Impact of ‘two-week wait’ referral pathway on the diagnosis, treatment and survival in upper and lower gastrointestinal cancers

Evaluation of treatment delays in hepatopancreatico-biliary surgery during the first COVID-19 wave

INTRODUCTION

The COVID-19 pandemic has caused oncological services worldwide to face unprecedented challenges resulting in treatment disruption for surgical patients. Hepatopancreatico-biliary (HPB) cancers are characterised by rapid disease progression. This study aims to assess delays in receiving surgery for this patient cohort during the first COVID-19 wave.

METHODS

Patients undergoing surgery between April and July 2020 (COVID-19 period) were compared with a control group from the preceding year. Delay in receiving surgery was defined as more than 50 days between referral and surgery date. Statistical analysis was carried out to evaluate predictors of delay and short-term outcomes.

RESULTS

During the COVID-19 and pre-COVID-19 periods, 94 and 115 patients underwent surgery, respectively. No patients contracted COVID-19 postoperatively. Some 118 patients waited more than 50 days for surgery versus 91 who received surgery within 50 days from referral. Independent predictors for surgical delay were undergoing surgery in the COVID-19 era (odds ratio (OR) 2.2, 95% confidence interval (CI) 1.2-4.1; p=0.015), referral pathway (OR 35.1, 95% CI 4.2-296; p=0.001) and presenting pathology (OR 8.3, 95% CI 1.2-56.1; p=0.03). Short-term outcomes were comparable between groups.

CONCLUSIONS

Patient referral pathway and presenting pathology may contribute to delays in undergoing HPB cancer surgery during COVID-19 outbreaks. It is hoped that a better understanding of these factors will aid in designing shifts in healthcare policy during future pandemic outbreaks.

Fast vs. Regular Track for Lung and Pancreatic Cancer Diagnosis-Time from Initial Finding to Final Diagnosis and Patient Survival

BACKGROUND

Health systems around the world have begun implementing unique tracks to expedite diagnosis and improve survival of patients with suspected cancers. This study aimed to compare characteristics and survival between patients diagnosed by way of fast and regular diagnostic tracks.

METHODS

A historical cohort study of patients (age ≥ 18) diagnosed with lung or pancreatic cancers between 09/2017 and 03/2020 on a fast diagnostic track and treated in a tertiary hospital versus a random sample of patients with the same cancer types who began treatment in the hospital over the same period of time after being diagnosed utilizing the regular track in the community.

RESULTS

The study included 336 patients (108 fast-track diagnostics, 228 regular track diagnostics). Advanced stages III-IV at diagnosis were more likely in the fast-track group (94.4% vs. 81.1%, p = 0.001). The median time from initial cancer suspicion to diagnosis was 21 days (IQR 14-37) for the fast-track vs. 31 days (IQR 18-51) for the regular track (p < 0.001). During the follow-up period, 56 patients from the fast-track and 131 patients from the regular track died. No significant difference was found in the median survival time between the fast and regular tracks, whether from the onset of symptoms, diagnosis, or treatment initiation.

CONCLUSION

Patients referred to the fast-track were more likely to be diagnosed at a further advanced stage of their cancer. The fast-track shortened the time until diagnosis and treatment but no difference was found in median survival between the tracks, perhaps due to late referral and high fatality rates.

Interventions to improve early cancer diagnosis of symptomatic individuals: a scoping review

OBJECTIVES

To summarise the current evidence regarding interventions for accurate and timely cancer diagnosis among symptomatic individuals.

DESIGN

A scoping review following the Joanna Briggs Institute's methodological framework for the conduct of scoping reviews and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist.

DATA SOURCES

MEDLINE (Ovid), CINAHL (EBSCOhost) and PsycINFO (Ovid) bibliographic databases, and websites of relevant organisations. Published and unpublished literature (grey literature) of any study type in the English language were searched for from January 2017 to January 2021.

ELIGIBILITY AND CRITERIA

Study participants were individuals of any age presenting at clinics with symptoms indicative of cancer. Interventions included practice guidelines, care pathways or other initiatives focused on achieving predefined benchmarks or targets for wait times, streamlined or rapid cancer diagnostic services, multidisciplinary teams and patient navigation strategies. Outcomes included accuracy and timeliness of cancer diagnosis.

DATA EXTRACTION AND SYNTHESIS

We summarised findings graphically and descriptively.

RESULTS

From 21 298 retrieved citations, 88 unique published articles and 16 unique unpublished documents (on 18 study reports), met the eligibility for inclusion. About half of the published literature and 83% of the unpublished literature were from the UK. Most of the studies were on interventions in patients with lung cancer. Rapid referral pathways and technology for supporting and streamlining the cancer diagnosis process were the most studied interventions. Interventions were mostly complex and organisation-specific. Common themes among the studies that concluded intervention was effective were multidisciplinary collaboration and the use of a nurse navigator.

CONCLUSIONS

Multidisciplinary cooperation and involvement of a nurse navigator may be unique features to consider when designing, delivering and evaluating interventions focused on improving accurate and timely cancer diagnosis among symptomatic individuals. Future research should examine the effectiveness of the interventions identified through this review.

