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Tørring ML, Murchie P, Hamilton W, Vedsted P, Esteva M, Lautrup M, Winget M, Rubin G. Evidence of advanced stage colorectal cancer with longer diagnostic intervals: a pooled analysis of seven primary care cohorts comprising 11 720 patients in five countries. Br J Cancer 2017; 117:888-897. [PMID: 28787432 PMCID: PMC5589987 DOI: 10.1038/bjc.2017.236] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/24/2017] [Accepted: 06/29/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The benefits from expedited diagnosis of symptomatic cancer are uncertain. We aimed to analyse the relationship between stage of colorectal cancer (CRC) and the primary and specialist care components of the diagnostic interval. METHODS We identified seven independent data sets from population-based studies in Scotland, England, Canada, Denmark and Spain during 1997-2010 with a total of 11 720 newly diagnosed CRC patients, who had initially presented with symptoms to a primary care physician. Data were extracted from patient records, registries, audits and questionnaires, respectively. Data sets were required to hold information on dates in the diagnostic interval (defined as the time from the first presentation of symptoms in primary care until the date of diagnosis), symptoms at first presentation in primary care, route of referral, gender, age and histologically confirmed stage. We carried out reanalysis of all individual data sets and, using the same method, analysed a pooled individual patient data set. RESULTS The association between intervals and stage was similar in the individual and combined data set. There was a statistically significant convex (∩-shaped) association between primary care interval and diagnosis of advanced (i.e., distant or regional) rather than localised CRC (P=0.004), with odds beginning to increase from the first day on and peaking at 90 days. For specialist care, we saw an opposite and statistically significant concave (∪-shaped) association, with a trough at 60 days, between the interval and diagnosis of advanced CRC (P<0.001). CONCLUSIONS This study provides evidence that longer diagnostic intervals are associated with more advanced CRC. Furthermore, the study cannot define a specific 'safe' waiting time as the length of the primary care interval appears to have negative impact from day one.
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Affiliation(s)
- M L Tørring
- Department of Anthropology, School of Culture and Society, Aarhus University, Moesgaard Allé 20, Højbjerg DK-8270, Denmark
| | - P Murchie
- Division of Applied Health Sciences, Centre of Academic Primary Care, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - W Hamilton
- University of Exeter, College House, St Luke’s Campus, Magdalen Road, Exeter EX1 2 LU, UK
| | - P Vedsted
- Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Bartholins Allé 20, Aarhus C DK-8000, Denmark
| | - M Esteva
- Primary Care Research Unit, Primary Care Majorca Department, Balearic Islands Health Research Institute (IdISBa), Reina Esclaramunda 9, Palma Mallorca 07003, Spain
| | - M Lautrup
- Department of Organ and Plastic Surgery, Breast Centre, Vejle Hospital, Kabbeltoft 25, Vejle DK-7100, Denmark
| | - M Winget
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, MSOB #X214, Stanford, California CA 94305, USA
| | - G Rubin
- School of Medicine, Pharmacy and Health, Wolfson Research Institute, Durham University, Queen’s Campus, University Boulevard, Stockton on Tees, England TS17 6BH, UK
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Abstract
BACKGROUND Long waiting times from early symptoms to diagnosis and treatment may influence the staging and prognosis of patients with colorectal cancer. We analyzed the effect of colonoscopy timing on the outcome of these patients. OBJECTIVE This study aimed to compare the outcome (tumoral staging and long-term survival) of patients with suspected colorectal cancer according to diagnostic colonoscopy timing. DESIGN This study is an analysis of a prospectively maintained database. SETTINGS The study was conducted at the Open Access Endoscopy Service of the tertiary public healthcare center Hospital Universitario de Canarias, in the Spanish island of Tenerife. PATIENTS Consecutive patients diagnosed of colorectal cancer between February 2008 and October 2010, fulfilling 1 or more National Institute for Health and Clinical Excellence criteria, were assigned to early colonoscopy (<30 days from referral) or to standard-schedule colonoscopy at the discretion of the referring physician. Tumor staging (TNM classification) at diagnosis and long-term survival after treatment were compared in both strategies. MAIN OUTCOME MEASURES The primary outcomes measured were the stage at presentation and overall survival, as determined by prompt or standard referral. RESULTS Overall, 257 patients with colorectal cancer were diagnosed (101 at early colonoscopy and 156 at standard-schedule colonoscopy). TNM stages I and II were found in 52 (54.2%) and 60 (41.7%) patients in the early colonoscopy group and standard-schedule colonoscopy group. Stage IV was confirmed in 13 patients (13.5%) diagnosed in the early colonoscopy group and in 40 (28%) detected in the standard-schedule colonoscopy group. Survival rates at 12 and 60 months after treatment were significantly higher in the early colonoscopy group compared with the standard-schedule colonoscopy group (p < 0.001). LIMITATIONS Controlled randomization of early versus standard-referral colonoscopy, size and scope of analysis, the time interval from symptom onset to first physician assessment, and the different locations of colorectal cancer between groups were limitations of the study. CONCLUSIONS Colonoscopy within 30 days from referral improves outcome in patients with symptomatic colorectal cancer. See Video Abstract at http://journals.lww.com/dcrjournal/Pages/videogallery.aspx.
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Aslam MI, Chaudhri S, Singh B, Jameson JS. The “two-week wait” referral pathway is not associated with improved survival for patients with colorectal cancer. Int J Surg 2017; 43:181-185. [DOI: 10.1016/j.ijsu.2017.05.046] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 04/20/2017] [Accepted: 05/09/2017] [Indexed: 01/22/2023]
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Zarcos-Pedrinaci I, Fernández-López A, Téllez T, Rivas-Ruiz F, Rueda A A, Suarez-Varela MMM, Briones E, Baré M, Escobar A, Sarasqueta C, de Larrea NF, Aguirre U, Quintana JM, Redondo M. Factors that influence treatment delay in patients with colorectal cancer. Oncotarget 2017; 8:36728-36742. [PMID: 27888636 PMCID: PMC5482692 DOI: 10.18632/oncotarget.13574] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 11/12/2016] [Indexed: 01/07/2023] Open
Abstract
A prospective study was performed of patients diagnosed with colorectal cancer (CRC), distinguishing between colonic and rectal location, to determine the factors that may provoke a delay in the first treatment (DFT) provided.2749 patients diagnosed with CRC were studied. The study population was recruited between June 2010 and December 2012. DFT is defined as time elapsed between diagnosis and first treatment exceeding 30 days.Excessive treatment delay was recorded in 65.5% of the cases, and was more prevalent among rectal cancer patients. Independent predictor variables of DFT in colon cancer patients were a low level of education, small tumour, ex-smoker, asymptomatic at diagnosis and following the application of screening. Among rectal cancer patients, the corresponding factors were primary school education and being asymptomatic.We conclude that treatment delay in CRC patients is affected not only by clinicopathological factors, but also by sociocultural ones. Greater attention should be paid by the healthcare provider to social groups with less formal education, in order to optimise treatment attention.
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Affiliation(s)
- Irene Zarcos-Pedrinaci
- Research Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | | | - Teresa Téllez
- Research Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Francisco Rivas-Ruiz
- Research Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Antonio Rueda A
- Servicio de Oncología Médica, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - María Manuela Morales Suarez-Varela
- Unit of Public Health, Hygiene and Environmental Health, Department of Preventive Medicine and Public Health, Food Science, Toxicology and Legal Medicine, University of Valencia, CIBER-Epidemiology and Public Health (CIBERESP), Valencia, Spain
| | - Eduardo Briones
- Public Health Unit, Distrito Sanitario Sevilla, Consorcio de Investigación Biomédica de Epidemiología y Salud Pública, Madrid, Spain
| | - Marisa Baré
- Clinical Epidemiology and Cancer Screening, Corporació Sanitària Parc Taulí, Sabadell, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Antonio Escobar
- Research Unit, Hospital Universitario Basurto, Bilbao, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Cristina Sarasqueta
- Research Unit, Donostia University Hospital, San Sebastián, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Nerea Fernández de Larrea
- Area of Environmental Epidemiology and Cancer, National Epidemiology Centre, Instituto de Salud Carlos III, Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiología y Salud Pública, CIBERESP), Madrid, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Urko Aguirre
- Research Unit, Hospital Galdakao-Usansolo, Galdakao, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - José María Quintana
- Research Unit, Hospital Galdakao-Usansolo, Galdakao, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Maximino Redondo
- Research Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
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Brenkman HJF, Visser E, van Rossum PSN, Siesling S, van Hillegersberg R, Ruurda JP. Association Between Waiting Time from Diagnosis to Treatment and Survival in Patients with Curable Gastric Cancer: A Population-Based Study in the Netherlands. Ann Surg Oncol 2017; 24:1761-1769. [PMID: 28353020 PMCID: PMC5486840 DOI: 10.1245/s10434-017-5820-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Indexed: 01/09/2023]
Abstract
Background In the Netherlands, a maximum waiting time from diagnosis to treatment (WT) of 5 weeks is recommended for curative cancer treatment. This study aimed to evaluate the association between WT and overall survival (OS) in patients undergoing gastrectomy for cancer. Methods This nationwide study included data from patients diagnosed with curable gastric adenocarcinoma between 2005 and 2014 from the Netherlands Cancer Registry. Patients were divided into two groups: patients who received neoadjuvant therapy followed by gastrectomy, or patients who underwent gastrectomy as primary surgery. WT was analyzed as a categorical (≤5 weeks [Reference], 5–8 weeks, >8 weeks) and as a discrete variable. Multivariable Cox regression analysis was used to assess the influence of WT on OS. Results Among 3778 patients, 1701 received neoadjuvant chemotherapy followed by gastrectomy, and 2077 underwent primary gastrectomy. In the neoadjuvant group, median WT to neoadjuvant treatment was 4.6 weeks (interquartile range [IQR] 3.4–6.0), and median OS was 32 months. In the surgery group, median WT to surgery was 6.0 weeks (IQR 4.3–8.4), and median OS was 25 months. For both groups, WT did not influence OS (neoadjuvant: 5–8 weeks, hazard ratio [HR] 0.82, p = 0.068; >8 weeks, HR 0.85, p = 0.354; each additional week WT, HR 0.96, p = 0.078; surgery: 5–8 weeks, HR 0.91, p = 0.175; >8 weeks, HR 0.92, p = 0.314; each additional week WT, HR 0.99, p = 0.264). Conclusions Longer WT until the start of curative treatment for gastric cancer is not associated with worse OS. These results could help to put WT into perspective as indicator of quality of care and reassure patients with gastric cancer.
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Affiliation(s)
- H J F Brenkman
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - E Visser
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P S N van Rossum
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S Siesling
- Department of Research, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands.,Department of Health Technology and Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - R van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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Leiva A, Esteva M, Llobera J, Macià F, Pita-Fernández S, González-Luján L, Sánchez-Calavera MA, Ramos M. Time to diagnosis and stage of symptomatic colorectal cancer determined by three different sources of information: A population based retrospective study. Cancer Epidemiol 2017; 47:48-55. [PMID: 28126583 DOI: 10.1016/j.canep.2016.10.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 09/29/2016] [Accepted: 10/31/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Survival rates from colorectal cancer (CRC) are highly variable in Europe. This variability could potentially be explained by differences in healthcare system delays in diagnosis. However, even when such delays are reduced, the relationship of the diagnostic interval (time from presentation with symptoms to diagnosis) with outcome is uncertain. METHODS A total of 795 patients with CRC from 5 regions of Spain were retrospectively examined in this population-based multicenter study. Consecutive incident cases of CRC were identified from pathology services. The total diagnostic interval (TDI) was defined as the time from the first presentation with symptoms to diagnosis based on 3 different sources of information: (i) patient-recorded data (PR-TDI) by interview, (ii) hospital-recorded data (HR-TDI), and (iii) general practitioner-recorded data (GPR-TDI). Concordance correlation coefficients (CCCs) were used to estimate the agreement of 3 different TDIs. The TDIs of patients with different stages of CRC were also compared using the Kruskal-Wallis test. RESULTS The median TDI was 131days based on patient interview data, 91days based on HR data, and 111days based on GPR data. Overall, the agreement of these TDIs was poor (CCCPRvsHR=0.399, CCCPRvsGPR=0.518, CCCHRvsGPR=0.383). Univariate analysis indicated that the TDI was greater in those with less advanced CRC for all 3 methods of calculation, but this association was only statistically significant for the HR-TDI (p=0.021). CONCLUSION There is no evidence that patients with more advanced CRC have longer TDIs. In fact, we found an inverse relationship between the TDI and CRC stage, an example of the "waiting time paradox". This association may likely be due to the presence of unmeasured confounders as the stage when symptoms appear or the tumour aggressiveness.
