What are the clinical features of lung cancer before the diagnosis is made? A population based case-control study

Unresectable stage III non-small cell lung cancer: Insights from a Portuguese expert panel

INTRODUCTION

The management of unresectable stage III non-small cell lung cancer (NSCLC) is clinically challenging and there is no current consensus on optimal strategies. Herein, a panel of Portuguese experts aims to present practical recommendations for the global management of unresectable stage III NSCLC patients.

METHODS

A group of Portuguese lung cancer experts debated aspects related to the diagnosis, staging and treatment of unresectable stage III NSCLC in light of current evidence. Recent breakthroughs in immunotherapy as part of a standard therapeutic approach were also discussed. This review exposes the major conclusions obtained.

RESULTS

Practical recommendations for the management of unresectable stage III NSCLC were proposed, aiming to improve the pathways of diagnosis and treatment in the Portuguese healthcare system. Clinical heterogeneity of patients with stage III NSCLC hinders the development of single standardised algorithm where all fit.

CONCLUSIONS

A timely diagnosis and a proper staging contribute to the best management of each patient, optimizing treatment tolerance and effectiveness. The expert panel considered chemoradiotherapy as the preferable approach when surgery is not possible. Management of adverse events and immunotherapy as a consolidation therapy are also essential steps for a successful strategy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Identifying Existing Evidence to Potentially Develop a Machine Learning Diagnostic Algorithm for Cough in Primary Care Settings: Scoping Review

BACKGROUND

Primary care is known to be one of the most complex health care settings because of the high number of theoretically possible diagnoses. Therefore, the process of clinical decision-making in primary care includes complex analytical and nonanalytical factors such as gut feelings and dealing with uncertainties. Artificial intelligence is also mandated to offer support in finding valid diagnoses. Nevertheless, to translate some aspects of what occurs during a consultation into a machine-based diagnostic algorithm, the probabilities for the underlying diagnoses (odds ratios) need to be determined.

OBJECTIVE

Cough is one of the most common reasons for a consultation in general practice, the core discipline in primary care. The aim of this scoping review was to identify the available data on cough as a predictor of various diagnoses encountered in general practice. In the context of an ongoing project, we reflect on this database as a possible basis for a machine-based diagnostic algorithm. Furthermore, we discuss the applicability of such an algorithm against the background of the specifics of general practice.

METHODS

The PubMed, Scopus, Web of Science, and Cochrane Library databases were searched with defined search terms, supplemented by the search for gray literature via the German Journal of Family Medicine until April 20, 2023. The inclusion criterion was the explicit analysis of cough as a predictor of any conceivable disease. Exclusion criteria were articles that did not provide original study results, articles in languages other than English or German, and articles that did not mention cough as a diagnostic predictor.

RESULTS

In total, 1458 records were identified for screening, of which 35 articles met our inclusion criteria. Most of the results (11/35, 31%) were found for chronic obstructive pulmonary disease. The others were distributed among the diagnoses of asthma or unspecified obstructive airway disease, various infectious diseases, bronchogenic carcinoma, dyspepsia or gastroesophageal reflux disease, and adverse effects of angiotensin-converting enzyme inhibitors. Positive odds ratios were found for cough as a predictor of chronic obstructive pulmonary disease, influenza, COVID-19 infections, and bronchial carcinoma, whereas the results for cough as a predictor of asthma and other nonspecified obstructive airway diseases were inconsistent.

CONCLUSIONS

Reliable data on cough as a predictor of various diagnoses encountered in general practice are scarce. The example of cough does not provide a sufficient database to contribute odds to a machine learning-based diagnostic algorithm in a meaningful way.

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.

Liquefied Lung Cancer: An Uncommon Form of Squamous Cell Carcinoma of the Lung

Lung cancer is a significant global health concern, with high incidence and mortality rates. This case report presents the atypical presentation of a 71-year-old female with a history of lung cancer who initially presented with symptoms suggestive of infection secondary to a liquefied lung malignancy and later developed bronchial obstruction. Diagnosis of lung cancer requires a high level of clinical suspicion, and imaging techniques, such as PET and CT scans, provide additional evidence. However, necrotic lesions do not have specific findings on radiology. Treatment options depend on the cancer stage, with surgical resection being the primary approach. Chemotherapy and radiation are used for unresectable cases. Liquefied lung cancer is associated with poor outcomes. Post-obstructive pneumonia with necrotic lesions, particularly in cases without an underlying organism, is a relatively rare phenomenon in lung cancer that requires further investigation. Large-scale studies are needed to explore this aspect further and enhance our understanding of lung cancer complications.

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

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

DESIGN

Case-control study.

SETTING

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

PARTICIPANTS, OUTCOMES

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

RESULTS

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

CONCLUSIONS

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

Protocol for a pragmatic cluster randomised controlled trial assessing the clinical effectiveness and cost-effectiveness of Electronic RIsk-assessment for CAncer for patients in general practice (ERICA)

INTRODUCTION

The UK has worse cancer outcomes than most comparable countries, with a large contribution attributed to diagnostic delay. Electronic risk assessment tools (eRATs) have been developed to identify primary care patients with a ≥2% risk of cancer using features recorded in the electronic record.

METHODS AND ANALYSIS

This is a pragmatic cluster randomised controlled trial in English primary care. Individual general practices will be randomised in a 1:1 ratio to intervention (provision of eRATs for six common cancer sites) or to usual care. The primary outcome is cancer stage at diagnosis, dichotomised to stage 1 or 2 (early) or stage 3 or 4 (advanced) for these six cancers, assessed from National Cancer Registry data. Secondary outcomes include stage at diagnosis for a further six cancers without eRATs, use of urgent referral cancer pathways, total practice cancer diagnoses, routes to cancer diagnosis and 30-day and 1-year cancer survival. Economic and process evaluations will be performed along with service delivery modelling. The primary analysis explores the proportion of patients with early-stage cancer at diagnosis. The sample size calculation used an OR of 0.8 for a cancer being diagnosed at an advanced stage in the intervention arm compared with the control arm, equating to an absolute reduction of 4.8% as an incidence-weighted figure across the six cancers. This requires 530 practices overall, with the intervention active from April 2022 for 2 years.

ETHICS AND DISSEMINATION

The trial has approval from London City and East Research Ethics Committee, reference number 19/LO/0615; protocol version 5.0, 9 May 2022. It is sponsored by the University of Exeter. Dissemination will be by journal publication, conferences, use of appropriate social media and direct sharing with cancer policymakers.

TRIAL REGISTRATION NUMBER

ISRCTN22560297.

Lung cancer in the emergency department

Background

Though decreasing in incidence and mortality in the USA, lung cancer remains the deadliest of all cancers. For a significant number of patients, the emergency department (ED) provides the first pivotal step in lung cancer prevention, diagnosis, and management. As screening recommendations and treatments advance, ED providers must stay up-to-date with the latest lung cancer recommendations. The purpose of this review is to identify the many ways that emergency providers may intersect with the disease spectrum of lung cancer and provide an updated array of knowledge regarding detection, management, complications, and interdisciplinary care.

