The Aarhus statement on cancer diagnostic research: turning recommendations into new survey instruments

Time to Diagnosis and Presenting Symptoms of Patients Diagnosed With Cancer Through Emergency and Nonemergency Routes: A Large Retrospective Study From a High-Volume Center

PURPOSE

The symptoms with which a patient with cancer presents and the route taken to diagnosis (emergency v nonemergency) may affect the speed with which the diagnosis of cancer is made, thereby affecting outcomes. We examined time to diagnosis by symptom for cancers diagnosed through emergency and nonemergency routes (NERs).

METHODS

We performed a retrospective review of patients diagnosed with 10 solid cancers at Hospital Clínic of Barcelona between March 2013 and June 2023. Cancers were diagnosed through emergency presentation and admission (inpatient emergency route [IER]), emergency presentation and outpatient referral (outpatient emergency route [OER]), and primary care presentation and outpatient referral (NER). We assessed the effect of diagnostic routes on intervals to diagnosis for 19 cancer symptoms.

RESULTS

A total of 5,174 and 1,607 patients were diagnosed with cancer through emergency routes and NERs, respectively. Over 85% of patients presenting with alarm (localizing) symptoms such as hematuria through emergency routes were diagnosed with the expected cancer, whereas those with nonlocalizing symptoms such as abdominal pain had a more heterogeneous cancer-site composition. Median intervals were shorter for alarm than nonlocalizing symptoms and tended to be shorter in IERs than OERs. However, for most symptoms, intervals in both routes were invariably shorter than in the NER. For example, diagnostic intervals for hematuria and abdominal pain were 3 and 5 days shorter in IERs than OERs, but they were 5-8 and 17-22 days shorter than in the NER, respectively.

CONCLUSION

For patients with alarm symptoms, intervals were shorter than for those with nonlocalizing symptoms and, for most symptoms, intervals were shorter when patients were evaluated by emergency routes rather than NERs.

Time intervals and previous primary care consultations in the pathway to emergency cancer diagnosis

BACKGROUND

Time intervals and number of prior consultations in primary care (PC) are recognised metrics of diagnostic timeliness of cancer and are interrelated. However, whether and how the two measures correlate with each other in the emergency diagnostic pathway is unknown. We investigated the association between the number of prereferral consultations and the length of intervals from PC presentation to cancer diagnosis following emergency referral to hospital.

METHODS

Patients were eligible if they first consulted in PC and were diagnosed with cancer following emergency or nonemergency referral to hospital. We analysed for differences in PC and diagnostic intervals and number of consultations between emergency and nonemergency presenters and determined their associations by cancer type. Differences in presenting symptoms and stage at diagnosis between populations and according to number of consultations were also examined.

RESULTS

There were 796 emergency and 865 nonemergency presenters with comparable sociodemographic and comorbidity data. Correlation analysis in emergency presenters revealed a strong positive association between number of consultations and intervals for seven of 13 different cancers, including cancers characterised by high proportions of > 3 consultations and long intervals (pancreatic, lung, and colorectal cancer) and vice versa for others (e.g., endometrial, cervical, or oesophageal cancer). Additionally, emergency presenters with > 3 consultations were more likely than those with 1-2 to report nonspecific symptoms (60 vs. 40%, respectively) and to be diagnosed at a later stage.

CONCLUSION

System level interventions are needed to reduce unnecessary delays in the emergency diagnostic pathway, particularly in cancer patients with multiple prereferral consultations. The findings also suggest opportunities to reduce the proportion of emergency diagnoses by targeting symptomatic individuals pre-presentation.

Factors influencing the timeliness of care for patients with lung cancer in Bangladesh

BACKGROUND

This study explored the factors associated with timeliness of care in the healthcare seeking pathway among patients with lung cancer in Bangladesh.

METHODS

A structured questionnaire was used for data collection from 418 patients with lung cancer through face-to-face interviews in three tertiary care hospitals. Log-rank tests were performed to test differences in the length of intervals between points in healthcare by socioeconomic characteristics and care seeking behaviours of the patients. Cox Proportional Hazard (PH) regression analysis was performed to identify the predictors of the intervals after adjustment for variations in other variables.