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Affiliation(s)
- Alfonso Leiva
- Primary Care Research Unit of Mallorca, Baleares Health Services-IbSalut, 07005 Palma, España, Instituto de Investigación Sanitaria de Palma, 07010 Palma, Spain.
| | - Magdalena Esteva
- Primary Care Research Unit of Mallorca, Baleares Health Services-IbSalut, 07005 Palma, España, Instituto de Investigación Sanitaria de Palma, 07010 Palma, Spain.
| | - Joan Llobera
- Primary Care Research Unit of Mallorca, Baleares Health Services-IbSalut, 07005 Palma, España, Instituto de Investigación Sanitaria de Palma, 07010 Palma, Spain.
| | - Francesc Macià
- Evaluation and Clinical Epidemiology Department, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain.
| | - Salvador Pita-Fernández
- Clinical Epidemiology and Biostatistics Unit, A Coruña University, Complexo Hospitalario Universitario A Coruña, Xubias de Arriba, 84, Hotel de los pacientes 7ª planta, 15006, A Coruña, Spain.
| | - Luis González-Luján
- Serreria II Primary Care Centre, Valencia Institute of Health, C/Pedro de Valencia 28, 46022, Valencia, Spain.
| | | | - María Ramos
- Department of Public Health, Balearic Department of Health, C/Jesus n 33, 07001, Instituto de Investigación Sanitaria de Palma, 07010 Palma, Spain, Spain.
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Visser E, van Rossum PSN, Leeftink AG, Siesling S, van Hillegersberg R, Ruurda JP. Impact of diagnosis-to-treatment waiting time on survival in esophageal cancer patients - A population-based study in The Netherlands. Eur J Surg Oncol 2016; 43:461-470. [PMID: 27847286 DOI: 10.1016/j.ejso.2016.10.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 09/27/2016] [Accepted: 10/21/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The aim of this study was to determine whether the waiting time from diagnosis to treatment with curative intent for esophageal cancer impacts oncologic outcomes. PATIENTS AND METHODS All patients treated by esophagectomy for esophageal carcinoma in 2005-2013 were identified from the Netherlands Cancer Registry. Patients who underwent multimodality treatment and patients treated with surgery only were analyzed separately. Multivariable logistic regression analyses were performed to evaluate the impact of diagnosis-to-treatment waiting time on pT-status, pN-status, and R0 resection rates. Cox regression was applied to estimate the influence of waiting time on overall survival. Analyses were performed with the original scale and in three categorized groups of waiting time (≤5 weeks, 5-8 weeks, and >8 weeks) based on guidelines and previous studies. RESULTS Of 3839 patients, 2589 underwent multimodality treatment and 1250 were treated with surgery only. In both groups, pT-status, pN-status, and R0 resection rates were not significantly influenced by waiting time (p-values >0.05). Also, waiting time was not significantly associated with overall survival in the multimodality treatment group (5-8 weeks vs. ≤5 weeks, hazard ratio [HR] 1.12, p = 0.171; and >8 weeks vs. ≤5 weeks, HR 1.21, p = 0.167), nor in the surgery only group (5-8 weeks vs. ≤5 weeks, HR 0.92, p = 0.432; and >8 weeks vs. ≤5 weeks, HR 1.00, p = 0.973). CONCLUSION This large population-based cohort study demonstrates that longer waiting time from diagnosis to treatment in patients treated for esophageal cancer with curative intent does not negatively impact pT-status, pN-status, R0 resection rates, and overall survival.
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Affiliation(s)
- E Visser
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands.
| | - P S N van Rossum
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands; Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - A G Leeftink
- Center for Healthcare Operations Improvement and Research, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, The Netherlands; UMC Utrecht Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - S Siesling
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Hoedemakerplein 2, 7511 JP, Enschede, The Netherlands; Department of Health Technology and Services Research, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, The Netherlands
| | - R van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands.
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Weingart SN, Stoffel EM, Chung DC, Sequist TD, Lederman RI, Pelletier SR, Shields HM. Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures. Jt Comm J Qual Patient Saf 2016; 43:32-40. [PMID: 28334584 DOI: 10.1016/j.jcjq.2016.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although delayed colorectal cancer diagnoses figure prominently in medical malpractice claims, little is known about the quality of primary care clinicians' workup of rectal bleeding. METHODS In this study, 438 patients were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for rectal bleeding, hemorrhoids, and blood in the stool at 10 Boston adult primary care practices. Following nurse chart abstraction, physician reviewers assessed the overall quality of care and key care processes. Subjects' characteristics and physician reviewers' processes-of-care assessments were tabulated, and logistic regression models were used to examine the association of process failures with overall quality and guideline concordance. RESULTS Although reviewers judged the overall quality of care to be good or excellent in 337 (77%) of 438 cases, 312 (71%) patients experienced at least one process-of-care failure in the workup of rectal bleeding. Clinicians failed to obtain an adequate family history in 38% of cases, complete a pertinent physical exam in 23%, and order laboratory tests in 16%. Failure to order or perform tests, or to make follow-up plans were associated with increased odds of poor or fair care. Guideline concordance bore little relationship with quality judgments. Reviewers judged that 128 delays could have been reduced or prevented. CONCLUSION Process-of-care failures among adult primary care patients with rectal bleeding were frequent and associated with fair or poor quality. Educating practitioners and creating systems to ensure adequate history taking, physical examination, and processes for ordering, performing, and interpreting diagnostic tests may improve performance.
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Inadequate critical appraisal of studies in systematic reviews of time to diagnosis. J Clin Epidemiol 2016; 78:43-51. [DOI: 10.1016/j.jclinepi.2016.03.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 03/02/2016] [Accepted: 03/21/2016] [Indexed: 01/07/2023]
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Pita-Fernández S, González-Sáez L, López-Calviño B, Seoane-Pillado T, Rodríguez-Camacho E, Pazos-Sierra A, González-Santamaría P, Pértega-Díaz S. Effect of diagnostic delay on survival in patients with colorectal cancer: a retrospective cohort study. BMC Cancer 2016; 16:664. [PMID: 27549406 PMCID: PMC4994409 DOI: 10.1186/s12885-016-2717-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 08/09/2016] [Indexed: 12/14/2022] Open
Abstract
Background Disparate and contradictory results make studies necessary to investigate in more depth the relationship between diagnostic delay and survival in colorectal cancer (CRC) patients. The aim of this study is to analyse the relationship between the interval from first symptom to diagnosis (SDI) and survival in CRC. Methods Retrospective study of n = 942 CRC patients. SDI was calculated as the time from the diagnosis of cancer and the first symptoms of CRC. Cox regression was used to estimate five-year mortality hazard ratios as a function of SDI, adjusting for age and gender. SDI was modelled according to SDI quartiles and as a continuous variable using penalized splines. Results Median SDI was 3.4 months. SDI was not associated with stage at diagnosis (Stage I = 3.6 months, Stage II-III = 3.4, Stage IV = 3.2; p = 0.728). Shorter SDIs corresponded to patients with abdominal pain (2.8 months), and longer SDIs to patients with muchorrhage (5.2 months) and rectal tenesmus (4.4 months). Adjusting for age and gender, in rectum cancers, patients within the first SDI quartile had lower survival (p = 0.003), while in colon cancer no significant differences were found (p = 0.282). These results do not change after adjusting for TNM stage. The splines regression analysis revealed that, for rectum cancer, 5-year mortality progressively increases for SDIs lower than the median (3.7 months) and decreases as the delay increases until approximately 8 months. In colon cancer, no significant relationship was found between SDI and survival. Conclusions Short diagnostic intervals are significantly associated with higher mortality in rectal but not in colon cancers, even though a borderline significant effect is also observed in colon cancer. Longer diagnostic intervals seemed not to be associated with poorer survival. Other factors than diagnostic delay should be taken into account to explain this “waiting-time paradox”.
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Affiliation(s)
- Salvador Pita-Fernández
- Clinical Epidemiology and Biostatistics Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Universidade da Coruña, A Coruña, Spain.
| | - Luis González-Sáez
- Surgery Department, Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Universidade da Coruña, A Coruña, Spain
| | - Beatriz López-Calviño
- Clinical Epidemiology and Biostatistics Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Universidade da Coruña, A Coruña, Spain
| | - Teresa Seoane-Pillado
- Clinical Epidemiology and Biostatistics Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Universidade da Coruña, A Coruña, Spain
| | - Elena Rodríguez-Camacho
- Department of Population Screening Programs, SERGAS, Santiago de Compostela, A Coruña, Spain
| | - Alejandro Pazos-Sierra
- Department of Information and Communication Technologies, Computer Science Faculty, University of A Coruña, A Coruña, Spain
| | | | - Sonia Pértega-Díaz
- Clinical Epidemiology and Biostatistics Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Universidade da Coruña, A Coruña, Spain
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Jooste V, Dejardin O, Bouvier V, Arveux P, Maynadie M, Launoy G, Bouvier AM. Pancreatic cancer: Wait times from presentation to treatment and survival in a population-based study. Int J Cancer 2016; 139:1073-80. [PMID: 27130333 DOI: 10.1002/ijc.30166] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 04/20/2016] [Indexed: 11/08/2022]
Abstract
Pancreatic survival is one of the worst in oncology. To what extent wait times affect outcomes in unknown No population-based study has previously explored patient and treatment delays among individuals with pancreatic cancer. The aim of this study was to estimate patient and treatment delays in patients with pancreatic cancer and to measure their association with survival in a nonselected population. All patients diagnosed with pancreatic cancer for the first time between 2009 and 2011 and registered in two French digestive cancer registries were included. Patient delay (time from onset of symptoms until the first consultation categorized into <1 or ≥1 month), and treatment delay (time between the first consultation and treatment categorized into less or more than 29 days, the median time) were collected. Overall delay was used to test associations between survival and the timeliness of care by combining patient delay and treatment delay. Patient delay was longer than 1 month in 46% of patients. A patient delay longer than one month was associated with the absence of jaundice (p < 0.001) and the presence of metastasis (p = 0.003). After adjusting for other covariates, such as symptoms and treatment, the presence of metastasis was negatively associated with treatment delay longer than 29 days (p = 0.025). After adjustment for other covariates, especially metastatic dissemination and the result of the resection, overall delay was not significantly associated with prognosis. We found little evidence to suggest that timely care was associated with the survival of patients.