Findings

Lung cancer, encompassing 10-12% of cancer-related emergency department visits and a 66% admission rate, is the most fatal malignancy in both men and women. Most patients presenting to the ED have not seen a primary care provider or undergone screening. Ultimately, half of those with a new lung cancer diagnosis in the ED die within 1 year. Incidental findings on computed tomography are mostly benign, but emergency staff must be aware of the factors that make them high risk. Radiologic presentations range from asymptomatic nodules to diffuse metastatic lesions with predominately pulmonary symptoms, and some may present with extra-thoracic manifestations including neurologic. The short-term prognosis for ED lung cancer patients is worse than that of other malignancies. Screening offers new hope through earlier diagnosis but is underutilized which may be due to racial and socioeconomic disparities. New treatments provide optimism but lead to new complications, some long-term. Multidisciplinary care is essential, and emergency medicine is responsible for the disposition of patients to the appropriate specialists at inpatient and outpatient centers.

Conclusion

ED providers are intimately involved in all aspects of lung cancer care. Risk factor modification and referral for lung cancer screening are opportunities to further enhance patient care. In addition, with the advent of newer cancer therapies, ED providers must stay vigilant and up-to-date with all aspects of lung cancer including disparities, staging, symptoms of disease, prognosis, treatment, and therapy-related complications.

Lung Cancer With Vertebral Metastases Presenting as Low Back Pain in the Chiropractic Office: A Case Report

Lung cancer commonly metastasizes to the skeletal system, and when affecting the spine, it may initially be mistaken for a typical musculoskeletal source of back pain. We report a previously healthy 52-year-old male non-smoker with an eight-week history of low back pain that radiated into his left thigh and recent weight loss, yet no respiratory symptoms. Initially, the patient visited his primary care physician, who suspected a musculoskeletal condition and prescribed a nonsteroidal anti-inflammatory drug and muscle relaxant, then referred the patient to the chiropractor. Based on the patient's pain pattern, limited mobility, and other features, the chiropractor suspected a lumbar disc herniation. However, the patient's condition worsened during a one-week trial of care, so the chiropractor ordered magnetic resonance imaging (MRI) and, as the findings suggested vertebral metastasis, promptly referred the patient to an oncologist, who confirmed a diagnosis of lung adenocarcinoma via positron emission tomography (PET)/computed tomography and biopsy. Chiropractors should be aware of warning signs of malignancy, such as unexplained weight loss or progressive worsening despite treatment. If providers suspect spinal metastasis, they should order advanced imaging such as an MRI and refer patients to an oncologist for timely care.

Underlying cancer risk among patients with fatigue and other vague symptoms: a population-based cohort study in primary care

BACKGROUND

Presenting to primary care with fatigue is associated with slightly increased cancer risk, although it is unknown how this varies in the presence of other 'vague' symptoms.

AIM

To quantify cancer risk in patients with fatigue who present with other 'vague' symptoms in the absence of 'alarm' symptoms for cancer.

DESIGN AND SETTING

Cohort study of patients presenting in UK primary care with new-onset fatigue during 2007-2015, using Clinical Practice Research Datalink data linked to national cancer registration data.

METHOD

Patients presenting with fatigue without co-occurring alarm symptoms or anaemia were identified, who were further characterised as having co-occurrence of 19 other 'vague' potential cancer symptoms. Sex- and age-specific 9-month cancer risk for each fatigue-vague symptom cohort were calculated.

RESULTS

Of 285 382 patients presenting with new-onset fatigue, 84% (n = 239 846) did not have co-occurring alarm symptoms or anaemia. Of these, 38% (n = 90 828) presented with ≥1 of 19 vague symptoms for cancer. Cancer risk exceeded 3% in older males with fatigue combined with any of the vague symptoms studied. The age at which risk exceeded 3% was 59 years for fatigue-weight loss, 65 years for fatigue-abdominal pain, 67 years for fatigue-constipation, and 67 years for fatigue-other upper gastrointestinal symptoms. For females, risk exceeded 3% only in older patients with fatigue-weight loss (from 65 years), fatigue-abdominal pain (from 79 years), or fatigue-abdominal bloating (from 80 years).

CONCLUSION

In the absence of alarm symptoms or anaemia, fatigue combined with specific vague presenting symptoms, alongside patient age and sex, can guide clinical decisions about referral for suspected cancer.

Navigating patient journey in early diagnosis of lung cancer in India

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

Understanding patient barriers and facilitators to uptake of lung screening using low dose computed tomography: a mixed methods scoping review of the current literature

BACKGROUND

Targeted lung cancer screening is effective in reducing mortality by upwards of twenty percent. However, screening is not universally available and uptake is variable and socially patterned. Understanding screening behaviour is integral to designing a service that serves its population and promotes equitable uptake. We sought to review the literature to identify barriers and facilitators to screening to inform the development of a pilot lung screening study in Scotland.

METHODS

We used Arksey and O'Malley's scoping review methodology and PRISMA-ScR framework to identify relevant literature to meet the study aims. Qualitative, quantitative and mixed methods primary studies published between January 2000 and May 2021 were identified and reviewed by two reviewers for inclusion, using a list of search terms developed by the study team and adapted for chosen databases.

RESULTS

Twenty-one articles met the final inclusion criteria. Articles were published between 2003 and 2021 and came from high income countries. Following data extraction and synthesis, findings were organised into four categories: Awareness of lung screening, Enthusiasm for lung screening, Barriers to lung screening, and Facilitators or ways of promoting uptake of lung screening. Awareness of lung screening was low while enthusiasm was high. Barriers to screening included fear of a cancer diagnosis, low perceived risk of lung cancer as well as practical barriers of cost, travel and time off work. Being health conscious, provider endorsement and seeking reassurance were all identified as facilitators of screening participation.

CONCLUSIONS

Understanding patient reported barriers and facilitators to lung screening can help inform the implementation of future lung screening pilots and national lung screening programmes.

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

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

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

How does safety netting for lung cancer symptoms help patients to reconsult appropriately? A qualitative study

Background

Safety netting in primary care is considered an important intervention for managing diagnostic uncertainty. This is the first study to examine how patients understand and interpret safety netting advice around low-risk potential lung cancer symptoms, and how this affects reconsultation behaviours.

Methods

Qualitative interview study in UK primary care. Pre-covid-19, five patients were interviewed in person within 2–3 weeks of a primary care consultation for potential lung cancer symptom(s), and again 2–5 months later. The general practitioner (GP) they last saw was interviewed face-to-face once. During the covid-19 pandemic, an additional 15 patients were interviewed only once via telephone, and their GPs were not interviewed or contacted in any way. Audio-recorded interviews were transcribed verbatim and analysed using inductive thematic analysis.

Results

The findings from our thematic analysis suggest that patients prefer active safety netting, as part of thorough and logical diagnostic uncertainty management. Passive or ambiguous safety netting may be perceived as dismissive and cause delayed reconsultation. GP safety netting strategies are not always understood, potentially causing patient worry and dissatisfaction. Telephone consultations and the diagnostic overshadowing of COVID-19 on respiratory symptoms impacted GPs’ safety netting strategies and patients’ appetite for active follow up measures.

Conclusions

Safety netting guidelines do not yet offer solutions that have been proven to promote symptom vigilance and timely reconsultation for low-risk lung cancer symptoms. This may have been affected by primary care practices during the COVID-19 pandemic. Patients prefer active or pre-planned safety netting coupled with thorough consultation techniques and a comprehensible diagnostic strategy, and may respond adversely to passive safety netting advice.

