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Pearson C, Fraser J, Peake M, Valori R, Poirier V, Coupland VH, Hiom S, McPhail S, Moffat J, Lyratzopoulos G, Shelton J. Establishing population-based surveillance of diagnostic timeliness using linked cancer registry and administrative data for patients with colorectal and lung cancer. Cancer Epidemiol 2019; 61:111-118. [PMID: 31207483 PMCID: PMC6650618 DOI: 10.1016/j.canep.2019.05.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 04/26/2019] [Accepted: 05/26/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Diagnostic timeliness in cancer patients is important for clinical outcomes and patient satisfaction but, to-date, continuous monitoring of diagnostic intervals in nationwide incident cohorts has been impossible in England. METHODS We developed a new methodology for measuring the secondary care diagnostic interval (SCDI - first relevant secondary care contact to diagnosis) using linked cancer registration and healthcare utilisation data. Using this method, we subsequently examined diagnostic timeliness in colorectal and lung cancer patients (2014-15) by socio-demographic characteristics, diagnostic route and stage at diagnosis. RESULTS The approach assigned SCDIs to 94.4% of all incident colorectal cancer cases [median length (90th centile) of 25 (104) days] and 95.3% of lung cancer cases [36 (144) days]. Advanced stage patients had shorter intervals (median, colorectal: stage 1 vs 4 - 34 vs 19 days; lung stage 1&2 vs 3B&4 - 70 vs 27 days). Routinely referred patients had the longest (colorectal: 61, lung: 69 days) and emergency presenters the shortest intervals (colorectal: 3, lung: 14 days). Comorbidities and additional diagnostic tests were also associated with longer intervals. CONCLUSION This new method can enable repeatable nationwide measurement of cancer diagnostic timeliness in England and identifies actionable variation to inform early diagnosis interventions and target future research.
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Affiliation(s)
- Clare Pearson
- Cancer Research UK, Angel Building, 407 St John Street, London, EC1V 4AD, UK; National Cancer Registration and Analysis Service (NCRAS), Public Health England, 6th Floor, Wellington House, 133-155 Waterloo Rd, London, SE1 8UG, UK.
| | - Jess Fraser
- Cancer Research UK, Angel Building, 407 St John Street, London, EC1V 4AD, UK; National Cancer Registration and Analysis Service (NCRAS), Public Health England, 6th Floor, Wellington House, 133-155 Waterloo Rd, London, SE1 8UG, UK
| | - Michael Peake
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, 6th Floor, Wellington House, 133-155 Waterloo Rd, London, SE1 8UG, UK; University College London Hospitals (UCLH) Cancer Collaborative, UCLH Cancer Division, 47 Wimpole Street, London, W1G 8SE, UK; Respiratory Medicine, University Hospitals of Leicester, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
| | - Roland Valori
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, 6th Floor, Wellington House, 133-155 Waterloo Rd, London, SE1 8UG, UK; Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire Royal Hospital, Great Western Road, Gloucester, GL1 3NN, UK
| | - Veronique Poirier
- Cancer Research UK, Angel Building, 407 St John Street, London, EC1V 4AD, UK
| | - Victoria H Coupland
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, 6th Floor, Wellington House, 133-155 Waterloo Rd, London, SE1 8UG, UK
| | - Sara Hiom
- Cancer Research UK, Angel Building, 407 St John Street, London, EC1V 4AD, UK
| | - Sean McPhail
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, 6th Floor, Wellington House, 133-155 Waterloo Rd, London, SE1 8UG, UK; ECHO (Epidemiology of Cancer Healthcare and Outcomes) Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, 1-19 Torrington Place, London, WC1E 6BT, UK
| | - Jodie Moffat
- Cancer Research UK, Angel Building, 407 St John Street, London, EC1V 4AD, UK
| | - Georgios Lyratzopoulos
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, 6th Floor, Wellington House, 133-155 Waterloo Rd, London, SE1 8UG, UK; ECHO (Epidemiology of Cancer Healthcare and Outcomes) Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, 1-19 Torrington Place, London, WC1E 6BT, UK
| | - Jon Shelton
- Cancer Research UK, Angel Building, 407 St John Street, London, EC1V 4AD, UK.
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Xing P, Zhu Y, Wang L, Hui Z, Liu S, Ren J, Zhang Y, Song Y, Liu C, Huang Y, Liao X, Xing X, Wang D, Yang L, Du L, Liu Y, Zhang Y, Liu Y, Wei D, Zhang K, Shi J, Qiao Y, Chen W, Li J, Dai M. What are the clinical symptoms and physical signs for non-small cell lung cancer before diagnosis is made? A nation-wide multicenter 10-year retrospective study in China. Cancer Med 2019; 8:4055-4069. [PMID: 31150167 PMCID: PMC6639195 DOI: 10.1002/cam4.2256] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 04/27/2019] [Accepted: 05/03/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Most lung cancer patients are diagnosed after the onset of symptoms. However, whether the symptoms of lung cancer were independently associated with the diagnosis of lung cancer is unknown, especially in the Chinese population. METHODS We conducted a 10 years (2005-2014) nationwide multicenter retrospective clinical epidemiology study of lung cancer patients diagnosed in China. As such, this study focused on nonsmall cell lung cancer (NSCLC). We calculated the odds ratios (ORs) for variables associated with the symptoms and physical signs using multivariate unconditional logistic regressions. RESULTS A total of 7184 lung cancer patients were surveyed; finally, 6398 NSCLC patients with available information about their symptoms and physical signs were included in this analysis. The most common initial symptom and physical sign was chronic cough (4156, 65.0%), followed by sputum with blood (2110, 33.0%), chest pain (1146, 17.9%), shortness of breath (1090, 17.0%), neck and supraclavicular lymphadenectasis (629, 9.8%), weight loss (529, 8.3%), metastases pain (378, 5.9%), fatigue (307, 4.8%), fever (272, 4.3%), and dyspnea (270, 4.2%). Patients with squamous carcinoma and stage III disease were more likely to present with chronic cough (P < 0.0001) and sputum with blood (P < 0.0001) than patients with other pathological types and clinical stages, respectively. Metastases pain (P < 0.0001) and neck and supraclavicular lymphadenectasis (P = 0.0006) were more likely to occur in patients with nonsquamous carcinoma than in patients with other carcinomas. Additionally, patients with stage IV disease had a higher percentage of chest pain, shortness of breath, dyspnea, weight loss, and fatigue than patients with other stages of disease. In multivariable logistic analyses, compared with patients with adenocarcinoma, patients with squamous carcinoma were more likely to experience symptoms (OR = 2.885, 95% confidence interval [CI] 2.477-3.359) but were less likely to present physical signs (OR = 0.844, 95% CI 0.721-0.989). The odds of having both symptoms and physical signs were higher in patients with late-stage disease than in those with early-stage disease (P < 0.0001). CONCLUSIONS The symptoms and physical signs of lung cancer were associated with the stage and pathological diagnosis of NSCLC. Patients with squamous carcinoma were more likely to develop symptoms, but not signs, than patients with adenocarcinoma. The more advanced the stage at diagnosis, the more likely that symptoms or physical signs are to develop. Further prospective cohort studies are needed to explore these results.
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Affiliation(s)
- Pu‐Yuan Xing
- National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Yi‐Xiang Zhu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
- Affiliated Hospital of Guizhou Medical University, Guizhou Province Tumor HospitalGuiyangP.R. China
| | - Le Wang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Zhou‐Guang Hui
- National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Shang‐Mei Liu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Jian‐Song Ren
- National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Ye Zhang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Yan Song
- National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Cheng‐Cheng Liu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | | | | | | | | | - Li Yang
- Guangxi Medical UniversityNanningP.R. China
| | | | - Yu‐Qin Liu
- Gansu Provincial Cancer HospitalLanzhou, GansuP.R. China
| | | | - Yun‐Yong Liu
- Liaoning Cancer Hospital & InstituteShenyangP.R. China
| | | | - Kai Zhang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Ju‐Fang Shi
- National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - You‐Lin Qiao
- National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Wan‐Qing Chen
- National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Jun‐Ling Li
- National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Min Dai
- National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
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203
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Rendle KA, Sarma EA, Quaife SL, Blake KD, Moser RP, Suls JM, Edwards HM, Kobrin SC. Cancer Symptom Recognition and Anticipated Delays in Seeking Care Among U.S. Adults. Am J Prev Med 2019; 57:e1-e9. [PMID: 31128956 DOI: 10.1016/j.amepre.2019.02.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 02/14/2019] [Accepted: 02/15/2019] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Early stage diagnosis strongly predicts cancer survival. Recognition of potential symptoms of cancer may improve survival by reducing time to seeking care. METHODS Telephone interviews with a population-representative sample of English-speaking adults (aged ≥50 years) in the U.S. (N=1,425) were conducted in 2014 using an instrument adapted from the International Cancer Benchmarking Partnership Awareness and Beliefs about Cancer survey. Anticipated time to seeking care for four cancer symptoms (persistent cough, rectal bleeding, mole changes, and breast changes) was assessed, and delay was defined as waiting >2 weeks. Recognition of symptoms as potential cancer signs was assessed dichotomously. Multivariate logistic regression models were used to assess associations between symptom recognition and anticipated delay, adjusting for demographics, cancer experience, self-reported health, and healthcare access. Analyses were weighted and conducted in 2017. RESULTS Symptom recognition varied but was relatively high across all symptoms (76.9%-95.5%). Anticipated delay varied by symptom and was highest for persistent cough (41.2%) and lowest for rectal bleeding (9.1%). For rectal bleeding (AOR=2.65, 95% CI=1.31, 5.36) and mole changes (AOR=3.30, 95% CI=1.48, 7.33), anticipated delay was more likely among individuals who did not recognize the symptom as a warning sign. Adults with lower education levels (p<0.05) and African Americans (p<0.05) were less likely to delay for some symptoms. CONCLUSIONS Lack of symptom recognition was associated with anticipated delay in seeking care for some cancer symptoms. Differences in recognition and delays by symptom could be driven partly by screening messaging or by ambiguity and functional impact of each symptom.
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Affiliation(s)
- Katharine A Rendle
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Elizabeth A Sarma
- Cancer Prevention Fellowship Program, Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland
| | - Samantha L Quaife
- Department of Behavioral Science and Health, University College London, London, England
| | - Kelly D Blake
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | - Richard P Moser
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | - Jerry M Suls
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | - Heather M Edwards
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | - Sarah C Kobrin
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
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204
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Nador G, Ramasamy K, Panitsas F, Pratt G, Sadler R, Javaid MK. Testing and management for monoclonal gammopathy of uncertain significance and myeloma patients presenting with osteoporosis and fragility fractures. Rheumatology (Oxford) 2019; 58:1142-1153. [PMID: 31225884 DOI: 10.1093/rheumatology/kez127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 03/03/2019] [Indexed: 12/19/2022] Open
Abstract
Multiple myeloma, the second most frequent blood cancer, and its precursor, monoclonal gammopathy of uncertain significance, are associated with an increased risk of fragility fractures. However, current guidelines fail to offer explicit indications for healthcare professionals in terms of testing and thresholds for onward referral. The purpose of this review is to present the association of these conditions and metabolic bone disease and to highlight the importance of considering a diagnosis of monoclonal gammopathy of uncertain significance and myeloma in the context of a secondary fracture prevention assessment and of a multidisciplinary approach in managing these patients.
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Affiliation(s)
- Guido Nador
- Department of Clinical Haematology, Oxford University Hospitals, Oxford, UK
| | - Karthik Ramasamy
- Department of Clinical Haematology, Oxford University Hospitals, Oxford, UK.,NIHR, BRC Blood Theme, Oxford, UK
| | - Fotios Panitsas
- Haematology Department, Larissa University Hospital, Larissa, Greece
| | - Guy Pratt
- Haematology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham
| | - Ross Sadler
- Department of Immunology, Oxford University Hospitals, Oxford
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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205
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Birch RJ, Taylor JC, Downing A, Spencer K, Finan PJ, Audisio RA, Carrigan CM, Selby PJ, Morris EJA. Rectal cancer in old age -is it appropriately managed? Evidence from population-based analysis of routine data across the English national health service. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2019; 45:1196-1204. [PMID: 30661923 PMCID: PMC6602152 DOI: 10.1016/j.ejso.2019.01.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 12/05/2018] [Accepted: 01/02/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND There is significant debate as to where to draw the line between undertreating older rectal cancer patients and minimising treatment risks. This study sought to examine the use of radical rectal cancer treatments and associated outcomes in relation to age across the English NHS. METHODS Patient, tumour and treatment characteristics for all patients diagnosed with a first primary rectal cancer in England between 1st April 2009 and 31st December 2014 were obtained from the CORECT-R data repository. Descriptive analyses and adjusted logistic regression models were undertaken to examine any association between age and the use of major resection and post-surgical outcomes. Funnel plots were used to show variation in adjusted rates of major resection. RESULTS The proportion of patients who underwent a major surgical resection fell from 66.5% to 31.7%, amongst those aged <70 and aged ≥80 respectively. After adjustment, 30-day post-operative mortality, failure to rescue and prolonged length of stay were significantly higher among the oldest group when compared to the youngest. Patient reported outcomes were not significantly worse amongst older patients. Significant variation was observed in adjusted surgical resection rates in the oldest patients between NHS Trusts. The probability of death due to cancer was comparable across all age groups. CONCLUSIONS Older patients who are selected for surgery have good outcomes, often comparable to their younger counterparts. Significant variation in the treatment of older patients could not be explained by differences in measured characteristics and required further investigation.