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Affiliation(s)
- Valérie Jooste
- CHU Dijon Bourgogne, Registre Bourguignon des Cancers Digestifs, F-21000 Dijon, France; INSERM, LNC UMR866, F-21000 Dijon, France; Université Bourgogne Franche-Comté, LNC UMR866, F-21000 Dijon, France
| | - Olivier Dejardin
- University Hospital of Caen, U1086 INSERM UCBN "Cancers & Preventions", Caen, F-14, France
| | - Véronique Bouvier
- University Hospital of Caen, U1086 INSERM UCBN "Cancers & Preventions", Caen, F-14, France
| | - Patrick Arveux
- Breast and Gynaecologic Cancer Registry of Côte D'Or, Centre Georges-François Leclerc Comprehensive Cancer Care Centre, Dijon, F-21, France
| | - Marc Maynadie
- Registre Des Hémopathies Malignes De Côte D'Or, EA4184, University of Burgundy, Dijon, F-21, France
| | - Guy Launoy
- University Hospital of Caen, U1086 INSERM UCBN "Cancers & Preventions", Caen, F-14, France
| | - Anne-Marie Bouvier
- CHU Dijon Bourgogne, Registre Bourguignon des Cancers Digestifs, F-21000 Dijon, France; INSERM, LNC UMR866, F-21000 Dijon, France; Université Bourgogne Franche-Comté, LNC UMR866, F-21000 Dijon, France
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Time to first treatment after colonoscopy in patients suffering from colon or rectum cancer in France. Cancer Epidemiol 2015; 39:877-84. [PMID: 26651450 DOI: 10.1016/j.canep.2015.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 09/07/2015] [Accepted: 10/01/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Time to treatment of cancer is becoming a serious political and social issue. A greater understanding of the timeframes involved in cancer care is needed to reduce inequalities in access to care caused by delays. OBJECTIVE To describe indicators of time to first treatment after colonoscopy in colon cancer (CC) and rectum cancer (RC) patients in France. METHOD Using the international classification of diseases and medical procedures codes, from national hospital discharge and long term illness databases we selected patients newly diagnosed for CC or RC in 2009-2010 who had undergone treatment. RESULTS We included 15 694 and 6 623 patients for CC and RC, respectively. Median times to surgery in patients with a surgical treatment pathway for CC and RC were 22 (Q1=14; Q3=34) and 97 (Q1=34; Q3=141) days, respectively. Median times to chemotherapy for patients with a non-surgical treatment pathway, for CC and RC were 36 (Q1=21; Q3=59) and 40 (Q1=27; Q3=59) days, respectively. The median time to radiotherapy in RC patients was 53 (Q1=39; Q3=78) days.Time to surgery as first treatment in RC patients (46 days) was twice as long as that in CC patients (22 days). Time to treatment was longer in most northern regions and in overseas districts, and shorter in southern regions, for both CC and RC. CONCLUSION The findings in this unprecedented study in France will inform decision-making policies on the future implementation of guidelines on timeframes for colorectal cancer treatment access.
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Hepatocellular Carcinoma From Epidemiology to Prevention: Translating Knowledge into Practice. Clin Gastroenterol Hepatol 2015; 13:2140-51. [PMID: 26284591 PMCID: PMC4618036 DOI: 10.1016/j.cgh.2015.08.014] [Citation(s) in RCA: 383] [Impact Index Per Article: 42.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 08/11/2015] [Accepted: 08/11/2015] [Indexed: 02/07/2023]
Abstract
The epidemiology of hepatocellular carcinoma (HCC) is characterized by dynamic temporal trends, several major established (i.e., HCV, HBV, alcohol) and emerging (i.e., diabetes, obesity, NAFLD) risk factors. Epidemiologic studies and clinical trials have identified additional demographic, clinical, pharmacological, genetic and life style factors that further affect or modify the likelihood of HCC and can be used in clinical practice to identify at-risk patients (i.e., risk stratification or prognostic algorithms) that can be targeted for prevention and early detection programs. These studies have also paved the way toward several well established preventive measures including HBV vaccination, HBV treatment, HCV treatment and HCC surveillance, and potential chemoprevention using statins, metformin or coffee. However, the effectiveness of HCC prevention in clinical practice and at the population level has lagged behind due to patient, provider, system, and societal factors. The Quality in the Continuum of Cancer Care model provides a framework for evaluating the HCC prevention processes, including potential failures that create a gap between efficacy and effectiveness.
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Affiliation(s)
- Laurie Elit
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada.
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Seiber EE, Camacho F, Zeeshan MF, Kern TT, Fleming ST. Disparities in Colorectal Cancer Treatment Delay Within Appalachia--The Role of For-Profit Hospitals. J Rural Health 2015; 31:382-91. [PMID: 26032695 DOI: 10.1111/jrh.12122] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND Appalachian residents have a higher overall cancer burden than the rest of the United States because of the unique features of the region. Treatment delays vary widely within Appalachia, with colorectal cancer patients undergoing median treatment delays of 5 days in Kentucky compared to 9 days for patients in Pennsylvania, Ohio, and North Carolina combined. OBJECTIVE This study identified the source of this disparity in treatment delay using statistical decomposition techniques. METHODOLOGY This study used linked 2006 to 2008 cancer registry and Medicare claims data for the Appalachian counties of Kentucky, Pennsylvania, Ohio, and North Carolina to estimate a 2-part model of treatment delay. An Oaxaca Decomposition of the 2-part model revealed the contribution of the individual determinants to the disparity in delay between Kentucky counties and the remaining 3 states. RESULTS The Oaxaca Decomposition revealed that the higher percentage of patients treated at for-profit facilities in Kentucky proved the key contributor to the observed disparity. In Kentucky, 22.3% patients began their treatment at a for-profit facility compared to 1.4% in the remaining states. Patients initiating treatment at for-profit facilities explained 79% of the observed difference in immediate treatment (<2 days after diagnosis) and 72% of Kentucky's advantage in log days to treatment. CONCLUSIONS The unique role of for-profit facilities led to reduced treatment delay for colorectal cancer patients in Kentucky. However, it remains unknown whether for-profit hospitals' more rapid treatment converts to better health outcomes for colorectal cancer patients.
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Affiliation(s)
- Eric E Seiber
- Division of Health Services Management and Policy, College of Public Health, Ohio State University, Columbus, Ohio
| | - Fabian Camacho
- Department of Public Health Science, College of Medicine, University of Virginia, Charlottesville, Virginia
| | - Muhammad Fazal Zeeshan
- Department of Community Health Sciences, Peshawar Medical College, Riphah International University, Peshawar, Pakistan
| | - Teresa T Kern
- Department of Public Health Science, College of Medicine, University of Virginia, Charlottesville, Virginia
| | - Steven T Fleming
- Department of Epidemiology, University of Kentucky, Lexington, Kentucky
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Redaniel MT, Martin RM, Ridd MJ, Wade J, Jeffreys M. Diagnostic intervals and its association with breast, prostate, lung and colorectal cancer survival in England: historical cohort study using the Clinical Practice Research Datalink. PLoS One 2015; 10:e0126608. [PMID: 25933397 PMCID: PMC4416709 DOI: 10.1371/journal.pone.0126608] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 04/03/2015] [Indexed: 01/07/2023] Open
Abstract
Rapid diagnostic pathways for cancer have been implemented, but evidence whether shorter diagnostic intervals (time from primary care presentation to diagnosis) improves survival is lacking. Using the Clinical Practice Research Datalink, we identified patients diagnosed with female breast (8,639), colorectal (5,912), lung (5,737) and prostate (1,763) cancers between 1998 and 2009, and aged >15 years. Presenting symptoms were classified as alert or non-alert, according to National Institute for Health and Care Excellence guidance. We used relative survival and excess risk modeling to determine associations between diagnostic intervals and five-year survival. The survival of patients with colorectal, lung and prostate cancer was greater in those with alert, compared with non-alert, symptoms, but findings were opposite for breast cancer. Longer diagnostic intervals were associated with lower mortality for colorectal and lung cancer patients with non-alert symptoms, (colorectal cancer: Excess Hazards Ratio, EHR >6 months vs <1 month: 0.85; 95% CI: 0.72-1.00; Lung cancer: EHR 3-6 months vs <1 month: 0.87; 95% CI: 0.80-0.95; EHR >6 months vs <1 month: 0.81; 95% CI: 0.74-0.89). Prostate cancer mortality was lower in patients with longer diagnostic intervals, regardless of type of presenting symptom. The association between diagnostic intervals and cancer survival is complex, and should take into account cancer site, tumour biology and clinical practice. Nevertheless, unnecessary delay causes patient anxiety and general practitioners should continue to refer patients with alert symptoms via the cancer pathways, and actively follow-up patients with non-alert symptoms in the community.
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Affiliation(s)
- Maria Theresa Redaniel
- NIHR CLAHRC West, University of Bristol, Bristol, United Kingdom
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
- * E-mail:
| | - Richard M. Martin
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Matthew J. Ridd
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Julia Wade
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Mona Jeffreys
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
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Abstract
Background Alarm symptom presentations are predictive of cancer diagnosis but may also be associated with cancer survival. Aim To evaluate diagnostic time intervals, and consultation patterns after presentation with alarm symptoms, and their association with cancer diagnosis and survival. Design and setting Cohort study using the Clinical Practice Research Database, with linked Cancer Registry data, in 158 general practices. Method Participants included those with haematuria, haemoptysis, dysphagia, and rectal bleeding or urinary tract cancer, lung cancer, gastro-oesophageal cancer, and colorectal cancer. Results The median (interquartile range) interval in days from first symptom presentation to the corresponding cancer diagnosis was: haematuria and urinary tract cancer, 59 (28–109); haemoptysis and lung cancer, 35 (18–89); dysphagia and gastro-oesophageal cancer, 25 (12–48); rectal bleeding and colorectal cancer, 49 (20–157). Three or more alarm symptom consultations were associated with increased odds of diagnosis of urinary tract cancer (odds ratio [OR] 1.84, 95% CI = 1.50 to 2.27), lung cancer (OR = 1.76, 95% CI = 1.07 to 2.90) and gastro-oesophageal cancer (OR = 2.17, 95% CI = 1.48 to 3.19). Longer diagnostic intervals were associated with increased mortality only for urinary tract cancer (hazard ratio 2.23, 95% CI = 1.35 to 3.69). Patients with no preceding alarm symptom had shorter survival from diagnosis of urinary tract, lung or colorectal cancer than those presenting with a relevant alarm symptom. Conclusion After alarm symptom presentation, repeat consultations are associated with cancer diagnoses. Longer diagnostic intervals appeared to be associated with a worse prognosis for urinary tract cancer only. Mortality is higher when cancer is diagnosed in the absence of alarm symptoms.
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Neal RD, Tharmanathan P, France B, Din NU, Cotton S, Fallon-Ferguson J, Hamilton W, Hendry A, Hendry M, Lewis R, Macleod U, Mitchell ED, Pickett M, Rai T, Shaw K, Stuart N, Tørring ML, Wilkinson C, Williams B, Williams N, Emery J. Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review. Br J Cancer 2015; 112 Suppl 1:S92-107. [PMID: 25734382 PMCID: PMC4385982 DOI: 10.1038/bjc.2015.48] [Citation(s) in RCA: 638] [Impact Index Per Article: 70.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND It is unclear whether more timely cancer diagnosis brings favourable outcomes, with much of the previous evidence, in some cancers, being equivocal. We set out to determine whether there is an association between time to diagnosis, treatment and clinical outcomes, across all cancers for symptomatic presentations. METHODS Systematic review of the literature and narrative synthesis. RESULTS We included 177 articles reporting 209 studies. These studies varied in study design, the time intervals assessed and the outcomes reported. Study quality was variable, with a small number of higher-quality studies. Heterogeneity precluded definitive findings. The cancers with more reports of an association between shorter times to diagnosis and more favourable outcomes were breast, colorectal, head and neck, testicular and melanoma. CONCLUSIONS This is the first review encompassing many cancer types, and we have demonstrated those cancers in which more evidence of an association between shorter times to diagnosis and more favourable outcomes exists, and where it is lacking. We believe that it is reasonable to assume that efforts to expedite the diagnosis of symptomatic cancer are likely to have benefits for patients in terms of improved survival, earlier-stage diagnosis and improved quality of life, although these benefits vary between cancers.