Diagnosis of Peritoneal Carcinomatosis of Colorectal Origin Based on an Innovative Fuzzy Logic Approach

Colorectal cancer represents one of the most important causes worldwide of cancer related morbidity and mortality. One of the complications which can occur during cancer progression, is peritoneal carcinomatosis. In the majority of cases, it is diagnosed in late stages due to the lack of diagnostic tools capable of revealing the early-stage peritoneal burden. Therefore, still associates with poor prognosis and quality of life, despite recent therapeutic advances. The aim of the study was to develop a fuzzy logic approach to assess the probability of peritoneal carcinomatosis presence using routine blood test parameters as input data. The patient data was acquired retrospective from patients diagnosed between 2010-2021. The developed model focuses on the specific quantitative alteration of these parameters in the presence of peritoneal carcinomatosis, which is an innovative approach as regards the literature in the field and validates the feasibility of using a fuzzy logic approach in the noninvasive diagnosis of peritoneal carcinomatosis.

Increased use of diagnostic CT imaging increases the detection of stage IA lung cancer: pathways and patient characteristics

Background

At Silkeborg Regional Hospital, Denmark, the number of stage IA lung cancer increased after implementation of increased use of CT investigations and a corresponding reduction in chest X-ray. The aim of the present study was to understand the changes in referral pathways, patient characteristics and imaging procedures behind the observed increase in early-stage lung cancer.

Methods

The referral and imaging pathways for all patients diagnosed with lung cancer in 2013–2018 were described based on manually curated information from the electronic health care systems and staging information from the Danish Lung Cancer Registry. We compared the clinical characteristics of patients diagnosed in 2013–2015 and in 2016–2018 after implementation of a change in the use of low dose CT scan (LDCT). For patients diagnosed in 2016–2018, stage IA lung cancer were compared to higher stages using univariable logistic regression analysis.

Results

Five hundred and forty-seven patients were diagnosed with lung cancer in 2013–2018. Stage IA constituted 13.8% (34/247) in 2013–2015, and 28.3% (85/300) in 2016–2018. Stage IA patients in 2016–2018 were characterised by more comorbidity, fewer packyears and tended to be older than patients with higher stages. In 2016–2018, the largest proportion of stage IA patients (55%) came from within-hospital referrals. The majority of these lung cancers were detected due to imaging procedures with other indications than suspicion of lung cancer.

The proportion of stage IA increased from 12% (12/99) to 36% (47/129) (p < 0.001) for hospital referrals and from 17% (22/129) to 23% (38/165) for GP referrals (p = 0.21). The imaging procedures contributing to the increase in stage IA was contrast enhanced CT (22%¸11/51), LDCT (35%; 18/51) and X-ray followed by LDCT (25%; 13/51).

Conclusion

The increased access to LDCT for patients referred from general practice and the increased hospital requested CT activity resulted in an increase in the number of stage IA lung cancers. Incidental findings on imaging performed for diagnostic purposes unrelated to suspicion of lung cancer contributed a large proportion of the increase.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09585-2.

Dynamic contrast-enhanced CT compared with positron emission tomography CT to characterise solitary pulmonary nodules: the SPUtNIk diagnostic accuracy study and economic modelling

BACKGROUND

Current pathways recommend positron emission tomography-computerised tomography for the characterisation of solitary pulmonary nodules. Dynamic contrast-enhanced computerised tomography may be a more cost-effective approach.

OBJECTIVES

To determine the diagnostic performances of dynamic contrast-enhanced computerised tomography and positron emission tomography-computerised tomography in the NHS for solitary pulmonary nodules. Systematic reviews and a health economic evaluation contributed to the decision-analytic modelling to assess the likely costs and health outcomes resulting from incorporation of dynamic contrast-enhanced computerised tomography into management strategies.

DESIGN

Multicentre comparative accuracy trial.

SETTING

Secondary or tertiary outpatient settings at 16 hospitals in the UK.

PARTICIPANTS

Participants with solitary pulmonary nodules of ≥ 8 mm and of ≤ 30 mm in size with no malignancy in the previous 2 years were included.

INTERVENTIONS

Baseline positron emission tomography-computerised tomography and dynamic contrast-enhanced computer tomography with 2 years' follow-up.

MAIN OUTCOME MEASURES

Primary outcome measures were sensitivity, specificity and diagnostic accuracy for positron emission tomography-computerised tomography and dynamic contrast-enhanced computerised tomography. Incremental cost-effectiveness ratios compared management strategies that used dynamic contrast-enhanced computerised tomography with management strategies that did not use dynamic contrast-enhanced computerised tomography.

RESULTS

A total of 380 patients were recruited (median age 69 years). Of 312 patients with matched dynamic contrast-enhanced computer tomography and positron emission tomography-computerised tomography examinations, 191 (61%) were cancer patients. The sensitivity, specificity and diagnostic accuracy for positron emission tomography-computerised tomography and dynamic contrast-enhanced computer tomography were 72.8% (95% confidence interval 66.1% to 78.6%), 81.8% (95% confidence interval 74.0% to 87.7%), 76.3% (95% confidence interval 71.3% to 80.7%) and 95.3% (95% confidence interval 91.3% to 97.5%), 29.8% (95% confidence interval 22.3% to 38.4%) and 69.9% (95% confidence interval 64.6% to 74.7%), respectively. Exploratory modelling showed that maximum standardised uptake values had the best diagnostic accuracy, with an area under the curve of 0.87, which increased to 0.90 if combined with dynamic contrast-enhanced computerised tomography peak enhancement. The economic analysis showed that, over 24 months, dynamic contrast-enhanced computerised tomography was less costly (£3305, 95% confidence interval £2952 to £3746) than positron emission tomography-computerised tomography (£4013, 95% confidence interval £3673 to £4498) or a strategy combining the two tests (£4058, 95% confidence interval £3702 to £4547). Positron emission tomography-computerised tomography led to more patients with malignant nodules being correctly managed, 0.44 on average (95% confidence interval 0.39 to 0.49), compared with 0.40 (95% confidence interval 0.35 to 0.45); using both tests further increased this (0.47, 95% confidence interval 0.42 to 0.51).

LIMITATIONS

The high prevalence of malignancy in nodules observed in this trial, compared with that observed in nodules identified within screening programmes, limits the generalisation of the current results to nodules identified by screening.

CONCLUSIONS

Findings from this research indicate that positron emission tomography-computerised tomography is more accurate than dynamic contrast-enhanced computerised tomography for the characterisation of solitary pulmonary nodules. A combination of maximum standardised uptake value and peak enhancement had the highest accuracy with a small increase in costs. Findings from this research also indicate that a combined positron emission tomography-dynamic contrast-enhanced computerised tomography approach with a slightly higher willingness to pay to avoid missing small cancers or to avoid a 'watch and wait' policy may be an approach to consider.

FUTURE WORK

Integration of the dynamic contrast-enhanced component into the positron emission tomography-computerised tomography examination and the feasibility of dynamic contrast-enhanced computerised tomography at lung screening for the characterisation of solitary pulmonary nodules should be explored, together with a lower radiation dose protocol.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018112215 and CRD42019124299, and the trial is registered as ISRCTN30784948 and ClinicalTrials.gov NCT02013063.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 17. See the NIHR Journals Library website for further project information.

Cancer diagnostic tools to aid decision-making in primary care: mixed-methods systematic reviews and cost-effectiveness analysis

BACKGROUND

Tools based on diagnostic prediction models are available to help general practitioners diagnose cancer. It is unclear whether or not tools expedite diagnosis or affect patient quality of life and/or survival.

OBJECTIVES

The objectives were to evaluate the evidence on the validation, clinical effectiveness, cost-effectiveness, and availability and use of cancer diagnostic tools in primary care.