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Affiliation(s)
- Rebecca J Birch
- Cancer Epidemiology Group, Leeds Institute for Data Analytics, Worsley Building, University of Leeds, LS2 9NL, UK.
| | - John C Taylor
- Cancer Epidemiology Group, Leeds Institute for Data Analytics, Worsley Building, University of Leeds, LS2 9NL, UK
| | - Amy Downing
- Cancer Epidemiology Group, Leeds Institute for Data Analytics, Worsley Building, University of Leeds, LS2 9NL, UK
| | - Katie Spencer
- Cancer Epidemiology Group, Leeds Institute for Data Analytics, Worsley Building, University of Leeds, LS2 9NL, UK; Leeds Cancer Centre, Bexley Wing, St James's University Teaching Hospital, Leeds, LS9 7TF, UK
| | - Paul J Finan
- Cancer Epidemiology Group, Leeds Institute for Data Analytics, Worsley Building, University of Leeds, LS2 9NL, UK
| | - Riccardo A Audisio
- Department of Surgery, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Christopher M Carrigan
- Cancer Epidemiology Group, Leeds Institute for Data Analytics, Worsley Building, University of Leeds, LS2 9NL, UK
| | - Peter J Selby
- Leeds Institute of Cancer and Pathology, St James's University Hospital, Leeds, LS9 7TF, UK
| | - Eva J A Morris
- Cancer Epidemiology Group, Leeds Institute for Data Analytics, Worsley Building, University of Leeds, LS2 9NL, UK
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206
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Nair HS, Knight SR, McKenzie C, MacDonald AJ, Macdonald A. Age at death and the effect of lead-time bias in patients with colorectal cancer: a 10-year follow-up. Colorectal Dis 2019; 21:775-781. [PMID: 30848537 DOI: 10.1111/codi.14602] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/07/2019] [Indexed: 12/28/2022]
Abstract
AIM Studies addressing the benefit of early intervention are prone to lead-time bias, which results in an artificial improvement in cancer-specific mortality. We have previously compared the age at death for patients with colorectal cancer presenting on an emergency or elective basis. In this study, we aimed to repeat the analysis with a minimum follow-up of 10 years. METHOD A nonscreen-detected cohort of patients presenting with colorectal cancer to three Lanarkshire Hospitals between 2000 and 2006 were entered into a prospective database, with analysis performed on 28 November 2016. The following data were collected: age at death, presentation type (emergency/elective), operative intent (palliative/curative) and Dukes stage. Results are presented as [mean (95% confidence intervals)]. Statistical analysis was undertaken using Student's t-test and multivariate analysis performed using Cox proportional hazard models. RESULTS One thousand six hundred and thirty-six patients were identified. Elective patients presented younger than emergency patients [67.9 (67.3-68.5) vs 70.9 (69.6-72.2) years; P < 0.0001]. Overall mortality was 71.1% at time of analysis; no difference was seen in the mean age at death between emergency and elective presentation [73.5 (72.4-74.8) vs 73.6 (72.3-74.9) years; P = 0.841]. CONCLUSION Current early detection strategies to diagnose colorectal cancer may improve cancer-specific survival by increasing lead-time bias. However, in our cohort of symptomatic patients, treatment on an elective or emergency basis does not influence overall survival. These data suggest that in selected patients, particularly where there is comorbidity, it may be reasonable to adopt a more expectant approach to investigate and treat colorectal symptoms.
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Affiliation(s)
- H S Nair
- Lanarkshire Colorectal Study Group, Monklands Hospital, Airdrie, UK
| | - S R Knight
- Lanarkshire Colorectal Study Group, Monklands Hospital, Airdrie, UK
| | - C McKenzie
- Lanarkshire Colorectal Study Group, Monklands Hospital, Airdrie, UK
| | - A J MacDonald
- Lanarkshire Colorectal Study Group, Monklands Hospital, Airdrie, UK
| | - A Macdonald
- Lanarkshire Colorectal Study Group, Monklands Hospital, Airdrie, UK
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207
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Dommett RM, Pring H, Cargill J, Beynon P, Cameron A, Cox R, Nechowska A, Wint A, Stevens MCG. Achieving a timely diagnosis for teenagers and young adults with cancer: the ACE "too young to get cancer?" study. BMC Cancer 2019; 19:616. [PMID: 31234813 PMCID: PMC6591830 DOI: 10.1186/s12885-019-5776-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 05/30/2019] [Indexed: 02/03/2023] Open
Abstract
Background Time to diagnosis (TTD) concerns teenagers and young adults (TYA) with cancer and may affect outcome. Methods Healthcare records from 105 TYA in a regional cancer service were assessed to document events from 1st symptom to treatment start. Detailed pathway construction was possible for 104 patients and allowed a multidisciplinary panel review of each pathway with assessment of good practice and lessons for the future. Results 1st presentation was to primary care in 86, and 93% consulted in primary care before diagnosis. Routes to Diagnosis were 45% via urgent 2 Week Wait pathways and 38% as emergency referrals. Total Interval (time from 1st presentation to treatment start) was median 63 (range 1–559) days, varying within/between diagnoses. Patient interval (time from 1st symptom to 1st presentation) was longest for lymphoma, carcinoma and bone tumour (medians: 9, 12, 20 days). Overall, time in primary care was short (median 3, range 0–537 days) compared to secondary care (median 29, range 0–195 days) and longest for lymphoma, carcinoma, brain/CNS (medians: 10, 15, 16 days). Specialist Care interval (time from 1st specialist visit to treatment start) was longest for bone, brain/CNS, lymphoma, carcinoma (medians: 30, 33, 36, 48 days). 40% pathways were rated as showing good/best practice but 16% were less than satisfactory. Continued safety-netting/support was identified from primary care but analysis suggested opportunities for improvement in transition through secondary care. Conclusions Previous reports of prolonged TTD have focused on delay in referral from primary care but this study suggests that this might be reduced by optimising management in secondary care.
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Affiliation(s)
- Rachel M Dommett
- South West TYA Cancer Service, Bristol Haematology Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Horfield Road, Bristol, BS2 8ED, UK.,Department of Paediatric Haematology Oncology & BMT, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Hannah Pring
- South West TYA Cancer Service, Bristol Haematology Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Horfield Road, Bristol, BS2 8ED, UK
| | - Jamie Cargill
- South West TYA Cancer Service, Bristol Haematology Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Horfield Road, Bristol, BS2 8ED, UK
| | - Paul Beynon
- South West TYA Cancer Service, Bristol Haematology Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Horfield Road, Bristol, BS2 8ED, UK
| | - Alison Cameron
- South West TYA Cancer Service, Bristol Haematology Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Horfield Road, Bristol, BS2 8ED, UK
| | - Rachel Cox
- Department of Paediatric Haematology Oncology & BMT, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Aoife Nechowska
- South West TYA Cancer Service, Bristol Haematology Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Horfield Road, Bristol, BS2 8ED, UK
| | - Alison Wint
- Macmillan GP and NHS Bristol, North Somerset & South Gloucestershire CCG, Bristol, UK
| | - Michael C G Stevens
- South West TYA Cancer Service, Bristol Haematology Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Horfield Road, Bristol, BS2 8ED, UK. .,Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
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208
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Donnelly C, Hart N, McCrorie AD, Donnelly M, Anderson L, Ranaghan L, Gavin A. Predictors of an early death in patients diagnosed with colon cancer: a retrospective case-control study in the UK. BMJ Open 2019; 9:e026057. [PMID: 31221871 PMCID: PMC6588982 DOI: 10.1136/bmjopen-2018-026057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 03/20/2019] [Accepted: 05/02/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Despite considerable improvements, 5-year survival rates for colon cancer in the UK remain poor when compared with other socioeconomically similar countries. Variation in 5-year survival can be partly explained by higher rates of death within 3 months of diagnosis in the UK. This study investigated the characteristics of patients who died within 3 months of a diagnosis of colon cancer with the aim of identifying specific patient factors that can be addressed or accounted for to improve survival outcomes. DESIGN A retrospective case-control study design was applied with matching on age, sex and year diagnosed. Patient, disease, clinical and service characteristics of patients diagnosed with colon cancer in a UK region (2005-2010) who survived less than 3 months from diagnosis (cases) were compared with patients who survived between 6 and 36 months (controls). Patient and clinical data were sourced from general practice notes and hospital databases 1-3 years prediagnosis. RESULTS Being older (aged ≥78 years) and living in deprivation quintile 5 (OR=2.64, 95% CI 1.15 to 6.06), being unmarried and living alone (OR=1.64, 95% CI 1.07 to 2.50), being underweight compared with normal weight or obese (OR=3.99, 95% CI 1.14 to 14.0), and being older and living in a rural as opposed to urban area (OR=1.96, 95% CI 1.21 to 3.17) were all independent predictors of early death from colon cancer. Missing information was also associated with early death, including unknown stage, histological type and marital/accommodation status after accounting for other factors. CONCLUSION Several factors typically associated with social isolation were a recurring theme in patients who died early from colon cancer. This association is unexplained by clinical or diagnostic pathway characteristics. Socially isolated patients are a key target group to improve outcomes of the worst surviving patients, but further investigation is required to determine if being isolated itself is actually a cause of early death from colon cancer.
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Affiliation(s)
- Conan Donnelly
- University of Cork, National Cancer Registry Ireland, Cork, Ireland
| | - Nigel Hart
- School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Alan David McCrorie
- Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, UK
| | - Michael Donnelly
- Centre for Public Health, Queen’s University Belfast, Belfast, UK
| | - Lesley Anderson
- Centre for Public Health, Queen’s University Belfast, Belfast, UK
| | - Lisa Ranaghan
- Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Anna Gavin
- N Ireland Cancer Registry, Queen’s University Belfast, Belfast, UK
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209
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Murage P, Bachmann MO, Crawford SM, McPhail S, Jones A. Geographical access to GPs and modes of cancer diagnosis in England: a cross-sectional study. Fam Pract 2019; 36:284-290. [PMID: 30452584 DOI: 10.1093/fampra/cmy077] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Poor geographical access to health services and routes to a cancer diagnosis such as emergency presentations have previously been associated with worse cancer outcomes. However, the extent to which access to GPs determines the route that patients take to obtain a cancer diagnosis is unknown. METHODS We used a linked dataset of cancer registry and hospital records of patients with a cancer diagnosis between 2006 and 2010 across eight different cancer sites. Primary outcomes were defined as 'desirable routes to diagnosis' [screen-detected and 2-week wait (TWW) referrals] and 'less desirable routes' [emergency presentations and death certificate only (DCO)]. All other routes (GP referral, inpatient elective and other outpatient) were specified as the reference category. Geographical access was measured as travel time in minutes from patients to their GP, and multinomial logistic regression was used to estimate relative risk ratios (RRR). RESULTS Longer travel was associated with increased risk of diagnosis via emergency and DCO, but decreased risk of diagnosis via screening and TWW. Patients travelling over 30 minutes had the highest risk of a DCO diagnosis, which was statistically significant for breast, colorectal, lung, prostate, stomach and ovarian cancers (compared with patients with travel times ≤10 minutes: RRR 5.89, 7.02, 2.30, 4.75, 10.41; P < 0.01 and 3.51, P < 0.05). DISCUSSION Poor access to GPs may discourage early engagement with health services, decreasing the likelihood of screening uptake and increasing the likelihood of emergency presentations. Extra effort is needed to promote early diagnosis in more distant patients.
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Affiliation(s)
- Peninah Murage
- Norwich Medical School, Department of Public Health and Primary Care, University of East Anglia, Norwich, UK
| | - Max O Bachmann
- Norwich Medical School, Department of Public Health and Primary Care, University of East Anglia, Norwich, UK
| | | | - Sean McPhail
- National Cancer Registration and Analysis Services, Public Health England, Bristol, UK
| | - Andy Jones
- Norwich Medical School, Department of Public Health and Primary Care, University of East Anglia, Norwich, UK
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Renzi C, Lyratzopoulos G, Hamilton W, Maringe C, Rachet B. Contrasting effects of comorbidities on emergency colon cancer diagnosis: a longitudinal data-linkage study in England. BMC Health Serv Res 2019; 19:311. [PMID: 31092238 PMCID: PMC6521448 DOI: 10.1186/s12913-019-4075-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 04/08/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND One in three colon cancers are diagnosed as an emergency, which is associated with worse cancer outcomes. Chronic conditions (comorbidities) affect large proportions of adults and they might influence the risk of emergency presentations (EP). METHODS We aimed to evaluate the effect of specific pre-existing comorbidities on the risk of colon cancer being diagnosed following an EP rather than through non-emergency routes. The cohort study included 5745 colon cancer patients diagnosed in England 2005-2010, with individually-linked cancer registry, primary and secondary care data. In addition to multivariable analyses we also used potential-outcomes methods. RESULTS Colon cancer patients with comorbidities consulted their GP more frequently with cancer symptoms during the pre-diagnostic year, compared with non-comorbid cancer patients. EP occurred more frequently in patients with 'serious' or complex comorbidities (diabetes, cardiac and respiratory diseases) diagnosed/treated in hospital during the years pre-cancer diagnosis (43% EP in comorbid versus 27% in non-comorbid individuals; multivariable analysis Odds Ratio (OR), controlling for socio-demographic factors and symptoms: men OR = 2.40; 95% CI 2.0-2.9 and women OR = 1.98; 95% CI 1.6-2.4. Among women younger than 60, gynaecological (OR = 3.41; 95% CI 1.2-9.9) or recent onset gastro-intestinal conditions (OR = 2.84; 95% CI 1.1-7.7) increased the risk of EP. In contrast, primary care visits for hypertension monitoring decreased EPs for both genders. CONCLUSIONS Patients with comorbidities have a greater risk of being diagnosed with cancer as an emergency, although they consult more frequently with cancer symptoms during the year pre-cancer diagnosis. This suggests that comorbidities may interfere with diagnostic reasoning or investigations due to 'competing demands' or because they provide 'alternative explanations'. In contrast, the management of chronic risk factors such as hypertension may offer opportunities for earlier diagnosis. Interventions are needed to support the diagnostic process in comorbid patients. Appropriate guidelines and diagnostic services to support the evaluation of new or changing symptoms in comorbid patients may be useful.