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Affiliation(s)
- R D Neal
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - P Tharmanathan
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - B France
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - N U Din
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - S Cotton
- Betsi Cadwaladr University Health Board, Wrexham Maelor Hospital, Wrexham LL13 7TD, UK
| | - J Fallon-Ferguson
- Primary Care Collaborative Cancer Clinical Trials Group, School of Primary, Aboriginal, and Rural Healthcare, University of Western Australia, M706, 35 Stirling Highway, Crawley, Western Australia 6009, Australia
| | - W Hamilton
- University of Exeter Medical School, Exeter EX1 2LU, UK
| | - A Hendry
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - M Hendry
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - R Lewis
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - U Macleod
- Centre for Health and Population studies, Hull York Medical School, University of Hull, Hull HU6 7RX, UK
| | - E D Mitchell
- Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9LJ, UK
| | - M Pickett
- Betsi Cadwaladr University Health Board, Wrexham Maelor Hospital, Wrexham LL13 7TD, UK
| | - T Rai
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor LL57 2PZ, UK
| | - K Shaw
- Primary Care Collaborative Cancer Clinical Trials Group, School of Primary, Aboriginal, and Rural Healthcare, University of Western Australia, M706, 35 Stirling Highway, Crawley, Western Australia 6009, Australia
| | - N Stuart
- School of Medical Sciences, Bangor University, Bangor, LL57 2AS UK
| | - M L Tørring
- Research Unit for General Practice, Aarhus University, Bartholins Alle 2, Aarhus DK-8000, Denmark
| | - C Wilkinson
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - B Williams
- Primary Care Collaborative Cancer Clinical Trials Group, School of Primary, Aboriginal, and Rural Healthcare, University of Western Australia, M706, 35 Stirling Highway, Crawley, Western Australia 6009, Australia
| | - N Williams
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor LL57 2PZ, UK
| | - J Emery
- Primary Care Collaborative Cancer Clinical Trials Group, School of Primary, Aboriginal, and Rural Healthcare, University of Western Australia, M706, 35 Stirling Highway, Crawley, Western Australia 6009, Australia
- General Practice & Primary Care Academic Centre, University of Melbourne, 200 Berkeley Street, Melbourne, Victoria 3053, Australia
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Aggarwal A, Herz N, Campbell P, Arkush L, Short S, Rees J. Diagnostic delay and survival in high-grade gliomas - evidence of the 'waiting time paradox'? Br J Neurosurg 2015; 29:520-3. [PMID: 25738427 DOI: 10.3109/02688697.2015.1012050] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION We present a retrospective single-centre study to determine whether delays in diagnosis of high-grade glioma (HGG) impact on overall survival (OS). MATERIAL AND METHODS Consecutive patients diagnosed with HGG at a single neuroscience centre in 2011 were reviewed. Route of referral and time from initial presentation to diagnosis were analysed and correlated with OS. RESULTS 118 patients were studied - 92 patients with glioblastoma (GBM). Diagnosis of GBM in patients presenting to emergency services was quicker than that through outpatients (8 days vs. 26 days, p < 0.0001), but these patients had significantly worse OS (181 days vs. 386 days p = 0.0075). This trend was observed for the whole cohort (Grade III and GBM), with OS 278 days in patients presenting to emergency services compared with 423 days for patients presenting via outpatients (p = 0.0034). Patients presenting to outpatients were younger (median age: 54 years) compared with patients presenting to emergency services (median age: 62.5 years) (p = 0.0106). There were no other differences between the two groups with respect to the nature of presenting symptoms. CONCLUSION Earlier diagnosis is paradoxically associated with a worse OS in GBM. An 'aggressive' phenotype with rapid symptomatic deterioration and hence emergency presentation is a poor prognostic factor not influenced by earlier diagnosis.
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Affiliation(s)
- Ajay Aggarwal
- a National Hospital for Neurology and Neurosurgery , Queen Square, London , UK
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van Harten MC, Hoebers FJP, Kross KW, van Werkhoven ED, van den Brekel MWM, van Dijk BAC. Determinants of treatment waiting times for head and neck cancer in the Netherlands and their relation to survival. Oral Oncol 2015; 51:272-8. [PMID: 25541458 DOI: 10.1016/j.oraloncology.2014.12.003] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 12/02/2014] [Accepted: 12/05/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Michel C van Harten
- Department of Head and Neck Surgery and Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Frank J P Hoebers
- Department of Radiation Oncology (MAASTRO), Research Institute GROW, Maastricht University, Maastricht, The Netherlands
| | - Kenneth W Kross
- Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Erik D van Werkhoven
- Department of Biometrics, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michiel W M van den Brekel
- Department of Head and Neck Surgery and Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Oral and Maxillofacial Surgery, Academic Medical Center, University of Amsterdam, The Netherlands; Department of Phonetic Sciences, University of Amsterdam, The Netherlands
| | - Boukje A C van Dijk
- Department of Research, Comprehensive Cancer Centre The Netherlands (IKNL), Utrecht, The Netherlands; Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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Law CW, Rampal S, Roslani AC, Mahadeva S. Development of a risk score to stratify symptomatic adults referred for colonoscopy. J Gastroenterol Hepatol 2014; 29:1890-6. [PMID: 24909623 DOI: 10.1111/jgh.12638] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM With an increasing burden on overstretched colonoscopy services, a simple risk score for significant pathology in symptomatic patients may aid in the prioritization of patients. METHODS A derivative study of a risk score model for colonic neoplasia (colorectal carcinoma [CRC] and advanced adenoma) and CRC alone was conducted in symptomatic adults referred for an index colonoscopy. The accuracy of the final model was assessed by the area under the curve (AUC) of the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS A total of 1013 subjects (mean age 59.9 ± 13.7 years, 52.3% females) from a multi-ethnic Asian background (Chinese 56%, Malay 20.4%, Indian 21.5%) were recruited. Colonic neoplasia and CRC were identified in 175 (17.3%) and 114 (11.3%) cases, respectively. Risk scores were assigned to individual factors identified in a logistic regression model of both demographic (age, gender, ethnicity, education level, smoking history, Aspirin use) and clinical symptoms (change in bowel habit, bloody stool, weight loss, appetite loss, lethargy). The risk score for each patient was the sum of their individual risk factors. The AUC of the risk score for colonic neoplasia and CRC was 0.76 (Hosmer-Lemeshow goodness-of-fit statistic of P = 0.745) and 0.83 (Hosmer-Lemeshow goodness-of-fit statistic of P = 0.982), respectively. CONCLUSION A simple risk score for colonic neoplasia and CRC may be able to prioritize colonoscopy referrals in symptomatic subjects from a multi-ethnic background. A further study to validate this scoring system is required.
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Affiliation(s)
- Chee-Wei Law
- Division of Colorectal Surgery, Department of Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
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Amri R, Bordeianou LG, Sylla P, Berger DL. Colon cancer surgery following emergency presentation: effects on admission and stage-adjusted outcomes. Am J Surg 2014; 209:246-53. [PMID: 25457246 DOI: 10.1016/j.amjsurg.2014.07.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 06/27/2014] [Accepted: 07/03/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Emergency presentation with colon cancer is intuitively related to advanced disease. We measured its effect on outcomes of surgically treated colon cancer. METHODS A retrospective cohort of 1,071 surgical colon cancer patients (2004 to 2011), with 102 emergency cases requiring surgery within the index admission, was analyzed. RESULTS Emergency patients required longer surgeries (median 141 vs 124 minutes; P = .04), longer median admissions (8% vs 5%; P < .001), more readmissions (12.7% vs 7.1%; P = .040), and perioperative mortality (7.8% vs .8%; P < .001). Surgical pathology displayed higher rates of node-positive disease (56.6% vs 38.6%; P < .001), extramural vascular invasion (39.6% vs 29.1%; P = .021), and metastatic disease (19.6% vs 8%; P < .001). Consequently, adjusting for staging, emergency presentations had considerably higher mortality (odds ratio = 2.07; P = .003) and shorter disease-free survival (hazard ratio = 1.39; P = .042). CONCLUSIONS Emergency presentation is a stage-independent poor prognostic factor associated with aggressive tumor biology, resulting in longer surgeries and admissions, frequent readmissions, worsening outcomes, and increasing healthcare costs.
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Affiliation(s)
- Ramzi Amri
- Division of General and Gastrointestinal Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Liliana G Bordeianou
- Division of General and Gastrointestinal Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Patricia Sylla
- Division of General and Gastrointestinal Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - David L Berger
- Division of General and Gastrointestinal Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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Redaniel MT, Martin RM, Blazeby JM, Wade J, Jeffreys M. The association of time between diagnosis and major resection with poorer colorectal cancer survival: a retrospective cohort study. BMC Cancer 2014; 14:642. [PMID: 25175937 PMCID: PMC4159515 DOI: 10.1186/1471-2407-14-642] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 08/22/2014] [Indexed: 12/02/2022] Open
Abstract
Background Colorectal cancer survival in the UK is lower than in other developed countries, but the association of time interval between diagnosis and treatment on excess mortality remains unclear. Methods Using data from cancer registries in England, we identified 46,511 patients with localised colorectal cancer between 1996–2009, who were 15 years and older, and who underwent a major surgical resection within 62 days of diagnosis. We used relative survival and excess risk modeling to investigate the association of time between diagnosis and major resection (exposure) with survival (outcome). Results Compared to patients who had major resection within 25–38 days of diagnosis, patients with a shorter time interval between diagnosis and resection and those waiting longer for resection had higher excess mortality (Excess Hazards Ratio, EHR <25 vs 25–38 days: 1.50; 95% Confidence Interval, CI: 1.37 to 1.66; EHR 39–62 vs 25–38 days : 1.16; 95% CI: 1.04 to 1.29). Excess mortality was associated with age (EHR 75+ vs. 15–44 year olds: 2.62; 95% CI: 2.00 to 3.42) and deprivation (EHR most vs. least deprived: 1.27; 95% CI: 1.12 to 1.45), but time between diagnosis and resection did not explain these differences. Conclusion Within 62 days of diagnosis, a U-shaped association of time between diagnosis and major resection with excess mortality for localised colorectal cancer was evident. This indicates a complicated treatment pathway, particularly for patients who had resection earlier than 25 days, and requires further investigation.
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Affiliation(s)
- Maria Theresa Redaniel
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK.
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Tiong J, Gray A, Jackson C, Thompson-Fawcett M, Schultz M. Audit of the association between length of time spent on diagnostic work-up and tumour stage in patients with symptomatic colon cancer. ANZ J Surg 2014; 87:138-142. [DOI: 10.1111/ans.12804] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Jimmy Tiong
- Department of Medicine; Dunedin School of Medicine; University of Otago; Dunedin New Zealand
| | - Andrew Gray
- Department of Preventive and Social Medicine; University of Otago; Dunedin New Zealand
| | | | - Mark Thompson-Fawcett
- Department of Surgery; Dunedin School of Medicine, University of Otago; Dunedin New Zealand
- Department of Surgery, Dunedin Hospital; Southern District Health Board; Dunedin New Zealand
| | - Michael Schultz
- Department of Gastroenterology; Southern District Health Board; Dunedin New Zealand
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Murchie P, Raja EA, Brewster DH, Campbell NC, Ritchie LD, Robertson R, Samuel L, Gray N, Lee AJ. Time from first presentation in primary care to treatment of symptomatic colorectal cancer: effect on disease stage and survival. Br J Cancer 2014; 111:461-9. [PMID: 24992583 PMCID: PMC4119995 DOI: 10.1038/bjc.2014.352] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 05/12/2014] [Accepted: 05/30/2014] [Indexed: 01/03/2023] Open
Abstract
Background: British 5-year survival from colorectal cancer (CRC) is below the European average, but the reasons are unclear. This study explored if longer provider delays (time from presentation to treatment) were associated with more advanced stage disease at diagnosis and poorer survival. Methods: Data on 958 people with CRC were linked with the Scottish Cancer Registry, the Scottish Death Registry and the acute hospital discharge (SMR01) dataset. Time from first presentation in primary care to first treatment, disease stage at diagnosis and survival time from date of first presentation in primary care were determined. Logistic regression and Cox survival analyses, both with a restricted cubic spline, were used to model stage and survival, respectively, following sequential adjustment of patient and tumour factors. Results: On univariate analysis, those with <4 weeks from first presentation in primary care to treatment had more advanced disease at diagnosis and the poorest prognosis. Treatment delays between 4 and 34 weeks were associated with earlier stage (with the lowest odds ratio occurring at 20 weeks) and better survival (with the lowest hazard ratio occurring at 16 weeks). Provider delays beyond 34 weeks were associated with more advanced disease at diagnosis, but not increased mortality. Following adjustment for patient, tumour factors, emergency admissions and symptoms and signs, no significant relationship between provider delay and stage at diagnosis or survival from CRC was found. Conclusions: Although allowing for a nonlinear relationship and important confounders, moderately long provider delays did not impact adversely on cancer outcomes. Delays are undesirable because they cause anxiety; this may be fuelled by government targets and health campaigns stressing the importance of very prompt cancer diagnosis. Our findings should reassure patients. They suggest that a health service's primary emphasis should be on quality and outcomes rather than on time to treatment.
