a single centre in the UK.

Materials and methods:

Electronic case notes and radiotherapy records of lung cancer patients treated between January 2014 and December 2016 were retrospectively reviewed. Adult Comorbidity Evaluation-27 score was used to evaluate comorbidities. Mean lung doses and percentage of lung receiving more than 20 Gy were calculated for all patients. Survival outcomes were estimated using Kaplan–Meier curves.

Results:

Fifty-three patients were included in the study; the median follow-up was 20.2 months. 87% of patients had stage I disease. There was no 30-day post-treatment mortality. Ninety-day mortality rate after radiotherapy was 3.8%. Grade 2 pneumonitis was seen in five patients while no grade 3 or 4 pneumonitis was observed. The median progression-free survival (PFS) and overall survival (OS) were 18.5 months and 28.2 months, respectively. The estimated 1 and 2 years PFS were 62.3% and 41.3%, respectively, and OS were 77.4% and 56.6%, respectively. Worsening performance status was associated with worse survival on cox regression analysis. Disease relapsed in 36% of patients. 7.5% of patients with relapsed disease had infield recurrence.

Findings:

50 Gy in 15 fractions radiotherapy for central early-stage lung cancer is a feasible choice that requires further randomised trials.

Targeted encouragement of GP consultations for possible cancer symptoms: a randomised controlled trial

BACKGROUND

For some common cancers, survival is lower in the UK than in comparable high-income countries.

AIM

To assess the effectiveness of a targeted postal intervention (to promote awareness of cancer symptoms and earlier help seeking) on patient consultation rates.

DESIGN AND SETTING

A two-arm randomised controlled trial was carried out on patients aged 50-84 years registered at 23 general practices in rural and urban areas of Greater London, Greater Manchester, and the North East of England.

METHOD

Patients who had not had a consultation at their general practice in the previous 12 months and had at least two other risk factors for late presentation with cancer were randomised to intervention and control arms. The intervention consisted of a posted letter and leaflet. Primary outcome was the number of consultations at the practice with patients randomised to each arm in the 6 months subsequent to posting the intervention. All patients with outcome data were included in the intention-to-treat analyses.

RESULTS

In total, 1513 patients were individually randomised to the intervention (n = 783) and control (n = 730) arms between Nov 2016 - May 2017; outcome data were available for 749 and 705 patients, respectively, with a statistically significantly higher rate of consultation in the intervention arm compared with the control arm: 436 versus 335 consultations (relative risk 1.40, 95% confidence interval = 1.11 to 1.77, P = 0.004). There was, however, no difference in the numbers of patients consulting.

CONCLUSION

Targeted interventions of this nature can change behaviour; there is a need to develop interventions that can be more effective at engaging patients with primary care. This study demonstrates that targeted interventions promoting both awareness of possible cancer symptoms and earlier health seeking, can change behaviour. There is a need to develop and test interventions that can be more effective at engaging the most at-risk patients.

Evaluating the delay prior to primary care presentation in patients with lung cancer: a cohort study

Background

Little is known about 'within-patient delay', which is the time from first symptom of lung cancer to contacting primary care.

Aim

Primary outcomes were length of within-patient delay and the proportion of total delay it represents. Secondary outcomes were factors causing delay and survival.

Design & setting

A cohort study of newly diagnosed patients with lung cancer at two hospitals in Norfolk.

Method

Patients completed questionnaires regarding onset of symptoms, whether they had delayed, and their reasons. GPs completed correlating questionnaires. Pathway times and other data were extracted from cancer registry and hospital records, and outcomes obtained prospectively. Factors causing delay were compared using ratios of geometric means.