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Affiliation(s)
- Cristina Renzi
- Department of Behavioural Science and Health, ECHO (Epidemiology of Cancer Healthcare & Outcomes) Research Group, University College London, 1-19 Torrington Place, London, WC1E 6BT UK
- Department of Non-communicable Disease Epidemiology, Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
| | - Georgios Lyratzopoulos
- Department of Behavioural Science and Health, ECHO (Epidemiology of Cancer Healthcare & Outcomes) Research Group, University College London, 1-19 Torrington Place, London, WC1E 6BT UK
| | - Willie Hamilton
- University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
| | - Camille Maringe
- Department of Non-communicable Disease Epidemiology, Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
| | - Bernard Rachet
- Department of Non-communicable Disease Epidemiology, Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
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211
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McShane CM, Murphy B, Santin O, Anderson LA. Low knowledge and awareness of monoclonal gammopathy of undetermined significance (MGUS) among general practitioners. BMC FAMILY PRACTICE 2019; 20:61. [PMID: 31088396 PMCID: PMC6518797 DOI: 10.1186/s12875-019-0944-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 04/10/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION While multiple myeloma (MM) is a rare diagnosis within primary care, its precursor MGUS (monoclonal gammopathy of undetermined significance) is more common, particularly among older populations. Upon first detection, the majority of MGUS patients will be under the care of their General Practitioner (GP)/Family Doctor who is also often the first healthcare professional that patients report symptoms of progression to. However, our previous work with MGUS patients and haematology healthcare professionals has suggested that knowledge and awareness of MGUS is low among GPs. METHODS An online survey was undertaken to investigate knowledge and awareness of MGUS and services needed by GPs/GP trainees to support these patients. The survey was promoted at a large European primary care conference and via social media. Descriptive statistics were utilised to compare participant responses. RESULTS In total 58 GPs (n = 35 GPs and n = 23 GP trainees) from 24 countries responded. Overall, self-reported familiarity with the term MGUS was low (mean score: 2.21/5, standard deviation (SD): 1.09), but higher among GPs who reported having at least one MGUS patient (mean score: 2.83/5, SD 0.99). The majority (88.2%) of GPs/GP trainees stated they would feel uncomfortable discussing MGUS with patients. The increased risk of haematological malignancies was identified by 62.1% of GPs/GP trainees with MM, lymphoma and myelodysplastic syndromes the most commonly reported cancers associated with MGUS. The majority (81.6%) of GPs/GP trainees were supportive of patient follow-up via telephone clinics (phlebotomy performed in GP practice with patient management maintained by haematology) but only 27.1% stated they would be happy to solely manage all low/low-intermediate risk MGUS patients. A laboratory report alerting to the possibility of MGUS or a haematological malignancy was reported as the most useful service which could be implemented to help GPs manage MGUS patients. The need for MGUS focused information and education resources for GPs was also highlighted. CONCLUSIONS The findings of this study highlight a lack of knowledge and awareness of MGUS among GPs/ GP trainees. The majority of GPs/GP trainees are happy to support haematology in managing these patients but require assistance and support in providing these services.
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Affiliation(s)
- Charlene M. McShane
- Cancer Epidemiology Research Group, Centre for Public Health, Queen’s University Belfast, Grosvenor Road, Belfast, BT12 6BJ Northern Ireland
| | - Blain Murphy
- Cancer Epidemiology Research Group, Centre for Public Health, Queen’s University Belfast, Grosvenor Road, Belfast, BT12 6BJ Northern Ireland
| | - Olinda Santin
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, Northern Ireland
| | - Lesley A. Anderson
- Cancer Epidemiology Research Group, Centre for Public Health, Queen’s University Belfast, Grosvenor Road, Belfast, BT12 6BJ Northern Ireland
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Lee A, Khulusi S, Watson R. Gastroesophageal cancer patients need earlier palliative intervention - Using data to inform appropriate care. Eur J Oncol Nurs 2019; 40:126-130. [PMID: 31229202 DOI: 10.1016/j.ejon.2019.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 03/19/2019] [Accepted: 04/26/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE To evaluate demographics of survival in patients with gastroesophageal cancer so that it informs nursing practice. METHOD Data on 2215 patients diagnosed with gastroesophageal cancer who presented to a specialist referral centre between the years 2000 and 2011 were extracted from a Public Health repository. Survival time was calculated and analysed against clinical and lifestyle factors to reveal whether they had an impact on survival outcomes. RESULTS Over 60% of patients had died within the first year, 39% of these died within the first 6 months. Survival outcomes were reduced in advancing age, and in those patients who present as 'emergency' cases. One quarter of patients were seen by a GP, but were not referred urgently through the two week wait system, to specialist care. Thus, gastroesophageal cancer patients need specific and appropriate treatment options, including earlier referrals to palliative care provision. There is also a need for cancer specific education and information at community and clinical levels. CONCLUSIONS The globally applied one and five-year statistics applied to cancer survival studies do not adequately capture rates of early demise with gastroesophageal cancer. This study presents a novel approach to statistical analysis, based on patient derived data. It identifies factors linked to earlier deaths. However, rather than a focus on early presentation and diagnosis (which are essential) - it also reveals a significant need to consider early referrals for palliative care and nursing interventions to alleviate pain and suffering in patients with poor prognosis.
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Affiliation(s)
- Amanda Lee
- University of Hull, Faculty of Health Sciences, Cottingham Road, Hull, HU67RX, UK.
| | - Sam Khulusi
- Gastroenterology Specialist Medical Consultant and Cancer Lead, Queens' Medical Centre, Hull, UK
| | - Roger Watson
- University of Hull, Editor-in-Chief, Journal of Advanced Nursing, UK
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213
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Sarma EA, Silver MI, Kobrin SC, Marcus PM, Ferrer RA. Cancer screening: health impact, prevalence, correlates, and interventions. Psychol Health 2019; 34:1036-1072. [DOI: 10.1080/08870446.2019.1584673] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Elizabeth A. Sarma
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - Michelle I. Silver
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - Sarah C. Kobrin
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - Pamela M. Marcus
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - Rebecca A. Ferrer
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
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214
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Scott SE, Penfold C, Saji S, Curtis S, Watts C, Hamilton W, Joannides AJ, Walter FM. 'It was nothing that you would think was anything': Qualitative analysis of appraisal and help seeking preceding brain cancer diagnosis. PLoS One 2019; 14:e0213599. [PMID: 30901334 PMCID: PMC6430370 DOI: 10.1371/journal.pone.0213599] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/25/2019] [Indexed: 12/29/2022] Open
Abstract
Background The patient’s interpretation of the events and decisions leading up to consultation with a healthcare professional for symptoms of brain cancer is under researched. The aim of this study was to document responses to noticing the changes preceding a diagnosis of brain cancer and living with them, focusing on appraisal of changes and the decision to seek (and re-seek) help, with attention to the psychological processes underpinning the appraisal and help-seeking intervals. Method In this qualitative study set in Eastern and NW England, in-depth interviews with adult patients recently diagnosed with primary brain cancer and their family members were analysed thematically, using the Model of Pathways to Treatment as a conceptual framework. Results 39 adult patients were interviewed. Regarding the appraisal interval, cognitive heuristics were found to underpin explanations of changes/symptoms. The subtlety and normality of changes often suggested nothing serious was wrong. Common explanations included stress or being busy at work, or age and these did not seem to warrant a visit to a doctor. Explanations and the decision to seek help were made within the social context, with friends, family and work colleagues contributing to appraisal and help-seeking decisions. Regarding the help-seeking interval, barriers to seeking help reflected components of Social Cognitive Theory, and included having other priorities, outcome expectations (e.g. ‘feeling silly’, not sure much can be done about it, not wanting to waste doctors’ time) and accessibility of a preferred healthcare professional. Conclusion Application of psychological theory facilitated understanding of the influences on cognition and behaviour. The study highlights implications for theory, awareness campaigns and potential opportunities promoting more timely help-seeking.
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Affiliation(s)
- Suzanne E. Scott
- Centre for Oral, Clinical & Translational Science, Faculty of Dentistry, Oral and Craniofacial Sciences, King’s College London, Guy’s Hospital, London, United Kingdom
- * E-mail:
| | - Clarissa Penfold
- The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Smiji Saji
- Clinical School, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Sarah Curtis
- Centre for Oral, Clinical & Translational Science, Faculty of Dentistry, Oral and Craniofacial Sciences, King’s College London, Guy’s Hospital, London, United Kingdom
| | - Colin Watts
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Willie Hamilton
- Willie Hamilton, St Luke’s Campus, University of Exeter, Exeter, United Kingdom
| | - Alexis J. Joannides
- Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Fiona M. Walter
- The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, United Kingdom
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215
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Missed opportunities for diagnosing brain tumours in primary care: a qualitative study of patient experiences. Br J Gen Pract 2019; 69:e224-e235. [PMID: 30858332 PMCID: PMC6428480 DOI: 10.3399/bjgp19x701861] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 11/26/2018] [Indexed: 12/11/2022] Open
Abstract
Background Brain tumours are uncommon, and have extremely poor outcomes. Patients and GPs may find it difficult to recognise early symptoms because they are often non-specific and more likely due to other conditions. Aim To explore patients’ experiences of symptom appraisal, help seeking, and routes to diagnosis. Design and setting Qualitative study set in the East and North West of England. Method In-depth interviews with adult patients recently diagnosed with a primary brain tumour and their family members were analysed thematically, using the Model of Pathways to Treatment as a conceptual framework. Results Interviews were carried out with 39 patients. Few participants (n = 7; 18%) presented as an emergency without having had a previous GP consultation; most had had one (n = 15; 38%), two (n = 9; 23%), or more (n = 8; 21%) GP consultations. Participants experienced multiple subtle ‘changes’ rather than ‘symptoms’, often noticed by others rather than the patient, which frequently led to loss of interest or less ability to engage with daily living activities. The most common changes were in cognition (speaking, writing, comprehension, memory, concentration, and multitasking), sleep, and other ‘head feelings’ such as dizziness. Not all patients experienced a seizure, and few seizures were experienced ‘out of the blue’. Quality of communication in GP consultations played a key role in patients’ subsequent symptom appraisal and the timing of their decision to re-consult. Conclusion Multiple subtle changes and frequent GP visits often precede brain tumour diagnosis, giving possible diagnostic opportunities for GPs. Refined community symptom awareness and GP guidance could enable more direct pathways to diagnosis, and potentially improve patient experiences and outcomes.
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216
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Renzi C, Lyratzopoulos G, Hamilton W, Rachet B. Opportunities for reducing emergency diagnoses of colon cancer in women and men: A data-linkage study on pre-diagnostic symptomatic presentations and benign diagnoses. Eur J Cancer Care (Engl) 2019; 28:e13000. [PMID: 30734381 PMCID: PMC6492167 DOI: 10.1111/ecc.13000] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 09/17/2018] [Accepted: 12/18/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To identify opportunities for reducing emergency colon cancer diagnoses, we evaluated symptoms and benign diagnoses recorded before emergency presentations (EP). METHODS Cohort of 5,745 colon cancers diagnosed in England 2005-2010, with individually linked cancer registry and primary care data for the 5-year pre-diagnostic period. RESULTS Colon cancer was diagnosed following EP in 34% of women and 30% of men. Among emergency presenters, 20% of women and 15% of men (p = 0.002) had alarm symptoms (anaemia/rectal bleeding/change in bowel habit) 2-12 months pre-diagnosis. Women with abdominal symptoms (change in bowel habit/constipation/diarrhoea) received a benign diagnosis (irritable bowel syndrome (IBS)/diverticular disease) more frequently than men in the year before EP: 12% vs. 6% among women and men (p = 0.002). EP was more likely in women (OR = 1.20; 95% CI 1.1-1.4), independently of socio-demographic factors and symptoms. Benign diagnoses in the pre-diagnostic year (OR = 2.01; 95% CI 1.2-3.3) and anaemia 2-5 years pre-diagnosis (OR = 1.91; 95% CI 1.2-3.0) increased the risk of EP in women but not men. The risk was particularly high for women aged 40-59 with a recent benign diagnosis vs. none (OR = 4.41; 95% CI 1.3-14.9). CONCLUSIONS Women have an increased risk of EP, in part due to less specific symptoms and their more frequent attribution to benign diagnoses. For women aged 40-59 years with new-onset IBS/diverticular disease innovative diagnostic strategies are needed, which might include use of quantitative faecal haemoglobin testing (FIT) or other colorectal cancer investigations. One-fifth of women had alarm symptoms before EP, offering opportunities for earlier diagnosis.
