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

Exploring colorectal cancer patients' diagnostic pathways and general practitioners' assessment of the diagnostic processes: a Danish survey study

INTRODUCTION

Colorectal cancer (CRC) is among the most common cancers and the prognosis of CRC is highly dependent on stage at diagnosis. Although many cases are diagnosed swiftly, there is still room for improvement.

AIM

We aimed to explore CRC diagnostic pathways, encompassing (1) place of initial contact; (2) associations with symptom presentations, sex, and age with events in the diagnostic process and initial referrals and (3) the general practitioner's (GP's) evaluation of the diagnostic processes.

METHODS

All GPs in North-, Central-, and Southern Denmark were invited to fill in questionnaires for their listed patients diagnosed with cancer during the past two years.

RESULTS

Among 1,032 recorded CRC patients, 65% had their initial contact in general practice, 5% within the out-of hours service, 10% in the hospital, and 20% were diagnosed based on screening. A total of 27% of CRC patients over 40 who initially presented in general practice were treated or referred on suspicion of another disease first, and 9% were reported to have had hesitated in seeking medical attention. Some 37% presented solely non-specific symptoms, increasing the odds of the GP advising watchful waiting (OR 2.48; 95% CI 1.06-5.81), treating or referring on the suspicion of another illness first (OR 2.57; 95% CI 1.76-3.75), wait due to normal findings (OR 2.11; 95% CI 1.16-3.85), or referring to diagnostic imaging (OR 3.07; 95% CI 1.63-5.79). The GPs assessed nearly one fifth of the diagnostic processes as poor.

CONCLUSION

Most CRC patients are diagnosed with initial presentation in general practice. Having non-specific symptoms is common and challenges timely diagnosis.

Gender and sex interactions are intrinsic components of cancer phenotypes

Sex is a significant determinant of cancer incidence and outcome. The effects of sexual differentiation on normal and cancer biology underly this epidemiology. The resultant sex differences in therapeutic target pathways and processes provide a foundation for developing more personalized cancer treatments. However, our efforts at personalization cannot stop there. Humans also have gender, and sex and gender are highly interactive in individuation. Thus, we will also need to consider how gender-sex interactions (GSI) affect cancer biology and clinical parameters such as the timing of diagnoses, clinical trial enrolment, and the completeness of efficacy and toxicity data. Ignoring the effects of GSI can compromise the quality of basic biological and clinical data and the conclusions drawn from them. This is not to say that GSI will always have a significant effect or any effect at all in every cancer study. Rather, it is to say that we know enough about GSI and human cancer to anticipate measurable differences when GSI are considered in research, enabling us to experimentally determine whether their effects are significant. Here, I delve deeply into GSI and cancer, as this approach to treatment personalization holds great promise to benefit all patients with cancer.

Understanding ethnic inequalities in cancer diagnostic intervals: a cohort study of patients presenting suspected cancer symptoms to GPs in England

BACKGROUND

UK Asian and Black patients experience longer cancer diagnostic intervals - the period between initial symptomatic presentation in primary care and cancer diagnosis.

AIM

To determine whether the differences in diagnostic intervals are because of prolonged primary care, referral, or secondary care interval.

DESIGN AND SETTING

A cohort study was undertaken of 70 971 patients with seven cancers (breast, lung, prostate, colorectal, oesophagogastric, myeloma, ovarian) diagnosed after symptom presentation in English primary care.

METHOD

Data on symptom presentation and diagnosis were extracted from cancer registry-linked primary care and secondary care data. Primary interval was defined as the period between first primary care presentation and secondary care referral, referral interval as the period between referral and first secondary care appointment, and secondary care interval as the period between the first secondary care appointment and diagnosis. Accelerated failure time models were used to investigate ethnic differences across all four intervals.

RESULTS

Across all sites, the median diagnostic interval was 46 days, ranging from 13 days for breast cancer to 116 days for lung cancer. It was 14% longer for Black patients (adjusted time ratio [ATR] 1.14, 95% confidence interval [CI] = 1.05 to 1.25) and 13% longer for Asian patients (ATR 1.13, 95% CI = 1.03 to 1.23) compared with White patients. Site-specific analyses showed that, for myeloma, lung, prostate, and colorectal cancer, the secondary care interval was longer in Asian and Black patients, who also had a longer primary care interval in breast and colorectal cancer. There was little evidence of ethnic differences in referral interval.

CONCLUSION

This study found evidence of ethnic differences in diagnostic intervals, with prolonged secondary care intervals for four common cancers and prolonged primary care intervals for two. Although these differences are relatively modest, they are unjustified and may indicate shortcomings in healthcare delivery that disproportionately affect ethnic minorities.

Are we ignoring sex differences in haematological malignancies? A call for improved reporting

There are clear sex-based differences in the incidence, risk factors and mortality of most haematologic malignancies (HM). Despite known differences in physiology, haematopoiesis, molecular profiles, drug pharmacokinetics, treatment-related toxicities and treatment experience, males and females receive standardized and identical treatment for most HMs. Previous published work has demonstrated disparities in female representation in cancer clinical trials and highlighted a paucity of information on differential treatment outcomes and toxicities by sex. We analysed references of 182 clinical trials which form the basis of recent treatment guidelines from the National Comprehensive Cancer Network and found a minority (17/9.3%) did not report the sex distribution of trial participants. However, a majority (165/90.6%) did not report sex-disaggregated outcomes. Of those that did, 36.5% showed outcome differences by sex. Academic leadership by women in the assessed trials as well as in guidelines committees was disproportionately lower than their representation in the profession. We call on all clinical trials leaders, consortia and guideline builders to include sex-disaggregated data in their analyses, reporting these in a transparent manner (as per regulations mandating such reporting), and for investigators to assess whether aetiological factors differ by sex. These actions will enhance personalized prevention, therapy and follow-up.

Chronic conditions, cancer disparities, and the unique needs of Black women with ovarian cancer

Chronic conditions among women contribute to cancer disparities. Consideration of unique influence sex and gender may be useful in understanding the experiences of Black women with ovarian cancer.

Epidemiology of glioblastoma in Pakistan: a secondary analysis of the Pakistan Brain Tumor Epidemiology Study (PBTES)

PURPOSE

The incidence and outcomes of glioblastoma (GBM) patients in Pakistan remain unassessed owing to a lack of cancer registries and the absence of population-based studies. For any specific population-based oncological intervention, epidemiology must be studied. Therefore, this study aims to examine the epidemiological characteristics of glioblastoma patients in Pakistan, as part of a secondary analysis of a nationwide epidemiological study.

METHODS

Data comprising of sociodemographic, tumor and treatment characteristics of 2750 patients from the Pakistan Brain Tumor Epidemiology Study were extracted and analyzed for cases between January 1, 2019, and December 31, 2019. Chi-square tests identified outcome and treatment differences. Data analysis was performed using SPSS version 26.

RESULTS

A total of 260 GBM cases were analyzed, with a mean diagnosis age of 45 years. Males accounted for 68.8%. Most patients were from a middle- (39.6%) or lower-income (42.7%) socioeconomic background and received care from a public institution (63.8%). GBM tumors were mainly located in the frontal lobe with similar proportions of right and left laterality. A median distance of 119 km was traveled for oncological care, and the mean time to surgery from the initial radiological diagnosis was 72 days. Gross total resection was achieved in 47.3% of first surgeries, with 23 reoperations for recurrence. At the end of the study period, 33% of the GBM cohort was recorded as alive with 47% being lost to follow-up.

CONCLUSION

Our analysis is the first population-based analysis of GBM in Pakistan. This epidemiologic study can serve as a basis for future research in etiology, treatment, and outcomes for glioblastoma in the Pakistani population.