Results

In 379 patients, mean within-patient delay and pre-secondary care delay were 188.6 days and 241 days (61.4% and 78.5% of total delay, respectively). It was found that 38.8% of patients felt they had delayed. Patient-related causes of delay were denial (ratio of means [ROM] = 4.36; P = 0.002, 95% confidence interval [CI] = 1.71 to 11.1); anxiety (ROM = 3.36; P = 0.026; 95% CI = 1.16 to 9.76); non-recognition of symptoms (ROM = 2.80; P = 0.004; 95% CI = 1.41 to 5.59); and smoking (ROM = 1.76; P = 0.021; 95% CI = 1.09 to 2.86), respectively. These symptoms were associated with delay: finger swelling or discomfort (ROM = 2.72; P = 0.009, 95% CI = 1.29 to 5.74); cough (ROM = 2.53; P<0.001; 95% CI = 1.52 to 4.19); weight loss (ROM = 2.41; P<0.001; 95% CI = 1.49 to 3.88); weakness (ROM = 2.35; P = 0.001; 95% CI = 1.45 to 3.83); dyspnoea (ROM = 2.30; P = 0.001; 95% CI = 1.40 to 3.80); voice change (ROM = 1.90; P = 0.010; 95% CI = 1.17 to 3.10); and sputum (ROM = 1.66; P = 0.039; 95% CI = 1.03 to 2.67), respectively, also having more than five symptoms (compared with 1–3) (ROM = 3.69; P<0.001; 95% CI = 2.05 to 6.64). No overall relation between within-patient delay and survival was seen.

Conclusion

Using smoking registers, awareness literature, and self-care manuals, primary care staff could liaise with people who have ever smoked regarding their symptoms to ensure early referral to secondary care.

Chest X-ray sensitivity and lung cancer outcomes: a retrospective observational study

Background

Chest X-ray (CXR) is the first-line investigation for lung cancer in many healthcare systems. An understanding of the consequences of false-negative CXRs on time to diagnosis, stage, and survival is limited.

Aim

To determine the sensitivity of CXR for lung cancer and to compare stage at diagnosis, time to diagnosis, and survival between those with CXR that detected, or did not detect, lung cancer.

Design and setting

Retrospective observational study using routinely collected healthcare data.

Method

All patients diagnosed with lung cancer in Leeds Teaching Hospitals NHS Trust during 2008–2015 who had a GP-requested CXR in the year before diagnosis were categorised based on the result of the earliest CXR performed in that period. The sensitivity of CXR was calculated and analyses were performed with respect to time to diagnosis, survival, and stage at diagnosis.

Results

CXR was negative for 17.7% of patients (n = 376/2129). Median time from initial CXR to diagnosis was 43 days for those with a positive CXR and 204 days for those with a negative CXR. Of those with a positive CXR, 29.8% (95% confidence interval [CI] = 27.9% to 31.8%) were diagnosed at stage I or II, compared with 33.5% (95% CI = 28.8% to 38.6%) with a negative CXR.

Conclusion

GPs should consider lung cancer in patients with persistent symptoms even when CXR is negative. Despite longer duration to diagnosis for those with false-negative CXRs, there was no evidence of an adverse impact on stage at diagnosis or survival; however, this comparison is likely to be affected by confounding variables.

Estimating lung cancer risk from chest X-ray and symptoms: a prospective cohort study

Background

Chest X-ray (CXR) is the first-line investigation for lung cancer in many countries but previous research has suggested that the disease is not detected by CXR in approximately 20% of patients. The risk of lung cancer, with particular symptoms, following a negative CXR is not known.

Aim

To establish the sensitivity and specificity of CXR requested by patients who are symptomatic; determine the positive predictive values (PPVs) of each presenting symptom of lung cancer following a negative CXR; and determine whether symptoms associated with lung cancer are different in those who had a positive CXR result compared with those who had a negative CXR result.

Design and setting

A prospective cohort study was conducted in Leeds, UK, based on routinely collected data from a service that allowed patients with symptoms of lung cancer to request CXR.

Method

Symptom data were combined with a diagnostic category (positive or negative) for each CXR, and the sensitivity and specificity of CXR for lung cancer were calculated. The PPV of lung cancer associated with each symptom or combination of symptoms was estimated for those patients with a negative CXR.