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Affiliation(s)
- Cristina Renzi
- Department of Behavioural Science and HealthUniversity College LondonLondonUK
- Cancer Survival Group, Department of Non‐communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | | | | | - Bernard Rachet
- Cancer Survival Group, Department of Non‐communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
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217
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Koshiaris C. Methods for reducing delays in the diagnosis of multiple myeloma. Int J Hematol Oncol 2019; 8:IJH13. [PMID: 30863530 PMCID: PMC6410016 DOI: 10.2217/ijh-2018-0014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 01/17/2019] [Indexed: 11/21/2022] Open
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218
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Purdie S, Creighton N, White KM, Baker D, Ewald D, Lee CK, Lyon A, Man J, Michail D, Miller AA, Tan L, Currow D, Young JM. Pathways to diagnosis of non-small cell lung cancer: a descriptive cohort study. NPJ Prim Care Respir Med 2019; 29:2. [PMID: 30737397 PMCID: PMC6368611 DOI: 10.1038/s41533-018-0113-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 12/06/2018] [Indexed: 11/17/2022] Open
Abstract
Little has been published on the diagnostic and referral pathway for lung cancer in Australia. This study set out to quantify general practitioner (GP) and lung specialist attendance and diagnostic imaging in the lead-up to a diagnosis of non-small cell lung cancer (NSCLC) and identify common pathways to diagnosis in New South Wales (NSW), Australia. We used linked health data for participants of the 45 and Up Study (a NSW population-based cohort study) diagnosed with NSCLC between 2006 and 2012. Our main outcome measures were GP and specialist attendances, X-rays and computed tomography (CT) scans of the chest and lung cancer-related hospital admissions. Among our study cohort (N = 894), 60% (n = 536) had ≥4 GP attendances in the 3 months prior to diagnosis of NSCLC, 56% (n = 505) had GP-ordered imaging (chest X-ray or CT scan), 39% (N = 349) attended a respiratory physician and 11% (N = 102) attended a cardiothoracic surgeon. The two most common pathways to diagnosis, accounting for one in three people, included GP and lung specialist (respiratory physician or cardiothoracic surgeon) involvement. Overall, 25% of people (n = 223) had an emergency hospital admission. For 14% of people (N = 129), an emergency hospital admission was the only event identified on the pathway to diagnosis. We found little effect of remoteness of residence on access to services. This study identified a substantial proportion of people with NSCLC being diagnosed in an emergency setting. Further research is needed to establish whether there were barriers to the timely diagnosis of these cases. Examining events leading to the diagnosis of non-small cell lung cancer (NSCLC) in Australia yields insights to guide further research and perhaps improve the pathways to diagnosis. NSCLC is by far the most common form of lung cancer. Researchers, led by the Cancer Institute New South Wales, investigated clinical care contacts leading to diagnosis, using a descriptive cohort study of 894 patients diagnosed between 2006 and 2012. The researchers quantified contact with GPs and lung specialists, hospital admissions and diagnostic imaging procedures. Living in remote locations had little influence on access to services. More than half of the patients did not see a lung specialist during the pathway to diagnosis, while a quarter received their diagnosis in an emergency setting. Further research should investigate whether there are barriers preventing timely diagnosis.
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Affiliation(s)
| | | | | | | | - Dan Ewald
- North Coast Primary Health Network, Ballina, NSW, Australia.,University Centre for Rural Health, Lismore, NSW, Australia
| | - Chee Khoon Lee
- Cancer Care Centre, St George Hospital, Sydney, NSW, Australia.,NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Alison Lyon
- School of Medicine, Western Sydney University, Sydney, NSW, Australia
| | - Johnathan Man
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, NSW, Australia
| | - David Michail
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, NSW, Australia
| | - Alexis Andrew Miller
- Illawarra Cancer Care Centre, Wollongong Hospital, Wollongong, NSW, Australia.,Centre for Oncology Informatics, University of Wollongong, Gwynneville, NSW, Australia
| | - Lawrence Tan
- School of Medicine, Western Sydney University, Sydney, NSW, Australia
| | | | - Jane M Young
- School of Public Health, University of Sydney, Sydney, NSW, Australia.,Surgical Outcomes Research Centre, Sydney Local Health District, Sydney, NSW, Australia
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Bibby AC, de Fonseka D, Carslake DJ, Maskell NA. Is pleural infection associated with longer survival in mesothelioma? A population-based cohort study using data from Hospital Episode Statistics. Cancer Epidemiol 2019; 59:75-82. [PMID: 30708341 DOI: 10.1016/j.canep.2019.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 01/18/2019] [Accepted: 01/24/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Historically pleural infection was thought to be associated with longer survival in thoracic malignancies. The aim of this population-based cohort study was to investigate this hypothesis in mesothelioma, using national data from a high incidence country. METHODS Case records for all patients with mesothelioma seen in English hospitals between 01/01/2005 and 31/12/2014 were extracted from Hospital Episode Statistics using International Classification of Diseases Tenth Edition (ICD-10) codes. Episodes of pleural infection were identified. Linked mortality data was obtained from the Office of National Statistics. The primary outcome was all-cause mortality. The explanatory variable was pleural infection. Cox proportional hazards model was used to analyse survival, with pleural infection, chemotherapy and thoracic surgery handled as time-variable co-factors. RESULTS Of 22,215 patients with mesothelioma, 512 (2.3%) developed pleural infection at some point in their illness. Overall median survival was 7.0 months (IQR 2.3-16.4). Pleural infection was associated with shorter survival in the immediate post-infection period (up to 30 days - HR 1.81, 95% CI 1.45-2.22) and longer term (>30 days - HR 1.81, 95% CI 1.63-1.99). Other factors associated with increased mortality were age, male gender and being diagnosed as an inpatient. Receiving chemotherapy and being less economically deprived were associated with longer survival. CONCLUSION Pleural infection occurred in 2.3% of people with mesothelioma and was associated with shorter survival. This refutes previous reports suggesting pleural infection may be associated with better outcomes in thoracic malignancy.
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Affiliation(s)
- Anna C Bibby
- Academic Respiratory Unit, Bristol Medical School, University of Bristol, UK; North Bristol Lung Centre, North Bristol NHS Trust, Bristol, UK.
| | - Duneesha de Fonseka
- Academic Respiratory Unit, Bristol Medical School, University of Bristol, UK; North Bristol Lung Centre, North Bristol NHS Trust, Bristol, UK
| | - David J Carslake
- MRC Integrative Epidemiology Unit, University of Bristol, UK; Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Nick A Maskell
- Academic Respiratory Unit, Bristol Medical School, University of Bristol, UK
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Harrison CJ, Spencer RG, Shackley DC. Transforming cancer outcomes in England: earlier and faster diagnoses, pathways to success, and empowering alliances. J Healthc Leadersh 2019; 11:1-11. [PMID: 30774494 PMCID: PMC6357885 DOI: 10.2147/jhl.s150924] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Cancer outcomes and patient experience in England have never been better but survival remains worse than in comparable countries. Differences in stage at diagnosis and, to a lesser extent, access to optimal treatments are likely to be the most important factors. The national cancer plan emphasizes earlier and faster diagnosis and the creation of cancer alliances providing strategic leadership and coordination. Earlier diagnosis is being promoted by national awareness campaigns designed to overcome fatalism and perceived barriers to consulting a general practitioner as well as improvements to existing screening programs and the introduction of more targeted screening such as Lung Health Checks. These are supported by local social marketing campaigns in which trained volunteers support and advise others about cancer and cancer care. The epidemiology of symptoms in general practice provides an organizing framework for cancer diagnostic pathways. Alliances are implementing a broader model of cancer diagnostic clinics at a larger scale taking into account the different needs of patients with 1) obvious alert symptoms, 2) low risk but not no risk symptoms, and 3) serious but not specific symptoms. Faster diagnosis is being promoted by the introduction of a Faster Diagnosis Standard requiring patients are given a diagnosis of cancer or have it ruled out within 28 days of referral. The three cancer alliances forming the National Cancer Vanguard together with NHS England are publishing clinically led evidence-based Timed Diagnostic Pathways which show how the drastic changes needed can be achieved. Cancer alliances have been successful in developing clinical cancer pathways which need support by improved commissioning and regulatory approaches which align clinical pathways with financial and performance ratings. Clinical leadership has been essential but further focus is needed on making sure that performance and regulatory approaches give proper attention and encouragement to earlier and faster diagnosis.
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Affiliation(s)
- Christopher J Harrison
- University of Manchester Division of Cancer Sciences, The Christie NHS Foundation Trust, Manchester, UK,
| | - Roger G Spencer
- Chief Executive's Office, The Christie NHS Foundation Trust, Manchester, UK
| | - David C Shackley
- University of Manchester Division of Cancer Sciences, Greater Manchester Cancer, Manchester, UK
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221
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Gartland N, Long H, Skevington SM. Undiagnosed cancer symptoms in the community: does poor quality of life influence the decision to seek help? Qual Life Res 2019; 28:1327-1335. [PMID: 30671707 PMCID: PMC6470111 DOI: 10.1007/s11136-018-2088-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Although a cancer diagnosis is linked with decrements to quality of life (QoL), it is unknown exactly when QoL starts to deteriorate, and whether this occurs during the pre-diagnostic pathway. This study aimed to examine QoL during this phase, and in addition investigate whether QoL levels influence decisions about seeking professional help. This is important, because early diagnosis is linked to lower cancer mortality rates. METHODS Working alongside a Cancer Research UK Roadshow in socially deprived communities, the recent QoL of adult visitors was assessed, before attending primary care. Using a cross-sectional design, we compared QoL in those presenting a potential cancer symptom/sign, with others seeking lifestyle advice to reduce cancer risk. Self-reported QoL (WHOQOL-BREF), and intention to seek help, were measured. RESULTS Of 107 recruited, 50% were men. The potential cancer symptom group reported significantly poorer general QoL and psychological QoL, than lifestyle controls. Prior poorer physical QoL predicted stronger intentions to consult a general practitioner (GP) in the next 2 weeks, when controlling for symptom presence. CONCLUSIONS QoL is poorer for those with potential cancer symptoms, before they first seek advice from primary care. Poorer physical QoL is associated with stronger intentions to make a GP appointment. An implication for longer term health is that if public awareness about the impact of symptoms on QoL was raised, this could provide an impetus to seek help.
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Affiliation(s)
- Nicola Gartland
- Manchester Centre for Health Psychology and International Hub for Quality of Life Research (IHQoLR), Faculty of Biology, Medicine and Health, University of Manchester, Manchester, MP13 9PL, UK.
| | - Hannah Long
- Manchester Centre for Health Psychology and International Hub for Quality of Life Research (IHQoLR), Faculty of Biology, Medicine and Health, University of Manchester, Manchester, MP13 9PL, UK
| | - Suzanne M Skevington
- Manchester Centre for Health Psychology and International Hub for Quality of Life Research (IHQoLR), Faculty of Biology, Medicine and Health, University of Manchester, Manchester, MP13 9PL, UK
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222
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Emery JD, Murray SR, Walter FM, Martin A, Goodall S, Mazza D, Habgood E, Kutzer Y, Barnes DJ, Murchie P. The Chest Australia Trial: a randomised controlled trial of an intervention to increase consultation rates in smokers at risk of lung cancer. Thorax 2019; 74:362-370. [PMID: 30630891 PMCID: PMC6484693 DOI: 10.1136/thoraxjnl-2018-212506] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 11/26/2018] [Accepted: 12/03/2018] [Indexed: 12/11/2022]
Abstract
Background International research has focused on screening and mass media campaigns to promote earlier patient presentation and detect lung cancer earlier. This trial tested the effect of a behavioural intervention in people at increased risk of lung cancer on help-seeking for respiratory symptoms. Methods Parallel, individually randomised controlled trial. Eligible participants were long-term smokers with at least 20 pack-years, aged 55 and above. The CHEST intervention entailed a consultation to discuss and implement a self-help manual, followed by self-monitoring reminders to encourage help-seeking for respiratory symptoms. The control group received a brief discussion about lung health. Both groups had baseline spirometry. Telephone randomisation was conducted, 1:1, stratified Medical Research Council (MRC) dyspnoea score and general practice. Participants could not be blinded; data extraction and statistical analyses were performed blinded to group assignment. The primary outcome was respiratory consultation rates. Results We randomised 551 participants (274 intervention, 277 control) from whom the primary outcome was determined for 542 (269 intervention, 273 control). There was a 40% relative increase in respiratory consultations in the intervention group: (adjusted rates (95% CI) intervention 0.57 (0.47 to 0.70), control 0.41 (0.32 to 0.52), relative rate 1.40 (1.08 to 1.82); p=0.0123). There were no significant differences in time to first respiratory consultation, total consultation rates or measures of psychological harm. The incremental cost-effectiveness ratio was $A1289 per additional respiratory consultation. Conclusions A behavioural intervention can significantly increase consulting for respiratory symptoms in patients at increased risk of lung cancer. This intervention could have an important role in primary care as part of a broader approach to improve respiratory health in patients at higher risk. Trial registration number Australian New Zealand Clinical Trial Registry (1261300039 3752). This was registered pre-results.