Diagnosis Challenges in Adult Leukemia: Insights From a Single-Center Retrospective Study in Qatar (2016-2021)

ObjectivesWhile delays in leukemia detection remain an ongoing challenge in hematologic cancer care, little is known about the factors associated with these delays. This article focuses on identifying the barriers hindering timely diagnosis of leukemia through a cohort analysis (2016-2021) of 220 Acute Myeloid Leukemia (AML), 161 Chronic Myeloid Leukemia (CML), 90 Acute Lymphocytic Leukemia (ALL), and 121 Chronic Lymphocytic Leukemia (CLL) patients in Qatar.MethodsOf the 592 patients used for the study, subsets were identified and analyzed for delay (423), risk stratification (437), and leukemia stage (282).ResultsThere was an increasing trend in leukemia cases, with 32% of patients being diagnosed in the high-risk category. Out of 423 (median delay = 28 days) patients, 45% reported delayed diagnosis (median delay = 44 days). Further analysis of the association of delayed leukemia diagnosis using the univariate χ 2 independence test revealed significant associations to patient referral type, and the presence of certain comorbidities and symptoms.ConclusionSignificant delays in leukemia diagnosis were identified, though the exact cause remains unclear. These delays can be attributed to factors such as patient, primary care, referral, system, and physician delays. Therefore, further investigation is imperative for improving the detection, diagnosis, and referral processes in hematologic cancers.

The American Cancer Society National Lung Cancer Roundtable strategic plan: Lung cancer in women

Lung cancer in women is a modern epidemic and represents a global health crisis. Cigarette smoking remains the most important risk factor for lung cancer in all patients and, among women globally, rates of smoking continue to increase. Although some data exist supporting sex-based differences across the continuum of lung cancer, there is currently a dearth of research exploring the differences in risk, biology, and treatment outcomes in women. Consequently, the American Cancer Society National Lung Cancer Roundtable recognizes the urgent need to promote awareness and future research that will close the knowledge gaps regarding lung cancer in women. To this end, the American Cancer Society National Lung Cancer Roundtable Task Group on Lung Cancer in Women convened a summit undertaking the following to: (1) summarize existing evidence and identify knowledge gaps surrounding the epidemiology, risk factors, biologic differences, and outcomes of lung cancer in women; (2) develop and prioritize research topics and questions that address research gaps and advance knowledge to improve quality of care of lung cancer in women; and (3) propose strategies for future research. PLAIN LANGUAGE SUMMARY: Lung cancer is the leading cause of cancer mortality in women, and, despite comparatively lower exposures to occupational and environmental carcinogens compared with men, disproportionately higher lung cancer rates in women who ever smoked and women who never smoked call for increased awareness and research that will close the knowledge gaps regarding lung cancer in women.

Standardised and Reproducible Phenotyping Using Distributed Analytics and Tools in the Data Analysis and Real World Interrogation Network (DARWIN EU)

PURPOSE

The generation of representative disease phenotypes is important for ensuring the reliability of the findings of observational studies. The aim of this manuscript is to outline a reproducible framework for reliable and traceable phenotype generation based on real world data for use in the Data Analysis and Real-World Interrogation Network (DARWIN EU). We illustrate the use of this framework by generating phenotypes for two diseases: pancreatic cancer and systemic lupus erythematosus (SLE).

METHODS

The phenotyping process involves a 14-steps process based on a standard operating procedure co-created by the DARWIN EU Coordination Centre in collaboration with the European Medicines Agency. A number of bespoke R packages were utilised to generate and review codelists for two phenotypes based on real world data mapped to the OMOP Common Data Model.

RESULTS

Codelists were generated for both pancreatic cancer and SLE, and cohorts were generated in six OMOP-mapped databases. Diagnostic checks were performed, which showed these cohorts had broadly similar incidence and prevalence figures to previously published literature, despite significant inter-database variability. Co-occurrent symptoms, conditions, and medication use were in keeping with pre-specified clinical descriptions based on previous knowledge.

CONCLUSIONS

Our detailed phenotyping process makes use of bespoke tools and allows for comprehensive codelist generation and review, as well as large-scale exploration of the characteristics of the resulting cohorts. Wider use of structured and reproducible phenotyping methods will be important in ensuring the reliability of observational studies for regulatory purposes.

Health inequalities in cancer care: a literature review of pathways to diagnosis in the United Kingdom

This literature review discusses current health disparities in cancer care in the United Kingdom, spanning access to services, diagnosis, and outcomes. These inequities stem from a complex interplay of factors such as health literacy, ethnicity, socioeconomic status, age, gender, geography, and lifestyle choices. Health literacy plays a crucial role in timely healthcare seeking and diagnosis, while cultural beliefs significantly shape perceptions and behaviours. Socioeconomic barriers often result in delayed diagnosis and inferior outcomes due to limited access to preventive measures and high-quality treatment. Barriers to timely diagnosis include non-specific symptoms, variations in diagnostic intervals influenced by age and gender, and non-attendance at secondary care appointments. Addressing these challenges necessitates initiatives aimed at improving health literacy, implementing culturally sensitive screening approaches, and enhancing accessibility to both primary and secondary care services.

The effect of comorbidities on diagnostic interval for lung cancer in England: a cohort study using electronic health record data

BACKGROUND

Comorbid conditions may delay lung cancer diagnosis by placing demand on general practioners' time reducing the possibility of prompt cancer investigation ("competing demand conditions"), or by offering a plausible non-cancer explanation for signs/symptoms ("alternative explanation conditions").

METHOD

Patients in England born before 1955 and diagnosed with incident lung cancer between 1990 and 2019 were identified in the Clinical Practice Research Datalink and linked hospital admission and cancer registry data. Diagnostic interval was defined as time from first presentation in primary care with a relevant sign/symptom to the diagnosis date. 14 comorbidities were classified as ten "competing demand" and four "alternative explanation" conditions. Associations with diagnostic interval were investigated using multivariable linear regression models.

RESULTS

Complete data were available for 11870 lung cancer patients. In adjusted analyses diagnostic interval was longer for patients with "alternative explanation" conditions, by 31 and 74 days in patients with one and ≥2 conditions respectively versus those with none. Number of "competing demand" conditions did not remain in the final adjusted regression model for diagnostic interval.

CONCLUSIONS

Conditions offering alternative explanations for lung cancer symptoms are associated with increased diagnostic intervals. Clinical guidelines should incorporate the impact of alternative and competing causes upon delayed diagnosis.

Re-Exposure to Culprit Medication Following Adverse Drug Event Diagnosis in Canadian Emergency Department Patients: A Cohort Study

PURPOSE

The magnitude of repeat exposures to culprit medications after hospital discharge is not well studied. We combined prospective cohort data with administrative health data to understand the frequency of repeat exposures to culprit medications after discharge and the risk factors for their occurrence.

METHODS

This was a retrospective analysis of three prospective cohorts of patients who presented to the hospital with an adverse drug event in British Columbia, from 2008 to 2015 (n = 849). We linked prospectively identified adverse drug events to administrative data to examine patterns of redispensing of culprit medications. We used Cox regression to assess risk factors for re-exposure, and conducted subgroup analyses for essential vs. nonessential medications.

RESULTS

Among 849 diagnosed adverse drug events, 45.2% had subsequent culprit medication redispensing within a year of hospital discharge. The factors associated with re-exposures included atrial fibrillation, adverse drug event type (e.g. adverse reaction), culprit medication type, and longer historical duration of medication use.

CONCLUSIONS

Re-exposures to culprit medications occurred in almost half of the adverse drug events diagnosed in emergency departments. Many of these were appropriate re-exposures to essential medications for indications in which the risk of uncontrolled disease likely outweighed the risk of a repeat adverse event. More research is needed to understand re-exposures to nonessential medications or medications with safer alternatives.

Income differences in time to colon cancer diagnosis

INTRODUCTION

People with low income have worse outcomes throughout the cancer care continuum; however, little is known about income and the diagnostic interval. We described diagnostic pathways by neighborhood income and investigated the association between income and the diagnostic interval.

METHODS

This was a retrospective cohort study of colon cancer patients diagnosed 2007-2019 in Ontario using routinely collected data. The diagnostic interval was defined as the number of days from the first colon cancer encounter to diagnosis. Asymptomatic pathways were defined as first encounter with a colonoscopy or guaiac fecal occult blood test not occurring in the emergency department and were examined separately from symptomatic pathways. Quantile regression was used to determine the association between neighborhood income quintile and the conditional 50th and 90th percentile diagnostic interval controlling for age, sex, rural residence, and year of diagnosis.