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Affiliation(s)
- P Murchie
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - E A Raja
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - D H Brewster
- Scottish Cancer Registry, Information Services Division of NHS National Services Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh EH12 9EB, UK
| | - N C Campbell
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - L D Ritchie
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - R Robertson
- Scottish Collaboration for Public Health Research and Policy (SCPHRP), 20 West Richmond Street, Edinburgh EH8 9DX, UK
| | - L Samuel
- Department of Oncology, Aberdeen Royal Infirmary, Aberdeen, AB25 2ZN, UK
| | - N Gray
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - A J Lee
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
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Prognosis and delay of diagnosis among Kaposi's sarcoma patients in Uganda: a cross-sectional study. Infect Agent Cancer 2014; 9:17. [PMID: 24904686 PMCID: PMC4045870 DOI: 10.1186/1750-9378-9-17] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 04/07/2014] [Indexed: 01/07/2023] Open
Abstract
Background In low- and middle-income countries, the association between delay to treatment and prognosis for Kaposi’s sarcoma (KS) patients is yet to be studied. Methods This is a prospective study of HIV-infected adults with histologically-confirmed KS treated at the Uganda Cancer Institute (UCI). Standardized interviews were conducted in English or Luganda. Medical records were abstracted for KS stage at admission to UCI. Multivariable logistic regression assessed relationships between diagnostic delay and stage at diagnosis. Results Of 161 patients (90% response rate), 69% were men, and the mean age was 34.0 years (SD 7.7). 26% had been seen in an HIV clinic within 3 months, 72% were on antiretroviral therapy, and 26% had visited a traditional healer prior to diagnosis. 45% delayed seeking care at UCI for ≥3 months from symptom onset. Among those who delayed, 36% waited 6 months, and 25% waited 12 months. Common reasons for delay were lack of pain (48%), no money (32%), and distance to UCI (8%). In adjusted analysis patients who experienced diagnostic delay were more likely than those who did not delay to have poor-risk KS stage (OR 3.41, p = 0.002, 95% CI: 1.46-7.45). In adjusted analyses visiting a traditional healer was the only variable associated with greater likelihood of delay (OR 2.69, p = 0.020, 95% CI: 1.17-6.17). Conclusions Diagnostic delay was associated with poor-risk stage at diagnosis, and visiting a traditional healer was associated with higher odds of delay. The relationship between traditional and Western medicine presents a critical intervention point to improve KS-related outcomes in Uganda.
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Ruys AT, Heuts SG, Rauws EA, Busch ORC, Gouma DJ, Gulik TM. Delay in surgical treatment of patients with hilar cholangiocarcinoma: does time impact outcomes? HPB (Oxford) 2014; 16:469-74. [PMID: 24033549 PMCID: PMC4008165 DOI: 10.1111/hpb.12156] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 03/27/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Substantial time elapses before patients with hilar cholangiocarcinoma (HCC) receive surgical treatment because of time-consuming preoperative staging and other interventions, including biliary drainage and portal vein embolization. Prolonged times potentially lead to unresectability and the formation of metastases, yet these issues have not been investigated previously in HCC. This study aimed to evaluate the time between onset of symptoms and the provision of ultimate treatment in patients with HCC and the impact of the length of time on outcomes. METHODS Delays in the treatment of consecutive patients with HCC were evaluated by contacting general practitioners (GPs) and extracting data from hospital files. Time periods were correlated with resectability, occurrence of metastasis, tumour stage and survival using logistic and Cox regression analyses. RESULTS Treatment times in 209 consecutive HCC patients were evaluated. The median time from first GP visit until presentation at the tertiary centre was 35 days. Time until treatment was longer when initial symptoms did not include jaundice (non-specific symptoms, P < 0.001). Duration of workup and preoperative biliary drainage at the tertiary centre prior to final surgical treatment resulted in an additional median time of 74 days. No correlation was found between treatment time in weeks and resectability [odds ratio (OR) 1.010, 95% confidence interval (CI) 0.985-1.036], metastasis (OR = 0.947, 95% CI 0.897-1.000), tumour stage (OR = 1.006, 95% CI 0.981-1.031) or survival in resected patients (hazard ratio = 0.996, 95% CI 0.975-1.018). CONCLUSIONS The time that elapses between the presentation of symptoms and final treatment in patients with HCC is substantial, especially in patients with non-specific symptoms. This time, however, does not affect resectability, metastasis, tumour stage or survival, which suggests that preoperative optimization should not be omitted because of potential delays in treatment.
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Affiliation(s)
| | | | | | | | | | - Thomas M Gulik
- Correspondence Thomas M. van Gulik, Department of Surgery, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands. Tel: +31 20 566 5572. Fax: +31 20 697 6621. E-mail:
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Time from (clinical or certainty) diagnosis to treatment onset in cancer patients: the choice of diagnostic date strongly influences differences in therapeutic delay by tumor site and stage. J Clin Epidemiol 2013; 66:928-39. [DOI: 10.1016/j.jclinepi.2012.12.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 10/30/2012] [Accepted: 12/14/2012] [Indexed: 11/20/2022]
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Pita-Fernández S, Pértega-Díaz S, López-Calviño B, Seoane-Pillado T, Gago-García E, Seijo-Bestilleiro R, González-Santamaría P, Pazos-Sierra A. Diagnostic and treatment delay, quality of life and satisfaction with care in colorectal cancer patients: a study protocol. Health Qual Life Outcomes 2013; 11:117. [PMID: 23845102 PMCID: PMC3710493 DOI: 10.1186/1477-7525-11-117] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 07/09/2013] [Indexed: 01/12/2023] Open
Abstract
Background Due to recent improvements in colorectal cancer survival, patient-reported outcomes, including health-related quality of life and satisfaction with care, have become well-established endpoints to determine the impact of the disease on the lives of patients. The aim of this study is to determine prospectively, in a cohort of colorectal cancer incident cases: a) health-related quality of life, b) satisfaction with hospital-based care, and c) functional status. A secondary objective is to determine whether diagnostic/therapeutic delay influence quality of life or patients’ satisfaction levels. Methods/design Single-centre prospective follow-up study of colorectal cancer patients diagnosed during the period 2011–2012 (n = 375). This project was approved by the corresponding ethics review board, and informed consent is obtained from each patient. After diagnosis, patients are interviewed by a trained nurse, obtaining information on sociodemographic characteristics, family history of cancer, first symptoms, symptom perception and reaction to early symptoms. Quality of life is assessed with the EORTC QLQ-C30 and QLQ-CR29 questionnaires, and patients’ satisfaction with care is determined using the EORTC IN-PATSAT32. Functional status is measured with the Karnofsky Performance Status Scale. Clinical records are also reviewed to collect information on comorbidity, tumour characteristics, treatment, hospital consultations and exploratory procedures. Symptoms-to-diagnosis interval is defined as the time from the date of first symptoms until the cytohistological confirmation of cancer. Treatment delay is defined as the time between diagnosis and surgical treatment. All the patients will be followed-up for a maximum of 2 years. For survivors, assessments will be re-evaluated at one and two years after the diagnosis. Multiple linear/logistic regression models will be used to identify variables associated with the patients’ functional status, quality of life and satisfaction with care score. Changes in quality of life over time will be analysed with linear mixed-effects regression models. Discussion The results will provide a deeper understanding of the impact of colorectal cancer from a more patient-centred approach, allowing us to identify groups of patients in need of additional attention, as well as areas for improvement. Special attention will be given to the relationship between diagnostic/therapeutic delay and patients’ quality of life and satisfaction with the care received.
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Affiliation(s)
- Salvador Pita-Fernández
- Clinical Epidemiology and Biostatistics Unit, Complexo Hospitalario Universitario A Coruña, Universidade de A Coruña, Hotel de Pacientes 7a Planta, As Xubias 84, A Coruña, Spain.
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Pruitt SL, Harzke AJ, Davidson NO, Schootman M. Do diagnostic and treatment delays for colorectal cancer increase risk of death? Cancer Causes Control 2013; 24:961-77. [PMID: 23446843 PMCID: PMC3708300 DOI: 10.1007/s10552-013-0172-6] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 02/08/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Using 1998-2005 SEER-Medicare data, we examined the effect of diagnostic and treatment delays on all-cause and colorectal cancer (CRC)-specific death among US adults aged ≥ 66 years with invasive colon or rectal cancer. We hypothesized that longer delays would be associated with a greater risk of death. METHODS We defined diagnostic and treatment delays, respectively, as days between (1) initial medical consult for CRC symptoms and pathologically confirmed diagnosis (maximum: 365 days) and (2) pathologically confirmed diagnosis and treatment (maximum: 120 days). Cases (CRC deaths) and controls (deaths due to other causes or censored) were matched on survival time. Logistic regression analyses adjusted for sociodemographic, tumor, and treatment factors. RESULTS Median diagnostic delays were 60 (colon) and 40 (rectal) days and treatment delays were 13 (colon) and 16 (rectal) days in 10,663 patients. Colon cancer patients with the longest diagnostic delays (8-12 months vs. 14-59 days) had higher odds of all-cause (aOR: 1.31 CI: 1.08-1.58), but not CRC-specific death. Colon cancer patients with the shortest treatment delays (<1 vs. 1-2 weeks) had higher odds of all-cause (aOR: 1.23 CI: 1.01-1.49), but not CRC-specific death. Among rectal cancer patients, delays were not associated with risk of all-cause or CRC-specific death. CONCLUSIONS Longer delays of up to 1 year after symptom onset and 120 days for treatment did not increase odds of CRC-specific death. There may be little clinical benefit in detecting and treating existing symptomatic disease earlier. Screening prior to symptom onset must remain the primary goal to reduce CRC incidence, morbidity, and mortality.
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Affiliation(s)
- Sandi L Pruitt
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX 75390-9169, USA.
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81
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Tørring ML, Frydenberg M, Hansen RP, Olesen F, Vedsted P. Evidence of increasing mortality with longer diagnostic intervals for five common cancers: a cohort study in primary care. Eur J Cancer 2013; 49:2187-98. [PMID: 23453935 DOI: 10.1016/j.ejca.2013.01.025] [Citation(s) in RCA: 171] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 01/22/2013] [Accepted: 01/24/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Early diagnosis is considered a key factor in improving the outcomes in cancer therapy; it remains unclear, however, whether long pre-diagnostic patient pathways influence clinical outcomes negatively. The aim of this study was to assess the association between the length of the diagnostic interval and the five-year mortality for the five most common cancers in Denmark while addressing known biases. METHODS A total of 1128 patients with colorectal, lung, melanoma skin, breast or prostate cancer were included in a prospective, population-based study in a Danish county. The diagnostic interval was defined as the time from the first presentation of symptoms in primary care till the date of diagnosis. Each type of cancer was analysed separately and combined, and all analyses were stratified according to the general practitioner's (GP's) interpretation of the presenting symptoms. We used conditional logistic regression to estimate five-year mortality odds ratios as a function of the diagnostic interval using restricted cubic splines and adjusting for comorbidity, age, sex and type of cancer. RESULTS We found increasing mortality with longer diagnostic intervals among the approximately 40% of the patients who presented in primary care with symptoms suggestive of cancer or any other serious illness. In the same group, very short diagnostic intervals were also associated with increased mortality. Patients presenting with vague symptoms not directly related to cancer or any other serious illness had longer diagnostic intervals and the same survival probability as those who presented with cancer suspicious/serious symptoms. For the former, we found no statistically significant association between the length of the diagnostic interval and mortality. CONCLUSION In full coherence with clinical logic, the healthcare system instigates prompt investigation of seriously ill patients. This likely explains the counter-intuitive findings of high mortality with short diagnostic intervals; but it does not explain the increasing mortality with longer diagnostic intervals. Thus, the study provides further evidence for the hypothesis that the length of the diagnostic interval affects mortality negatively.