Results

In total, 114 (1.3%) of 8996 patients who requested a CXR were diagnosed with lung cancer within 1 year. Sensitivity was 75.4% and specificity was 90.2%. The PPV of all symptoms for a diagnosis of lung cancer within 1 year of CXR was <1% for all individual symptoms except for haemoptysis, which had a PPV of 2.9%. PPVs for a diagnosis of lung cancer within 2 years of CXR was <1.5% for all single symptoms except for haemoptysis, which had a PPV of 3.9%.

Conclusion

CXR has limited sensitivity; however, in a population with a low prevalence of lung cancer, its high specificity and negative predictive value means that lung cancer is very unlikely to be present following a negative result. Findings also support guidance that unexplained haemoptysis warrants urgent referral, regardless of CXR result.

Promoting lung cancer awareness, help-seeking and early detection: a systematic review of interventions

Lung cancer (LC) is the leading cause of cancer death. Barriers to the early presentation for LC include lack of symptom awareness, symptom misappraisal, poor relationship with doctors and lack of access to healthcare services. Addressing such barriers can help detect LC early. This systematic review describes the effect of recent interventions to improve LC awareness, help-seeking and early detection. This review was guided by the Cochrane Handbook for Systematic Reviews of Interventions. Electronic databases MEDLINE, CINAHL, ERIC, APA PsycARTICLES, APA PsycInfo and Psychology and Behavioral Sciences Collection were searched. Sixteen studies were included. Knowledge of LC was successfully promoted in most studies using educational sessions and campaigns. LC screening uptake varied with most studies successfully reducing decision conflicts using decision aids. Large campaigns, including UK-based campaign 'Be Clear on Cancer', were instrumental in enhancing LC awareness, promoting help-seeking and yielding an increase in chest X-rays and a decrease in the number of individuals diagnosed with advanced LC. Multimodal public health interventions, such as educational campaigns are best suited to raise awareness, reduce barriers to help-seeking and help detect LC early. Future interventions ought to incorporate targeted information using educational resources, face-to-face counselling and video- and web-based decision aids.

Perceived barriers to seeking cancer care in the Gaza Strip: a cross-sectional study

BACKGROUND

Several factors might contribute to the delay to get cancer care including poor cancer awareness and having barriers to seeking help. This study described these barriers in Gaza and their association with recalling and recognizing cancer symptoms and risk factors.

METHODS

A cross-sectional study was conducted in Gaza. Adult visitors (≥18 years) to the largest three governmental hospitals and adolescent students (15-17 years) from ten high schools were recruited. A translated-into-Arabic version of the validated Cancer Awareness Measure (CAM) was used to collect data in face-to-face interviews. It described demographic data, barriers to seek cancer care as well as recall and recognition of cancer symptoms and risk factors. Responses were compared between adults and adolescents as well as males and females.

RESULTS

Of 3033 participants approached, 2886 completed the CAM (response rate= 95.2%). Among them, 1429 (49.5%) were adult (702 females; 49.1%) and 1457 (50.5%) were adolescent (781 females; 53.6%). The mean age± standard deviation (SD) of adult and adolescent participants was 33.7±11.7 years and 16.3±0.8 years, respectively. Emotional barriers were the most common barriers with 'feeling scared' as the most reported barrier (n=1512, 52.4%). Females and adolescents were more likely to report 'feeling scared' as a barrier than males and adults, respectively. Higher recall scores for cancer symptoms were associated with lower likelihood to report 'embarrassment', 'worry about wasting doctor's time' and 'difficulty arranging transport'. This was also seen for recalling risk factors, where 'embarrassment' and all practical barriers showed significant inverse associations with higher scores. In addition, greater recognition scores of cancer risk factors were inversely associated with reporting 'embarrassment' and 'feeling scared'.

