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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Stage-specific incidence trends of renal cancers in the East of England, 1999-2016

OBJECTIVES

To determine stage-specific time-trends in renal cancer incidence.

METHODS

We used population-based East Anglia data 1999-2016 (population ∼2 million) on 5,456 primary renal cancer diagnoses, estimating stage-specific annual incidence using Poisson regression, allowing for changing time-trends, and adjusting for sex, age, and socioeconomic deprivation.

RESULTS

Renal cancer incidence increased from 9.8-16.4 cases per 100,000 during 1999-2016. Incidence of Stage I, II, and III cases increased over time, most steeply for Stage I, with annual Incidence Rate Ratio [IRR] for Stage I of 1.09 (95 % CI 1.07-1.12) during 1999-2010; and 1.03 (1.00-1.05) during 2011-2016. In contrast, the annual incidence of Stage IV renal cancer decreased during most years, IRR of 0.99 (0.98-1.00) during 2003-2016.

CONCLUSION

The findings are consistent with both earlier detection of symptomatic renal cancer and increasing identification of asymptomatic lesions. However, the decreasing incidence of late-stage disease suggests genuine shifts towards earlier diagnosis.

Association of Self-reported Presenting Symptoms With Timeliness of Help-Seeking Among Adolescents and Young Adults With Cancer in the BRIGHTLIGHT Study

Importance

Evidence regarding the presenting symptoms of cancer in adolescents and young adults can support the development of early diagnosis interventions.

Objective

To examine common presenting symptoms in adolescents and young adults aged 12 to 24 years who subsequently received a diagnosis of cancer and potential variation in time to help-seeking by presenting symptom.

Design, Setting, and Participants

This multicenter study is a cross-sectional analysis of the BRIGHTLIGHT cohort study, which was conducted across hospitals in England. Participants included adolescents and young adults aged 12 to 24 years with cancer. Information on 17 prespecified presenting symptoms and the interval between symptom onset and help-seeking (the patient interval) was collected through structured face-to-face interviews and was linked to national cancer registry data. Data analysis was performed from January 2018 to August 2019.

Exposures

Self-reported presenting symptoms.

Main Outcomes and Measures

The main outcomes were frequencies of presenting symptoms and associated symptom signatures by cancer group and the proportion of patients with each presenting symptom whose patient interval was longer than 1 month.

Results

The study population consisted of 803 adolescents and young adults with valid symptom information (443 male [55%]; 509 [63%] aged 19-24 years; 705 [88%] White). The number of symptoms varied by cancer group: for example, 88 patients with leukemia (86%) presented with 2 or more symptoms, whereas only 9 patients with melanoma (31%) presented with multiple symptoms. In total, 352 unique symptom combinations were reported, with the 10 most frequent combinations accounting for 304 patients (38%). Lump or swelling was reported by more than one-half the patients (419 patients [52%; 95% CI, 49%-56%]). Other common presenting symptoms across all cancers were extreme tiredness (308 patients [38%; 95% CI, 35%-42%]), unexplained pain (281 patients [35%; 95% CI, 32%-38%]), night sweats (192 patients [24%; 95% CI, 21%-27%]), lymphadenopathy (191 patients [24%; 95% CI, 21%-27%]), and weight loss (190 patients [24%; 95% CI, 21%-27%]). The relative frequencies of presenting symptoms also varied by cancer group; some symptoms (such as lump or swelling) were highly prevalent across several cancer groups (seen in >50% of patients with lymphomas, germ cell cancers, carcinomas, bone tumors, and soft-tissue sarcomas). More than 1 in 4 patients (27%) reported a patient interval longer than 1 month; this varied from 6% (1 patient) for fits and seizures to 43% (18 patients) for recurrent infections.

Conclusions and Relevance

Adolescents and young adults with cancer present with a broad spectrum of symptoms, some of which are shared across cancer types. These findings point to discordant presenting symptom prevalence estimates when information is obtained from patient report vs health records and indicate the need for further symptom epidemiology research in this population.

Stage-specific incidence trends of melanoma in an English region, 1996-2015: longitudinal analyses of population-based data

The aim of this study was to examine temporal trends in overall and stage-specific incidence of melanoma. Using population-based data on patients diagnosed with melanoma in East Anglia, England, 1996-2015, we estimated age-standardized time trends in annual incidence rates for each stage at diagnosis. Negative binomial regression was used to model trends over time adjusted for sex, age group and deprivation, and to subsequently examine variation in stage-specific trends by sex and age group. The age-standardized incidence increased from 14 to 29 cases/100 000 persons (i.e. 4% annually). Increasing incidence was apparent across all stages but was steepest for stage I [adjusted annual increase: 5%, 95% confidence interval (CI): 5-6%, and more gradual for stage II-IV disease (stage II: 3%, 95% CI: 2-4%; stage III/IV: 2%, 95% CI: 1-3%)]. Stage II-IV increase was apparent in men across age groups and in women aged 50 years or older. Increases in incidence were steeper in those aged 70 years or older, and in men. The findings suggest that both a genuine increase in the incidence of consequential illness and a degree of overdiagnosis may be responsible for the observed increasing incidence trends in melanoma in our population during the study period. They also suggest the potentially lower effectiveness of public health awareness campaigns in men and older people.