RESULTS

A higher education level was associated significantly (p < 0.05) with a shorter interval between first contact with a healthcare provider (HCP) and diagnosis (median 81 days) and initiation of treatment (median 101 days). Higher monthly household income was associated significantly with a shorter time from first contact and diagnosis (median 91 days), onset of symptom and diagnosis (median 99 days), onset of symptom and treatment (median 122 days), and first contact with any HCP to treatment (median 111 days). Consulting with additional HCPs prior to diagnosis was associated significantly with longer intervals from first contact with any HCP and diagnosis (median 127 days), onset of symptom and diagnosis (median 154 days), onset of symptom and treatment (median 205 days), and first contact with any HCP to treatment (median 174 days). Consulting with informal HCPs was associated significantly with a longer time interval from symptom to treatment (median 171 days). Having more than one triggering symptom was associated significantly with a shorter interval between onset of symptoms and first contact with any HCP.

CONCLUSION

The predictors for timeliness of lung cancer care used in this study affected different intervals in the care seeking pathway. Higher education and income predicted shorter intervals whereas consulting informal healthcare providers and multiple providers were associated with longer intervals.

The impact of lag time to cancer diagnosis and treatment on clinical outcomes prior to the COVID-19 pandemic: A scoping review of systematic reviews and meta-analyses

Background

The COVID-19 pandemic has disrupted cancer care, raising concerns regarding the impact of wait time, or 'lag time', on clinical outcomes. We aimed to contextualize pandemic-related lag times by mapping pre-pandemic evidence from systematic reviews and/or meta-analyses on the association between lag time to cancer diagnosis and treatment with mortality- and morbidity-related outcomes.

Methods

We systematically searched MEDLINE, EMBASE, Web of Science, and Cochrane Library of Systematic Reviews for reviews published prior to the pandemic (1 January 2010-31 December 2019). We extracted data on methodological characteristics, lag time interval start and endpoints, qualitative findings from systematic reviews, and pooled risk estimates of mortality- (i.e., overall survival) and morbidity- (i.e., local regional control) related outcomes from meta-analyses. We categorized lag times according to milestones across the cancer care continuum and summarized outcomes by cancer site and lag time interval.

Results

We identified 9032 records through database searches, of which 29 were eligible. We classified 33 unique types of lag time intervals across 10 cancer sites, of which breast, colorectal, head and neck, and ovarian cancers were investigated most. Two systematic reviews investigating lag time to diagnosis reported different findings regarding survival outcomes among paediatric patients with Ewing's sarcomas or central nervous system tumours. Comparable risk estimates of mortality were found for lag time intervals from surgery to adjuvant chemotherapy for breast, colorectal, and ovarian cancers. Risk estimates of pathologic complete response indicated an optimal time window of 7-8 weeks for neoadjuvant chemotherapy completion prior to surgery for rectal cancers. In comparing methods across meta-analyses on the same cancer sites, lag times, and outcomes, we identified critical variations in lag time research design.

Conclusions

Our review highlighted measured associations between lag time and cancer-related outcomes and identified the need for a standardized methodological approach in areas such as lag time definitions and accounting for the waiting-time paradox. Prioritization of lag time research is integral for revised cancer care guidelines under pandemic contingency and assessing the pandemic's long-term effect on patients with cancer.

Funding

The present work was supported by the Canadian Institutes of Health Research (CIHR-COVID-19 Rapid Research Funding opportunity, VR5-172666 grant to Eduardo L. Franco). Parker Tope, Eliya Farah, and Rami Ali each received an MSc. stipend from the Gerald Bronfman Department of Oncology, McGill University.