METHODS

Two systematic reviews were conducted to examine the clinical effectiveness (review 1) and the development, validation and accuracy (review 2) of diagnostic prediction models for aiding general practitioners in cancer diagnosis. Bibliographic searches were conducted on MEDLINE, MEDLINE In-Process, EMBASE, Cochrane Library and Web of Science) in May 2017, with updated searches conducted in November 2018. A decision-analytic model explored the tools' clinical effectiveness and cost-effectiveness in colorectal cancer. The model compared patient outcomes and costs between strategies that included the use of the tools and those that did not, using the NHS perspective. We surveyed 4600 general practitioners in randomly selected UK practices to determine the proportions of general practices and general practitioners with access to, and using, cancer decision support tools. Association between access to these tools and practice-level cancer diagnostic indicators was explored.

RESULTS

Systematic review 1 - five studies, of different design and quality, reporting on three diagnostic tools, were included. We found no evidence that using the tools was associated with better outcomes. Systematic review 2 - 43 studies were included, reporting on prediction models, in various stages of development, for 14 cancer sites (including multiple cancers). Most studies relate to QCancer^® (ClinRisk Ltd, Leeds, UK) and risk assessment tools.

DECISION MODEL

In the absence of studies reporting their clinical outcomes, QCancer and risk assessment tools were evaluated against faecal immunochemical testing. A linked data approach was used, which translates diagnostic accuracy into time to diagnosis and treatment, and stage at diagnosis. Given the current lack of evidence, the model showed that the cost-effectiveness of diagnostic tools in colorectal cancer relies on demonstrating patient survival benefits. Sensitivity of faecal immunochemical testing and specificity of QCancer and risk assessment tools in a low-risk population were the key uncertain parameters.

SURVEY

Practitioner- and practice-level response rates were 10.3% (476/4600) and 23.3% (227/975), respectively. Cancer decision support tools were available in 83 out of 227 practices (36.6%, 95% confidence interval 30.3% to 43.1%), and were likely to be used in 38 out of 227 practices (16.7%, 95% confidence interval 12.1% to 22.2%). The mean 2-week-wait referral rate did not differ between practices that do and practices that do not have access to QCancer or risk assessment tools (mean difference of 1.8 referrals per 100,000 referrals, 95% confidence interval -6.7 to 10.3 referrals per 100,000 referrals).

LIMITATIONS

There is little good-quality evidence on the clinical effectiveness and cost-effectiveness of diagnostic tools. Many diagnostic prediction models are limited by a lack of external validation. There are limited data on current UK practice and clinical outcomes of diagnostic strategies, and there is no evidence on the quality-of-life outcomes of diagnostic results. The survey was limited by low response rates.

CONCLUSION

The evidence base on the tools is limited. Research on how general practitioners interact with the tools may help to identify barriers to implementation and uptake, and the potential for clinical effectiveness.

FUTURE WORK

Continued model validation is recommended, especially for risk assessment tools. Assessment of the tools' impact on time to diagnosis and treatment, stage at diagnosis, and health outcomes is also recommended, as is further work to understand how tools are used in general practitioner consultations.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017068373 and CRD42017068375.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology programme and will be published in full in Health Technology Assessment; Vol. 24, No. 66. See the NIHR Journals Library website for further project information.

Using patients' own knowledge of early sensations and symptoms to develop an interactive, individualized e-questionnaire to facilitate early diagnosis of lung cancer

Background

One reason for the often late diagnosis of lung cancer (LC) may be that potentially-indicative sensations and symptoms are often diffuse, and may not be considered serious or urgent, making their interpretation complicated. However, with only a few exceptions, efforts to use people’s own in-depth knowledge about prodromal bodily experiences has been a missing link in efforts to facilitate early LC diagnosis. In this study, we describe and discuss facilitators and challenges in our process of developing and initial testing an interactive, self-completion e-questionnaire based on patient descriptions of experienced prodromal sensations and symptoms, to support early identification of lung cancer (LC).

Methods

E-questionnaire items were derived from in-depth, detailed explorative interviews with individuals undergoing investigation for suspected LC. The descriptors of sensations/symptoms and the background items obtained were the basis for developing an interactive, individualized instrument, PEX-LC, which was refined for usability through think-aloud and other interviews with patients, members of the public, and clinical staff.

Results

Major challenges in the process of developing PEX-LC related to collaboration among many actors, and design/user interface problems including technical issues. Most problems identified through the think-aloud interviews related to design/user interface problems and technical issues rather than content, for example we re-ordered questions to be in line with patients’ chronological, rather than retrospective, descriptions of their experiences. PEX-LC was developed into a final e-questionnaire on a touch-screen smart tablet with one background module covering sociodemographic characteristics, 10 interactive, individualized modules covering early sensations and symptoms, and a 12th assessing current symptoms.

Conclusions

Close collaboration with patients throughout the process was intrinsic for developing PEX-LC. Similarly, we recognized the extent to which clinicians and technical experts were also important in this process. Similar endeavors should assure all necessary competence is included in the core research team, to facilitate timely progress. Our experiences developing PEX-LC combined with new empirical research suggest that this individualized, interactive e-questionnaire, developed through systematizing patients’ own formulations of their prodromal symptom experiences, is both feasible for use and has potential value in the intended group.

Functional Decline as an Indicator of Ill-Health: A Retrospective Case Study of the Process Leading to Lung Cancer

Purpose

Lung cancer claims more lives than any cancer in the world and remains difficult to diagnosis at early stages. Detecting lung cancer is challenging due to nonspecific symptom presentation. Literature was reviewed to consider functional decline as an indicator for ill-health. This study explored the process experienced from recognition in a change of health to receiving a lung cancer diagnosis from a patient’s perspective in order to examine this phase through a biopsychosocial lens.

Patients and Methods

A single-case design methodology was used for this study. The method of data collection was semi-structured interviews with people diagnosed with lung cancer utilizing criterion sampling. The case study was bound by diagnostic and geographical factors to frame the single-case: participants were limited to those living in Alaska diagnosed with stage III or stage IV lung cancer.

Results

One (n = 1) person participated in this study. Themes consistent with lung cancer detection process from a patient’s perspective include symptom denial, symptom reductionism, and gradual impact on function.

Conclusion

Although the number of participants was extremely limited due to the COVID-19 pandemic at the time of recruitment, this case study suggests a decline in function present prior to being diagnosed with lung cancer. Opportunities exist within the provider and patient interface to promote earlier detection include educating medical providers to ask specific, closed-ended, non-disease related functional questions to ascertain more details and a holistic representation of patients’ health. Raising public awareness of lung cancer symptoms, such as fatigue and dyspnea, is also warranted.

Transcriptomic signals in blood prior to lung cancer focusing on time to diagnosis and metastasis

Recent studies have indicated that there are functional genomic signals that can be detected in blood years before cancer diagnosis. This study aimed to assess gene expression in prospective blood samples from the Norwegian Women and Cancer cohort focusing on time to lung cancer diagnosis and metastatic cancer using a nested case–control design. We employed several approaches to statistically analyze the data and the methods indicated that the case–control differences were subtle but most distinguishable in metastatic case–control pairs in the period 0–3 years prior to diagnosis. The genes of interest along with estimated blood cell populations could indicate disruption of immunological processes in blood. The genes identified from approaches focusing on alterations with time to diagnosis were distinct from those focusing on the case–control differences. Our results support that explorative analyses of prospective blood samples could indicate circulating signals of disease-related processes.