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Affiliation(s)
- Jon D Emery
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia.,Department of General Practice, The Medical School, University of Western Australia, Perth, Australia.,The Primary Care Unit, Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sonya R Murray
- Department of General Practice, The Medical School, University of Western Australia, Perth, Australia
| | - Fiona M Walter
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia.,Department of General Practice, The Medical School, University of Western Australia, Perth, Australia.,The Primary Care Unit, Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Andrew Martin
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Stephen Goodall
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Danielle Mazza
- Department of General Practice, Monash University, Melbourne, Victoria, Australia
| | - Emily Habgood
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia
| | - Yvonne Kutzer
- Department of General Practice, The Medical School, University of Western Australia, Perth, Australia.,School of Nursing and Midwifery, Edith Cowan University, Perth, Western Australia, Australia
| | - David John Barnes
- Royal Prince Alfred Hospital, Newtown, New South Wales, Australia.,Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Peter Murchie
- The Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
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223
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Suhail A, Crocker CE, Das B, Payne JI, Manos D. Initial presentation of lung cancer in the emergency department: a descriptive analysis. CMAJ Open 2019; 7:E117-E123. [PMID: 30808631 PMCID: PMC6404960 DOI: 10.9778/cmajo.20180061] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Guidelines aimed at improving care for lung cancer, the leading cause of cancer-related death in Canada and worldwide, require accurate knowledge of the diagnostic setting or pathway. We sought to determine how often lung cancer is initially diagnosed through the emergency department. METHODS We performed a descriptive study that included all cases of primary lung cancer diagnosed in residents of Nova Scotia in 2014. Cancer registry data included diagnostic data and date of death to Aug. 31, 2016. We reviewed linked hospital records, including laboratory and imaging results, to identify the first positive diagnostic study and the route of presentation (emergency department v. other). We evaluated time from diagnosis to death as a function of presentation route using Kaplan-Meier curves and Cox regression (hazard rate ratios [HRRs]). RESULTS Sufficient data were available for 946 of 951 cases identified, of which 336 (35.5%) were diagnosed through the emergency department. Cases diagnosed via the emergency department were more likely to be at an advanced stage (stage IV, 59.5% v. 43.4%), with patients experiencing shorter survival (1-yr survival, 28.4% v. 49.5%), including stage-specific survival. Mortality for cases diagnosed in the emergency department was 54% higher than for the non-emergency department group after adjusting for age and stage (HRR 1.54, 95% confidence interval 1.32-1.81). Few patients (7.1%, n = 24) who presented to the emergency department reported having no family physician. INTERPRETATION The emergency department is a common route of presentation for lung cancer and is associated with advanced stage at diagnosis and reduced survival time. Strategies are needed to encourage pre-emergent diagnosis and to ensure that emergency providers are supported in the initial care of patients with lung cancer.
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Affiliation(s)
- Aamir Suhail
- Departments of Diagnostic Radiology (Suhail, Crocker, Payne, Manos), Psychiatry (Crocker) and Emergency Medicine (Das), Dalhousie University, Halifax, NS
| | - Candice E Crocker
- Departments of Diagnostic Radiology (Suhail, Crocker, Payne, Manos), Psychiatry (Crocker) and Emergency Medicine (Das), Dalhousie University, Halifax, NS
| | - Bijon Das
- Departments of Diagnostic Radiology (Suhail, Crocker, Payne, Manos), Psychiatry (Crocker) and Emergency Medicine (Das), Dalhousie University, Halifax, NS
| | - Jennifer I Payne
- Departments of Diagnostic Radiology (Suhail, Crocker, Payne, Manos), Psychiatry (Crocker) and Emergency Medicine (Das), Dalhousie University, Halifax, NS
| | - Daria Manos
- Departments of Diagnostic Radiology (Suhail, Crocker, Payne, Manos), Psychiatry (Crocker) and Emergency Medicine (Das), Dalhousie University, Halifax, NS
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224
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Herbert A, Abel GA, Winters S, McPhail S, Elliss-Brookes L, Lyratzopoulos G. Are inequalities in cancer diagnosis through emergency presentation narrowing, widening or remaining unchanged? Longitudinal analysis of English population-based data 2006-2013. J Epidemiol Community Health 2019; 73:3-10. [PMID: 30409920 PMCID: PMC6839789 DOI: 10.1136/jech-2017-210371] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 08/01/2018] [Accepted: 08/31/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Diagnosis of cancer through emergency presentation is associated with poorer prognosis. While reductions in emergency presentations have been described, whether known sociodemographic inequalities are changing is uncertain. METHODS We analysed 'Routes to Diagnosis' data on patients aged ≥25 years diagnosed in England during 2006-2013 with any of 33 common or rarer cancers. Using binary logistic regression we determined time-trends in diagnosis through emergency presentation by age, deprivation and cancer site. RESULTS Overall adjusted proportions of emergency presentations decreased during the study period (2006: 23%, 2013: 20%). Substantial baseline (2006) inequalities in emergency presentation risk by age and deprivation remained largely unchanged. There was evidence (p<0.05) of reductions in the risk of emergency presentations for most (28/33) cancer sites, without apparent associations between the size of reduction and baseline risk (p=0.26). If there had been modest reductions in age inequalities (ie, patients in each age group acquiring the same percentage of emergency presentations as the adjacent group with lower risk), in the last study year we could have expected around 11 000 fewer diagnoses through emergency presentation (ie, a nationwide percentage of 16% rather than the observed 20%). For similarly modest reductions in deprivation inequalities, we could have expected around 3000 fewer (ie, 19%). CONCLUSION The proportion of cancer diagnoses through emergency presentation is decreasing but age and deprivation inequalities prevail, indicating untapped opportunities for further improvements by reducing these inequalities. The observed reductions in proportions across nearly all cancer sites are likely to reflect both earlier help-seeking and improvements in diagnostic healthcare pathways, across both easier-to-suspect and harder-to-suspect cancers.
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Affiliation(s)
- Annie Herbert
- ECHO (Epidemiology of Cancer Healthcare and Outcomes) Research Group, Department of Behavioural Sciences and Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Gary A Abel
- University of Exeter Medical School (Primary Care), Exeter, UK
| | - Sam Winters
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, London, UK
| | - Sean McPhail
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, London, UK
| | - Lucy Elliss-Brookes
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, London, UK
| | - Georgios Lyratzopoulos
- ECHO (Epidemiology of Cancer Healthcare and Outcomes) Research Group, Department of Behavioural Sciences and Health, Institute of Epidemiology and Health Care, University College London, London, UK
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, London, UK
- THIS (The Health Improvement Studies) Institute, and Cambridge Centre for Health Services Research, University of Cambridge, Institute of Public Health, Cambridge, UK
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225
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Williams R, Alexander G, Aspinall R, Batterham R, Bhala N, Bosanquet N, Severi K, Burton A, Burton R, Cramp ME, Day N, Dhawan A, Dillon J, Drummond C, Dyson J, Ferguson J, Foster GR, Gilmore I, Greenberg J, Henn C, Hudson M, Jarvis H, Kelly D, Mann J, McDougall N, McKee M, Moriarty K, Morling J, Newsome P, O'Grady J, Rolfe L, Rice P, Rutter H, Sheron N, Thorburn D, Verne J, Vohra J, Wass J, Yeoman A. Gathering momentum for the way ahead: fifth report of the Lancet Standing Commission on Liver Disease in the UK. Lancet 2018; 392:2398-2412. [PMID: 30473364 DOI: 10.1016/s0140-6736(18)32561-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/04/2018] [Accepted: 10/10/2018] [Indexed: 02/06/2023]
Abstract
This report presents further evidence on the escalating alcohol consumption in the UK and the burden of liver disease associated with this major risk factor, as well as the effects on hospital and primary care. We reiterate the need for fiscal regulation by the UK Government if overall alcohol consumption is to be reduced sufficiently to improve health outcomes. We also draw attention to the effects of drastic cuts in public services for alcohol treatment, the repeated failures of voluntary agreements with the drinks industry, and the influence of the industry through its lobbying activities. We continue to press for reintroduction of the alcohol duty escalator, which was highly effective during the 5 years it was in place, and the introduction of minimum unit pricing in England, targeted at the heaviest drinkers. Results from the introduction of minimum unit pricing in Scotland, with results from Wales to follow, are likely to seriously expose the weakness of England's position. The increasing prevalence of obesity-related liver disease, the rising number of people diagnosed with type 2 diabetes and its complications, and increasing number of cases of end-stage liver disease and primary liver cancers from non-alcoholic fatty liver disease make apparent the need for an obesity strategy for adults. We also discuss the important effects of obesity and alcohol on disease progression, and the increased risk of the ten most common cancers (including breast and colon cancers). A new in-depth analysis of the UK National Health Service (NHS) and total societal costs shows the extraordinarily large expenditures that could be saved or redeployed elsewhere in the NHS. Excellent results have been reported for new antiviral drugs for hepatitis C virus infection, making elimination of chronic infection a real possibility ahead of the WHO 2030 target. However, the extent of unidentified cases remains a problem, and will also apply when new curative drugs for hepatitis B virus become available. We also describe efforts to improve standards of hospital care for liver disease with better understanding of current service deficiencies and a new accreditation process for hospitals providing liver services. New commissioning arrangements for primary and community care represent progress, in terms of effective screening of high-risk subjects and the early detection of liver disease.
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Affiliation(s)
| | | | | | - Rachel Batterham
- National Institute of Health Research, UCLH Biomedical Research Centre, London, UK
| | - Neeraj Bhala
- Queen Elizabeth Hospital Birmingham and University of Birmingham, Edgbaston, Birmingham, UK
| | - Nick Bosanquet
- Department of Bioengineering, Imperial College London, London, UK
| | | | - Anya Burton
- Hepatocellular Carcinoma UK and National Cancer Registration and Analysis Service, Public Health England, Bristol, UK
| | | | - Matthew E Cramp
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | | | - John Dillon
- Medical Research Institute, University of Dundee, Dundee, UK
| | - Colin Drummond
- Institute of Psychiatry, Psychology & Neuroscience, King's College London and South London and Maudsley NHS Foundation Trust, London, UK
| | | | - James Ferguson
- National Institute for Health Research Birmingham Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Graham R Foster
- Barts Liver Centre, Queen Mary University of London, London, UK
| | | | | | | | | | - Helen Jarvis
- Institute of Health and Society, Newcastle University, Newcastle, UK; The Royal College of General Practitioners, London, UK
| | - Deirdre Kelly
- Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Jake Mann
- Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | | | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Joanne Morling
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK; Nottingham Digestive Diseases Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Philip Newsome
- National Institute for Health Research, Birmingham Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | | | | | - Peter Rice
- Scottish Health Action on Alcohol Problems (SHAAP), Bath, UK
| | | | - Nick Sheron
- National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton, Southampton, UK
| | | | | | - Jyotsna Vohra
- Cancer Policy Research Centre, Cancer Research UK, London
| | - John Wass
- Department of Endocrinology, Churchill Hospital, Oxford, UK
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226
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National cancer control plans. Lancet Oncol 2018; 19:e665. [DOI: 10.1016/s1470-2045(18)30830-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 10/30/2018] [Indexed: 11/22/2022]
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227
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Arhi CS, Bottle A, Burns EM, Clarke JM, Aylin P, Ziprin P, Darzi A. Comparison of cancer diagnosis recording between the Clinical Practice Research Datalink, Cancer Registry and Hospital Episodes Statistics. Cancer Epidemiol 2018; 57:148-157. [DOI: 10.1016/j.canep.2018.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/23/2018] [Accepted: 08/26/2018] [Indexed: 02/05/2023]
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228
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Weller D, Menon U, Zalounina Falborg A, Jensen H, Barisic A, Knudsen AK, Bergin RJ, Brewster DH, Cairnduff V, Gavin AT, Grunfeld E, Harland E, Lambe M, Law RJ, Lin Y, Malmberg M, Turner D, Neal RD, White V, Harrison S, Reguilon I, Vedsted P. Diagnostic routes and time intervals for patients with colorectal cancer in 10 international jurisdictions; findings from a cross-sectional study from the International Cancer Benchmarking Partnership (ICBP). BMJ Open 2018; 8:e023870. [PMID: 30482749 PMCID: PMC6278806 DOI: 10.1136/bmjopen-2018-023870] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE International differences in colorectal cancer (CRC) survival and stage at diagnosis have been reported previously. They may be linked to differences in time intervals and routes to diagnosis. The International Cancer Benchmarking Partnership Module 4 (ICBP M4) reports the first international comparison of routes to diagnosis for patients with CRC and the time intervals from symptom onset until the start of treatment. Data came from patients in 10 jurisdictions across six countries (Canada, the UK, Norway, Sweden, Denmark and Australia). DESIGN Patients with CRC were identified via cancer registries. Data on symptomatic and screened patients were collected; questionnaire data from patients' primary care physicians and specialists, as well as information from treatment records or databases, supplemented patient data from the questionnaires. Routes to diagnosis and the key time intervals were described, as were between-jurisdiction differences in time intervals, using quantile regression. PARTICIPANTS A total of 14 664 eligible patients with CRC diagnosed between 2013 and 2015 were identified, of which 2866 were included in the analyses. PRIMARY AND SECONDARY OUTCOME MEASURES Interval lengths in days (primary), reported patient symptoms (secondary). RESULTS The main route to diagnosis for patients was symptomatic presentation and the most commonly reported symptom was 'bleeding/blood in stool'. The median intervals between jurisdictions ranged from: 21 to 49 days (patient); 0 to 12 days (primary care); 27 to 76 days (diagnostic); and 77 to 168 days (total, from first symptom to treatment start). Including screen-detected cases did not significantly alter the overall results. CONCLUSION ICBP M4 demonstrates important differences in time intervals between 10 jurisdictions internationally. The differences may justify efforts to reduce intervals in some jurisdictions.