Diagnostic delay of oral squamous cell carcinoma and the fear of diagnosis: A scoping review

The mortality rate of patients affected with oral squamous cell carcinoma (OSCC) has been stable in recent decades due to several factors, especially diagnostic delay, which is often associated with a late stage diagnosis and poor prognosis. The aims of this paper were to: analyze diagnostic delay in OSCC and to discuss the various psychological factors of patients with OSCC, with particular attention to the patient's fear of receiving news regarding their health; and the professional dynamics related to the decision-making processes in cases of suspected OSCC. A preliminary review of literature focusing on OSCC diagnostic delay was performed. Seven articles were included with the diagnostic delay ranging from 45  days to approximately 6  months. Patients' fears and, to a lesser degree, the concerns of dentists, were found to be still poorly investigated. On the basis of the authors' professional experience, the development of oral lesions of unknown origin may generate different behaviors in the decision-making processes by patients and clinicians, and fear may play a key role in the distinct steps of this process. It is crucial to increase awareness and inform patients about the onset of OSCC, and contemporaneously encourage experimental studies on patients' fear and professional behaviors with respect to communication regarding OSCC.

The effect of the number of biopsies on the delay in the time from the delivery of mammography results to breast cancer histopathological diagnosis

PURPOSE

The delay in the time (in calendar days) from the delivery of mammography results to histopathological breast cancer (BC) diagnosis could be associated with more advanced clinical stages, a worse prognosis and higher mortality. Therefore, we assessed the association between the number of biopsies and the delay in the time (in calendar days) from the delivery of mammography results to histopathological BC.

METHODS

A survey was performed on 563 women aged between 35 and 69 years with histopathologically confirmed BC who attended 11 Mexican hospitals.

RESULTS

After adjusting for potential confounders, the odds of having a delay in the time (in calendar days) from the delivery of mammography results to histopathological BC diagnosis (≥ 60 days) among women with ≥ 3 biopsies were 2.99 times the odds of those who had only one biopsy (95% CI 1.35, 6.63).

CONCLUSION

The number of biopsies should be considered as a predictor of the time delay between the delivery of the mammography result and the diagnostic result.

Prehospital care for ovarian cancer in Catalonia: could we do better in primary care? Retrospective cohort study

OBJECTIVE

To assess the impact of prehospital factors (diagnostic pathways, first presentation to healthcare services, intervals, participation in primary care) on 1-year and 5-year survival in people with epithelial ovarian cancer (EOC).

DESIGN

Retrospective quasi-population-based cohort study.

SETTING

Catalan Integrated Public Healthcare System.

PARTICIPANTS

People with EOC who underwent surgery with a curative intent in public Catalan hospitals between 1 January 2013 and 31 December 2014.

OUTCOME MEASURES

Data from primary and secondary care clinical histories and care processes in the 18 months leading up to confirmation (signs and symptoms at presentation, diagnosis pathways, referrals, diagnosis interval) of the EOC diagnosis (stage, histology type, treatment). Diagnostic process intervals were based on the Aarhus statement. 1-year and 5-year survival analysis was undertaken.

RESULTS

Of the 513 patients included in the cohort, 67.2% initially consulted their family physician, while 36.4% were diagnosed through emergency services. In the Cox models, survival was influenced by advanced stage at 1 year (HR 3.84, 95% CI 1.23 to 12.02) and 5 years (HR 5.36, 95% CI 3.07 to 9.36), as was the type of treatment received, although this association was attenuated over follow-up. Age became significant at 5 years of follow-up. After adjusting for age, adjusted morbidity groups, stage at diagnosis and treatment, 5-year survival was better in patients presenting with gynaecological bleeding (HR 0.35, 95% CI 0.16 to 0.79). Survival was not associated with a starting point involving primary care (HR 1.39, 95% CI 0.93 to 2.09), diagnostic pathways involving referral to elective gynaecological care from non-general practitioners (HR 0.80, 95% CI 0.51 to 1.26), or self-presentation to emergency services (HR 0.82, 95% CI 0.52 to 1.31).

CONCLUSIONS

Survival in EOC is not associated with diagnostic pathways or prehospital healthcare, but it is influenced by stage at diagnosis, administration of primary cytoreduction plus chemotherapy and patient age.

Morbidity and measures of the diagnostic process in primary care for patients subsequently diagnosed with cancer

BACKGROUND

There is uncertainty regarding how pre-existing conditions (morbidities) may influence the primary care investigation and management of individuals subsequently diagnosed with cancer.