Sensations, symptoms, and then what? Early bodily experiences prior to diagnosis of lung cancer

Lung cancer (LC) generally lacks unique core symptoms or signs. However, there are a multitude of bodily sensations that are often non-specific, not easily understood, and many times initially not recognized as indicative of LC by the affected person, which often leads to late diagnosis. In this international qualitative study, we inductively analyzed retrospective accounts of 61 people diagnosed with LC in Denmark, England and Sweden. Using the bodily sensations they most commonly spoke about (tiredness, breathlessness, pain, and cough), we constructed four sensation-based cases to understand the pre-diagnostic processes of reasoning and practice triggered by these key indicators of LC. We thereafter critically applied Hay's model of sensations to symptoms transformation, examining its central concepts of duration, disability and vulnerability, to support understanding of these processes. We found that while duration and disability are clearly relevant, vulnerability is more implicitly expressed in relation to perceived threat. Tiredness, even when of long duration and causing disability, was often related to normal aging, rather than a health threat. Regardless of duration, breathlessness was disturbing and threatening enough to lead to care-seeking. Pain varied by location, duration and degree of disability, and thus also varied in degree of threat perceived. Preconceived, but unmet expectations of what LC-related cough and pain would entail could cause delays by misleading participants; if cough lasted long enough, it could trigger health care contact. Duration, disability, and sense of threat, rather than vulnerability, were found to be relevant concepts for understanding the trajectory to diagnosis for LC among these participants. The process by which an individual, their family and health care providers legitimize sensations, allowing them to be seen as potential symptoms of disease, is also an essential, but varying part of the diagnostic processes described here.

A 58-Year-Old Man with a Painful Gluteal Mass as the First Presentation of Metastatic Adenocarcinoma of the Lung

Patient: Male, 58-year-old

Final Diagnosis: Metastatic lung adenocarcinoma

Symptoms: Gluteal mass

Medication:—

Clinical Procedure: —

Specialty: Oncology • Pulmonology

The association between thrombocytosis and subtype of lung cancer: a systematic review and meta-analysis

Background

Thrombocytosis is associated with poor lung cancer prognosis and has recently been identified as having a high positive predictive value in lung cancer detection. Lung cancer has multiple histological and genetic subtypes and it is not known whether platelet levels differ across these subtypes, or whether thrombocytosis is predictive of a particular subtype.

Methods

PubMed and Embase were systematically searched for studies that reported pre-treatment platelet count, as either averages or proportion of patients with thrombocytosis, by subtype of lung cancer using a pre-specified search strategy. The Newcastle-Ottowa scale was used to assess study quality and risk of bias. Suitable studies were synthesised in meta-analyses and subgroup analyses examined for differences across subtypes.

Results

The prevalence of pre-treatment thrombocytosis across all lung cancer patients was 27% (95% CI: 17% to 37%). By subtype, this was 22% (95% CI: 7% to 41%) for adenocarcinoma, 28% (95% CI: 15% to 43%) for squamous cell carcinoma (SCC), 36% (95% CI: 13% to 62%) for large cell carcinoma (LCC), and 30% (95% CI: 8% to 58%) for small cell lung cancer (SCLC). The pooled mean platelet count for lung cancer patients was 289×10⁹/L (95% CI: 268 to 311). By subtype, this was 282×10⁹/L (95% CI: 259 to 306) for adenocarcinoma, 297×10⁹/L (95% CI: 238 to 356) for SCC, 290×10⁹/L (95% CI: 176 to 404) for LCC, and 293×10⁹/L (95% CI: 244 to 342) for SCLC. There was no difference in thrombocytosis prevalence (P=0.76) or mean platelet count (P=0.96) across the subtypes.

Conclusions

These findings suggest thrombocytosis is no more indicative of one lung cancer subtype over another. We therefore conclude a high platelet count is likely to be generic across all lung cancer subtypes.

Are Regulations Safe? Reflections From Developing a Digital Cancer Decision-Support Tool

PURPOSE

Informatics solutions to early diagnosis of cancer in primary care are increasingly prevalent, but it is not clear whether existing and planned standards and regulations sufficiently address patients' safety nor whether these standards are fit for purpose. We use a patient safety perspective to reflect on the development of a computerized cancer risk assessment tool embedded within a UK primary care electronic health record system.

METHODS

We developed a computerized version of the CAncer Prevention in ExetER studies risk assessment tool, in compliance with the European Union's Medical Device Regulations. The process of building this tool afforded an opportunity to reflect on clinical concerns and whether current regulations for medical devices are fit for purpose. We identified concerns for patient safety and developed nine practical recommendations to mitigate these concerns.

RESULTS

We noted that medical device regulations (1) were initially created for hardware devices rather than software, (2) offer one-shot approval rather than supporting iterative innovation and learning, (3) are biased toward loss-transfer approaches that attempt to manage the fallout of harm instead of mitigating hazards becoming harmful, and (4) are biased toward known hazards, despite unknown hazards being an expected consequence of health care as a complex adaptive system. Our nine recommendations focus on embedding less-reductionist and stronger system perspectives into regulations and standards.

CONCLUSION

Our intention is to share our experience to support research-led collaborative development of health informatics solutions in cancer. We argue that regulations in the European Union do not sufficiently address the complexity of healthcare information systems with consequences for patient safety. Future standards and regulations should continue to follow a system-based approach to risk, safety, and accident avoidance.

[Current Status and Progress of Early Lung Cancer Screening under the Normal State of COVID-19 Epidemic Prevention and Control]

Lung cancer is the malignant tumor with the highest incidence in China. Early detection and identification of symptomatic lung cancer patients and timely screen out asymptomatic patients from high-risk groups require multiple cooperation. At present, although combined imaging, serology, genomics, proteomics and other methods have been combined to screen for suspected lung cancer, there are still problems such as missed diagnosis and misdiagnosis. Meanwhile, the spread of the corona virus disease 2019 (COVID-19) epidemic has brought new challenges to early lung cancer screening. Under the normalization of epidemic prevention and control, the work of early lung cancer screening should be changed accordingly: improve the population's awareness of cancer prevention and control, strengthen the management of medical procedures, improve the efficiency of tumor detection, optimize detection technology, and utilize internet and big data platforms rationally. We should establish an ideal model, combining multiple screening methods, which is streamlined and efficient for early lung cancer screening under normal epidemic prevention and control.
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Time from presentation to pre-diagnostic chest X-ray in patients with symptomatic lung cancer: a cohort study using electronic patient records from English primary care

BACKGROUND

National guidelines in England recommend prompt chest X-ray (within 14 days) in patients presenting in general practice with unexplained symptoms of possible lung cancer, including persistent cough, shortness of breath, or weight loss.

AIM

To examine time to chest X-ray in symptomatic patients in English general practice before lung cancer diagnosis, and explore demographical variation.

DESIGN AND SETTING

Retrospective cohort study using routinely collected general practice, cancer registry, and imaging data from England.

METHOD

Patients with lung cancer who presented symptomatically in general practice in the year pre-diagnosis and who had a pre-diagnostic chest X-ray were included. Time from presentation to chest X-ray (presentation-test interval) was determined and intervals classified based on national guideline recommendations as concordant (≤14 days) or non-concordant (>14 days). Variation in intervals was examined by age, sex, smoking status, and deprivation.

RESULTS

In a cohort of 2102 patients with lung cancer, the median presentation-test interval was 49 (interquartile range [IQR] 5-172) days. Of these, 727 (35%) patients had presentation-test intervals of ≤14 days (median 1 [IQR 0-6] day) and 1375 (65%) had presentation-test intervals of >14 days (median 128 [IQR 52-231] days). Intervals were longer among patients who smoke (equivalent to 63% longer than non-smokers; P<0.001), older patients (equivalent to 7% longer for every 10 years from age 27; P = 0.013), and females (equivalent to 12% longer than males; P = 0.016).