CONCLUSIONS

The most commonly perceived barriers to seeking cancer care were 'feeling scared' and 'feeling worried about what the doctor might find', followed by practical and service barriers. Females and adolescents were more likely to report 'fear' as a barrier to seek medical advice. Having a higher recall of cancer symptoms and risk factors was inversely associated with reporting most barriers. To improve patient outcome, early presentation can be facilitated by targeting barriers specific to population groups.

Using Google Trends to assess the impact of global public health days on online health information seeking behaviour in Central and South America

Background

Public health awareness can help prevent illness and result in earlier intervention when it does occur. For this reason, health promotion and disease awareness campaigns have great potential to alleviate the global burden of disease. Global Public Health Days (GPHD) are frequently implemented with this intent, but research evaluating their effectiveness, especially in the developing world setting, is scant.

Objectives

We aimed to evaluate the impact of four GPHDs (World Cancer Day, World Diabetes Day, World Mental Health Day, World AIDS Day) on online health information seeking behaviour (OHISB) in five Central and South American (CSA) countries which differ in their stage of economic development and epidemiological transition (Uruguay, Chile, Brazil, Colombia, Nicaragua).

Methods

Google Trends data was used as a ‘surrogate’ of OHISB. This was measured on the 28 days leading up to the GPHD, on the date of the GPHD, and on the seven days following it. The Joinpoint regression programme was used to perform a time trend analysis on the Google Trends data. This allowed us to identify statistically significant time points of a change in trend, which reflect significant ‘changes’ to OHISB.

Results

GPHDs were inconsistently effective at influencing internet search query activity in the studied countries. In situations where an effect was significant, this impact was consistently short-term, with Relative Search Volume level returning to precampaign levels within 7 days of the GPHD.

Conclusions

Our findings imply the need to revise GPHDs or create alternative health awareness campaigns, perhaps with a more long-term approach and tailored to the specific health needs of the CSA population. Developing effective preventive strategies is vital in helping combat the rising threat of NCDs in this region.

The promises and challenges of early non-small cell lung cancer detection: patient perceptions, low-dose CT screening, bronchoscopy and biomarkers

Lung cancer survival statistics are sobering with survival ranking among the poorest of all cancers despite the addition of targeted therapies and immunotherapies. However, improvements in tools for early detection hold promise. The Nederlands–Leuvens Longkanker Screenings Onderzoek (NELSON) trial recently corroborated the findings from the previous National Lung Screening Trial low‐dose Computerised Tomography (NLST) screening trial in reducing lung cancer mortality. Biomarker research and development is increasing at pace as the molecular life histories of lung cancers become further unravelled. Low‐dose CT screening (LDCT) is effective but targets only those at the highest risk and is burdensome on healthcare. An optimally designed CT screening programme at best will only detect a low proportion of overall lung cancers as only those at very high‐risk meet screening criteria. Biomarkers that help risk stratify suitable patients for LDCT screening, and those that assist in determining which LDCT detected nodules are likely to represent malignant disease are needed. Some biomarkers have been proposed as standalone lung cancer diagnosis tools. Bronchoscopy technology is improving, with better capacity to identify and obtain samples from early lung cancers. Clinicians need to be aware of each early lung cancer detection method’s inherent limitations. We anticipate that the future of early lung cancer diagnosis will involve a synergistic, multimodal approach, combining several early detection methods.

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC): Lung cancer

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC) are written by experts representing all disciplines involved in cancer care in Europe. They give patients, health professionals, managers and policymakers a guide to essential care throughout the patient journey. Lung cancer is the leading cause of cancer mortality and has a wide variation in treatment and outcomes in Europe. It is a major healthcare burden and has complex diagnosis and treatment challenges. Care must only be carried out in lung cancer units or centres that have a core multidisciplinary team (MDT) and an extended team of health professionals detailed here. Such units are far from universal in European countries. To meet European aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.