METHODS

We identified morbidities using information from both primary and secondary care records among 11,716 patients included in the English National Cancer Diagnosis Audit (NCDA) 2014. We examined variation in 5 measures of the diagnostic process (the primary care interval, diagnostic interval, number of pre-referral consultations, use of primary care-led investigations, and referral type) by both primary care- and hospital records-derived measures of morbidity.

RESULTS

Morbidity prevalence recorded before cancer diagnosis was almost threefold greater using the primary care (75%) vs secondary care-derived measure (28%). After adjustment, there was limited variation in the primary care interval and the number of pre-referral consultations by either definition of morbidity. Patients with more severe morbidities were less likely to have had a primary care-led investigation before cancer diagnosis compared with those without any morbidity (adjusted odds ratio, OR [95% confidence interval]: 0.72 [0.60-0.86] for Charlson score 3+ vs 0; joint P < 0.001). Patients with multiple primary care-recorded conditions or a Charlson score of 3+ were more likely to have diagnostic intervals exceeding 60 days (aOR: 1.26 [1.10-1.45] and 1.19 [>1.00-1.41], respectively), and more likely to receive an emergency referral (aOR: 1.60 [1.26-2.02] and 1.61 [1.26-2.06], respectively).

CONCLUSION

Among cancer cases with up to 2 morbidities, there was no evidence of differences in diagnostic processes and intervals in primary care but higher morbidity burden was associated with longer time to diagnosis and higher likelihood of emergency referral.

Defining timeliness in care for patients with lung cancer: a scoping review

OBJECTIVES

Early diagnosis and reducing the time taken to achieve each step of lung cancer care is essential. This scoping review aimed to examine time points and intervals used to measure timeliness and to critically assess how they are defined by existing studies of the care seeking pathway for lung cancer.

METHODS

This scoping review was guided by the methodological framework for scoping reviews by Arksey and O'Malley. MEDLINE, EMBASE, CINAHL and PsycINFO electronic databases were searched for articles published between 1999 and 2019. After duplicate removal, all publications went through title and abstract screening followed by full text review and inclusion of articles in the review against the selection criteria. A narrative synthesis describes the time points, intervals and measurement guidelines used by the included articles.

RESULTS

A total of 2113 articles were identified from the initial search. Finally, 68 articles were included for data charting process. Eight time points and 14 intervals were identified as the most common events researched by the articles. Eighteen different lung cancer care guidelines were used to benchmark intervals in the included articles; all were developed in Western countries. The British Thoracic Society guideline was the most frequently used guideline (20%). Western guidelines were used by the studies in Asian countries despite differences in the health system structure.

CONCLUSION

This review identified substantial variations in definitions of some of the intervals used to describe timeliness of care for lung cancer. The differences in healthcare delivery systems of Asian and Western countries, and between high-income countries and low-income-middle-income countries may suggest different sets of time points and intervals need to be developed.

Healthcare practices that increase the quality of care in cancer trajectories from a general practice perspective: a scoping review

OBJECTIVE

General practice plays an important role in cancer trajectories, and cancer patients request the continuous involvement of general practice. The objective of this scoping review was to identify healthcare practices that increase the quality of care in cancer trajectories from a general practice perspective.

DESIGN, SETTING, AND SUBJECTS

A scoping review of the literature published in Danish or English from 2010 to 2020 was conducted. Data was collected using identified keywords and indexed terms in several databases (PubMed, MEDLINE, EBSCO CINAHL, Scopus, and ProQuest), contacting key experts, searching through reference lists, and reports from selected health political, research- and interest organizations' websites.

MAIN OUTCOME MEASURES

We identified healthcare practices in cancer trajectories that increase quality care. Identified healthcare practices were grouped into four contextual domains and allocated to defined phases in the cancer trajectory. The results are presented according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR).