RESULTS

A total of 64,303 colon cancer patients were included. Patients residing in the lowest income neighborhoods were more likely to be diagnosed through symptomatic pathways and in the emergency department. Living in low-income neighborhoods was associated with longer 50th and 90th-percentile symptomatic diagnostic intervals compared to patients living in the highest income neighborhoods. For example, the 90th percentile diagnostic interval was 15 days (95% CI 6-23) longer in patients living in the lowest income neighborhoods compared to the highest.

CONCLUSION

These findings reveal income inequities during the diagnostic phase of colon cancer. Future work should determine pathways to reducing inequalities along the diagnostic interval and evaluate screening and diagnostic assessment programs from an equity perspective.

Anogenital HPV-Related Cancers in Women: Investigating Trends and Sociodemographic Risk Factors

The incidences of anogenital HPV-related cancers in women are on the rise; this is especially true for anal cancer. Medical societies are now beginning to recommend anal cancer screening in certain high-risk populations, including high-risk women with a history of genital dysplasia. The aim of this study is to investigate national anogenital HPV cancer trends as well as the role of demographics, deprivation, and ethnicity on anogenital cancer incidence in England, in an attempt to better understand this cohort of women which is increasingly affected by anogenital HPV-related disease. Demographic data from the Clinical Outcomes and Services Dataset (COSD) were extracted for all patients diagnosed with anal, cervical, vulval and vaginal cancer in England between 2014 and 2020. Outcomes included age, ethnicity, deprivation status and staging. An age over 55 years, non-white ethnicity and high deprivation are significant risk factors for late cancer staging, as per logistic regression. In 2019, the incidences of anal and vulval cancer in white women aged 55-74 years surpassed that of cervical cancer. More needs to be done to educate women on HPV-related disease and their lifetime risk of these conditions.

Sex differences in the pre-hospital ambulance delay, assessment and treatment of patients with acute coronary syndrome: a rapid evidence review

Background

Chest pain is a frequent symptom suffered by adult patients attended by ambulance. Evidence suggests female patients may suffer different symptoms to their male counterparts, potentiating differences in pre-hospital time delays, assessment and treatment.

Objective

To explore the sex differences in the pre-hospital ambulance delay, assessment and treatment of patients with acute coronary syndrome (ACS).

Methods

A rapid evidence review was conducted following the Cochrane rapid review guidelines. MEDLINE and CINAHL Complete were searched via EBSCOhost on 2 February 2023, and reference lists of included studies and reviews were screened. The Joanna Briggs Institute checklist for analytical cross-sectional studies was used to perform critical appraisal, and a narrative synthesis was conducted.

Results

From 216 articles screened, nine were included, representing over 3.1 million patients from five different countries. Female patients were more likely to suffer delays in time to first electrocardiogram (ECG) and delays in transport time to the emergency department by ambulance. Female patients were also less likely to receive an ECG, aspirin, glyceryl trinitrate and other analgesics.

Conclusion

There are sex disparities in the pre-hospital ambulance delay, assessment and treatment of patients with ACS. Future research is urgently needed to fully understand the reasons for these observations.

Diagnostic journey for individuals with fibrous dysplasia / McCune albright syndrome (FD/MAS)

BACKGROUND

Reducing delayed diagnosis is a significant healthcare priority for individuals with rare diseases. Fibrous Dysplasia/ McCune Albright Syndrome (FD/MAS) is a rare bone disease caused by somatic activation mutations of NASA. FD/MAS has a broad clinical phenotype reflecting variable involvement of bone, endocrine and other tissues, distribution and severity. The variable phenotype is likely to prolong the diagnostic journey for patients further.

AIM

To describe the time from symptom onset to final diagnosis in individuals living with FDMAS.

METHODS

We used the UK-based RUDY research database ( www.rudystudy.org ), where patients self-report their diagnosis of FD/MAS. Participants are invited to complete the diagnostic journey based on the EPIRARE criteria.

RESULTS

51 individuals diagnosed with FD/MAS were included in this analysis. Among them, 70% were female, and the median age was 51.0 years (IQR 34.5-57.5]. 12 (35%) individuals reported McCune Albright Syndrome, 11 (21.6%) craniofacial and 11(21.6%) for each of poly- and mono-ostotic FD and 6 (11.8%) did not know their type of FD/MAS. Pain was the commonest first symptom (58.8%), and 47.1% received another diagnosis before the diagnosis of FD/MAS. The median time to final diagnosis from the first symptom was two years with a wide IQR (1,18) and range (0-59 years). Only 12 (23.5%) of individuals were diagnosed within 12 months of their first symptoms. The type of FD/MAS was not associated with the reported time to diagnosis. Significant independent predictors of longer time to final diagnosis included older current age, younger age at first symptom and diagnosis after 2010.

CONCLUSION

Individuals with FDMAS have a variable time to diagnosis that can span decades. This study highlights the need for further research on how to improve diagnostic pathways within Orthopaedic and Ear, Nose and Throat (ENT)/Maxillofacial services. Our data provides a baseline to assess the impact of novel NHS diagnostic networks on reducing the diagnostic odyssey.

Gender as a social and structural variable: research perspectives from the National Institutes of Health (NIH)

Gender is a social and structural variable that encompasses multiple domains, each of which influences health: gender identity and expression, gender roles and norms, gendered power relations, and gender equality and equity. As such, gender has far-reaching impacts on health. Additional research is needed to continue delineating and untangling the effects of gender from the effects of sex and other biological variables. The National Institutes of Health (NIH) vision for women's health is a world in which the influence of sex and/or gender are integrated into the health research enterprise. However, much of the NIH-supported research on gender and health has, to date, been limited to a small number of conditions (e.g., HIV, mental health, pregnancy) and locations (e.g., sub-Saharan Africa; India). Opportunities exist to support transdisciplinary knowledge transfer and interdisciplinary knowledge building by advancing health-related social science research that incorporates best practices from disciplines that have well-established methods, theories, and frameworks for examining the health impacts of gender and other social, cultural, and structural variables.

Black-White differences in uterine cancer symptomatology and stage at diagnosis

OBJECTIVE

To examine whether uterine cancer symptoms differ between Black and White patients and how this may influence their stage at diagnosis.

METHODS

Using the Surveillance, Epidemiology and End Results-Medicare database, we identified 2328 Black and 21,774 White patients with uterine cancer in 2008-2017. Their symptoms in the 18 months before diagnosis were categorized as postmenopausal bleeding (PMB) alone, PMB together with other symptoms (e.g., abdominal/pelvic pain, bloating), non-PMB symptoms alone, or no symptoms. Stage at diagnosis was dichotomized as advanced (i.e., regional/distant) versus localized. The association between race and stage was analyzed using regression models incrementally adjusting for symptoms and other patient characteristics.

RESULTS

A larger proportion of Black than White patients experienced PMB together with other symptoms (63.1% versus 58.0%) or experienced non-PMB symptoms alone (13.1% versus 9.4%) (p < 0.001). Black patients had a higher risk of advanced-stage diagnosis than White patients (45.0% versus 30.3%, unadjusted RR = 1.52, 95% CI: 1.44-1.59). Adjusting for Black-White differences in symptoms attenuated the RR to 1.46 (95% CI: 1.39-1.53). Compared to PMB symptoms alone, having additional non-PMB symptoms (RR = 1.21, 95% CI: 1.15-1.26) and having non-PMB symptoms alone (RR = 1.99, 95% CI: 1.88-2.10) were associated with increased risk of advanced-stage diagnosis. Further adjusting for histology and other patient characteristics reduced Black-White disparity in advanced-stage diagnosis to 1.08 (95% CI: 1.03-1.14) but symptoms remained significantly associated with stage at diagnosis.

CONCLUSIONS

Having non-PMB symptoms was associated with more advanced stage at diagnosis. Non-PMB symptoms were more common among Black than White patients, which might hinder symptom recognition/evaluation.