A Proposal to Improve the Early Diagnosis of Symptomatic Cancers in the United States

Many people are diagnosed with cancer after presenting with signs and symptoms of their disease to a healthcare provider. Research from developed countries suggests that, in addition to indicating later-stage disease, symptoms can also indicate earlier-stage disease, leading to investment in research and quality improvement efforts in the early detection of symptomatic cancers. This approach, labeled early diagnosis of symptomatic cancers, focuses on identifying cancer at the earliest possible stage in patients with potential signs and symptoms of cancer, and subsequently diagnosing and treating the cancer without delay. In the United States, early detection has focused on cancer screening, with relatively less research focused on early diagnosis of symptomatic cancers. In this commentary, we propose that research focused on early diagnosis of symptomatic cancers provides an important opportunity to achieve more earlier-stage cancer diagnoses in the United States. We highlight the potential of these efforts to improve cancer outcomes, and outline a research agenda to improve early diagnosis of symptomatic cancers in the United States focused on defining and describing pathways to cancer diagnosis, identifying signs and symptoms that can be used to promote early cancer detection, and developing interventions to improve early diagnosis of symptomatic cancers.

Role of chest radiographs in early lung cancer detection

Background

Lung cancer is the second most common and the most fatal form of cancer. Although annual low-dose computed tomography is used as the primary method of cancer screening, it presents challenges regarding resources as well as potential health risks from radiation exposure. Chest radiography (CXR), though less effective, is used frequently and commonly. Moreover, often in clinical settings, CXR is the first imaging modality used; computed tomography is subsequently performed if abnormalities are detected on CXRs. This study examined whether controlling for distractors and time constraints, as well as side-by-side comparison of multiple CXRs in clinical settings can aid earlier detection of radiological abnormalities indicative of lung cancer lesions.

Methods

Thirty-two attending physicians in the Republic of Korea examined 1,750 radiographs of 50 lung cancer cases. Using “hot spot” technology, participants indicated the possible locations of cancer lesions on each radiograph. Subsequently, the same radiographs, cropped to focus the anatomical regions where lung cancers were diagnosed, were shown side-by-side to the participants. The participants were asked to identify the radiograph which first enabled the diagnosis of lung cancer and which first showed a possible lesion.

Results

Removal of systemic constraints alone significantly improved lesion identification by 221.72±9.69 days. Presenting radiographs side-by-side, cropped to relevant areas, had an additional significant and positive impact on cancer detection in both hidden and open areas on CXRs. Also, lesions were detected at smaller sizes and earlier than when actually diagnosed.

Conclusions

CXR with improved methods and settings provides an easily accessible and low-risk imaging method for earlier detection of lung cancer compared to current clinical imaging settings. Further, this study demonstrates the potential effectiveness of programs that allow side-by-side comparisons of cropped areas of multiple radiographs to detect radiological abnormalities.

Predictive values of lung cancer alarm symptoms in the general population: a nationwide cohort study

We aimed to firstly determine the 1-year predictive values of lung cancer alarm symptoms in the general population and to analyse the proportion of alarm symptoms reported prior to diagnosis, and secondly analyse how smoking status and reported contact with general practitioners (GPs) regarding lung cancer alarm symptoms influence the predictive values. The study was a nationwide prospective cohort study of 69,060 individuals aged ≥40 years, randomly selected from the Danish population. Using information gathered in a survey regarding symptoms, lifestyle and healthcare-seeking together with registry information on lung cancer diagnoses in the subsequent year, we calculated the predictive values and likelihood ratios of symptoms that might be indicative of lung cancer. Furthermore, we analysed how smoking status and reported contact with GPs regarding the alarm symptoms affected the predictive values. We found that less than half of the patients had reported an alarm symptom six months prior to lung cancer diagnosis. The positive predictive values of the symptoms were generally very low, even for patients reporting GP contact regarding an alarm symptom. The highest predictive values were found for dyspnoea, hoarseness, loss of appetite and for current heavy smokers. The negative predictive values were high, all close to 100%. Given the low positive predictive values, our findings emphasise that diagnostic strategies should not focus on single, specific alarm symptoms, but should perhaps focus on different clusters of symptoms. For patients not experiencing alarm symptoms, the risk of overlooking lung cancer is very low.