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Affiliation(s)
- Marie Louise Tørring
- The Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Denmark; Department of Public Health - Section for General Medical Practice, Aarhus University, Denmark; Department of Culture and Society - Section for Anthropology, Aarhus University, Denmark.
| | - Morten Frydenberg
- Department of Public Health - Section for Biostatistics, Aarhus University, Denmark
| | - Rikke P Hansen
- The Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Denmark
| | - Frede Olesen
- The Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Denmark
| | - Peter Vedsted
- The Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Denmark
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Esteva M, Leiva A, Ramos M, Pita-Fernández S, González-Luján L, Casamitjana M, Sánchez MA, Pértega-Díaz S, Ruiz A, Gonzalez-Santamaría P, Martín-Rabadán M, Costa-Alcaraz AM, Espí A, Macià F, Segura JM, Lafita S, Arnal-Monreal F, Amengual I, Boscá-Watts MM, Hospital A, Manzano H, Magallón R. Factors related with symptom duration until diagnosis and treatment of symptomatic colorectal cancer. BMC Cancer 2013; 13:87. [PMID: 23432789 PMCID: PMC3598975 DOI: 10.1186/1471-2407-13-87] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2012] [Accepted: 02/18/2013] [Indexed: 12/13/2022] Open
Abstract
Background Colorectal cancer (CRC) survival depends mostly on stage at the time of diagnosis. However, symptom duration at diagnosis or treatment have also been considered as predictors of stage and survival. This study was designed to: 1) establish the distinct time-symptom duration intervals; 2) identify factors associated with symptom duration until diagnosis and treatment. Methods This is a cross-sectional study of all incident cases of symptomatic CRC during 2006–2009 (795 incident cases) in 5 Spanish regions. Data were obtained from patients’ interviews and reviews of primary care and hospital clinical records. Measurements: CRC symptoms, symptom perception, trust in the general practitioner (GP), primary care and hospital examinations/visits before diagnosis, type of referral and tumor characteristics at diagnosis. Symptom Diagnosis Interval (SDI) was calculated as time from first CRC symptoms to date of diagnosis. Symptom Treatment Interval (STI) was defined as time from first CRC symptoms until start of treatment. Nonparametric tests were used to compare SDI and STI according to different variables. Results Symptom to diagnosis interval for CRC was 128 days and symptom treatment interval was 155. No statistically significant differences were observed between colon and rectum cancers. Women experienced longer intervals than men. Symptom presentation such as vomiting or abdominal pain and the presence of obstruction led to shorter diagnostic or treatment intervals. Time elapsed was also shorter in those patients that perceived their first symptom/s as serious, disclosed it to their acquaintances, contacted emergencies services or had trust in their GPs. Primary care and hospital doctor examinations and investigations appeared to be related to time elapsed to diagnosis or treatment. Conclusions Results show that gender, symptom perception and help-seeking behaviour are the main patient factors related to interval duration. Health service performance also has a very important role in symptom to diagnosis and treatment interval. If time to diagnosis is to be reduced, interventions and guidelines must be developed to ensure appropriate examination and diagnosis during both primary and hospital care.
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Affiliation(s)
- Magdalena Esteva
- Unit of Research, Majorca Department of Primary Health Care, Balearic Institute of Health, Reina Esclaramunda 9, 07003 Palma de Mallorca, Spain.
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Trends in time to diagnosis of colon cancer and impact on clinical outcomes. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2013; 26:877-80. [PMID: 23248786 DOI: 10.1155/2012/363242] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND There has been a rapid increase in screening for colorectal cancer (CRC) over the past several years in North America. This could paradoxically lead to worsening outcomes if the system is not adapted to deal with the increased demand. For example, this could create increased wait times for endoscopy and delayed time to CRC diagnosis, which could worsen clinical outcomes such as stage at diagnosis and⁄or survival. No previous Canadian study has evaluated the association between time to CRC diagnosis and clinical outcomes. METHODS The present historical cohort study used Manitoba's population-based cancer registry and Manitoba Health administrative databases. The effect of time to diagnosis on patient survival was evaluated using Cox regression analysis with adjustment for stage at diagnosis, grade of CRC, age, sex, socioeconomic status, comorbidity index score and year of CRC diagnosis. The association between time to diagnosis and CRC stage at diagnosis was evaluated using multivariate logistic regression analysis. RESULTS The median time to CRC diagnosis increased significantly from 72 days (95% CI 61 days to 83 days) in 2004 to 105 days (95% CI 64 days to 129 days) in the first three months of 2009 (P=0.04). There was no significant association between time to diagnosis and survival. Individuals with the longest time to diagnosis were less likely to have stage III⁄IV CRC at diagnosis (quartile 4 versus quartile 1: OR 0.50 [95% CI 0.33 to 0.75). CONCLUSION Time to CRC diagnosis is continuing to increase in Manitoba. Although the present study did not detect a significant negative clinical effect of increasing time to diagnosis, additional studies are required.
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Postreferral colonoscopy delays in diagnosis of colorectal cancer: a mixed-methods analysis. Qual Manag Health Care 2013; 21:252-61. [PMID: 23011072 DOI: 10.1097/qmh.0b013e31826d1f28] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Delays in diagnosis of colorectal cancer (CRC) are one of the most common reasons for malpractice claims and lead to poor outcomes. However, they are not well studied. AIMS We used a mixed quantitative-qualitative approach to analyze postreferral colonoscopy delays in CRC patients and explored referring physician's perception of processes surrounding these delays. METHODS Two physician-raters conducted independent electronic health record reviews of new CRC cases in a large integrated safety-net system to determine postreferral colonoscopy delays, which we defined as failures to perform colonoscopy within 60 days of referral for an established indication(s). To explore perceptions of colonoscopy processes, we conducted semistructured interviews with a sample of primary care physicians (PCPs) and used a content analysis approach. RESULTS Of 104 CRC cases that met inclusion criteria, reviewers agreed on the presence of postreferral colonoscopy delays in 35 (33.7%) cases; κ = 0.99 (95% CI, 0.83-0.99). The median time between first referral and completion of colonoscopy was 123.0 days (range 62.0-938.0; interquartile range = 90.0 days). In about two-thirds of instances (64.8%), the reason for delay was a delayed future appointment with the gastroenterology service. On interviews, PCPs attributed long delays in scheduling to reduced endoscopic capacity and inefficient processes related to colonoscopy referral and scheduling, including considerable ambiguity regarding referral guidelines. Many suggested that navigation models be applied to streamline CRC diagnosis. CONCLUSION Postreferral delays in CRC diagnosis are potentially preventable. A comprehensive mixed-methods methodology might be useful for others to identify the steps in the diagnostic process that are in most need for improvement.
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85
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Management of colorectal cancer explains differences in 1-year relative survival between France and England for patients diagnosed 1997-2004. Br J Cancer 2013; 108:775-83. [PMID: 23392081 PMCID: PMC3590669 DOI: 10.1038/bjc.2013.33] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Few international population-based studies have provided information on potential determinants of international disparities in cancer survival. This population-based study was undertaken to identify the principal differences in disease characteristics and management that accounted for previously observed poorer survival in English compared with French patients with colorectal cancer. METHODS The study population comprised all cases of colorectal cancer diagnosed between 1997 and 2004 in the areas covered by three population-based cancer registries in France and one in England (N=40 613). To investigate the influence of clinical and treatment variables on survival, we applied multivariable excess hazard modelling based on generalised linear models with Poisson error. RESULTS Poorer survival for English patients was primarily due to a larger proportion dying within the first year after diagnosis. After controlling for inter-country differences in the use of chemotherapy and surgical resection with curative intent, country of residence was no-longer associated with 1-year survival for advanced colon cancer patients (excess hazard ratio (EHR)=0.99 (0.92-1.01), P=0.095)). Longer term (2-5 years) excess hazards of death for colon and rectal cancer patients did not differ between France and England. CONCLUSION This study suggests that difference in management close to diagnosis of colon and rectum cancer is related to differences in survival observed between France and England. All efforts (collection and standardisation of additional variables such as co-morbidity) to investigate the reasons for these disparities in management between these two countries, and more generally across Europe, should be encouraged.
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The relative roles of charge and a recognition peptide in luminal targeting of colorectal cancer by fluorescent polyacrylamide. Eur J Pharm Sci 2012; 47:904-13. [DOI: 10.1016/j.ejps.2012.09.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 08/18/2012] [Accepted: 09/03/2012] [Indexed: 11/19/2022]
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Cohen G, Lecht S, Arien-Zakay H, Ettinger K, Amsalem O, Oron-Herman M, Yavin E, Prus D, Benita S, Nissan A, Lazarovici P. Bio-imaging of colorectal cancer models using near infrared labeled epidermal growth factor. PLoS One 2012; 7:e48803. [PMID: 23144978 PMCID: PMC3493605 DOI: 10.1371/journal.pone.0048803] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2012] [Accepted: 10/01/2012] [Indexed: 01/11/2023] Open
Abstract
Novel strategies that target the epidermal growth factor receptor (EGFR) have led to the clinical development of monoclonal antibodies, which treat metastatic colorectal cancer (mCRC) but only subgroups of patients with increased wild type KRAS and EGFR gene copy, respond to these agents. Furthermore, resistance to EGFR blockade inevitably occurred, making future therapy difficult. Novel bio-imaging (BOI) methods may assist in quantization of EGFR in mCRC tissue thus complementing the immunohistochemistry methodology, in guiding the future treatment of these patients. The aim of the present study was to explore the usefulness of near infrared-labeled EGF (EGF-NIR) for bio-imaging of CRC using in vitro and in vivo orthotopic tumor CRC models and ex vivo human CRC tissues. We describe the preparation and characterization of EGF-NIR and investigate binding, using BOI of a panel of CRC cell culture models resembling heterogeneity of human CRC tissues. EGF-NIR was specifically and selectively bound by EGFR expressing CRC cells, the intensity of EGF-NIR signal to background ratio (SBR) reflected EGFR levels, dose-response and time course imaging experiments provided optimal conditions for quantization of EGFR levels by BOI. EGF-NIR imaging of mice with HT-29 orthotopic CRC tumor indicated that EGF-NIR is more slowly cleared from the tumor and the highest SBR between tumor and normal adjacent tissue was achieved two days post-injection. Furthermore, images of dissected tissues demonstrated accumulation of EGF-NIR in the tumor and liver. EGF-NIR specifically and strongly labeled EGFR positive human CRC tissues while adjacent CRC tissue and EGFR negative tissues expressed weak NIR signals. This study emphasizes the use of EGF-NIR for preclinical studies. Combined with other methods, EGF-NIR could provide an additional bio-imaging specific tool in the standardization of measurements of EGFR expression in CRC tissues.