Presence of Breast Cancer Information Recorded in United Kingdom Primary Care Databases: Comparison of CPRD Aurum and CPRD GOLD (Companion Paper 1)

Purpose

To evaluate the presence of data elements related to diagnosis and treatment of malignant breast cancer in CPRD Aurum compared to those in the previously validated CPRD GOLD.

Methods

Females in CPRD Aurum or GOLD with a first-time code for malignant breast cancer, mastectomy, or ≥1 prescription for tamoxifen or aromatase inhibitors (2004-2019) were selected. We compared the presence of the codes for breast cancer diagnosis, surgeries (mastectomy, lumpectomy), tamoxifen and aromatase inhibitor prescriptions, radiation, chemotherapy, and supporting clinical codes (suspected breast cancer, lump symptoms, biopsy, lumpectomy, cancer care, referral/visit to specialist, palliative care). Age standardized incidence rates of breast cancer diagnosis in CPRD Aurum and GOLD were calculated.

Results

There were 131,936 eligible patients in CPRD Aurum and 69,102 patients in GOLD. A similar proportion of patients in CPRD Aurum and GOLD had codes for breast cancer diagnosis, mastectomy, drug prescriptions, lump, biopsy, lumpectomy, chemotherapy, and cancer and palliative care coded in their electronic record during follow-up. However, suspected breast cancer, radiation, and referral/visits to specialists were coded more frequently in patients in CPRD Aurum compared to GOLD. Age-standardized incidence rates were similar for CPRD Aurum and GOLD.

Conclusion

Overall, there was consistency between data elements related to malignant breast cancer recorded in CPRD Aurum and GOLD, particularly for the most informative clinical details. These findings provide reassurance that breast cancer information recorded in CPRD Aurum is generally comparable to that recorded in the previously validated CPRD GOLD and support the use of CPRD Aurum for breast cancer research.

Patient-reported symptoms and diagnostic journey in Multiple Myeloma

Introduction

Late presentation of multiple myeloma (MM) heightens the risk of complication risks, including end-organ damage. This study aimed to: 1) detail the diagnostic journey of MM patients, encompassing symptoms, initial diagnoses, and healthcare professionals met; 2) establish the median duration from symptom onset to MM diagnosis; and 3) examine factors linked to timely MM diagnosis within 12 weeks.

Methods

A total of 300 adults self-reporting MM were analysed from the Rare and Undiagnosed Diseases cohort Study (RUDY). The RUDY study is a web-based platform, where participants provide dynamic consent and self-report their MM diagnosis and information about their diagnostic journey. This includes the estimated date of initial potential first symptoms, descriptions of these symptoms, the healthcare professionals they consulted, and other diagnoses received before the MM diagnosis. Descriptive statistics, combinatorial analyses and logistic regression analyses were used to describe and examine the diagnostic journey of individuals with MM.

Results

Overall, 52% of the participants reported other diagnoses before MM diagnosis, with musculoskeletal disorders (47.8%), such as osteoporosis, costochondritis, or muscle strains, being the most common. The most prevalent initial reported symptom was back pain/vertebral fractures (47%), followed by chest/shoulder pain, including rib pain and fractures (20%), and fatigue/tiredness (19.7%). 40% of participants were diagnosed by direct referral from primary care to haematology without seeing other healthcare professionals whilst 60% consulted additional specialists before diagnosis. The median time from symptom onset to MM diagnosis was 4 months (IQR 2-10 months, range 0-172). Seeing an Allied Healthcare Professional such as a physiotherapist, chiropractor or an osteopath (OR = 0.25, 95% CI [0.12, 0.47], p <0.001), experiencing infection symptoms (OR = 0.32, 95% CI [0.13, 0.76], p = 0.013), and having chest or shoulder pain (OR = 0.45, 95% CI [0.23, 0.86], p = 0.020) were associated with a lower likelihood of being diagnosed with MM within 12 weeks. Older age (OR = 1.04, 95% CI [1.02, 1.07], p = 0.001) was associated with a higher likelihood of diagnosis within 12 weeks.

Discussion

Developing resources for allied health professionals may improve early recognition of MM.

A taxonomy of early diagnosis research to guide study design and funding prioritisation

Researchers and research funders aiming to improve diagnosis seek to identify if, when, where, and how earlier diagnosis is possible. This has led to the propagation of research studies using a wide range of methodologies and data sources to explore diagnostic processes. Many such studies use electronic health record data and focus on cancer diagnosis. Based on this literature, we propose a taxonomy to guide the design and support the synthesis of early diagnosis research, focusing on five key questions: Do healthcare use patterns suggest earlier diagnosis could be possible? How does the diagnostic process begin? How do patients progress from presentation to diagnosis? How long does the diagnostic process take? Could anything have been done differently to reach the correct diagnosis sooner? We define families of diagnostic research study designs addressing each of these questions and appraise their unique or complementary contributions and limitations. We identify three further questions on relationships between the families and their relevance for examining patient group inequalities, supported with examples from the cancer literature. Although exemplified through cancer as a disease model, we recognise the framework is also applicable to non-neoplastic disease. The proposed framework can guide future study design and research funding prioritisation.

Advancing AI in healthcare: A comprehensive review of best practices

Artificial Intelligence (AI) and Machine Learning (ML) are powerful tools shaping the healthcare sector. This review considers twelve key aspects of AI in clinical practice: 1) Ethical AI; 2) Explainable AI; 3) Health Equity and Bias in AI; 4) Sponsorship Bias; 5) Data Privacy; 6) Genomics and Privacy; 7) Insufficient Sample Size and Self-Serving Bias; 8) Bridging the Gap Between Training Datasets and Real-World Scenarios; 9) Open Source and Collaborative Development; 10) Dataset Bias and Synthetic Data; 11) Measurement Bias; 12) Reproducibility in AI Research. These categories represent both the challenges and opportunities of AI implementation in healthcare. While AI holds significant potential for improving patient care, it also presents risks and challenges, such as ensuring privacy, combating bias, and maintaining transparency and ethics. The review underscores the necessity of developing comprehensive best practices for healthcare organizations and fostering a diverse dialogue involving data scientists, clinicians, patient advocates, ethicists, economists, and policymakers. We are at the precipice of significant transformation in healthcare powered by AI. By continuing to reassess and refine our approach, we can ensure that AI is implemented responsibly and ethically, maximizing its benefit to patient care and public health.

A disproportionality analysis of the adverse effect profiles of methimazole and propylthiouracil in patients with hyperthyroidism using the Japanese Adverse Drug Event Report Database

BACKGROUND

Antithyroid drugs (ATDs) are frequently used to achieve euthyroidism in patients with hyperthyroidism. ATDs cause characteristic common and rare adverse events; however, comprehensive comparisons between methimazole (MMI) and propylthiouracil (PTU) in terms of adverse events are limited.

METHODS

In this study, we thoroughly explored adverse events in association with MMI and PTU use with a disproportionality analysis using the Japanese Adverse Drug Event Report (JADER) database and evaluated the prevalence of MMI and PTU prescriptions using the National Database of Health Insurance Claims and Specific Health Checkups (NDB) Open Data Japan. We analyzed 3271 cases of MMI use and 1029 cases of PTU use with respect to 9789 preferred terms (PTs) for adverse events registered in the JADER database by calculating and comparing reporting odds ratios (RORs).

RESULTS

We found that 8 PTs, including agranulocytosis (p < 0.0001, 4.01-fold), aplasia cutis congenita (p < 0.0001, 123.22-fold), and exomphalos (p = 0.0002, 22.17-fold), demonstrated significantly higher RORs (more than 4-fold) for MMI use than for PTU use. Nineteen PTs, including anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (p < 0.0001, 29.84), rapidly progressive glomerulonephritis (p < 0.0001, 6.44), and pulmonary alveolar hemorrhage (p < 0.0001, 7.77), had RORs for PTU use more than four times those for MMI use. NDB Open Data Japan showed more frequent PTU prescriptions than MMI prescriptions for women of reproductive age.