Comparison of oesophageal and gastric cancer in the evaluation of urgent endoscopy referral criteria

BACKGROUND

The objective of the study is to identify differences in epidemiology and clinical presentation between oesophageal and gastric cancer and to evaluate the sensitivity of the Australian urgent endoscopy referral guidelines.

METHODS

Design; Observational cohort study from February 2013 to October 2018.

SETTING

A single tertiary specialist oesophago-gastric cancer centre: Flinders Medical Centre, South Australia.

PARTICIPANTS

Patients with oesophageal and gastric cancer that had surgery with curative intent 61.9% oesophageal cancer, 38.1% gastric cancer.

MAIN OUTCOME MEASURES

Differences between oesophageal and gastric cancer in terms of demographical variables, first presenting symptoms and sensitivity of the Australian urgent endoscopy referral guidelines.

RESULTS

Oesophageal cancer presented at a median age of 64.4 years old, with a male: female ratio of 6:1, and dysphagia as the first presenting symptom in 61%. Gastric cancer presented at a median age of 69.5, with a 2:1 male: female ratio and predominantly non-specific symptoms-blood loss (36%), weight loss, nausea, and anorexia (21%) and epigastric pain (13%). The Australia urgent endoscopy referral guidelines had 76% sensitivity for oesophageal cancer detection compared with a 33% sensitivity for gastric cancer in this cohort. Delays from symptom onset to referral occurred for most patients with timeframes over four times the recommended 2-week timeframe.

CONCLUSION

There should be a separate urgent referral guideline for oesophageal and gastric cancer. These should include dysphagia for oesophageal cancer and blood loss (anaemia, haematemesis, melaena) for gastric cancer. Delays from symptom onset to referral indicate the need for further education of the public and general practitioners on symptoms warranting urgent referral.

Impact of the updated NICE referral pathway for patients with suspected brain cancer on a neuroscience service

INTRODUCTION

The National Institute for Health and Clinical Excellence (NICE) publish guidelines to facilitate the referral of patients with suspected malignancies, including CNS tumours, from primary care to the appropriate hospital services. We aimed to assess the impact and utility of the most recently revised guidelines, published in 2015, on our neurosurgical service.

MATERIALS & METHODS

We performed a retrospective analysis of the 2-week wait (2WW) referrals received by the neurosurgery department at our institution over a 3 and a half year period between 2015 and 2019. Details pertaining to the patient's clinical condition and ultimate diagnosis were collected from their medical records and assessed to determine whether the referral criteria were fulfilled.

RESULTS

Referrals for 101 patients were received over the study period (mean 29/year). Of these, 82 patients (81.2%) were referred based on symptoms, whilst 19 patients (18.8%) were referred with an abnormal brain scan. Seventy-five referrals (74%) were deemed compliant with the guideline criteria. The sensitivity and specificity of the updated guidelines was 90% (73-98%, 95% CI) and 32.4% (22-45%, 95% CI) respectively. The commonest reason for a non-compliant referral, in 21 cases (81%), was headache disorder without neurological deficit. Overall, 30 patients (30%) referred via the 2WW rule were found to have a brain tumour. With guideline adherence, the brain tumour detection rate was 3-fold higher (36.0% vs 11.5%, p = 0.02).

CONCLUSIONS

An update to the NICE guidelines has coincided with an increase in the number of 2WW referrals received by our department, an increase in guideline compliant referrals and an improved rate of tumour detection, though a significant proportion of patients referred via this route ultimately do not require the services of a neurosurgeon. Greater provision of urgent imaging for general practitioners, in accordance with the current NICE guidelines, may reduce unnecessary neurosurgery consultations.

Patient experiences of the urgent cancer referral pathway-Can the NHS do better? Semi-structured interviews with patients with upper gastrointestinal cancer

Background

Timeliness is viewed as a key feature of health‐care quality. Internationally, this is challenging. In England, cancer waiting time targets are currently not being met. For example, between 2015 and 2018 only 71% of patients with upper gastrointestinal (UGI) cancer started treatment within the recommended 62 days of referral.

Objective

We explored patients’ experiences to identify areas for service improvement.

Design

Semi‐structured interviews were conducted.

Setting and participants

Twenty patients who were referred through the urgent (two‐week) GP referral route and were within six months of receiving first treatment were recruited.

Data analysis

Data from the interviews were analysed thematically.

Results

Four themes were developed: organization of care; diagnosis; support; and views and expectations of the NHS. Patients described cross‐cutting issues such as complex and varied pathways and uncertainty about what would happen next. They felt daunted by the intensity and speed of investigations. They were presented with a recommended course of action rather than options and had little involvement in decision making. They were grateful for care, reluctant to complain and resigned to the status quo.

Discussion and conclusions

In order to meet patient needs, the NHS needs to improve communication and streamline pathways. Future cancer pathways also need to be designed to support shared decision making, be truly person‐centred and informed by patient experience.