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Affiliation(s)
| | - Usha Menon
- MRC Clinical Trials Unit and Instittue of Clinical Trials and Methodology, University College London, London, UK
| | | | - Henry Jensen
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Andriana Barisic
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Anne Kari Knudsen
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Rebecca J Bergin
- Centre for Behavioral Research in Cancer, Cancer Council Victoria, Melbourne, Victoria, Australia
- Department of General Practice, University of Melbourne, Melbourne, Australia
| | - David H Brewster
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
- Scottish Cancer Registry, Information Services Division, NHS National Services Scotland, Edinburgh, UK
| | - Victoria Cairnduff
- Northern Ireland Cancer Registry, Queen's University Belfast, Belfast, UK
| | - Anna T Gavin
- Northern Ireland Cancer Registry, Queen's University Belfast, Belfast, UK
| | - Eva Grunfeld
- Health Services Research Program, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Elizabeth Harland
- Department of Epidemiology and Cancer Registry, Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Mats Lambe
- Regional Cancer Center Uppsala and Department of Medical Epidemiology and Biostatics, Karolinska Institutet, Stockholm, Sweden
| | - Rebecca-Jane Law
- North Wales Centre for Primary Care Research, Bangor Institute for Health and Medical Research, Bangor University, Bangor, UK
| | - Yulan Lin
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Martin Malmberg
- Department of Oncology, Lund University Hospital, Lund, Sweden
| | - Donna Turner
- Population Oncology, Cancer Care Manitoba, Winnipeg, Canada
| | - Richard D Neal
- North Wales Centre for Primary Care Research, Bangor Institute for Health and Medical Research, Bangor University, Bangor, UK
- Academic Unit of Primary Care, University of Leeds, Leeds, UK
| | - Victoria White
- Centre for Behavioral Research in Cancer, Cancer Council Victoria, Melbourne, Victoria, Australia
- School of Psychology, Deakin University School of Psychology, Burwood, Victoria, Australia
| | | | | | - Peter Vedsted
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
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Ziogas DC, Dimopoulos MA, Kastritis E. Prognostic factors for multiple myeloma in the era of novel therapies. Expert Rev Hematol 2018; 11:863-879. [DOI: 10.1080/17474086.2018.1537776] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Dimitrios C. Ziogas
- Department of Clinical Therapeutics, School of Medicine, “Alexandra” General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, “Alexandra” General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine, “Alexandra” General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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230
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Younger E, Husson O, Bennister L, Whelan J, Wilson R, Roast A, Jones RL, van der Graaf WT. Age-related sarcoma patient experience: results from a national survey in England. BMC Cancer 2018; 18:991. [PMID: 30333006 PMCID: PMC6192120 DOI: 10.1186/s12885-018-4866-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 09/26/2018] [Indexed: 01/04/2023] Open
Abstract
Background Sarcomas are rare, heterogeneous tumours affecting patients of any age. Previous surveys describe that sarcoma patients report a significantly worse experience than those with common cancers. Consequently, Sarcoma UK conducted a national survey and these data were examined for age- and tumour-related differences in patients’ experiences. Methods Patients were randomly selected from respondents to National Cancer Patient Experience Surveys (n = 900). Differences between patient groups according to age (Adolescents and Young Adults [AYA] 18–39 years, middle-aged 40–64 years, elderly 65 + years) and tumour type (soft-tissue [STS] vs. bone]) were analysed with t-tests or chi-square tests. Results Survey response rate was 62% (n = 558; STS 75%, bone sarcoma 25%). Delay in diagnosis was reported; 27% patients (n = 150) waited > 3 months and initial symptoms were incorrectly interpreted; AYA STS patients were significantly more likely to be treated for another condition, or advised that their symptoms were not serious, than older STS patients. Clinical trial participation was low (6%, n = 35). Symptom burden was high, most commonly daytime fatigue (48%, n = 277) and pain (44%, n = 248). AYAs were significantly more likely to report most side-effects and post-treatment concerns than older patients. Elderly patients were more satisfied with the information and emotional support provided than younger patients, however were significantly less likely to be referred to rehabilitation services. Conclusions This study identifies significant age-related differences in the sarcoma patient journey, which are not only related to variation in tumour-types. These results provide rationale for adopting an age-specific approach to the management of sarcoma patients in order to improve overall patient experience. Electronic supplementary material The online version of this article (10.1186/s12885-018-4866-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Olga Husson
- Sarcoma Unit, Royal Marsden Hospital, London, SW3 6JJ, UK.,Division of Clinical Studies, Institute of Cancer Research, London, SW7 3RP, UK
| | | | - Jeremy Whelan
- University College London Hospital (UCLH), London, NW1 2BU, UK
| | - Roger Wilson
- Sarcoma UK Registered Cancer Charity, London, N1 6AH, UK
| | - Andy Roast
- Sarcoma UK Registered Cancer Charity, London, N1 6AH, UK
| | - Robin L Jones
- Sarcoma Unit, Royal Marsden Hospital, London, SW3 6JJ, UK.,Division of Clinical Studies, Institute of Cancer Research, London, SW7 3RP, UK
| | - Winette Ta van der Graaf
- Sarcoma Unit, Royal Marsden Hospital, London, SW3 6JJ, UK. .,Division of Clinical Studies, Institute of Cancer Research, London, SW7 3RP, UK.
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231
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Muller P, Walters S, Coleman MP, Woods L. Which indicators of early cancer diagnosis from population-based data sources are associated with short-term mortality and survival? Cancer Epidemiol 2018; 56:161-170. [PMID: 30056051 PMCID: PMC6189520 DOI: 10.1016/j.canep.2018.07.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/20/2018] [Accepted: 07/16/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND A key component of recent English cancer policy is the monitoring of trends in early diagnosis of cancer. Early diagnosis can be defined by the disease stage at diagnosis or by other indicators derived from electronic health records. We evaluate the association between different early diagnosis indicators and survival, and discuss the implementation of the indicators in surveillance of early diagnosis. METHODS We searched the PubMed database and grey literature to identify early diagnosis indicators and evaluate their association with survival. We analysed cancer registrations for 355,502 cancer patients diagnosed in England during the period 2009-2013, and quantified the association between each early diagnosis indicator and 30-day mortality and five-year net survival. RESULTS Each incremental difference in stage (I-IV) predicts lower 5-year survival, so prognostic information is lost in comparisons which use binary stage indicators. Patients without a recorded stage have high risk of death shortly following diagnosis and lower 5-year survival. Emergency presentation is independently associated with lower five-year survival. Shorter intervals between first symptoms and diagnosis are not consistently associated with improved survival, potentially due to confounding from tumour characteristics. INTERPRETATION Contrary to current practice, we recommend that all the stage information should be used in surveillance. Patients missing stage should also be included to minimise bias. Combined data on stage and emergency presentation could be used to create summary prognostic measures. More work is needed to create statistics based on the diagnostic interval that will be useful for surveillance.
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Affiliation(s)
- Patrick Muller
- Cancer Survival Group, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
| | - Sarah Walters
- Cancer Survival Group, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Michel P Coleman
- Cancer Survival Group, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Laura Woods
- Cancer Survival Group, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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Esteva M, Ruiz-Díaz M, Sánchez MA, Pértega S, Pita-Fernández S, Macià F, Posso M, González-Luján L, Boscá-Wats MM, Leiva A, Ripoll J. Emergency presentation of colorectal patients in Spain. PLoS One 2018; 13:e0203556. [PMID: 30273339 PMCID: PMC6166931 DOI: 10.1371/journal.pone.0203556] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 07/25/2018] [Indexed: 12/22/2022] Open
Abstract
Background Colorectal cancer (CRC) is the leading cause of cancer deaths in Europe. Survival is poorer in patients admitted to hospitals through the emergency department than in electively admitted patients. Knowledge of factors associated with a cancer diagnosis through presentation at an emergency department may reduce the likelihood of an emergency diagnosis. This study evaluated factors influencing the diagnosis of CRC in the emergency department. Methods and findings This is a cross-sectional study in 5 Spanish regions; subjects were incident cases of CRC diagnosed in 9 public hospitals, between 2006 and 2008. Data were obtained from patient interviews and primary care and hospital clinical records. We found that approximately 40% of CRC patients first contacted a hospital for CRC through an emergency service. Women were more likely than men to be emergency presenters. The type of symptom associated with emergency presentation differed between patients with colon cancer and those with rectal cancer, in that the frequency of “alarm symptoms” was significantly lower in colon than in rectal cancer patients who initially presented to emergency services. Soon after symptom onset, some patients went to a hospital emergency service, whereas others contacted their GP. Lack of contact with a GP for CRC-related symptoms was consistently related to emergency presentation. Among patients who contacted a GP, a higher number of consultations for CRC symptoms and any referral to outpatient consultations reduced the likelihood of emergency presentation. All diagnostic time intervals were shorter in emergency presenters than in elective patients. Conclusions Emergency presenters are not a uniform category and can be divided into categories according to their symptoms, help seeking behavior trajectory and interaction with their GPs. Time constraints for testing and delays in obtaining outpatient appointments led patients to visit a hospital service either on their own or after referral by their GP.
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Affiliation(s)
- Magdalena Esteva
- Primary Care Research Unit, Majorca Department of Primary Care; Baleares Health Service [IbSalut], Balearic Islands Health Research Institute (IdISBa), Majorca, Spain
- * E-mail:
| | | | - M. Antonia Sánchez
- Centro de Salud Fuentes Norte Zaragoza, Department of Medicine, Psychiatry and Dermatology, University of Zaragoza, Zaragoza, Spain
| | - Sonia Pértega
- 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, España
| | - 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, España
| | - Francesc Macià
- Epidemiology and Evaluation Department, Hospital del Mar, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- REDISSEC (Health Services Research on Chronic Patients Network), Madrid, Spain
| | - Margarita Posso
- Epidemiology and Evaluation Department, Hospital del Mar, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- REDISSEC (Health Services Research on Chronic Patients Network), Madrid, Spain
| | - Luis González-Luján
- Serreria II Primary Care Centre, Valencia Institute of Health, Valencia, Spain
| | - Marta M. Boscá-Wats
- Digestive Medicine Unit, Hospital Clinic Universitari de València, València, Spain
| | - Alfonso Leiva
- Primary Care Research Unit, Majorca Department of Primary Care; Baleares Health Service [IbSalut], Balearic Islands Health Research Institute (IdISBa), Majorca, Spain
| | - Joana Ripoll
- Primary Care Research Unit, Majorca Department of Primary Care; Baleares Health Service [IbSalut], Balearic Islands Health Research Institute (IdISBa), Majorca, Spain
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Woznitza N, Steele R, Piper K, Burke S, Rowe S, Bhowmik A, Maughn S, Springett K. Increasing radiology capacity within the lung cancer pathway: centralised work-based support for trainee chest X-ray reporting radiographers. J Med Radiat Sci 2018; 65:200-208. [PMID: 29806102 PMCID: PMC6119729 DOI: 10.1002/jmrs.285] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 05/01/2018] [Accepted: 05/04/2018] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Diagnostic capacity and time to diagnosis are frequently identified as a barrier to improving cancer patient outcomes. Maximising the contribution of the medical imaging workforce, including reporting radiographers, is one way to improve service delivery. METHODS An efficient and effective centralised model of workplace training support was designed for a cohort of trainee chest X-ray (CXR) reporting radiographers. A comprehensive schedule of tutorials was planned and aligned with the curriculum of a post-graduate certificate in CXR reporting. Trainees were supported via a hub and spoke model (centralised training model), with the majority of education provided by a core group of experienced CXR reporting radiographers. Trainee and departmental feedback on the model was obtained using an online survey. RESULTS Fourteen trainees were recruited from eight National Health Service Trusts across London. Significant efficiencies of scale were possible with centralised support (48 h) compared to traditional workplace support (348 h). Trainee and manager feedback overall was positive. Trainees and managers both reported good trainee support, translation of learning to practice and increased confidence. Logistics, including trainee travel and release, were identified as areas for improvement. CONCLUSION Centralised workplace training support is an effective and efficient method to create sustainable diagnostic capacity and support improvements in the lung cancer pathway.
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Affiliation(s)
- Nick Woznitza
- Radiology DepartmentHomerton University HospitalLondonUK
- School of Allied Health ProfessionsCanterbury Christ Church UniversityCanterburyUK
| | - Rebecca Steele
- Radiology DepartmentUniversity College London HospitalLondonUK
| | - Keith Piper
- School of Allied Health ProfessionsCanterbury Christ Church UniversityCanterburyUK
| | - Stephen Burke
- Radiology DepartmentHomerton University HospitalLondonUK
| | - Susan Rowe
- Radiology DepartmentHomerton University HospitalLondonUK
| | - Angshu Bhowmik
- Department of Respiratory MedicineHomerton University HospitalLondonUK
| | - Sue Maughn
- City and Hackney Clinical Commissioning GroupLondonUK
| | - Kate Springett
- School of Allied Health ProfessionsCanterbury Christ Church UniversityCanterburyUK
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Early detection of multiple myeloma in primary care using blood tests: a case-control study in primary care. Br J Gen Pract 2018; 68:e586-e593. [PMID: 30104326 PMCID: PMC6104875 DOI: 10.3399/bjgp18x698357] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/14/2018] [Indexed: 12/14/2022] Open
Abstract
Background Multiple myeloma is a haematological cancer characterised by numerous non-specific symptoms leading to diagnostic delay in a large proportion of patients. Aim To identify which blood tests are useful in suggesting or excluding a diagnosis of myeloma. Design and setting A matched case–control study set in UK primary care using routinely collected data from the Clinical Practice Research Datalink. Method Symptom prevalence and blood tests were analysed up to 5 years before diagnosis in 2703 cases and 12 157 matched controls. Likelihood ratios (LR) were used to classify tests or their combinations as useful rule-in tests (LR+ = ≥5), or rule-out tests (LR− = ≤0.2). Results Raised plasma viscosity (PV) had an LR+ = 2.0, 95% confidence interval [CI] = 1.7 to 2.3; erythrocyte sedimentation rate (ESR) 1.9, 95% CI = 1.7 to 2.0; and C-reactive protein (CRP) 1.2, 95% CI = 1.1 to 1.4. A normal haemoglobin had an LR− = 0.42, 95% CI = 0.39 to 0.45; calcium LR− = 0.81, 95% CI = 0.78 to 0.83; and creatinine LR− = 0.80, 95% CI = 0.77 to 0.83. The test combination with the lowest LR− was all normal haemoglobin with calcium and PV, which had an LR− = 0.06, 95% CI = 0.02 to 0.18, though the LR− for normal haemoglobin and PV together was 0.12 (95% CI = 0.07 to 0.23). Conclusion Plasma viscosity and ESR are better for both ruling in and ruling out the disease compared with C-reactive protein. A combination of a normal ESR or PV and normal haemoglobin is a simple rule-out approach for patients currently being tested in primary care.