CONCLUSIONS

This large-scale study confirmed that a variety of congenital malformations were identified as having significantly high RORs for MMI use, while diseases related to ANCA-associated vasculitis were specific to PTU.

Structural Sexism and Cancer Care: The Effects on the Patient and Oncologist

Despite progress toward equity within our broad social context, the domains of gender as a social, cultural, and structural variable continue to exert influence on the delivery of oncology care. Although there have been vast advances in our understanding of the biological underpinnings of cancer and significant improvements in clinical care, disparities in cancer care for all women-including cisgender, transgender, and gender diverse women-persist. Similarly, despite inclusion within the oncology physician workforce, women and gender minorities, particularly those with additional identities under-represented in medicine, still face structural barriers to clinical and academic productivity and career success. In this article, we define and discuss how structural sexism influences both the equitable care of patients with cancer and the oncology workforce and explore the overlapping challenges in both realms. Solutions toward creating environments where patients with cancer of any gender receive optimal care and all physicians can thrive are put forward.

Chronic conditions in women: the development of a National Institutes of health framework

Rising rates of chronic conditions were cited as one of the key public health concerns in the Fiscal Year (FY) 2021 U.S. Senate and House of Representatives appropriations bills, where a review of current National Institutes of Health (NIH) portfolios relevant to research on women's health was requested. Chronic conditions were last defined by the US Department of Health and Human Services (HHS) in 2010. However, existing definitions of chronic conditions do not incorporate sex or gender considerations. Sex and gender influence health, yet significant knowledge gaps exist in the evidence-base for prevention, diagnosis, and treatment of chronic diseases amongst women. The presentation, prevalence, and long-term effects of chronic conditions and multimorbidity differs in women from men. A clinical framework was developed to adequately assess the NIH investment in research related to chronic conditions in women. The public health needs and NIH investment related to conditions included in the framework were measured. By available measures, research within the NIH has not mapped to the burden of chronic conditions among women. Clinical research questions and endpoints centered around women can be developed and implemented; clinical trials networks with expanded or extended eligibility criteria can be created; and data science could be used to extrapolate the effects of overlapping or multiple morbidities on the health of women. Aligning NIH research priorities to address the specific needs of women with chronic diseases is critical to addressing women's health needs from a life course perspective.

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.

Examining methodology to identify patterns of consulting in primary care for different groups of patients before a diagnosis of cancer: An exemplar applied to oesophagogastric cancer

BACKGROUND

Current methods for estimating the timeliness of cancer diagnosis are not robust because dates of key defining milestones, for example first presentation, are uncertain. This is exacerbated when patients have other conditions (multimorbidity), particularly those that share symptoms with cancer. Methods independent of this uncertainty are needed for accurate estimates of the timeliness of cancer diagnosis, and to understand how multimorbidity impacts the diagnostic process.

METHODS

Participants were diagnosed with oesophagogastric cancer between 2010 and 2019. Controls were matched on year of birth, sex, general practice and multimorbidity burden calculated using the Cambridge Multimorbidity Score. Primary care data (Clinical Practice Research Datalink) was used to explore population-level consultation rates for up to two years before diagnosis across different multimorbidity burdens. Five approaches were compared on the timing of the consultation frequency increase, the inflection point for different multimorbidity burdens, different aggregated time-periods and sample sizes.

RESULTS

We included 15,410 participants, of which 13,328 (86.5 %) had a measurable multimorbidity burden. Our new maximum likelihood estimation method found evidence that the inflection point in consultation frequency varied with multimorbidity burden, from 154 days (95 %CI 131.8-176.2) before diagnosis for patients with no multimorbidity, to 126 days (108.5-143.5) for patients with the greatest multimorbidity burden. Inflection points identified using alternative methods were closer to diagnosis for up to three burden groups. Sample size reduction and changing the aggregation period resulted in inflection points closer to diagnosis, with the smallest change for the maximum likelihood method.

DISCUSSION

Existing methods to identify changes in consultation rates can introduce substantial bias which depends on sample size and aggregation period. The direct maximum likelihood method was less prone to this bias than other methods and offers a robust, population-level alternative for estimating the timeliness of cancer diagnosis.

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.

Agreement between patient's description of abdominal symptoms of possible upper gastrointestinal cancer and general practitioner consultation notes: a qualitative analysis of video-recorded UK primary care consultation data

INTRODUCTION

Abdominal symptoms are common in primary care but infrequently might be due to an upper gastrointestinal (UGI) cancer. Patients' descriptions may differ from medical terminology used by general practitioners (GPs). This may affect how information about abdominal symptoms possibly due to an UGI cancer are documented, creating potential missed opportunities for timely investigation.

OBJECTIVES

To explore how abdominal symptoms are communicated during primary care consultations, and identify characteristics of patients' descriptions that underpin variation in the accuracy and completeness with which they are documented in medical records.

METHODS AND ANALYSIS

Primary care consultation video recordings, transcripts and medical records from an existing dataset were screened for adults reporting abdominal symptoms. We conducted a qualitative content analysis to capture alignments (medical record entries matching patient verbal and non-verbal descriptions) and misalignments (symptom information omitted or differing from patient descriptions). Categories were informed by the Calgary-Cambridge guide's 'gathering information' domains and patterns in descriptions explored.

RESULTS

Our sample included 28 consultations (28 patients with 18 GPs): 10 categories of different clinical features of abdominal symptoms were discussed. The information GPs documented about these features commonly did not match what patients described, with misalignments more common than alignments (67 vs 43 instances, respectively). Misalignments often featured patients using vague descriptors, figurative speech, lengthy explanations and broad hand gestures. Alignments were characterised by patients using well-defined terms, succinct descriptions and precise gestures for symptoms with an exact location. Abdominal sensations reported as 'pain' were almost always documented compared with expressions of 'discomfort'.

CONCLUSIONS

Abdominal symptoms that are well defined or communicated as 'pain' may be more salient to GPs than those expressed vaguely or as 'discomfort'. Variable documentation of abdominal symptoms in medical records may have implications for the development of clinical decision support systems and decisions to investigate possible UGI cancer.

"I Just Want to Feel Safe Going to a Doctor": Experiences of Female Patients with Chronic Conditions in Australia

Background

The androcentric history of medicine and medical research has led to an ongoing sex and gender gap in health research and education. Sex and gender gaps in research and education may translate into real-life health inequities for women. This study aimed to explore the experiences of female patients with chronic health conditions in the Australian health system, considering existing sex and gender gaps in medicine.

Methods

This qualitative study used semistructured in-depth interviews with a sample of adult women with chronic conditions in Australia. Thematic analysis was undertaken, guided by Braun and Clarke. Software NVivoX64 assisted in the management of the data. Coding was performed before grouping into subthemes and central themes. To allow for potential researcher biases, the principal researcher engaged in the practice of reflexivity, including the writing of detailed notes during analysis.

Results

Twenty adult Australian women with chronic conditions were interviewed. Diagnoses were varied and included Ehlers-Danlos syndrome, chronic fatigue syndrome, functional neurological disorder, and inflammatory bowel disease. Four central themes emerged: diagnostic difficulties; spectrum of health care experiences; understanding medical complexity; and coping with symptoms.

Conclusions

Women with chronic conditions in Australia report pain, fatigue, and suffering that significantly impacts upon their daily lives. There was a shared experience of feeling that the pain and suffering of women was dismissed or not taken seriously. Many women expressed trauma because of their experiences in health care and often this led to a fear of accessing health services. The participants highlighted a need for more knowledge, understanding, and empathy from health care practitioners.

Diagnostic pathways for breast cancer in 10 International Cancer Benchmarking Partnership (ICBP) jurisdictions: an international comparative cohort study based on questionnaire and registry data

OBJECTIVES

A growing body of evidence suggests longer time between symptom onset and start of treatment affects breast cancer prognosis. To explore this association, the International Cancer Benchmarking Partnership Module 4 examined differences in breast cancer diagnostic pathways in 10 jurisdictions across Australia, Canada, Denmark, Norway, Sweden and the UK.

SETTING

Primary care in 10 jurisdictions.