Knowledge level of cancer symptoms and risk factors in the Gaza Strip: a cross-sectional study

BACKGROUND

In low-income settings, cancer is often diagnosed in advanced stages due to late presentation. Good public awareness of cancer signs and symptoms has a positive impact on the time patients take before they present to healthcare professionals. Therefore, this study examined public knowledge of cancer signs and symptoms as well as risk factors in Gaza.

METHODS

This was a cross-sectional study. Participants were recruited from adult visitors (≥18 years) to governmental hospitals covering all five governorates of Gaza, and adolescent students (15 to 17 years) from 10 high schools in corresponding locations. An Arabic version of the Cancer Awareness Measure (CAM) was completed in a face-to-face interview. It described demographic data and knowledge of: cancer prevalence, age-related risk, signs and symptoms as well as risk factors both in recall and recognition questions.

RESULTS

Of 3033 participants invited, 2886 completed the CAM (response rate = 95.2%). Adult mean age ± standard deviation was 33.7 ± 11.7 years and that of adolescents was 16.3 ± 0.8 years. Half of the participants (n = 1457, 50.5%) were adolescent (781 females; 53.6%) and 1429 (49.5%) were adult (702 females; 49.1%). About two thirds (n = 1885) thought about cancer as unrelated to age. Only 196 participants (6.8%) identified colorectal cancer as the most common cancer among men. Awareness of cancer signs/symptoms was poor to fair, where 'lump' was most commonly recognized (n = 2227, 77.2%) and 'change of bowel habit' the least (n = 670, 23.2%). Only 217 participants (7.5%) had a good level of recognizing risk factors with 'smoking' being the most identified and 'eating less than five portions of fruits and vegetables a day' the least. There was a higher likelihood for adults to identify most cancer signs/symptoms and risk factors than adolescents, except for recalling 'unexplained pain', 'persistent cough/hoarseness', 'non-healing ulcer', 'smoking', and 'eating less than five portions of fruits and vegetables a day'.

CONCLUSION

Public awareness of cancer signs/symptoms and risk factors needs to improve to facilitate early presentation and diagnosis in Gaza. Combining the delivery of public campaigns with tailored education to population groups, including the youth, may increase their knowledge and maintain its impact.

Management of patients with early stage lung cancer - why do some patients not receive treatment with curative intent?

Backgrounds

This study aims to understand the factors that influence whether patients receive potentially curative treatment for early stage lung cancer. A key question was whether indigenous Māori patients were less likely to receive treatment.

Methods

Patients included those diagnosed with early stage lung cancer in 2011–2018 and resident in the New Zealand Midland Cancer Network region. Logistic regression model was used to estimate the odds ratios of having curative surgery/ treatment. The Kaplan Meier method was used to examine the all-cause survival and Cox proportional hazard model was used to estimate the hazard ratio of death.

Results

In total 419/583 (71.9%) of patients with Stage I and II disease were treated with curative intent - 272 (46.7%) patients had curative surgery. Patients not receiving potentially curative treatment were older, were less likely to have non-small cell lung cancer (NSCLC), had poorer lung function and were more likely to have an ECOG performance status of 2+. Current smokers were less likely to be treated with surgery and more likely to receive treatment with radiotherapy and chemotherapy. Those who were treated with surgery had a 2-year survival of 87.8% (95% CI: 83.8–91.8%) and 5-year survival of 69.6% (95% CI: 63.2–76.0%). Stereotactic ablative body radiotherapy (SABR) has equivalent effect on survival compared to curative surgery (hazard ratio: 0.77, 95% CI: 0.37–1.61). After adjustment we could find no difference in treatment and survival between Māori and non-Māori.

Conclusions

The majority of patients with stage I and II lung cancer are managed with potentially curative treatment – mainly surgery and increasingly with SABR. The outcomes of those being diagnosed with stage I and II disease and receiving treatment is positive with 70% surviving 5 years.