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Yap S, Goldsbury D, Yap ML, Yuill S, Rankin N, Weber M, Canfell K, O’Connell DL. Patterns of care and emergency presentations for people with non-small cell lung cancer in New South Wales, Australia: A population-based study. Lung Cancer 2018; 122:171-179. [DOI: 10.1016/j.lungcan.2018.06.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/15/2018] [Accepted: 06/08/2018] [Indexed: 10/14/2022]
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The value of using the faecal immunochemical test in general practice on patients presenting with non-alarm symptoms of colorectal cancer. Br J Cancer 2018; 119:471-479. [PMID: 30065255 PMCID: PMC6133998 DOI: 10.1038/s41416-018-0178-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 06/18/2018] [Indexed: 12/15/2022] Open
Abstract
Background Around 50% of individuals with colorectal cancer (CRC) initially
present with non-alarm symptoms. Methods We investigated the value of using the faecal immunochemical test
(FIT) in the diagnostic process of CRC and other serious bowel disease in
individuals presenting with non-alarm symptoms in general practice. The study was
conducted in the Central Denmark Region from 1 September 2015 to 30 August 2016.
The FIT was used as a rule-in test on patients aged ≥30 years with non-alarm
symptoms of CRC. The cut-off value was set to 10 µg Hb/g faeces. Results A total of 3462 valid FITs were performed. Of these, 540 (15.6%)
were positive. Three months after FIT performance, 51 (PPV: 9.4% (95% CI:
7.0;11.9)) individuals with a positive FIT were diagnosed with CRC and 73 (PPV:
13.5% (95%CI: 10.6;16.4)) with other serious bowel disease. Of CRCs, 66.7% were
diagnosed in UICC stage I & II and 19.6% in stage IV. The false negative rate
for CRC was <0.1% for the initial 3 months after FIT performance. Conclusion The FIT may be used as a supplementary diagnostic test in the
diagnostic process of CRC and other serious bowel disease in individuals with
non-alarm symptoms of CRC in general practice.
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237
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Maringe C, Rachet B, Lyratzopoulos G, Rubio FJ. Persistent inequalities in unplanned hospitalisation among colon cancer patients across critical phases of their care pathway, England, 2011-13. Br J Cancer 2018; 119:551-557. [PMID: 30108292 PMCID: PMC6162238 DOI: 10.1038/s41416-018-0170-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 06/05/2018] [Accepted: 06/13/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Reducing hospital emergency admissions is a key target for all modern health systems. METHODS We analysed colon cancer patients diagnosed in 2011-13 in England. We screened their individual Hospital Episode Statistics records in the 90 days pre-diagnosis, the 90 days post-diagnosis, and the 90 days pre-death (in the year following diagnosis), for the occurrence of hospital emergency admissions (HEAs). RESULTS Between a quarter and two thirds of patients experience HEA in the three 90-day periods examined: pre-diagnosis, post-diagnosis and before death. Patients with tumour stage I-III from more deprived backgrounds had higher proportions of HEAs than less deprived patients during all studied periods. This remains even after adjusting for differing distributions of risk factors such as age, sex, comorbidity and stage at diagnosis. CONCLUSIONS Although in some cases HEAs might be unavoidable or even appropriate, the proportion of HEAs varies by socioeconomic status, even after controlling for the usual patient factors, suggestive of remediable causes of excess emergency healthcare utilisation in patients belonging to higher deprivation groups. Future inquiries should address the potential role of clinical complications, sub-optimal healthcare administration, premature discharge or a lack of social support as potential explanations for these patterns of inequality.
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Affiliation(s)
- Camille Maringe
- Cancer Survival Group, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Bernard Rachet
- Cancer Survival Group, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, London, WC1E 7HB, UK
| | - Francisco Javier Rubio
- Cancer Survival Group, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.
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238
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Nygaard C, Jensen H, Christensen J, Vedsted P. Health care use before a diagnosis of primary intracranial tumor: a Danish nationwide register study. Clin Epidemiol 2018; 10:809-829. [PMID: 30038522 PMCID: PMC6049603 DOI: 10.2147/clep.s147865] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Introduction Detailed knowledge of prediagnostic health care use among patients with primary intracranial tumors is sparse. We aimed to investigate the health care use among adults during the 2 years preceding a diagnosis of a benign or malignant primary intracranial tumor in Denmark. Methods We conducted a population-based matched cohort study using historical data from Danish nationwide registries, including all patients aged 30–90 years diagnosed with a first-time primary intracranial tumor from January 1, 2009 to December 31, 2014, and with no prior cancer diagnosis (n=5,926). For each patient, ten comparison subjects were identified using density sampling. We analyzed differences in the frequency and timing of health care use within general practice, physiotherapy, radiology, ear –nose –throat, ophthalmology, neurology, and psychiatry. Odds ratios of having multiple contacts were calculated using a conditional logistical regression model. Monthly incidence rate ratios were estimated using a negative binomial regression model. Results Of all patients, 62% had a benign tumor. Patients with benign tumors were more likely to have multiple consultations with health care providers in the period 2–12 months prior to diagnosis and to have increased rates of consultations 1–24 months prior to diagnosis, depending on health service. Conclusion Patients diagnosed with a benign or a malignant primary intracranial tumor use the health care services differently. Increased health care use is seen within relatively close proximity to the diagnosis for patients with malignant tumors. However, patients with benign tumors have increased health care use from up to 2 years prior to diagnosis; this suggests a window of opportunity for earlier diagnosis.
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Affiliation(s)
- Charlotte Nygaard
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Research Unit for General Practice & Section for General Medicine, Department of Public Health, Aarhus University, Aarhus, Denmark,
| | - Henry Jensen
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Research Unit for General Practice & Section for General Medicine, Department of Public Health, Aarhus University, Aarhus, Denmark,
| | - Jakob Christensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Vedsted
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Research Unit for General Practice & Section for General Medicine, Department of Public Health, Aarhus University, Aarhus, Denmark, .,Department of Clinical Medicine, Aarhus University & Diagnostic Center, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
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240
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Salika T, Abel GA, Mendonca SC, von Wagner C, Renzi C, Herbert A, McPhail S, Lyratzopoulos G. Associations between diagnostic pathways and care experience in colorectal cancer: evidence from patient-reported data. Frontline Gastroenterol 2018; 9:241-248. [PMID: 30046429 PMCID: PMC6056077 DOI: 10.1136/flgastro-2017-100926] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/03/2018] [Accepted: 02/24/2018] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To examine how different pathways to diagnosis of colorectal cancer may be associated with the experience of subsequent care. DESIGN Patient survey linked to information on diagnostic route.English patients with colorectal cancer (analysis sample n=6837) who responded to a patient survey soon after their hospital treatment. MAIN OUTCOME MEASURES Odds Ratios and adjusted proportions of negative evaluation of key aspects of care for colorectal cancer, including the experience of shared decision-making about treatment, specialist nursing and care coordination, by diagnostic route (ie, screening detection, emergency presentation, urgent and elective general practitioner referral). RESULTS For 14 of 18 questions, there was evidence (p≤0.02) for variation in patient experience by diagnostic route, with 6-31 percentage point differences between routes in adjusted proportions of negative experience. Emergency presenters were more likely to report a negative experience for most questions, including those about adequacy of information about their diagnosis and sufficient explanation before operations. Screen-detected patients were least likely to report negative experiences except for support from primary care. Patients diagnosed through elective primary care referrals were most likely to report worse experience for questions for which overall variation by route was generally small. CONCLUSIONS Screening-detected patients tend to report the best and emergency presenters the worst experience of subsequent care. Improvement efforts can target care integration for screening-detected patients and provision of information about the diagnosis and treatment of emergency presenters.
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Affiliation(s)
- Theodosia Salika
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, Department of Behavioural Science and Health, University College London, London, UK
| | - Gary A Abel
- University of Exeter Medical School (Primary Care), Exeter, UK
| | - Silvia C Mendonca
- The Health Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Christian von Wagner
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, Department of Behavioural Science and Health, University College London, London, UK
- National Cancer Registration and Analysis Service, Public Health England, London, UK
| | - Cristina Renzi
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, Department of Behavioural Science and Health, University College London, London, UK
| | - Annie Herbert
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, Department of Behavioural Science and Health, University College London, London, UK
| | | | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, Department of Behavioural Science and Health, University College London, London, UK
- The Health Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
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241
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Andreano A, Peake MD, Janes SM, Valsecchi MG, Pritchard-Jones K, Hoag JR, Gross CP. The Care and Outcomes of Older Persons with Lung Cancer in England and the United States, 2008–2012. J Thorac Oncol 2018; 13:904-914. [DOI: 10.1016/j.jtho.2018.04.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 04/11/2018] [Accepted: 04/13/2018] [Indexed: 11/16/2022]
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242
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Kennedy MPT, Cheyne L, Darby M, Plant P, Milton R, Robson JM, Gill A, Malhotra P, Ashford-Turner V, Rodger K, Paramasivam E, Johnstone A, Bhartia B, Karthik S, Foster C, Lovatt V, Hewitt F, Cresswell L, Coupland VH, Lüchtenborg M, Jack RH, Moller H, Callister MEJ. Lung cancer stage-shift following a symptom awareness campaign. Thorax 2018; 73:1128-1136. [PMID: 29950525 DOI: 10.1136/thoraxjnl-2018-211842] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 05/29/2018] [Accepted: 06/04/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Lung cancer outcomes in the UK are worse than in many other developed nations. Symptom awareness campaigns aim to diagnose patients at an earlier stage to improve cancer outcomes. METHODS An early diagnosis campaign for lung cancer commenced in Leeds, UK in 2011 comprising public and primary-care facing components. Rates of community referral for chest X-ray and lung cancer stage (TNM seventh edition) at presentation were collected from 2008 to 2015. Linear trends were assessed by χ2 test for trend in proportions. Headline figures are presented for the 3 years pre-campaign (2008-2010) and the three most recent years for which data are available during the campaign (2013-2015). FINDINGS Community-ordered chest X-ray rates per year increased from 18 909 in 2008-2010 to 34 194 in 2013-2015 (80.8% increase). A significant stage shift towards earlier stage lung cancer was seen (χ2(1)=32.2, p<0.0001). There was an 8.8 percentage point increase in the proportion of patients diagnosed with stage I/II lung cancer (26.5% pre-campaign vs 35.3% during campaign) and a 9.3% reduction in the absolute number of patients diagnosed with stage III/IV disease (1254 pre-campaign vs 1137 during campaign). INTERPRETATION This is the largest described lung cancer stage-shift in association with a symptom awareness campaign. A causal link between the campaign and stage-shift cannot be proven but appears plausible. Limitations of the analysis include a lack of contemporary control population.
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Affiliation(s)
- Martyn P T Kennedy
- Department of Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Leanne Cheyne
- Department of Respiratory Medicine, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Michael Darby
- Department of Clinical Radiology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Paul Plant
- Department of Thoracic Medicine, Aintree University Hospital NHS Foundation Trust, Aintree University Hospital, Liverpool, UK
| | - Richard Milton
- Department of Thoracic Surgery, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Jonathan M Robson
- Department of Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Alison Gill
- Department of Respiratory Medicine, York Hospitals NHS Foundation Trust, York, UK
| | - Puneet Malhotra
- Department of Respiratory Medicine, St Helens and Knowsley Teaching Hospitals NHS Trust, Lancashire, UK
| | - Victoria Ashford-Turner
- Department of Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Kirsty Rodger
- Department of Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Elankumaran Paramasivam
- Department of Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Annette Johnstone
- Department of Clinical Radiology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Bobby Bhartia
- Department of Clinical Radiology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Shishir Karthik
- Department of Clinical Radiology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | | | - Veronica Lovatt
- St Gemma's Hospice, previously Leeds Primary Care Trust, Leeds, UK
| | - Francesca Hewitt
- Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Louise Cresswell
- Public Health, Leeds City Council previously Leeds Primary Care Trust, Leeds, UK
| | - Victoria H Coupland
- National Cancer Registration and Analysis Service, Public Health England, London, UK
| | - Margreet Lüchtenborg
- National Cancer Registration and Analysis Service, Public Health England, London, UK.,Cancer Epidemiology, Population and Global Health Programme, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Ruth H Jack
- National Cancer Registration and Analysis Service, Public Health England, London, UK
| | - Henrik Moller
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Matthew E J Callister
- Department of Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
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Koshiaris C, Oke J, Abel L, Nicholson BD, Ramasamy K, Van den Bruel A. Quantifying intervals to diagnosis in myeloma: a systematic review and meta-analysis. BMJ Open 2018; 8:e019758. [PMID: 29934381 PMCID: PMC6020959 DOI: 10.1136/bmjopen-2017-019758] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To quantify the duration of each step of the diagnostic pathway for patients with multiple myeloma from symptom onset to confirmation of diagnosis. DESIGN Systematic review and meta-analysis. DATA SOURCES AND SELECTION CRITERIA The MEDLINE and Embase databases were searched up until January 2018 to identify articles that reported time intervals from onset of symptoms to diagnosis. Articles focusing on children or adolescents and on the asymptomatic form of the disease (monoclonal gammopathies and smouldering myeloma) were excluded. DATA COLLECTION AND DATA ANALYSIS Data were extracted independently by two reviewers. Weighted estimates of the median and IQR were calculated. Risk of bias was assessed using the Aarhus checklist. MAIN RESULTS Nine studies were included. The patient interval (first symptom to first presentation) had a median of 26.3 days (IQR: 1-98, n=465, two studies). Subsequently, the primary care interval (first presentation to first referral) was 21.6 days (IQR: 4.6-55.8, n=326, two studies), the diagnostic interval (first presentation to diagnosis) was 108.6 days (IQR: 33.3-241.7, n=5395, seven studies) and the time to diagnosis (first symptom to diagnosis) interval was 163 days (IQR: 84-306, n=341, one study). No studies reported data for the referral to diagnosis interval. CONCLUSION The review demonstrates that there is scope for significant reductions in the time to myeloma diagnosis. At present, many patients experience a diagnostic interval longer than 3 months until diagnosis is confirmed. REVIEW REGISTRATION Not available. Protocol available in the appendix.