PARTICIPANT

Data were collated from 3471 women aged >40 diagnosed for the first time with breast cancer and surveyed between 2013 and 2015. Data were supplemented by feedback from their primary care physicians (PCPs), cancer treatment specialists and available registry data.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patient, primary care, diagnostic and treatment intervals.

RESULTS

Overall, 56% of women reported symptoms to primary care, with 66% first noticing lumps or breast changes. PCPs reported 77% presented with symptoms, of whom 81% were urgently referred with suspicion of cancer (ranging from 62% to 92%; Norway and Victoria). Ranges for median patient, primary care and diagnostic intervals (days) for symptomatic patients were 3-29 (Denmark and Sweden), 0-20 (seven jurisdictions and Ontario) and 8-29 (Denmark and Wales). Ranges for median treatment and total intervals (days) for all patients were 15-39 (Norway, Victoria and Manitoba) and 4-78 days (Sweden, Victoria and Ontario). The 10% longest waits ranged between 101 and 209 days (Sweden and Ontario).

CONCLUSIONS

Large international differences in breast cancer diagnostic pathways exist, suggesting some jurisdictions develop more effective strategies to optimise pathways and reduce time intervals. Targeted awareness interventions could also facilitate more timely diagnosis of breast cancer.

A systematic review of interventions to recognise, refer and diagnose patients with lung cancer symptoms

Patients with lung cancer (LC) often experience delay between symptom onset and treatment. Primary healthcare professionals (HCPs) can help facilitate early diagnosis of LC through recognising early signs and symptoms and making appropriate referrals. This systematic review describes the effect of interventions aimed at helping HCPs recognise and refer individuals with symptoms suggestive of LC. Seven studies were synthesised narratively. Outcomes were categorised into: Diagnostic intervals; referral and diagnosis patterns; stage distribution at diagnosis; and time interval from diagnosis to treatment. Rapid access pathways and continuing medical education for general practitioners can help reduce LC diagnostic and treatment delay. Awareness campaigns and HCP education can help inform primary HCPs about referral pathways. However, campaigns did not significantly impact LC referral rates or reduce diagnostic intervals. Disease outcomes, such as LC stage at diagnosis, recurrence, and survival were seldom measured. Review findings highlight the need for longitudinal, powered, and controlled studies.

Self-Reported Time to Diagnosis and Proportions of Rediagnosis in Female Patients with Chronic Conditions in Australia: A Cross-sectional Survey

Background

The diagnosis of chronic conditions in women is complicated by the historical androcentricity in medical research. Sex and gender gaps in health research may translate to unequal healthcare for women. This cross-sectional survey study aimed to ascertain the median time to diagnosis, proportions of rediagnosis and time to rediagnosis for Australian women with chronic conditions.

Methods

An online survey collected anonymous data from voluntary participants. Data were analyzed using Stata14. Cox Proportional Hazards model was used to analyze time to diagnosis and rediagnosis. Logistic regression analysis was used to assess the significance of rediagnosis rates by diagnosis, age at diagnosis, income, employment, state of residence, disability status, and Indigenous status.

Results

The median time from first appointment to initial diagnosis was 6 months (range 1 day-50 years) (interquartile range [IQR] 3.74 years). The median time to rediagnosis was 4 years (IQR 9) with a range of 1 day-43 years. Almost half of the women (n = 161/343, 47%) reported their primary condition being rediagnosed. From the complete responses, 40% were rediagnosed from one organic condition to another organic condition, however, 32% of women originally diagnosed with psychological, medically unexplained syndromes, or chronic pain were later rediagnosed with organic conditions.

Conclusion

Median wait times for a diagnosis for women in Australia, when factoring in high rates of rediagnosis and time to rediagnosis, was 4 years. It is important that clinicians are aware of the high rediagnosis rates in female patients with chronic conditions and understand the potential impact of systemic biases on the diagnostic process for women under their care.

Delayed diagnosis of Birt-Hogg-Dubé syndrome might be aggravated by gender bias

BACKGROUND

Birt-Hogg-Dubé syndrome is a rare genetic tumor syndrome characterized by renal cell cancer, lung bullae, pneumothorax, and fibrofolliculoma. Patients with such orphan tumor disorders are at risk of not receiving a timely diagnosis. In the present, gender-sensitive study, we analyzed the delay between onset of symptoms and diagnosis of Birt-Hogg-Dubé syndrome.

METHODS

Clinical data of 158 patients from 91 unrelated families were collected. FLCN mutation testing was performed in index patients and family members.

FINDINGS

The occurrence of the first symptom (fibrofolliculoma, pneumothorax or renal cell cancer) was rarely followed by a timely diagnosis of Birt-Hogg-Dubé syndrome and did so significantly less often in female (1.3%) compared to male (11.4%) patients (chi-square 6.83, p-value 0.009). Only 17 out of 39 renal cell cancers (7/17 female, 10/22 male patients) were promptly recognized as a symptom of Birt-Hogg-Dubé syndrome. Patients in which renal cell cancer was initially not recognized as a symptom of Birt-Hogg-Dubé syndrome waited 9.7 years (females SD 9.2, range 1-29) and 8.8 years (males, SD 4.1, range 2-11) for their diagnosis, respectively. Four (three female, one male) patients developed renal cell cancer twice before the genetic tumor syndrome was diagnosed. The delay between fibrofolliculoma or pneumothorax as a first symptom and diagnosis of Birt-Hogg-Dubé syndrome was considerable but not significantly different between females and males (18.1/17.19 versus 16.1/18.92 years). Furthermore, 73 patients were only diagnosed due to family history (delay 15.1 years in females and 17.4 years in males).

INTERPRETATION

The delay between onset of symptoms and diagnosis of Birt-Hogg-Dubé syndrome can be substantial and gender-dependent, causing considerable health risks for patients and their families. It is therefore important to create more awareness of Birt-Hogg-Dubé syndrome and resolve gender biases in diagnostic work-up.

FUNDING

None declared.

Concordance with urgent referral guidelines in patients presenting with any of six 'alarm' features of possible cancer: a retrospective cohort study using linked primary care records

BACKGROUND

Clinical guidelines advise GPs in England which patients warrant an urgent referral for suspected cancer. This study assessed how often GPs follow the guidelines, whether certain patients are less likely to be referred, and how many patients were diagnosed with cancer within 1 year of non-referral.

METHODS

We used linked primary care (Clinical Practice Research Datalink), secondary care (Hospital Episode Statistics) and cancer registration data. Patients presenting with haematuria, breast lump, dysphagia, iron-deficiency anaemia, post-menopausal or rectal bleeding for the first time during 2014-2015 were included (for ages where guidelines recommend urgent referral). Logistic regression was used to investigate whether receiving a referral was associated with feature type and patient characteristics. Cancer incidence (based on recorded diagnoses in cancer registry data within 1 year of presentation) was compared between those receiving and those not receiving referrals.

RESULTS

48 715 patients were included, of which 40% (n=19 670) received an urgent referral within 14 days of presentation, varying by feature from 17% (dysphagia) to 68% (breast lump). Young patients (18-24 vs 55-64 years; adjusted OR 0.20, 95% CI 0.10 to 0.42, p<0.001) and those with comorbidities (4 vs 0 comorbidities; adjusted OR 0.87, 95% CI 0.80 to 0.94, p<0.001) were less likely to receive a referral. Associations between patient characteristics and referrals differed across features: among patients presenting with anaemia, breast lump or haematuria, those with multi-morbidity, and additionally for breast lump, more deprived patients were less likely to receive a referral. Of 29 045 patients not receiving a referral, 3.6% (1047) were diagnosed with cancer within 1 year, ranging from 2.8% for rectal bleeding to 9.5% for anaemia.

CONCLUSIONS

Guideline recommendations for action are not followed for the majority of patients presenting with common possible cancer features. A significant number of these patients developed cancer within 1 year of their consultation, indicating scope for improvement in the diagnostic process.