RESULTS

A total of 45 peer-reviewed and six non-peer-reviewed articles and reports were included. Quality of care increases in all phases of the cancer trajectory when GPs listen carefully to the full story and use action plans. After diagnosis, quality of care increases when GPs and practice staff have a proactive care approach, act as interpreters of diagnosis, treatment options, and its consequences, and engage in care coordination with specialists in secondary care involving the patient.

CONCLUSION

This scoping review identified healthcare practices that increase the quality of care in cancer trajectories from a general practice perspective. The results support general practice in investigating own healthcare practices and identifying possibilities for quality improvement.KEY POINTSIdentified healthcare practices in general practice that increase the quality of care in cancer trajectories:Listen carefully to the full storyUse action plans and time-out-consultationsPlan and provide proactive careAct as an interpreter of diagnosis, treatment options, and its consequences for the patientCoordinate care with specialists, patients, and caregivers with mutual respectIdentified barriers for quality of care in cancer trajectories are:Time constraints in consultationsLimited accessibility for patients and caregiversHealth practices to increase the quality of care should be effective, safe, people-centered, timely, equitable, integrated, and efficient. These distinctions of quality of care, support general practice in investigating and improving quality of care in cancer trajectories.

Protein Cargo of Salivary Small Extracellular Vesicles as Potential Functional Signature of Oral Squamous Cell Carcinoma

The early diagnosis of oral squamous cell carcinoma (OSCC) is still an investigative challenge. Saliva has been proposed as an ideal diagnostic medium for biomarker detection by mean of liquid biopsy technique. The aim of this pilot study was to apply proteomic and bioinformatic strategies to determine the potential use of saliva small extracellular vesicles (S/SEVs) as a potential tumor biomarker source. Among the twenty-three enrolled patients, 5 were free from diseases (OSCC_FREE), 6 were with OSCC without lymph node metastasis (OSCC_NLNM), and 12 were with OSCC and lymph node metastasis (OSCC_LNM). The S/SEVs from patients of each group were pooled and properly characterized before performing their quantitative proteome comparison based on the SWATH_MS (Sequential Window Acquisition of all Theoretical Mass Spectra) method. The analysis resulted in quantitative information for 365 proteins differentially characterizing the S/SEVs of analyzed clinical conditions. Bioinformatic analysis of the proteomic data highlighted that each S/SEV group was associated with a specific cluster of enriched functional network terms. Our results highlighted that protein cargo of salivary small extracellular vesicles defines a functional signature, thus having potential value as novel predict biomarkers for OSCC.

Duration of intervals in the care seeking pathway for lung cancer in Bangladesh: A journey from symptoms triggering consultation to receipt of treatment

Timeliness in seeking care is critical for lung cancer patients' survival and better prognosis. The care seeking trajectory of patients with lung cancer in Bangladesh has not been explored, despite the differences in health systems and structures compared to high income countries. This study investigated the symptoms triggering healthcare seeking, preferred healthcare providers (including informal healthcare providers such as pharmacy retailers, village doctors, and "traditional healers"), and the duration of intervals in the lung cancer care pathway of patients in Bangladesh. A cross-sectional study was conducted in three tertiary care hospitals in Bangladesh among diagnosed lung cancer patients through face-to-face interview and medical record review. Time intervals from onset of symptom and care seeking events were calculated and compared between those who sought initial care from different providers using Wilcoxon rank sum tests. Among 418 study participants, the majority (90%) of whom were males, with a mean age of 57 ±9.86 years, cough and chest pain were the most common (23%) combination of symptoms triggering healthcare seeking. About two-thirds of the total respondents (60%) went to informal healthcare providers as their first point of contact. Living in rural areas, lower levels of education and lower income were associated with seeking care from such providers. The median duration between onset of symptom to confirmation of diagnosis was 121 days, between confirmation of diagnosis and initiation of treatment was 22 days, and between onset of symptom and initiation of treatment was 151 days. Pre-diagnosis durations were longer for those who had sought initial care from an informal provider (p<0.05). Time to first contact with a health provider was shorter in this study compared to other developed and developing countries but utilizing informal healthcare providers caused delays in diagnosis and initiation of treatment. Encouraging people to seek care from a formal healthcare provider may reduce the overall duration of the care seeking pathway.