Symptom Signatures and Diagnostic Timeliness in Cancer Patients: A Review of Current Evidence

Early diagnosis is an important aspect of contemporary cancer prevention and control strategies, as the majority of patients are diagnosed following symptomatic presentation. The nature of presenting symptoms can critically influence the length of the diagnostic intervals from symptom onset to presentation (the patient interval), and from first presentation to specialist referral (the primary care interval). Understanding which symptoms are associated with longer diagnostic intervals to help the targeting of early diagnosis initiatives is an area of emerging research. In this Review, we consider the methodological challenges in studying the presenting symptoms and intervals to diagnosis of cancer patients, and summarize current evidence on presenting symptoms associated with a range of common and rarer cancer sites. We propose a taxonomy of cancer sites considering their symptom signature and the predictive value of common presenting symptoms. Finally, we consider evidence on associations between symptomatic presentations and intervals to diagnosis before discussing implications for the design, implementation, and evaluation of public health or health system interventions to achieve the earlier detection of cancer.

Use of World Wide Web-based directories for tracing subjects in epidemiologic studies

The recent availability of World Wide Web-based directories has opened up a new approach for tracing subjects in epidemiologic studies. The completeness of two World Wide Web-based directories (Canada411 and InfoSpace Canada) for subject tracing was evaluated by using a randomized crossover design for 346 adults randomly selected from respondents in an ongoing cohort study. About half (56.4%) of the subjects were successfully located by using either Canada411 or InfoSpace. Of the 43.6% of the subjects who could not be located using either directory, the majority (73.5%) were female. Overall, there was no clear advantage of one directory over the other. Although Canada411 could find significantly more subjects than InfoSpace, the number of potential matches returned by Canada411 was also higher, which meant that a longer list of potential matches had to be examined before a true match could be found. One strategy to minimize the number of potential matches per true match is to first search by InfoSpace with the last name and first name, then by Canada411 with the last name and first name, and finally by InfoSpace with the last name and first initial. Internet-based searches represent a potentially useful approach to tracing subjects in epidemiologic studies.

Comparison of four habitual physical activity questionnaires in girls aged 7-15 yr

PURPOSE

Questionnaires provide a practical approach to measuring physical activity in children and adolescents, particularly for large-scale epidemiological studies. The purpose of the present study was to compare four habitual physical activity questionnaires and to assess their long-term reliabilities.

METHODS

Subjects were female, aged 7-15 yr (and their parents), who participated in a cohort study in which predictors of the onset of menarche were being investigated. Questionnaires consisted of three single-item and one multi-item habitual physical activity questions and were sent to the 640 participants. Test-retest reliability of the questionnaires was assessed on 100 randomly selected participants 11 months later.

RESULTS

The Spearman's correlation coefficient was highest (r = 0.40) between the Godin-Shephard Score and the Perspiration Score and was lowest (r = 0.10) between the Stairs Score and the Specific Activity Score. The correlation coefficients were higher when the questionnaires were reported to have been completed by the parents alone, rather than by parents with the assistance of their daughters. The test-retest reliabilities were r = 0.44 for the Perspiration Score, r = 0.59 for the Stairs Score, r = 0.48 for the Godin-Shephard Score, and r = 0.53 for the Specific Activity Score. The reliabilities were higher when the retest was reported to have been completed by the parents alone.

CONCLUSIONS

This study suggests that the Perspiration Score, the Godin-Shephard Score, and the Specific Activity Score may provide simple and practical measures of habitual physical activity for children and adolescents.

Accuracy of short-term recall of age at menarche

This study was conducted as part of the third annual follow-up of a cohort of 657 girls to test the accuracy of short-term recall of age at menarche. During the first and second annual follow-ups of the cohort, 101 girls had reported menarche. We sent questionnaires to these subjects at the third annual follow-up and asked them to recall the month and year of their menarche. Eighty-eight respondents returned their questionnaires with the relevant information. Overall, 59.1% of the respondents were able to recall their menarche with the exact month and year. The mean recall interval was 430 days. When the data were grouped by the interval of recall, higher accuracy was observed with a shorter interval of recall. With a mean interval of recall of 323 days, 66.1% of the subjects were able to recall their menarche correctly, whereas with a mean interval of 649 days, only 44.8% of the subjects were able to recall correctly.

Effect of soybean saponins and gypsophilla saponin on growth and viability of colon carcinoma cells in culture

The effects of soybean saponins (SS) and gypsophilla saponin (GS) on the growth and viability of colon tumor (HCT-15) cells in culture were investigated. Cells were incubated in various concentrations of saponins for 1 hour (short term) or 48 hours (long term). Cell growth and viability were monitored at 24 and 48 hours. SS and GS inhibited cell growth and reduced cell viability in a dose-dependent manner in long-term treatment. The viability of cells was also reduced by short-term treatment with GS. The saponins differed in their effects on cell surface morphology: GS induced a rough and granular cell surface, whereas SS-treated cells displayed only minor morphological alterations. Changes in membrane permeability were assessed by measuring leakage of the cytoplasmic enzyme lactate dehydrogenase from cells. GS showed a concentration-dependent increase in lactate dehydrogenase leakage, whereas SS did not exhibit this effect. These results suggest that SS and GS have a significant growth-inhibitory effect on colon tumor cells in culture. However, it would appear that they are acting through different mechanisms.