Effects of Tobacco Smoking on the Survivability of Patients with Multiple Cancers and Single Lung Cancer

Lung cancer is the leading cause of death worldwide among men and women. Tobacco smoking is the number one risk factor for lung cancer. The aim of our study was to evaluate the survivability of patients with single lung cancer in relation to the survival time in patients with multiple neoplasms whose last neoplasm was a lung cancer. A retrospective analysis was con-ducted of data from medical histories of patients hospitalized at the Pulmonary Hospital in Olsztyn (Poland) from 2012 to 2017, with a lung cancer diagnosis as the first or subsequent cancer. The total longevity of women with diagnosed multiple cancers was found to be shorter than that of men: 67.60 years (SD: 7.77) and 69.91 years (SD: 7.97), respectively. Among the ex-smokers, the longevity of men (68.93 years) was longer than that of women (66.18 years). Survival time, counted from the diagnosis of both the first and subsequent cancer, was longer among patients with multiple cancers than among patients with single lung cancer (p = 0.000). Women's survivability was worse than men's in the case of multiple cancers and in the group of people who quit smoking (p = 0.037; p = 0.000). To conclude, smoking tobacco affects the survival of patients with lung cancer. Smoking cessation improves overall survival.

Women's Health: Population Patterns and Social Determinants

Women's health, and what we know about it, are influenced by social factors. From the exclusion of women's bodies in medical research, to the silence and stigma of menstruation and menopause, to the racism reflected in maternal mortality, the relevance of social factors is paramount. After a brief history of research on women's health, we review selected patterns, trends, and inequalities in US women's health. These patterns reveal US women's poor and declining longevity relative to those in other high-income countries, gaps in knowledge about painful and debilitating conditions that affect millions of women, and deep inequalities that underscore the need to redress political and structural features of US society that enhance health for some and diminish it for others. We close by describing the challenges and opportunities for future research, and the promise of a social determinants of health approach for advancing a multilevel, intersectional, and biosocial understanding of women's health.

Assessing Ethnic Inequalities in Diagnostic Interval of Common Cancers: A Population-Based UK Cohort Study

BACKGROUND

This study investigated ethnic differences in diagnostic interval (DI)-the period between initial primary care presentation and diagnosis.

METHODS

We analysed the primary care-linked data of patients who reported features of seven cancers (breast, lung, prostate, colorectal, oesophagogastric, myeloma, and ovarian) one year before diagnosis. Accelerated failure time (AFT) models investigated the association between DI and ethnicity, adjusting for age, sex, deprivation, and morbidity.

RESULTS

Of 126,627 eligible participants, 92.1% were White, 1.99% Black, 1.71% Asian, 1.83% Mixed, and 2.36% were of Other ethnic backgrounds. Considering all cancer sites combined, the median (interquartile range) DI was 55 (20-175) days, longest in lung [127, (42-265) days], and shortest in breast cancer [13 (13, 8-18) days]. DI for the Black and Asian groups was 10% (AFT ratio, 95%CI 1.10, 1.05-1.14) and 16% (1.16, 1.10-1.22), respectively, longer than for the White group. Site-specific analyses revealed evidence of longer DI in Asian and Black patients with prostate, colorectal, and oesophagogastric cancer, plus Black patients with breast cancer and myeloma, and the Mixed group with lung cancer compared with White patients. DI was shorter for the Other group with lung, prostate, myeloma, and oesophagogastric cancer than the White group.

CONCLUSION

We found limited and inconsistent evidence of ethnic differences in DI among patients who reported cancer features in primary care before diagnosis. Our findings suggest that inequalities in diagnostic intervals, where present, are unlikely to be the sole explanation for ethnic variations in cancer outcomes.

Risk of cancer following primary care presentation with fatigue: a population-based cohort study of a quarter of a million patients

BACKGROUND

The management of adults presenting with fatigue presents a diagnostic challenge, particularly regarding possible underlying cancer.

METHODS

Using electronic health records, we examined cancer risk in patients presenting to primary care with new-onset fatigue in England during 2007-2013, compared to general population estimates. We examined variation by age, sex, deprivation, and time following presentation.

FINDINGS

Of 250,606 patients presenting with fatigue, 12-month cancer risk exceeded 3% in men aged 65 and over and women aged 80 and over, and 6% in men aged 80 and over. Nearly half (47%) of cancers were diagnosed within 3 months from first fatigue presentation. Site-specific cancer risk was higher than the general population for most cancers studied, with greatest relative increases for leukaemia, pancreatic and brain cancers.

CONCLUSIONS

In older patients, new-onset fatigue is associated with cancer risk exceeding current thresholds for urgent specialist referral. Future research should consider how risk is modified by the presence or absence of other signs and symptoms. Excess cancer risk wanes rapidly after 3 months, which could inform the duration of a 'safety-netting' period. Fatigue presentation is not strongly predictive of any single cancer, although certain cancers are over-represented; this knowledge can help prioritise diagnostic strategies.

A Cross-Sectional Analysis of Testicular Cancer Symptom Recognition and Stage of Diagnosis

There is a need to further explore the relationship between atypical symptom reporting and stage diagnosis to help develop a clearer defined list of possible testicular cancer (TC) symptoms that could assist physicians diagnose the disease earlier. A cross-sectional study was employed to explore possible associations between TC symptom presentation and stage of diagnosis. An original 40-item survey was distributed among 698 TC survivors to determine the potential impact of several risk factors, experiences, and behaviors upon diagnosis. This analysis aimed to explore how certain patient-driven experiences (e.g., symptoms, perceptions, and behaviors) could serve as catalysts for seeking medical care for testicular health concerns. Experiencing hot flashes or having no symptoms had a positive association with later-stage diagnosis while change in shape had a significant negative association with later-stage diagnosis. While the logistic regression model explained relatively low variance in the data (R² = .1415), it was statistically significant (χ²p < .001). Pain (odds ratio [OR] = 1.6524, p < .05), hot flashes (OR = 5.7893, p < .01), and no symptoms experienced (OR = 12.4836, p < .01) were all significant predictors of a more advanced stage diagnosis. The concern around uncommon/atypical symptoms are that they are indistinct and do not serve as clear signs that TC is present. However, perhaps in tandem with other more overt symptoms, their discovery can serve in a more confirmatory role for a suspect case. If observed with other uncommonly reported symptoms, these uncommon symptoms could provide another pathway in the TC diagnostic process. Clinical and patient education is warranted to increase awareness of uncommon TC symptoms.

Immortal time bias for life-long conditions in retrospective observational studies using electronic health records

Background

Immortal time bias is common in observational studies but is typically described for pharmacoepidemiology studies where there is a delay between cohort entry and treatment initiation.

Methods

This study used the Clinical Practice Research Datalink (CPRD) and linked national mortality data in England from 2000 to 2019 to investigate immortal time bias for a specific life-long condition, intellectual disability. Life expectancy (Chiang’s abridged life table approach) was compared for 33,867 exposed and 980,586 unexposed individuals aged 10+ years using five methods: (1) treating immortal time as observation time; (2) excluding time before date of first exposure diagnosis; (3) matching cohort entry to first exposure diagnosis; (4) excluding time before proxy date of inputting first exposure diagnosis (by the physician); and (5) treating exposure as a time-dependent measure.

Results

When not considered in the design or analysis (Method 1), immortal time bias led to disproportionately high life expectancy for the exposed population during the first calendar period (additional years expected to live: 2000–2004: 65.6 [95% CI: 63.6,67.6]) compared to the later calendar periods (2005–2009: 59.9 [58.8,60.9]; 2010–2014: 58.0 [57.1,58.9]; 2015–2019: 58.2 [56.8,59.7]). Date of entry of diagnosis (Method 4) was unreliable in this CPRD cohort. The final methods (Method 2, 3 and 5) appeared to solve the main theoretical problem but residual bias may have remained.

Conclusions

We conclude that immortal time bias is a significant issue for studies of life-long conditions that use electronic health record data and requires careful consideration of how clinical diagnoses are entered onto electronic health record systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01581-1.

Do presenting symptoms, use of pre-diagnostic endoscopy and risk of emergency cancer diagnosis vary by comorbidity burden and type in patients with colorectal cancer?