Presenting symptoms of cancer and stage at diagnosis: evidence from a cross-sectional, population-based study

BACKGROUND

Early diagnosis interventions such as symptom awareness campaigns increasingly form part of global cancer control strategies. However, these strategies will have little impact in improving cancer outcomes if the targeted symptoms represent advanced stage of disease. Therefore, we aimed to examine associations between common presenting symptoms of cancer and stage at diagnosis.

METHODS

In this cross-sectional study, we analysed population-level data from the English National Cancer Diagnosis Audit 2014 for patients aged 25 years and older with one of 12 types of solid tumours (bladder, breast, colon, endometrial, laryngeal, lung, melanoma, oral or oropharyngeal, ovarian, prostate, rectal, and renal cancer). We considered 20 common presenting symptoms and examined their associations with stage at diagnosis (TNM stage IV vs stage I-III) using logistic regression. For each symptom, we estimated these associations when reported as a single presenting symptom and when reported together with other symptoms.

FINDINGS

We analysed data for 7997 patients. The proportion of patients diagnosed with stage IV cancer varied substantially by presenting symptom, from 1% (95% CI 1-3; eight of 584 patients) for abnormal mole to 80% (71-87; 84 of 105 patients) for neck lump. Three of the examined symptoms (neck lump, chest pain, and back pain) were consistently associated with increased odds of stage IV cancer, whether reported alone or with other symptoms, whereas the opposite was true for abnormal mole, breast lump, postmenopausal bleeding, and rectal bleeding. For 13 of the 20 symptoms (abnormal mole, breast lump, post-menopausal bleeding, rectal bleeding, lower urinary tract symptoms, haematuria, change in bowel habit, hoarseness, fatigue, abdominal pain, lower abdominal pain, weight loss, and the "any other symptom" category), more than 50% of patients were diagnosed at stages other than stage IV; for 19 of the 20 studied symptoms (all except for neck lump), more than a third of patients were diagnosed at stages other than stage IV.

INTERPRETATION

Despite specific presenting symptoms being more strongly associated with advanced stage at diagnosis than others, for most symptoms, large proportions of patients are diagnosed at stages other than stage IV. These findings provide support for early diagnosis interventions targeting common cancer symptoms, countering concerns that they might be simply expediting the detection of advanced stage disease.

FUNDING

UK Department of Health's Policy Research Unit in Cancer Awareness, Screening and Early Diagnosis; and Cancer Research UK.

Evaluation of a national lung cancer symptom awareness campaign in Wales

Background

Lung cancer is the leading cause of cancer mortality in Wales. We conducted a before- and after- study to evaluate the impact of a four-week mass-media campaign on awareness, presentation behaviour and lung cancer outcomes.

Methods

Population-representative samples were surveyed for cough symptom recall/recognition and worry about wasting doctors’ time pre-campaign (June 2016; n = 1001) and post-campaign (September 2016; n = 1013). GP cough symptom visits, urgent suspected cancer (USC) referrals, GP-ordered radiology, new lung cancer diagnoses and stage at diagnosis were compared using routine data during the campaign (July–August 2016) and corresponding control (July–August 2015) periods.

Results

Increased cough symptom recall (p < 0.001), recognition (p < 0.001) and decreased worry (p < 0.001) were observed. GP visits for cough increased by 29% in the target 50+ age-group during the campaign (p < 0.001) and GP-ordered chest X-rays increased by 23% (p < 0.001). There was no statistically significant change in USC referrals (p = 0.82), new (p = 0.70) or early stage (p = 0.27) diagnoses, or in routes to diagnosis.

Conclusions

Symptom awareness, presentation and GP-ordered chest X-rays increased during the campaign but did not translate into increased USC referrals or clinical outcomes changes. Short campaign duration and follow-up, and the small number of new lung cancer cases observed may have hampered detection effects.