CONCLUSION

In symptomatic primary care patients who underwent chest X-ray before lung cancer diagnosis, only 35% were tested within the timeframe recommended by national guidelines. Patients who smoke, older patients, and females experienced longer intervals. These findings could help guide initiatives aimed at improving timely lung cancer diagnosis.

Lung Cancer Pre-Diagnostic Pathways from First Presentation to Specialist Referral

Background: Lung cancer is often diagnosed at a late stage with high associated mortality. Timely diagnosis depends on timely referral to a respiratory specialist; however, in Canada, little is known about how patients move through primary care to get to a respiratory specialist. Accordingly, we aimed to identify and describe lung cancer pre-diagnostic pathways in primary care from first presentation to referral. Methods: In this retrospective cohort study, patients with primary lung cancer were recruited using consecutive sampling (n = 50) from a lung cancer center in Montréal, Québec. Data on healthcare service utilization in primary care were collected from chart reviews and structured patient interviews and analyzed using latent class analysis to identify groups of patients with similar pre-diagnostic pathways. Each group was described based on patient- and tumor-related characteristics and the sequence of utilization activities. Results: 68% of the patients followed a pathway where family physician (FP) visits were dominant (“FP-centric”) and 32% followed a pathway where walk-in clinic and emergency department (ED) visits were dominant (“ED-centric”). Time to referral in the FP group was double that of the ED group (45 days (IQR: 12–111) vs. 22 (IQR: 5–69)) with more advanced disease (65% vs. 50%). In the FP group, 29% of the patients saw their FP three times or more before being referred and 41% had an ED visit. Conclusions: Our findings may reflect the challenge of diagnosing lung cancer in primary care, missed opportunities for earlier diagnosis, and a lack of integration between primary and specialist care.

Conceptual Framework to Guide Early Diagnosis Programs for Symptomatic Cancer as Part of Global Cancer Control

Diagnosing cancer earlier can enable timely treatment and optimize outcomes. Worldwide, national cancer control plans increasingly encompass early diagnosis programs for symptomatic patients, commonly comprising awareness campaigns to encourage prompt help-seeking for possible cancer symptoms and health system policies to support prompt diagnostic assessment and access to treatment. By their nature, early diagnosis programs involve complex public health interventions aiming to address unmet health needs by acting on patient, clinical, and system factors. However, there is uncertainty regarding how to optimize the design and evaluation of such interventions. We propose that decisions about early diagnosis programs should consider four interrelated components: first, the conduct of a needs assessment (based on cancer-site-specific statistics) to identify the cancers that may benefit most from early diagnosis in the target population; second, the consideration of symptom epidemiology to inform prioritization within an intervention; third, the identification of factors influencing prompt help-seeking at individual and system level to support the design and evaluation of interventions; and finally, the evaluation of factors influencing the health systems' capacity to promptly assess patients. This conceptual framework can be used by public health researchers and policy makers to identify the greatest evidence gaps and guide the design and evaluation of local early diagnosis programs as part of broader cancer control strategies.

The value of bronchoscopy in patients with non-massive haemoptysis and a clear or benign computer tomogram scan

INTRODUCTION

The preferred diagnostic pathway for patients presenting with non-massive haemoptysis and normal or benign computer tomography (CT) radiological findings is unclear. The common approach is to investigate with both CT and bronchoscopy, irrespective of patient-specific factors. The value of performing fibreoptic bronchoscopy (FOB) in patients with non-massive haemoptysis and clear or benign CT findings remains undetermined. We aimed to investigate its value using a large retrospective case series.

MATERIAL AND METHODS

A retrospective review of 4376 FOBs performed in Northumbria Healthcare NHS Foundation Trust from January 2012 to December 2019 for patients presenting with haemoptysis and clear or benign CT findings. Statistical analysis was performed to describe patient-specific variables, clinical characteristics, pathological findings and subsequent management decisions.

RESULTS

A total of 4376 FOBs were performed during the study period, 275 were indicated to investigate non-massive haemoptysis. Two hundred and fifty-nine patients underwent a CT scan (158 before and 101 after FOB); 16 never had a CT because the treating physician did not feel it was necessary. About 258 CT scans showed normal anatomy. All patients underwent FOB; 192 showed normal findings. Bronchoscopic findings did not alter clinical management in 274 patients. One patient was referred to the ear, nose and throat department following the identification of polypoid vocal cord lesion which, following thorough investigation, was confirmed as benign.

CONCLUSION

FOB provides minimal value for identifying lung malignancies in patients with non-massive haemoptysis and a clear or benign CT scan irrespective of patient-specific risk factors. Cost savings would be associated if physicians altered practice accordingly.

Understanding the role of GPs' gut feelings in diagnosing cancer in primary care: a systematic review and meta-analysis of existing evidence

BACKGROUND

Growing evidence for the role of GPs' gut feelings in cancer diagnosis raises questions about their origin and role in clinical practice.

AIM

To explore the origins of GPs' gut feelings for cancer, their use, and their diagnostic utility.

DESIGN AND SETTING

Systematic review and meta-analysis of international research on GPs' gut feelings in primary care.

METHOD

Six databases were searched from inception to July 2019, and internet searches were conducted. A segregated method was used to analyse, then combine, quantitative and qualitative findings.

RESULTS

Twelve articles and four online resources were included that described varied conceptualisations of gut feelings. Gut feelings were often initially associated with patients being unwell, rather than with a suspicion of cancer, and were commonly experienced in response to symptoms and non-verbal cues. The pooled odds of a cancer diagnosis were four times higher when gut feelings were recorded (OR 4.24, 95% confidence interval = 2.26 to 7.94); they became more predictive of cancer as clinical experience and familiarity with the patient increased. Despite being included in some clinical guidelines, GPs had varying experiences of acting on gut feelings as some specialists questioned their diagnostic value. Consequently, some GPs ignored or omitted gut feelings from referral letters, or chose investigations that did not require specialist approval.

CONCLUSION

GPs' gut feelings for cancer were conceptualised as a rapid summing up of multiple verbal and non-verbal patient cues in the context of the GPs' clinical knowledge and experience. Triggers of gut feelings not included in referral guidance deserve further investigation as predictors of cancer. Non-verbal cues that trigger gut feelings appear to be reliant on continuity of care and clinical experience; they tend to remain poorly recorded and are, therefore, inaccessible to researchers.

Prioritising primary care patients with unexpected weight loss for cancer investigation: diagnostic accuracy study

OBJECTIVE

To quantify the predictive value of unexpected weight loss (WL) for cancer according to patient's age, sex, smoking status, and concurrent clinical features (symptoms, signs, and abnormal blood test results).

DESIGN

Diagnostic accuracy study.

SETTING

Clinical Practice Research Datalink electronic health records data linked to the National Cancer Registration and Analysis Service in primary care, England.

PARTICIPANTS

63 973 adults (≥18 years) with a code for unexpected WL from 1 January 2000 to 31 December 2012.

MAIN OUTCOME MEASURES

Cancer diagnosis in the six months after the earliest weight loss code (index date). Codes for additional clinical features were identified in the three months before to one month after the index date. Diagnostic accuracy measures included positive and negative likelihood ratios, positive predictive values, and diagnostic odds ratios.