Delay in Cancer Diagnosis During the Era of the Coronavirus Disease 2019 Pandemic: Learning lessons

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Psychosocial influences on help-seeking behaviour for cancer in low-income and lower middle-income countries: a mixed-methods systematic review

Introduction

Starting cancer treatment early can improve outcomes. Psychosocial factors influencing patients’ medical help-seeking decisions may be particularly important in low and lower middle-income countries (LMIC) where cancer outcomes are poor. Comprehensive review evidence is needed to understand the psychosocial influences on medical help-seeking for cancer symptoms, attendance for diagnosis and starting cancer treatment.

Methods

Mixed-methods systematic review registered on PROSPERO (CRD42018099057). Peer-reviewed databases were searched until April 2020 for studies assessing patient-related barriers and facilitators to medical help-seeking for cancer symptoms, diagnosis and treatment in adults (18+ years) living in LMICs. Quality of included studies was assessed using the Critical Appraisal Skills Programme tool. Data were synthesised using meta-analytic techniques, meta-ethnography or narrative synthesis as appropriate.

Results

Of 3963 studies identified, 64 were included. In quantitative studies, use of traditional, complementary and alternative medicine (TCAM) was associated with 3.60 higher odds of prolonged medical help-seeking (95% CI 2.06 to 5.14). Qualitative studies suggested that use of TCAM was a key barrier to medical help-seeking in LMICs, and was influenced by causal beliefs, cultural norms and a preference to avoid biomedical treatment. Women face particular barriers, such as needing family permission for help-seeking, and higher stigma for cancer treatment. Additional psychosocial barriers included: shame and stigma associated with cancer such as fear of social rejection (eg, divorce/disownment); limited knowledge of cancer and associated symptoms; and financial and access barriers associated with travel and appointments.

Conclusion

Due to variable quality of studies, future evaluations would benefit from using validated measures and robust study designs. The use of TCAM and gender influences appear to be important barriers to help-seeking in LMIC. Cancer awareness campaigns developed with LMIC communities need to address cultural influences on medical help-seeking behaviour.

Difficulties in Accessing Cancer Care in a Small Island State: A Community-Based Pilot Study of Cancer Survivors in Saint Lucia

Developing robust systems for cancer care delivery is essential to reduce the high cancer mortality in small island developing states (SIDS). Indigenous data are scarce, but community-based cancer research can inform care in SIDS where formal research capacity is lacking, and we describe the experiences of cancer survivors in Saint Lucia in accessing health services. Purposive and snowball sampling was used to constitute a sample of survivors for interviews. Subjects were interviewed with a questionnaire regarding socio-demographics, clinical characteristics, health services accessed (physicians, tests, treatment), and personal appraisal of experience. We recruited 50 survivors (13 men, 37 women). Only 52% of first presentations were with general practitioners. The mean turnaround for biopsy results in Saint Lucia was three times longer than overseas (p = 0.0013). Approximately half of survivors commenced treatment more than one month following diagnosis (median of 32 days, IQR 19-86 days), and 56% of survivors traveled out-of-country for treatment. Most survivors (60%) paid for care with family/friends support, followed by savings and medical insurance (38% each). In conclusion, cancer survivors in Saint Lucia are faced with complex circumstances, including access-to-care and health consequences. This study can guide future research, and possibly guide practice improvements in the near term.

Experiences along the diagnostic pathway for patients with advanced lung cancer in the USA: a qualitative study

BACKGROUND

Most patients with lung cancer are diagnosed at advanced stages. However, the advent of oral targeted therapies has improved the prognosis of many patients with lung cancer.

PURPOSE

We aimed to understand the diagnostic experiences of patients with advanced lung cancer with oncogenic mutations.

METHODS

Qualitative interviews were conducted with patients with advanced or metastatic non-small cell lung cancer with oncogenic alterations. Patients were recruited from online support groups within the USA. Interviews were conducted remotely or in person. Analysis used an iterative inductive and deductive process. Themes were mapped to the Model for Pathways to Treatment.