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Affiliation(s)
- Gadi Cohen
- School of Pharmacy Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shimon Lecht
- School of Pharmacy Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hadar Arien-Zakay
- School of Pharmacy Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Keren Ettinger
- School of Pharmacy Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Orit Amsalem
- School of Pharmacy Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Mor Oron-Herman
- Advanced Technology Center, The Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Eylon Yavin
- School of Pharmacy Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Diana Prus
- Department of Pathology and Surgical Oncology Laboratory, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem, Israel
| | - Simon Benita
- School of Pharmacy Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aviram Nissan
- Department of Surgery, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem, Israel
| | - Philip Lazarovici
- School of Pharmacy Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- * E-mail:
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Courtney RJ, Paul CL, Sanson-Fisher RW, Macrae FA, Attia J, McEvoy M. Factors associated with consultation behaviour for primary symptoms potentially indicating colorectal cancer: a cross-sectional study on response to symptoms. BMC Gastroenterol 2012; 12:100. [PMID: 22862960 PMCID: PMC3503829 DOI: 10.1186/1471-230x-12-100] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 07/26/2012] [Indexed: 12/30/2022] Open
Abstract
Background Little data exists on the factors associated with health care seeking behaviour for primary symptoms of colorectal cancer (CRC). This study aimed to identify individual, provider and psychosocial factors associated with (i) ever seeking medical advice and (ii) seeking early medical advice for primary symptoms of colorectal cancer (CRC). Methods 1592 persons aged 56–88 years randomly selected from the Hunter Community Study (HCS) were sent a questionnaire. Results Males and those who had received screening advice from a doctor were at significantly higher odds of ever seeking medical advice for rectal bleeding. Persons who had private health coverage, consulted a doctor because the ‘symptom was serious’, or who did not wait to consult a doctor for another reason were at significantly higher odds of seeking early medical advice (< 2 weeks). For change in bowel habit, persons with lower income, within the healthy weight range, or who had discussed their family history of CRC irrespective of whether informed of ‘increased risk’ were at significantly higher odds of ever seeking medical advice. Persons frequenting their GP less often and seeing their doctor because the symptom persisted were at significantly higher odds of seeking early medical advice (< 2 weeks). Conclusions The seriousness of symptoms, importance of early detection, and prompt consultation must be articulated in health messages to at-risk persons. This study identified modifiable factors, both individual and provider-related to consultation behaviour. Effective health promotion efforts must heed these factors and target sub-groups less likely to seek early medical advice.
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Affiliation(s)
- Ryan J Courtney
- The Priority Research Centre for Health Behaviour, School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia.
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Zafar A, Mak T, Whinnie S, Chapman MAS. The 2-week wait referral system does not improve 5-year colorectal cancer survival. Colorectal Dis 2012; 14:e177-80. [PMID: 21920007 DOI: 10.1111/j.1463-1318.2011.02826.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
AIM The aim of this study was to compare 5-year survival rates in colorectal cancer (CRC) patients who underwent potentially curative surgery before and after the introduction of the 2-week wait (2WW) referral system. METHOD Data were collected retrospectively from a prospectively maintained cancer database for CRC patients who underwent surgery in 1999 (pre-2WW group, n = 150) and 2002 (post-2WW group, n = 126). Patients who presented as an emergency, those who died within 30 days of surgery and those who presented with incurable CRC were excluded. We used the Kaplan-Meier method to plot survival curves and the log rank test to compare survival rates between the two groups. RESULTS The 5-year survival rates in the pre-2WW and post-2WW groups did not differ significantly (71%vs 72%, respectively; P = 0.880). The number of CRC patients who presented via urgent pathways was higher in the post-2WW group than in the pre-2WW group (77%vs 38%, P < 0.001). Further, owing to this change in the referral pattern, the overall delay between referral and treatment was significantly lower in the post-2WW group than in the pre-2WW group (median 76 days vs 115, P = 0.009). CONCLUSION The 2WW referral system for patients with symptoms of CRC does not translate into improved survival. However, more patients with symptomatic CRC are being referred via urgent pathways.
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Affiliation(s)
- A Zafar
- Good Hope Hospital, Heart of England NHS Trust Warley Medical Centre, Kingsway, Oldbury, UK.
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Diagnostic interval and mortality in colorectal cancer: U-shaped association demonstrated for three different datasets. J Clin Epidemiol 2012; 65:669-78. [PMID: 22459430 DOI: 10.1016/j.jclinepi.2011.12.006] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 12/09/2011] [Accepted: 12/13/2011] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To test the theory of a U-shaped association between time from the first presentation of symptoms in primary care to the diagnosis (the diagnostic interval) and mortality after diagnosis of colorectal cancer (CRC). STUDY DESIGN AND SETTING Three population-based studies in Denmark and the United Kingdom using data from general practitioner's questionnaires, interviewer-administered patient questionnaires, and primary care records, respectively. RESULTS Despite variations in the potential selection and information bias when using different methods of identifying the date of first presentation, the association between the length of the diagnostic interval and 5-year mortality rate after the diagnosis of CRC was the same for all three types of data: displaying a U-shaped association with decreasing and subsequently increasing mortality with longer diagnostic intervals. CONCLUSION Unknown confounding and in particular confounding by indication is likely to explain the counterintuitive findings of higher mortality among patients with very short diagnostic intervals, but cannot explain the increasing mortality with longer diagnostic intervals. The results support the theory that longer diagnostic intervals cause higher mortality in patients with CRC.
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91
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Murchie P, Campbell NC, Delaney EK, Dinant GJ, Hannaford PC, Johansson L, Lee AJ, Rollano P, Spigt M. Comparing diagnostic delay in cancer: a cross-sectional study in three European countries with primary care-led health care systems. Fam Pract 2012; 29:69-78. [PMID: 21828375 DOI: 10.1093/fampra/cmr044] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The principal aim of this study was to determine the feasibility of a large-scale comparative study, between the UK, the Netherlands and Sweden, to investigate whether delays in the diagnostic pathway of cancer might explain differences in cancer survival between countries. METHODS Following a planning meeting to agree the format of a data collection instrument, data on delays in the cancer diagnostic pathway were abstracted from primary care-held medical records. Data were collected on 50 cases each (total of 150) from practices in each of Grampian, Northeast Scotland; Maastricht, the Netherlands and Skane, Sweden. Data were entered into SPSS 18.0 for analysis. RESULTS Data on delays in the cancer diagnostic pathway were readily available from primary care-held case records. However, data on demographic variables, cancer stage at diagnosis and treatment were less well recorded. There was no significant difference between countries in the way in which cases were referred from primary to secondary care. There was no significant difference between countries in the time delay between a patient presenting in primary care and being referred to secondary care. Median delay between referral and first appointment in secondary care [19 (8.0-47.5) days] was significantly longer in Scotland that in Sweden [1.0 (0-31.5) days] and the Netherlands [5.5 (0-31.5) days] (P < 0.001). Secondary care delay (between first appointment in secondary care and diagnosis) in Scotland [22.5 (0-39.5) days] was also significantly longer than in Sweden [14.0 (4.5-31.5) days] and the Netherlands [3.5 (0-16.5) days] (P = 0.003). Finally, overall delay in Scotland [53.5 (30.3-96.3) days] was also significantly longer than in Sweden [32.0 (14.0-71.0) days] and the Netherlands [22.0 (7.0-60.3) days] (P = 0.003). CONCLUSIONS A large-scale study comparing cancer delays in European countries and based on primary care-held records is feasible but would require supplementary sources of data in order to maximize information on demographic variables, the cancer stage at diagnosis and treatment details. Such a large-scale study is timely and desirable since our findings suggest systematic differences in the way cancer is managed in the three countries.
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Affiliation(s)
- Peter Murchie
- Centre of Academic Primary Care, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK.
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92
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Crawford SM, Sauerzapf V, Haynes R, Forman D, Jones AP. Social and geographical factors affecting access to treatment of colorectal cancer: a cancer registry study. BMJ Open 2012; 2:e000410. [PMID: 22535788 PMCID: PMC3341592 DOI: 10.1136/bmjopen-2011-000410] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Cancer outcomes vary between and within countries with patients from deprived backgrounds known to have inferior survival. The authors set out to explore the effect of deprivation in relation to the accessibility of hospitals offering diagnostic and therapeutic services on stage at presentation and receipt of treatment. DESIGN Analysis of a Cancer Registry Database. Data included stage and treatment details from the first 6 months. The socioeconomic status of the immediate area of residence and the travel time from home to hospital was derived from the postcode. SETTING Population-based study of patients resident in a large area in the north of England. PARTICIPANTS 39 619 patients with colorectal cancer diagnosed between 1994 and 2002. OUTCOMES MEASURED Stage of diagnosis and receipt of treatment in relation to deprivation and distance from hospital. RESULTS Patients in the most deprived quartile were significantly more likely to be diagnosed at stage 4 for rectal cancer (OR 1.516, p<0.05) but less so for colonic cancer. There was a trend for both sites for patients in the most deprived quartile to be less likely to receive chemotherapy for stage 4 disease. Patients with colonic cancer were very significantly less likely to receive any treatment if they came from any but the most affluent area (ORs 0.639, 0.603 and 0.544 in increasingly deprived quartiles), this may have been exacerbated if the hospital was distant from their residence (OR for forth quartile for both travel and deprivation 0.731, not significant). The effect was less for rectal cancer and no effect of distance was seen. CONCLUSIONS Residing in a deprived area is associated with tendencies to higher stage at diagnosis and especially in the case of colonic cancer to reduced receipt of treatment. These observations are consistent with other findings and indicate that access to diagnosis requires further investigation.
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Affiliation(s)
- S Michael Crawford
- Department of Medical Oncology, Airedale NHS Trust, Airedale General Hospital, Keighley, UK
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93
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Dupont-Lucas C, Dejardin O, Dancourt V, Launay L, Launoy G, Guittet L. Socio-geographical determinants of colonoscopy uptake after faecal occult blood test. Dig Liver Dis 2011; 43:714-20. [PMID: 21530429 DOI: 10.1016/j.dld.2011.03.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 02/23/2011] [Accepted: 03/13/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Survival from colorectal cancer is poorer in patients of lower socioeconomic level, or living far from the cancer reference centre. AIMS To evaluate the impact of material deprivation and geographical remoteness on the uptake of colonoscopy after a positive screening faecal occult blood test. METHODS Data from two large French average-risk population-based trials comparing two faecal occult blood tests were used. Compliance with colonoscopy after a positive faecal occult blood test was analysed using a logistic model and a Cox model considering time between faecal occult blood test and colonoscopy. Covariates studied were sex, age, distance to nearest gastroenterologist, distance to regional capital, and Townsend's deprivation score. RESULTS Amongst 4320 eligible subjects, 4131 were included. The rate of colonoscopy was 83.8%, within a median time of 66.0 days after faecal occult blood test. Distance to regional capital (p-trend=0.02) and study centre (p<0.0001) were independently associated with colonoscopy uptake. Time from positive faecal occult blood test to colonoscopy, was associated only with distance to the regional capital (p<0.0001, multivariate model stratified on study centre). CONCLUSION Geographical remoteness but not material deprivation was responsible for lower uptake of colonoscopy. Healthcare decision-makers should focus on geographical remoteness to promote equal access to diagnostic procedures in faecal occult blood test colorectal cancer screening programmes.
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Affiliation(s)
- Claire Dupont-Lucas
- INSERM ERI3 Cancers & Populations, Faculté de Médecine, avenue de la Côte de Nacre, Caen, France
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94
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Prades J, Espinàs JA, Font R, Argimon JM, Borràs JM. Implementing a Cancer Fast-track Programme between primary and specialised care in Catalonia (Spain): a mixed methods study. Br J Cancer 2011; 105:753-9. [PMID: 21829194 PMCID: PMC3171014 DOI: 10.1038/bjc.2011.308] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: The Cancer Fast-track Programme's aim was to reduce the time that elapsed between well-founded suspicion of breast, colorectal and lung cancer and the start of initial treatment in Catalonia (Spain). We sought to analyse its implementation and overall effectiveness. Methods: A quantitative analysis of the programme was performed using data generated by the hospitals on the basis of seven fast-track monitoring indicators for the period 2006–2009. In addition, we conducted a qualitative study, based on 83 semistructured interviews with primary and specialised health professionals and health administrators, to obtain their perception of the programme's implementation. Results: About half of all new patients with breast, lung or colorectal cancer were diagnosed via the fast track, though the cancer detection rate declined across the period. Mean time from detection of suspected cancer in primary care to start of initial treatment was 32 days for breast, 30 for colorectal and 37 for lung cancer (2009). Professionals associated with the implementation of the programme showed that general practitioners faced with suspicion of cancer had changed their conduct with the aim of preventing lags. Furthermore, hospitals were found to have pursued three specific implementation strategies (top-down, consensus-based and participatory), which made for the cohesion and sustainability of the circuits. Conclusion: The programme has contributed to speeding up diagnostic assessment and treatment of patients with suspicion of cancer, and to clarifying the patient pathway between primary and specialised care.