BACKGROUND

Cancer patients often have pre-existing comorbidities, which can influence timeliness of cancer diagnosis. We examined symptoms, investigations and emergency presentation (EP) risk among colorectal cancer (CRC) patients by comorbidity status.

METHODS

Using linked cancer registration, primary care and hospital records of 4836 CRC patients (2011-2015), and multivariate quantile and logistic regression, we examined variations in specialist investigations, diagnostic intervals and EP risk.

RESULTS

Among colon cancer patients, 46% had at least one pre-existing hospital-recorded comorbidity, most frequently cardiovascular disease (CVD, 18%). Comorbid versus non-comorbid cancer patients more frequently had records of anaemia (43% vs 38%), less frequently rectal bleeding/change in bowel habit (20% vs 27%), and longer intervals from symptom-to-first relevant test (median 136 vs 74 days). Comorbid patients were less likely investigated with colonoscopy/sigmoidoscopy, independently of symptoms (adjusted OR = 0.7[0.6, 0.9] for Charlson comorbidity score 1-2 and OR = 0.5 [0.4-0.7] for score 3+ versus 0. EP risk increased with comorbidity score 0, 1, 2, 3+: 23%, 35%, 33%, 47%; adjusted OR = 1.8 [1.4, 2.2]; 1.7 [1.3, 2.3]; 3.0 [2.3, 4.0]) and for patients with CVD (adjusted OR = 2.0 [1.5, 2.5]).

CONCLUSIONS

Comorbid individuals with as-yet-undiagnosed CRC often present with general rather than localising symptoms and are less likely promptly investigated with colonoscopy/sigmoidoscopy. Comorbidity is a risk factor for diagnostic delay and has potential, additionally to symptoms, as risk-stratifier for prioritising patients needing prompt assessment to reduce EP.

Does changing healthcare use signal opportunities for earlier detection of cancer? A review of studies using information from electronic patient records

BACKGROUND

It has been proposed that changes in healthcare use before cancer diagnosis could signal opportunities for quicker detection, but systematic appreciation of such evidence is lacking. We reviewed studies examining pre-diagnostic changes in healthcare utilisation (e.g. rates of GP or hospital consultations, prescriptions or diagnostic tests) among patients subsequently diagnosed with cancer.

METHODS

We identified studies through Pubmed searches complemented by expert elicitation. We extracted information on the earliest time point when diagnosis could have been possible for at least some cancers, together with variation in the length of such 'diagnostic windows' by tumour and patient characteristics.

RESULTS

Across twenty-eight studies, changes in healthcare use were observable at least six months pre-diagnosis for many common cancers, and potentially even earlier for colorectal cancer, multiple myeloma and brain tumours. Early changes were also identified for brain and colon cancer sub-sites.

CONCLUSION

Changing healthcare utilisation patterns before diagnosis indicate that future improvements in diagnostic technologies or services could help to shorten diagnostic intervals for cancer. There is greatest potential for quicker diagnosis for certain cancer types and patient groups, which can inform priorities for the development of decision support tools.

Role of primary care physician factors on diagnostic testing and referral decisions for symptoms of possible cancer: a systematic review

BACKGROUND

Missed opportunities for diagnosing cancer cause patients harm and have been attributed to suboptimal use of tests and referral pathways in primary care. Primary care physician (PCP) factors have been suggested to affect decisions to investigate cancer, but their influence is poorly understood.

OBJECTIVE

To synthesise evidence evaluating the influence of PCP factors on decisions to investigate symptoms of possible cancer.

METHODS

We searched MEDLINE, Embase, Scopus, CINAHL and PsycINFO between January 1990 and March 2021 for relevant citations. Studies examining the effect or perceptions and experiences of PCP factors on use of tests and referrals for symptomatic patients with any cancer were included. PCP factors comprised personal characteristics and attributes of physicians in clinical practice.

DATA EXTRACTION AND SYNTHESIS

Critical appraisal and data extraction were undertaken independently by two authors. Due to study heterogeneity, data could not be statistically pooled. We, therefore, performed a narrative synthesis.

RESULTS

29 studies were included. Most studies were conducted in European countries. A total of 11 PCP factors were identified comprising modifiable and non-modifiable factors. Clinical judgement of symptoms as suspicious or 'alarm' prompted more investigations than non-alarm symptoms. 'Gut feeling' predicted a subsequent cancer diagnosis and was perceived to facilitate decisions to investigate non-specific symptoms as PCP experience increased. Female PCPs investigated cancer more than male PCPs. The effect of PCP age and years of experience on testing and referral decisions was inconclusive.

CONCLUSIONS

PCP interpretation of symptoms as higher risk facilitated testing and referral decisions for possible cancer. However, in the absence of 'alarm' symptoms or 'gut feeling', PCPs may not investigate cancer. PCPs require strategies for identifying patients with non-alarm and non-specific symptoms who need testing or referral.

PROSPERO REGISTRATION NUMBER

CRD420191560515.

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

BACKGROUND

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

AIM

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

DESIGN AND SETTING

A systematic literature review.

METHOD

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

RESULTS

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

CONCLUSION

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

Cancer suspicion, referral to cancer patient pathway and primary care interval: a survey and register study exploring 10 different types of abdominal cancer

BACKGROUND

Abdominal cancers represent 30% of all diagnosed cancers. Nevertheless, it is unknown if the general practitioner's (GP's) initial cancer suspicion varies for different abdominal cancer types and how this is associated with referrals to standardized cancer patient pathways (CPPs).

OBJECTIVES

To explore initial cancer suspicion in GPs and to investigate how this was associated with GP referrals to CPPs and the duration of the primary care interval (PCI) in 10 different abdominal cancer types.

METHODS

We conducted a cohort study on 1104 incident abdominal cancer patients diagnosed in Denmark in 2016 using a combination of survey and register-based data. Poisson regression was used to estimate associations between GP cancer suspicion, CPP referral and PCI duration.

RESULTS

The GPs initially suspected cancer or other serious disease in 46-78% of cases, lowest in kidney cancer, and referred 35-65% to a CPP, lowest in oesophageal cancer. The GP's suspicion at the first presentation was strongly associated with referral to a CPP. The median (0-11 days) and 75th percentile (3-32 days) PCIs varied between the abdominal cancer types. The likelihood of a long PCI was more than 3-fold higher when the GP did not initially suspect cancer.

CONCLUSION

In up to half of abdominal cancer patients, there is no initial suspicion of cancer or serious disease. CPPs were used in only one-third to two-thirds of patients, depending on cancer type. For kidney cancer, as well as several abdominal cancers, we need better diagnostic strategies to support GPs to enable effective and efficient referral.

[Gender blindness in medical textbooks: the case of leukemias]

OBJECTIVE

To analyse the existence of sex-differences in the content on leukemias in the Haematology and Internal Medicine textbooks recommended in the Medical Degrees, 2019-2020, by comparison with the sex-differences recognized in the scientific literature.

METHOD

Manifest content analysis of the content of chapters on leukemias in the books on hematology and internal medicine, clinical haematology and haematology undergraduate. Analysis categories: epidemiology, etiopathogenesis, diagnosis, treatment and prognosis of leukemias.

RESULTS

Epidemiological information from the revised books has a greater consideration of sex differences in incidence and prognosis but does not contain data on mortality and survival. Etiopathogenesis is described in all books as the same physiological process for both sexes and no differences in the presentation of symptoms are described in any book. Three books describe a unique treatment that is assumed equal for both sexes; two books mention the treatment of acute myeloid leukemia in pregnant women and one in chronic myeloid leukemia. No book mentions sex-differences in pharmacokinetics, efficacy, or treatment toxicity, although there is greater evidence on unequal behavior between the sexes.

CONCLUSIONS

The contents of sex and gender differences in the leukemia chapters analyzed are insufficient compared to the evidence in the scientific literature today. Hematology textbooks might increase their scientific quality in future editions, including knowledge of sex-gender interaction in the sections of epidemiology, etiology, pathogenesis, diagnosis, treatment, prognosis, and consequences of leukemias, which will contribute to better professional practices, more efficient and equitable.