RESULTS

40 patients (12 male and 28 female) with a median age of 48 were included. We identified nine distinct themes. During the 'patient interval', individuals became concerned about symptoms, but often attributed them to other causes. Prolonged or more severe symptoms prompted care-seeking. During the 'primary care interval', doctors initially treated for illnesses other than cancer. Discovery of an imaging abnormality was a turning point in diagnostic pathways. Occasionally, severity of symptoms prompted patients to seek emergency care. During the 'secondary care interval', obtaining tissue samples was pivotal in confirming diagnosis. Delays in accessing oncology care sometimes led to patient distress. Obtaining genetic testing was crucial in directing patients to receive targeted treatments.

CONCLUSIONS

Patients experienced multiple different routes to their diagnosis. Some patients perceived delays, inefficiencies and lack of coordination, which could be distressing. Shifting the stage of diagnosis of lung cancer to optimise the impact of targeted therapies will require concerted efforts in early detection.

Non-specific symptoms and signs of cancer: different organisations of a cancer patient pathway in Denmark

OBJECTIVE

We aimed to investigate the Non-specific Symptoms and Signs of Cancer-Cancer Patient Pathway (NSSC-CPP) in order to describe organisational and clinical practice similarities and differences in the diagnostic work-up of suspected cancer in Denmark.

MATERIAL AND METHODS

A questionnaire on the organisation and practice pertaining to the NSSC-CPP was completed by all 21 diagnostic units in the five healthcare regions in Denmark.

RESULTS

The questionnaire responses revealed regional and intraregional differences in the organisation and clinical practice of the NSSC-CPP. CT scan was the most often used imaging in the NSSC-CPP but there was no consensus whether the CT scan should be ordered and evaluated by general practitioners (GPs) or by the diagnostic units. Two regions were consistent but had different modalities regarding referrals from GPs. Three regions had intra-regional differences. The units reported on different types and frequency of forum for patient plan discussion and how to end a NSSC-CPP.

CONCLUSION

The NSSC-CPP is implemented with great regional and intra-regional differences in Denmark. GPs face different requirements when referring to the NSSC-CPP, which indicates that the division of role and responsibility between GPs and the diagnostic units is not well defined.KEY POINTSIn Denmark, the cancer patient pathway for non-specific symptoms and signs of cancer (NSSC-CPP) has been implemented with variations, but little is known about these different modalities. This study showed that both at a regional and an intra-regional level:•General practitioners meet different implementation of national guidelines in the diagnostic units when referring to the NSSCP-CPP•The suitable patient group for the NSSC-CPP is not well defined•Quality criteria are needed to monitor, evaluate and improve the diagnostic work-up for patients with non-specific symptoms and signs of cancer.

Knowledge of symptoms, time to presentation and barriers to medical help-seeking among Omani women diagnosed with breast cancer: a cross-sectional study

OBJECTIVE

To identify knowledge of breast cancer (BC) symptoms, time taken to consult a doctor and factors contributing to delays in medical help-seeking.

DESIGN

A cross-sectional study of Omani women diagnosed with BC.

SETTING

The two main teaching hospitals in Oman: Royal Hospital and Sultan Qaboos University Hospital.

PARTICIPANTS

Adult Omani women recently diagnosed with BC.

TOOLS

The Breast Module of the Cancer Awareness Measure and the International Cancer Benchmarking Partnership questionnaire were used to collect data.

RESULTS

A total of 300 women with BC participated (response rate: 91.0%). The mean age at diagnosis was 43.0±12.50 years and 33.5% were diagnosed at stage III or IV. Although most women (74.4%) recognised breast/armpit lumps to be a symptom of BC, less than half identified other symptoms, including breast/armpit pain (44.0%), changes in the position of the nipple (36.2%), redness (31.7%), fatigue (26.3%), weight loss (23.4%) and loss of appetite (20.8%). While most (91.6%) were aware that BC could be cured if detected early, only 66.4% sought medical help within a month of developing symptoms. Initial responses to symptoms included informing husbands (40.2%) or family members (36.5%). Barriers to seeking medical help included feeling scared (68.9%) and worried about what the doctor might find (62.8%). Highly educated women were more likely to recognise the following as BC symptoms: changes in nipple position (OR: 0.16, 95% CI 0.03 to 0.81), breast pain (OR: 0.10, 95% CI 0.01 to 0.86) and unexplained weight loss (OR: 0.18, 95% CI 0.04 to 0.88) (all p<0.05).