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Affiliation(s)
- J Prades
- Catalonian Cancer Plan, Duran i Reynals Hospital, Av. Gran Via de l'Hospitalet 199-203, Hospitalet de Llobregat, Barcelona 08908, Spain
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95
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Al-Shuneigat JM, Mahgoub SS, Huq F. Colorectal carcinoma: nucleosomes, carcinoembryonic antigen and ca 19-9 as apoptotic markers; a comparative study. J Biomed Sci 2011; 18:50. [PMID: 21787404 PMCID: PMC3150249 DOI: 10.1186/1423-0127-18-50] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 07/25/2011] [Indexed: 01/21/2023] Open
Abstract
Background Colorectal carcinoma is a common and often fatal disease in which methods of early detection and monitoring are essential. The present study was conducted for measuring serum levels of nucleosomes, carcinoembryonic antigen (CEA) and CA 19-9 in patients newly diagnosed with colorectal carcinoma and confirmed by clinicopathological study. Method Thirty subjects were included in the current study: six normal subjects as a control group with mean age (45.6 ± 7.9) and twenty four colorectal carcinoma patients with mean age (46.9 ± 15.6), which were classified pathologically according to the degree of malignant cell differentiation into well differentiated (group I), moderately differentiated (group II) and poorly differentiated (group III). Fasting venous blood samples were collected preoperative. Results The results revealed a significant increase in serum level of nucleosomes in patients with poorly differentiated tumors versus patients with well differentiated tumors (p = 0.041). The levels of CEA and CA19-9 showed no significant increase (p = 0.569 and 0.450, respectively). Conclusion In conclusion, serum level of nucleosomes provides a highly sensitive and specific apoptotic marker for colorectal carcinoma.
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Affiliation(s)
- Jehad M Al-Shuneigat
- Faculty of Medicine, Department of Pharmacology and Biochemistry Mu'tah University, Al Karak, Jordan.
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96
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Tørring ML, Frydenberg M, Hansen RP, Olesen F, Hamilton W, Vedsted P. Time to diagnosis and mortality in colorectal cancer: a cohort study in primary care. Br J Cancer 2011; 104:934-40. [PMID: 21364593 PMCID: PMC3065288 DOI: 10.1038/bjc.2011.60] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background: The relationship between the diagnostic interval and mortality from colorectal cancer (CRC) is unclear. This association was examined by taking account of important confounding factors at the time of first presentation of symptoms in primary care. Methods: A total of 268 patients with CRC were included in a prospective, population-based study in a Danish county. The diagnostic interval was defined as the time from first presentation of symptoms until diagnosis. We analysed patients separately according to the general practitioner's interpretation of symptoms. Logistic regression was used to estimate 3-year mortality odds ratios as a function of the diagnostic interval using restricted cubic splines and adjusting for tumour site, comorbidity, age, and sex. Results: In patients presenting with symptoms suggestive of cancer or any other serious illness, the risk of dying within 3 years decreased with diagnostic intervals up to 5 weeks and then increased (P=0.002). In patients presenting with vague symptoms, the association was reverse, although not statistically significant. Conclusion: Detecting cancer in primary care is two sided: aimed at expediting ill patients while preventing healthy people from going to hospital. This likely explains the counterintuitive findings; but it does not explain the increasing mortality with longer diagnostic intervals. Thus, this study provides evidence for the hypothesis that the length of the diagnostic interval affects mortality in CRC patients.
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Affiliation(s)
- M L Tørring
- The Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, School of Public Health, Aarhus University, Bartholin Allé 2, DK-8000 Aarhus C, Denmark.
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97
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Abstract
A quandary of evolution is how to measure change over time. A natural inclination is to use morphologic criteria-the greater the differences between two phenotypes, the greater amount of time needed to evolve these differences. However, appearances may be deceiving, and another approach to infer time is with molecular clocks. Here, the greater the differences between two genomes, on average the greater the time since a common ancestor. Recent advances in DNA sequencing shed new light on how human cancers might evolve.
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Affiliation(s)
- Darryl Shibata
- Department of Pathology, University of Southern California Keck School of Medicine, Norris Cancer Center, Los Angeles, CA 90033, USA.
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98
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Pita Fernández S, Pértega Díaz S, López Calviño B, González Santamaría P, Seoane Pillado T, Arnal Monreal F, Maciá F, Sánchez Calavera MA, Espí Macías A, Valladares Ayerbes M, Pazos A, Reboredo López M, González Saez L, Montserrat MR, Segura Noguera JM, Monreal Aliaga I, González Luján L, Martín Rabadán M, Murta Nascimento C, Pueyo O, Boscá Watts MM, Cabeza Irigoyen E, Casmitjana Abella M, Pinilla M, Costa Alcaraz A, Ruiz Torrejón A, Burón Pust A, García Aranda C, de Lluc Bennasar M, Lafita Mainz S, Novella M, Manzano H, Vadell C, Falcó E, Esteva M. Diagnosis delay and follow-up strategies in colorectal cancer. Prognosis implications: a study protocol. BMC Cancer 2010; 10:528. [PMID: 20920369 PMCID: PMC2958943 DOI: 10.1186/1471-2407-10-528] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Accepted: 10/05/2010] [Indexed: 01/02/2023] Open
Abstract
Background Controversy exists with regard to the impact that the different components of diagnosis delay may have on the degree of invasion and prognosis in patients with colorectal cancer. The follow-up strategies after treatment also vary considerably. The aims of this study are: a) to determine if the symptoms-to-diagnosis interval and the treatment delay modify the survival of patients with colorectal cancer, and b) to determine if different follow-up strategies are associated with a higher survival rate. Methods/Design Multi-centre study with prospective follow-up in five regions in Spain (Galicia, Balearic Islands, Catalonia, Aragón and Valencia) during the period 2010-2012. Incident cases are included with anatomopathological confirmation of colorectal cancer (International Classification of Diseases 9th revision codes 153-154) that formed a part of a previous study (n = 953). At the time of diagnosis, each patient was given a structured interview. Their clinical records will be reviewed during the follow-up period in order to obtain information on the explorations and tests carried out after treatment, and the progress of these patients. Symptoms-to-diagnosis interval is defined as the time calculated from the diagnosis of cancer and the first symptoms attributed to cancer. Treatment delay is defined as the time elapsed between diagnosis and treatment. In non-metastatic patients treated with curative intention, information will be obtained during the follow-up period on consultations performed in the digestive, surgery and oncology departments, as well as the endoscopies, tumour markers and imaging procedures carried out. Local recurrence, development of metastases in the follow-up, appearance of a new tumour and mortality will be included as outcome variables. Actuarial survival analysis with Kaplan-Meier curves, Cox regression and competitive risk survival analysis will be performed. Discussion This study will make it possible to verify if the different components of delay have an impact on survival rate in colon cancer and rectal cancer. In consequence, this multi-centre study will be able to detect the variability present in the follow-up of patients with colorectal cancer, and if this variability modifies the prognosis. Ideally, this study could determine which follow-up strategies are associated with a better prognosis in colorectal cancer.
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Affiliation(s)
- Salvador Pita Fernández
- Clinical Epidemiology and Biostatistics Unit, A Coruña Hospital, Hotel de Pacientes 7ª Planta, As Xubias 84, A Coruña, 15006, Spain.
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99
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Ashing-Giwa KT, Gonzalez P, Lim JW, Chung C, Paz B, Somlo G, Wakabayashi MT. Diagnostic and therapeutic delays among a multiethnic sample of breast and cervical cancer survivors. Cancer 2010; 116:3195-204. [PMID: 20564623 DOI: 10.1002/cncr.25060] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Several publications reporting on health disparities document that ethnic minorities disproportionately experience delays in healthcare access, delivery, and treatment. However, few studies examine factors underlying access and receipt of healthcare among cancer survivors from the patient perspective. This study explores diagnostic and therapeutic care delays among a multiethnic sample of breast and cervical cancer survivors and examines contextual factors influencing diagnostic and therapeutic care delays. METHODS Population-based sampling and a cross-sectional design were used to recruit 1377 survivors (breast cancer, n = 698; cervical cancer, n = 679). This multiethnic sample included 449 European American, 185 African American, 468 Latina American, and 275 Asian American survivors. RESULTS Latina Americans were more likely to report diagnostic delays (P = .003), whereas African Americans were more likely to report therapeutic delays (P = .007). In terms of cancer type, cervical cancer survivors were more likely to report diagnostic (P = .004) and therapeutic delays (P = .000) compared with breast cancer survivors. "Fear of finding cancer" was the most frequently cited reason for diagnostic delays, and "medical reasons" were most frequently cited for therapeutic delays. CONCLUSIONS Due in part to a higher proportion of diagnostic and therapeutic delays, ethnic minorities endure greater cancer burden, including poorer survival and survivorship outcomes. The medical community must recognize the impact of existing psychological and cultural dimensions on diagnostic care, as well as the personal and healthcare system level barriers that contribute to therapeutic delays.
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Affiliation(s)
- Kimlin T Ashing-Giwa
- CCARE, Division of Population Sciences, City of Hope Medical Center, Duarte, California, USA.
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100
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Terhaar sive Droste JS, Oort FA, van der Hulst RWM, Coupé VMH, Craanen ME, Meijer GA, Morsink LM, Visser O, van Wanrooij RLJ, Mulder CJJ. Does delay in diagnosing colorectal cancer in symptomatic patients affect tumor stage and survival? A population-based observational study. BMC Cancer 2010; 10:332. [PMID: 20584274 PMCID: PMC2907342 DOI: 10.1186/1471-2407-10-332] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Accepted: 06/28/2010] [Indexed: 11/26/2022] Open
Abstract
Background Diagnosing colorectal cancer (CRC) at an early stage improves survival. To what extent any delay affects outcome once patients are symptomatic is still unclear. Our objectives were to evaluate the association between diagnostic delay and survival in symptomatic patients with early stage CRC and late stage CRC. Methods Prospective population-based observational study evaluating daily clinical practice in Northern Holland. Diagnostic delay was determined through questionnaire-interviews. Dukes' stage was classified into two groups: early stage (Dukes A or B) and late stage (Dukes C or D) cancer. Patients were followed up for 3.5 years after diagnosis. Results In total, 272 patients were available for analysis. Early stage CRC was present in 136 patients while 136 patients had late stage CRC. The mean total diagnostic delay (SE) was 31 (1.5) weeks in all CRC patients. No significant difference was observed in the mean total diagnostic delay in early versus late stage CRC (p = 0.27). In early stage CRC, no difference in survival was observed between patients with total diagnostic delay shorter and longer than the median (Kaplan-Meier, log-rank p = 0.93). In late stage CRC, patients with a diagnostic delay shorter than the median had a shorter survival than patients with a diagnostic delay longer than the median (log-rank p = 0.01). In the multivariate Cox regression model with survival as dependent variable and median delay, age, open access endoscopy, number and type of symptoms as independent variables, the odd's ratio for survival in patients with long delay (>median) versus short delay (≤median) was 1.8 (95% confidence interval (CI) 1.1 to 3.0; p = 0.01). Tumor-site was not associated with patient survival. When separating late stage CRC in Dukes C and Dukes D tumors, a shorter delay was associated with a shorter survival in Dukes D tumors only and not in Dukes C tumors. Conclusion In symptomatic CRC patients, a longer diagnostic and therapeutic delay in routine clinical practice was not associated with an adverse effect on survival. The time to CRC diagnosis and initiation of treatment did not differ between early stage and late stage colorectal cancer.
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