RESULTS

Of 63 973 adults with unexpected WL, 37 215 (58.2%) were women, 33 167 (51.8%) were aged 60 years or older, and 16 793 (26.3%) were ever smokers. 908 (1.4%) had a diagnosis of cancer within six months of the index date, of whom 882 (97.1%) were aged 50 years or older. The positive predictive value for cancer was above the 3% threshold recommended by the National Institute for Health and Care Excellence for urgent investigation in male ever smokers aged 50 years or older, but not in women at any age. 10 additional clinical features were associated with cancer in men with unexpected WL, and 11 in women. Positive likelihood ratios in men ranged from 1.86 (95% confidence interval 1.32 to 2.62) for non-cardiac chest pain to 6.10 (3.44 to 10.79) for abdominal mass, and in women from 1.62 (1.15 to 2.29) for back pain to 20.9 (10.7 to 40.9) for jaundice. Abnormal blood test results associated with cancer included low albumin levels (4.67, 4.14 to 5.27) and raised values for platelets (4.57, 3.88 to 5.38), calcium (4.28, 3.05 to 6.02), total white cell count (3.76, 3.30 to 4.28), and C reactive protein (3.59, 3.31 to 3.89). However, no normal blood test result in isolation ruled out cancer. Clinical features co-occurring with unexpected WL were associated with multiple cancer sites.

CONCLUSION

The risk of cancer in adults with unexpected WL presenting to primary care is 2% or less and does not merit investigation under current UK guidelines. However, in male ever smokers aged 50 years or older and in patients with concurrent clinical features, the risk of cancer warrants referral for invasive investigation. Clinical features typically associated with specific cancer sites are markers of several cancer types when they occur with unexpected WL.

Healthcare professionals' perspectives on lung cancer screening in the UK: a qualitative study

Background

Lung cancer screening with low-dose computed tomography (LDCT) has been shown to decrease mortality. Low lung cancer survival rates in the UK, driven primarily by late-stage presentation, provide the impetus for implementing screening. Nascent guidance on screening in the UK recommends primary care case-finding. However, the potential impact and acceptability on primary care, and the opportunistic utilisation of other case-finding routes, such as pharmacies, smoking cessation services, and respiratory clinics, have not been fully explored.

Aim

To explore healthcare professionals’ views and perspectives about lung cancer screening and their preparedness and willingness to be involved in its implementation.

Design & setting

A qualitative study was carried out with semi-structured interviews conducted with GPs, pharmacists, staff from smoking cessation services within Southwark and Lambeth in London, and staff from respiratory clinics in Guys’ and St Thomas’ NHS Foundation Trust in London between April 2018 and December 2018.

Method

Sixteen participants were interviewed and the interview transcripts were analysed thematically.

Results

Participants described lung cancer screening as an important diagnostic tool for capturing lung cancer at an earlier stage and in increasing survivorship. However, the majority expressed a lack of awareness and understanding, uncertainty and concerns about the validity of screening, and the potential impact on their patients and workload.

Conclusion

Study participants had mixed opinions about lung cancer screening and expressed their concerns about its implementation. Addressing these concerns by providing resources and effective and detailed guidelines for their use may lead to greater engagement and willingness to be involved in lung cancer screening.

Palliative Care Delivery in Cancer Patients in the Era of Covid-19 Outbreak: Unique Needs, Barriers, and Tools for Solutions

World is facing a pandemic recently due to the outbreak of COVID-19 infection. Cancer has been identified as one of the major comorbidities which cause more severe disease due to COVID-19 infection. Moreover, there are several resource limitations and restrictions to avail the standard oncological health facilities due to robust measures taken for infection control. In this situation, palliative care in cancer patients deserves special attention. Their symptom management, psychological, social, cultural needs tremendously increase during the epidemic. Thus, we need to recognize the unique palliative care needs of cancer patients during pandemic and formulate the plan to maintain continuity of services. Triaging systems are essential tools for proper resource allocation during a pandemic. Therefore, we suggest triaging tools for emergency in hospital palliative care services: community-based palliative care and end of life care for cancer patients. Incorporation of newer technologies and identifying the potential resources are the other key components of the preparedness strategy.

Metastatic Lung Cancer Presenting as Monocular Blindness and Panhypopituitarism Secondary to a Pituitary Metastasis

Patient: Female, 52-year-old

Final Diagnosis: Metastatic lung adenocarcinoma

Symptoms: Fatigue • vision loss

Medication: —

Clinical Procedure: —

Specialty: Endocrinology and metabolic

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.

Changes in the presenting symptoms of lung cancer from 2000-2017: a serial cross-sectional study of observational records in UK primary care

Background

Most patients diagnosed with lung cancer present with symptoms. It is not known if the proportions of patients presenting with each symptom has changed over time. Identifying trends in lung cancer’s presenting symptoms is important for medical education and early-diagnosis initiatives.

Aim

To identify the first reported symptom of possible lung cancer (index symptom), and to test whether the percentages of patients with each index symptom changed during 2000–2017.

Design and setting

This was a serial, cross-sectional, observational study using UK Clinical Practice Research Datalink (CPRD) data with cancer registry linkage.

Method

The index symptom was identified for patients with an incident diagnosis of lung cancer in annual cohorts between 1 January 2000 and 31 December 2017. Searches were constrained to symptoms in National Institute for Health and Care Excellence (NICE) suspected-cancer referral guidelines, and to the year before diagnosis. Generalised linear models (with a binomial function) were used to test if the percentages of patients with each index symptom varied during 2000–2017.

Results

The percentage of patients with an index symptom of cough (odds ratio [OR] 1.01; 95% confidence interval [CI] = 1.00 to 1.02 per year; P<0.0001) or dyspnoea (OR 1.05; CI = 1.05 to 1.06 per year; P<0.0001) increased. The percentages of patients with other index symptoms decreased, notably haemoptysis (OR 0.93; CI = 0.92 to 0.95; P<0.0001) and appetite loss (OR 0.94; CI = 0.90 to 0.97; P<0.0001).

Conclusion

During 2000–2017, the proportions of lung cancer patients with an index symptom of cough or dyspnoea increased, while the proportion of those with the index symptom haemoptysis decreased. This trend has implications for medical education and symptom awareness campaigns.

The barriers to initiating lung cancer care in low-and middle-income countries

Lung cancer in low-and middle-income countries is the leading and the second leading cause of cancer deaths in males and females, respectively. This, in part, is due to late presentation of patients in health facilities and late diagnosis, thereby compromising the effectiveness of treatment and resulting in poor treatment outcomes. Investigating patients’ late presentation to health facilities and late diagnosis, as barriers to achieving good treatment outcomes, is an important step towards improving the existing pathways of care. Therefore, the aim of this paper is to critically review the published and unpublished literature, including government reports on lung cancer care, with regards to the barriers to patient access, referral, diagnosis and treatment in low-and middle-income countries. The emphasis is on access point and the primary care continuum. This review has been packaged into themes in order to efficiently inform researchers and cancer health professionals, on the existing gaps necessary for developing appropriate intervention strategies and policy guidelines. This review has revealed that the timeous and correct diagnosis of lung cancer enables lung specialists to engage on options for improved patient care. Currently, there are variations in lung cancer management in low-and middle-income countries. Many of the factors impacting on health care outcomes are a function of patient circumstances and/or understanding, leading to delays in presentation to health facilities. Factors pertaining to individual patient circumstances are further compounded by inefficiencies within the health care system. Therefore, limited health system capacities and competing health priorities in these settings require action.

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.

Time intervals and routes to diagnosis for lung cancer in 10 jurisdictions: cross-sectional study findings from the International Cancer Benchmarking Partnership (ICBP)

OBJECTIVE

Differences in time intervals to diagnosis and treatment between jurisdictions may contribute to previously reported differences in stage at diagnosis and survival. The International Cancer Benchmarking Partnership Module 4 reports the first international comparison of routes to diagnosis and time intervals from symptom onset until treatment start for patients with lung cancer.