CONCLUSIONS

Although many Omani women with BC were aware of the importance of early diagnosis, most demonstrated inadequate knowledge of symptoms, did not prioritise seeking medical help and reported emotional barriers to help-seeking. More educational measures are needed to improve symptom recognition and address help-seeking barriers to minimise delays in diagnosis.

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.

Association between hospital interval and survival in patients with oral cancer: A waiting time paradox

BACKGROUND

In early diagnosis studies on symptomatic cancer, survival was the most recommended outcome. The magnitude and impact of the patient interval and primary care interval is well-known in oral cancer; however, the hospital interval and its influence on surviving this neoplasia are not well known.

AIMS

To quantify the interval between the first contact with the specialist and the start of treatment for patients with oral cancer and to evaluate whether there was a link between this interval and disease survival.

METHODS

We designed a hospital-based study that included 228 patients diagnosed with oral/oropharyngeal squamous cell carcinoma between 1998 and 2008 at A Coruña University Hospital (Spain) who were followed up until 2016. The data were extracted retrospectively from hospital medical charts. The study interval was defined in the context of the "pathways to treatment" model as the interval from the first specialist visit (start point) to the start of treatment (end point). We calculated the total interval (from first symptom to treatment) to evaluate the relative length of the hospital interval, and we considered the variables age, sex, location, comorbidity and tumour classification stage. Survival time was defined as the interval from the first treatment to death or censoring.

RESULTS

The median hospital interval was 20 days, with an interquartile range of 15-29.1 days. The most relevant prognostic variable was the tumour stage (III-IV: Exp. ß = 2.8, p = 0.001). The hospital interval was part of the multivariate model, and its association with mortality showed a V-shaped association, where patients with short hospital intervals (3-18 days) and those with long hospital intervals (26-55 days) had significantly higher mortality than those with medium hospital intervals (19-25 days).

CONCLUSION

The hospital interval represents a relevant interval for the patient's path towards treatment, has prognostic implications and is subject to a severity bias (waiting time paradox) that should be avoided.

Achieving a timely diagnosis for teenagers and young adults with cancer: the ACE "too young to get cancer?" study

Background

Time to diagnosis (TTD) concerns teenagers and young adults (TYA) with cancer and may affect outcome.

Methods

Healthcare records from 105 TYA in a regional cancer service were assessed to document events from 1st symptom to treatment start. Detailed pathway construction was possible for 104 patients and allowed a multidisciplinary panel review of each pathway with assessment of good practice and lessons for the future.

Results

1st presentation was to primary care in 86, and 93% consulted in primary care before diagnosis. Routes to Diagnosis were 45% via urgent 2 Week Wait pathways and 38% as emergency referrals. Total Interval (time from 1st presentation to treatment start) was median 63 (range 1–559) days, varying within/between diagnoses. Patient interval (time from 1st symptom to 1st presentation) was longest for lymphoma, carcinoma and bone tumour (medians: 9, 12, 20 days). Overall, time in primary care was short (median 3, range 0–537 days) compared to secondary care (median 29, range 0–195 days) and longest for lymphoma, carcinoma, brain/CNS (medians: 10, 15, 16 days). Specialist Care interval (time from 1st specialist visit to treatment start) was longest for bone, brain/CNS, lymphoma, carcinoma (medians: 30, 33, 36, 48 days). 40% pathways were rated as showing good/best practice but 16% were less than satisfactory. Continued safety-netting/support was identified from primary care but analysis suggested opportunities for improvement in transition through secondary care.

Conclusions

Previous reports of prolonged TTD have focused on delay in referral from primary care but this study suggests that this might be reduced by optimising management in secondary care.