DESIGN

Newly diagnosed patients with lung cancer, their primary care physicians (PCPs) and cancer treatment specialists (CTSs) were surveyed in Victoria (Australia), Manitoba and Ontario (Canada), Northern Ireland, England, Scotland and Wales (UK), Denmark, Norway and Sweden. Using Wales as the reference jurisdiction, the 50th, 75th and 90th percentiles for intervals were compared using quantile regression adjusted for age, gender and comorbidity.

PARTICIPANTS

Consecutive newly diagnosed patients with lung cancer, aged ≥40 years, diagnosed between October 2012 and March 2015 were identified through cancer registries. Of 10 203 eligible symptomatic patients contacted, 2631 (27.5%) responded and 2143 (21.0%) were included in the analysis. Data were also available from 1211 (56.6%) of their PCPs and 643 (37.0%) of their CTS.

PRIMARY AND SECONDARY OUTCOME MEASURES

Interval lengths (days; primary), routes to diagnosis and symptoms (secondary).

RESULTS

With the exception of Denmark (-49 days), in all other jurisdictions, the median adjusted total interval from symptom onset to treatment, for respondents diagnosed in 2012-2015, was similar to that of Wales (116 days). Denmark had shorter median adjusted primary care interval (-11 days) than Wales (20 days); Sweden had shorter (-20) and Manitoba longer (+40) median adjusted diagnostic intervals compared with Wales (45 days). Denmark (-13), Manitoba (-11), England (-9) and Northern Ireland (-4) had shorter median adjusted treatment intervals than Wales (43 days). The differences were greater for the 10% of patients who waited the longest. Based on overall trends, jurisdictions could be grouped into those with trends of reduced, longer and similar intervals to Wales. The proportion of patients diagnosed following presentation to the PCP ranged from 35% to 75%.

CONCLUSION

There are differences between jurisdictions in interval to treatment, which are magnified in patients with lung cancer who wait the longest. The data could help jurisdictions develop more focused lung cancer policy and targeted clinical initiatives. Future analysis will explore if these differences in intervals impact on stage or survival.

Early symptoms and sensations as predictors of lung cancer: a machine learning multivariate model

The aim of this study was to identify a combination of early predictive symptoms/sensations attributable to primary lung cancer (LC). An interactive e-questionnaire comprised of pre-diagnostic descriptors of first symptoms/sensations was administered to patients referred for suspected LC. Respondents were included in the present analysis only if they later received a primary LC diagnosis or had no cancer; and inclusion of each descriptor required ≥4 observations. Fully-completed data from 506/670 individuals later diagnosed with primary LC (n = 311) or no cancer (n = 195) were modelled with orthogonal projections to latent structures (OPLS). After analysing 145/285 descriptors, meeting inclusion criteria, through randomised seven-fold cross-validation (six-fold training set: n = 433; test set: n = 73), 63 provided best LC prediction. The most-significant LC-positive descriptors included a cough that varied over the day, back pain/aches/discomfort, early satiety, appetite loss, and having less strength. Upon combining the descriptors with the background variables current smoking, a cold/flu or pneumonia within the past two years, female sex, older age, a history of COPD (positive LC-association); antibiotics within the past two years, and a history of pneumonia (negative LC-association); the resulting 70-variable model had accurate cross-validated test set performance: area under the ROC curve = 0.767 (descriptors only: 0.736/background predictors only: 0.652), sensitivity = 84.8% (73.9/76.1%, respectively), specificity = 55.6% (66.7/51.9%, respectively). In conclusion, accurate prediction of LC was found through 63 early symptoms/sensations and seven background factors. Further research and precision in this model may lead to a tool for referral and LC diagnostic decision-making.

What are the clinical symptoms and physical signs for non-small cell lung cancer before diagnosis is made? A nation-wide multicenter 10-year retrospective study in China

Background

Most lung cancer patients are diagnosed after the onset of symptoms. However, whether the symptoms of lung cancer were independently associated with the diagnosis of lung cancer is unknown, especially in the Chinese population.

Methods

We conducted a 10 years (2005‐2014) nationwide multicenter retrospective clinical epidemiology study of lung cancer patients diagnosed in China. As such, this study focused on nonsmall cell lung cancer (NSCLC). We calculated the odds ratios (ORs) for variables associated with the symptoms and physical signs using multivariate unconditional logistic regressions.

Results

A total of 7184 lung cancer patients were surveyed; finally, 6398 NSCLC patients with available information about their symptoms and physical signs were included in this analysis. The most common initial symptom and physical sign was chronic cough (4156, 65.0%), followed by sputum with blood (2110, 33.0%), chest pain (1146, 17.9%), shortness of breath (1090, 17.0%), neck and supraclavicular lymphadenectasis (629, 9.8%), weight loss (529, 8.3%), metastases pain (378, 5.9%), fatigue (307, 4.8%), fever (272, 4.3%), and dyspnea (270, 4.2%). Patients with squamous carcinoma and stage III disease were more likely to present with chronic cough (P < 0.0001) and sputum with blood (P < 0.0001) than patients with other pathological types and clinical stages, respectively. Metastases pain (P < 0.0001) and neck and supraclavicular lymphadenectasis (P = 0.0006) were more likely to occur in patients with nonsquamous carcinoma than in patients with other carcinomas. Additionally, patients with stage IV disease had a higher percentage of chest pain, shortness of breath, dyspnea, weight loss, and fatigue than patients with other stages of disease. In multivariable logistic analyses, compared with patients with adenocarcinoma, patients with squamous carcinoma were more likely to experience symptoms (OR = 2.885, 95% confidence interval [CI] 2.477‐3.359) but were less likely to present physical signs (OR = 0.844, 95% CI 0.721‐0.989). The odds of having both symptoms and physical signs were higher in patients with late‐stage disease than in those with early‐stage disease (P < 0.0001).

Conclusions

The symptoms and physical signs of lung cancer were associated with the stage and pathological diagnosis of NSCLC. Patients with squamous carcinoma were more likely to develop symptoms, but not signs, than patients with adenocarcinoma. The more advanced the stage at diagnosis, the more likely that symptoms or physical signs are to develop. Further prospective cohort studies are needed to explore these results.

Development of practical recommendations for diagnostic accuracy studies in low-prevalence situations

OBJECTIVE

Low disease prevalence poses challenges for diagnostic accuracy studies because of the large sample sizes that are required to obtain sufficient precision. The aim is to collate and discuss designs of diagnostic accuracy studies suited for use in low-prevalence situations.

STUDY DESIGN AND SETTING

We conducted a literature search including backward citation tracking and expert consultation. Two reviewers independently selected studies on designs for estimating diagnostic accuracy in a low-prevalence situation. During a 1-day expert meeting, all designs were discussed and recommendations were formulated.

RESULTS

We identified six designs for diagnostic accuracy studies that are suitable in low-prevalence situations because they reduced the total sample size or the number of patients undergoing the index test or reference standard depending on which poses the highest burden. We described the advantages and limitations of these designs and evaluated efficiencies in sample sizes, risk of bias, and alignment with the clinical pathway for applicability in routine care.

CONCLUSION

Choosing a study design for diagnostic accuracy studies in low-prevalence situations should depend on whether the aim is to limit the number of patients undergoing the index test or reference standard, and the risk of bias associated with a particular design type.