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Affiliation(s)
| | - Jason Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Lucy Abel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Karthik Ramasamy
- Department of Haematology, Oxford University Hospitals NHS Trust, Oxford, UK
- National Institute for Health Research (NIHR) Biomedical Research Center Blood Theme, Oxford, UK
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Maringe C, Pashayan N, Rubio FJ, Ploubidis G, Duffy SW, Rachet B, Raine R. Trends in lung cancer emergency presentation in England, 2006-2013: is there a pattern by general practice? BMC Cancer 2018; 18:615. [PMID: 29855264 PMCID: PMC5984417 DOI: 10.1186/s12885-018-4476-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/02/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Emergency presentations (EP) represent over a third of all lung cancer admissions in England. Such presentations usually reflect late stage disease and are associated with poor survival. General practitioners (GPs) act as gate-keepers to secondary care and so we sought to understand the association between GP practice characteristics and lung cancer EP. METHODS Data on general practice characteristics were extracted for all practices in England from the Quality Outcomes Framework, the Health and Social Care Information Centre, the GP Patient Survey, the Cancer Commissioning Toolkit and the area deprivation score for each practice. After linking these data to lung cancer patient registrations in 2006-2013, we explored trends in three types of EP, patient-led, GP-led and 'other', by general practice characteristics and by socio-demographic characteristics of patients. RESULTS Overall proportions of lung cancer EP decreased from 37.9% in 2006 to 34.3% in 2013. Proportions of GP-led EP nearly halved during this period, from 28.3 to 16.3%, whilst patient-led emergency presentations rose from 62.1 to 66.7%. When focusing on practice-specific levels of EP, 14% of general practices had higher than expected proportions of EP at least once in 2006-13, but there was no evidence of clustering of patients within practice, meaning that none of the practice characteristics examined explained differing proportions of EP by practice. CONCLUSION We found that the high proportion of lung cancer EP is not the result of a few practices with very abnormal patterns of EP, but of a large number of practices susceptible to reaching high proportions of EP. This suggests a system-wide issue, rather than problems with specific practices. High proportions of lung cancer EP are mainly the result of patient-initiated attendances in A&E. Our results demonstrate that interventions to encourage patients not to bypass primary care must be system wide rather than targeted at specific practices.
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Affiliation(s)
- Camille Maringe
- Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel street, London, WC1E 7HT UK
| | - Nora Pashayan
- University College London, Department of Applied Health Research, London, UK
| | - Francisco Javier Rubio
- Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel street, London, WC1E 7HT UK
| | - George Ploubidis
- Centre for Longitudinal Studies, Department of Social Science, UCL - Institute of Education, University College London, London, UK
| | - Stephen W. Duffy
- Queen Mary University of London, Wolfson Institute of Preventive Medicine, Centre for Cancer Prevention, London, UK
| | - Bernard Rachet
- Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel street, London, WC1E 7HT UK
| | - Rosalind Raine
- University College London, Department of Applied Health Research, London, UK
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245
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Walsh B, Laudicella M. Disparities In Cancer Care And Costs At The End Of Life: Evidence From England's National Health Service. Health Aff (Millwood) 2018; 36:1218-1226. [PMID: 28679808 DOI: 10.1377/hlthaff.2017.0167] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In universal health care systems such as the English National Health Service, equality of access is a core principle, and health care is free at the point of delivery. However, even within a universal system, disparities in care and costs exist along a socioeconomic gradient. Little is known about socioeconomic disparities at the end of life and how they affect health care costs. This study examines disparities in end-of-life treatment costs for cancer patients in England. Analyzing data on over 250,000 colorectal, breast, prostate, and lung cancer patients from multiple national databases, we found evidence illustrating that disparities are driven largely by the greater use of emergency inpatient care among patients of lower socioeconomic status. Even within a system with free health care, differences in the use of care create disparities in cancer costs. While further studies of these barriers is required, our research suggests that disparities may be reduced through better management of needs through the use of less expensive and more effective health care settings and treatments.
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Affiliation(s)
- Brendan Walsh
- Brendan Walsh is a research officer at the Economic and Social Research Institute in Dublin, Ireland, and a research affiliate in the School of Health Sciences, City University of London, in England
| | - Mauro Laudicella
- Mauro Laudicella is a senior lecturer at City University of London
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246
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Di Girolamo C, Walters S, Benitez Majano S, Rachet B, Coleman MP, Njagi EN, Morris M. Characteristics of patients with missing information on stage: a population-based study of patients diagnosed with colon, lung or breast cancer in England in 2013. BMC Cancer 2018; 18:492. [PMID: 29716543 PMCID: PMC5930770 DOI: 10.1186/s12885-018-4417-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 04/20/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Stage is a key predictor of cancer survival. Complete cancer staging is vital for understanding outcomes at population level and monitoring the efficacy of early diagnosis initiatives. Cancer registries usually collect details of the disease extent but staging information may be missing because a stage was never assigned to a patient or because it was not included in cancer registration records. Missing stage information introduce methodological difficulties for analysis and interpretation of results. We describe the associations between missing stage and socio-demographic and clinical characteristics of patients diagnosed with colon, lung or breast cancer in England in 2013. We assess how these associations change when completeness is high, and administrative issues are assumed to be minimal. We estimate the amount of avoidable missing stage data if high levels of completeness reached by some Clinical Commissioning Groups (CCGs), were achieved nationally. METHODS Individual cancer records were retrieved from the National Cancer Registration and linked to the Routes to Diagnosis and Hospital Episode Statistics datasets to obtain additional clinical information. We used multivariable beta binomial regression models to estimate the strength of the association between socio-demographic and clinical characteristics of patients and missing stage and to derive the amount of avoidable missing stage. RESULTS Multivariable modelling showed that old age was associated with missing stage irrespective of the cancer site and independent of comorbidity score, short-term mortality and patient characteristics. This remained true for patients in the CCGs with high completeness. Applying the results from these CCGs to the whole cohort showed that approximately 70% of missing stage information was potentially avoidable. CONCLUSIONS Missing stage was more frequent in older patients, including those residing in CCGs with high completeness. This disadvantage for older patients was not explained fully by the presence of comorbidity. A substantial gain in completeness could have been achieved if administrative practices were improved to the level of the highest performing areas. Reasons for missing stage information should be carefully assessed before any study, and potential distortions introduced by how missing stage is handled should be considered in order to draw the most correct inference from available statistics.
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Affiliation(s)
- Chiara Di Girolamo
- Cancer Survival Group, Faculty of Epidemiology and Population Health, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK
- Department of Medical and Surgical Sciences, Alma Mater Studiorum – University of Bologna, Via Zamboni, 33 40126 Bologna, Italy
| | - Sarah Walters
- Cancer Survival Group, Faculty of Epidemiology and Population Health, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK
| | - Sara Benitez Majano
- Cancer Survival Group, Faculty of Epidemiology and Population Health, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK
| | - Bernard Rachet
- Cancer Survival Group, Faculty of Epidemiology and Population Health, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK
| | - Michel P. Coleman
- Cancer Survival Group, Faculty of Epidemiology and Population Health, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK
| | - Edmund Njeru Njagi
- Cancer Survival Group, Faculty of Epidemiology and Population Health, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK
| | - Melanie Morris
- Cancer Survival Group, Faculty of Epidemiology and Population Health, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK
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247
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Rasmussen S, Haastrup PF, Balasubramaniam K, Christensen RD, Søndergaard J, Jarbøl DE. Predictive values of upper gastrointestinal cancer alarm symptoms in the general population: a nationwide cohort study. BMC Cancer 2018; 18:440. [PMID: 29669540 PMCID: PMC5907174 DOI: 10.1186/s12885-018-4376-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 04/16/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Survival rates for upper gastrointestinal (GI) cancer are poor since many are diagnosed at advanced stages. Fast track endoscopy has been introduced to prompt diagnosis for patients with alarm symptoms that could be indicative of upper GI cancer. However, these symptoms may represent benign conditions and little is known about the predictive values of alarm symptoms of upper GI cancer in the general population. METHODS The study is a nationwide cohort study of 60,562 individuals aged 45 years or above randomly selected from the Danish general population. Participants were invited to complete a survey comprising of questions on several symptom experiences, including alarm symptoms for upper GI cancer within the past four weeks. The participants were asked about specific symptoms (repeated vomiting, difficulty swallowing, signs of upper GI bleeding or persistent and recent-onset abdominal pain) and non-specific symptoms (nausea, weight loss, loss of appetite, feeling unwell and tiredness). We obtained information on upper GI cancer diagnosed in a 12-month period after completing the questionnaire from the Danish Cancer Registry. We calculated positive predictive values and positive likelihood ratios for the association between alarm symptom and subsequent upper GI cancer. RESULTS A total of 33,040 individuals above 45 years completed the questionnaire, yielding a response rate of 54.6%. Respondents were fairly respresentative of the study sample. During the follow-up period, 18 people were diagnosed with upper GI cancer. The number of incident cancers was similar among eligible non-respondents. Two thirds of the respondents with an upper GI malignancy had experienced one or more alarm symptoms. The positive predictive value for being diagnosed with upper GI cancer after reporting a least one alarm symptom was 0.1% (95% CI:0.0-0.1%). The positive likelihood ratio was 4.4 for specific alarm symptoms and 1.1 for non-specific alarm symptoms. CONCLUSIONS We found that positive predictive values of alarm symptoms of upper GI cancer experienced in the general population are low. It is important knowledge that despite denoted alarm symptoms even patients with specific alarm symptoms of upper GI cancer have a low risk of being diagnosed with upper GI cancer.
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Affiliation(s)
- Sanne Rasmussen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000, Odense C, Denmark
| | - Peter Fentz Haastrup
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000, Odense C, Denmark.
| | - Kirubakaran Balasubramaniam
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000, Odense C, Denmark
| | - René DePont Christensen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000, Odense C, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000, Odense C, Denmark
| | - Dorte Ejg Jarbøl
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000, Odense C, Denmark
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248
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Laudicella M, Walsh B, Burns E, Li Donni P, Smith PC. What is the impact of rerouting a cancer diagnosis from emergency presentation to GP referral on resource use and survival? Evidence from a population-based study. BMC Cancer 2018; 18:394. [PMID: 29625606 PMCID: PMC5889525 DOI: 10.1186/s12885-018-4274-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 03/21/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Studies on alternative routes to diagnosis stimulated successful policy interventions reducing the number of emergency diagnoses and associated mortality risk. A dearth of evidence on the costs of such interventions might prevent new policies from achieving more ambitious targets. METHODS We conducted a retrospective cohort study on the population of colorectal (88,051), breast (90,387), prostate (96,219), and lung (97,696) cancer patients diagnosed after a GP referral or an emergency presentation and reported in the Cancer Registry of England. Resource use and survival were compared 1 year before and 5 years after diagnosis (3 years for lung), including the costs of GP referrals not converted into a positive diagnosis. Risk-adjusted statistical models were used to calculate the effect of rerouting patient' diagnoses from emergency presentation to GP referral. RESULTS Rerouting a cancer diagnosis results in a relatively small additional costs to the National Health System against additional years of life saved to the patient. The cost per year of life saved is £6456 in colorectal, £1057 in breast, -£662 in prostate (savings), and £819 in lung cancer. Reducing the overall prevalence of emergency presentations to the level achieved by the 20% of Clinical Commissioning Groups with the lowest prevalence would result in £11,481,948 against 1863 years of life saved for Colorectal, £847,750 against 889 years for breast, -£943,434 (cost savings) against 1195 years for prostate, and £609,938 against 1011 years for lung cancer. CONCLUSION Redirecting diagnoses from emergency presentation to GP referral appears an achievable target that can produce large benefits to patients against modest additional costs to the National Health System.
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Affiliation(s)
- Mauro Laudicella
- School of Health Sciences, City, University of London, EC1V 0HB, London, UK.
| | - Brendan Walsh
- Social Research Division, Economic and Social Research Institute, Dublin, D02 K138, Ireland
| | - Elaine Burns
- Department of Surgery and Cancer, Imperial College London, St Mary's Campus, London, W2 1NY, UK
| | - Paolo Li Donni
- Economics Department, University of Palermo, Viale delle Scienze, 90128, Palermo, Italy
| | - Peter C Smith
- Business School, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
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249
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Howell DA, Hart RI, Smith AG, Macleod U, Patmore R, Cook G, Roman E. Myeloma: Patient accounts of their pathways to diagnosis. PLoS One 2018; 13:e0194788. [PMID: 29617390 PMCID: PMC5884527 DOI: 10.1371/journal.pone.0194788] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 03/10/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pathways to myeloma diagnosis can be prolonged, and are often preceded by multiple GP consultations and emergency presentation. This is the first qualitative study to examine events leading to diagnosis by asking patients about their experiences during this time. METHODS Set within a UK population-based cohort, semi-structured interviews were conducted with 20 myeloma patients with varying characteristics and pathways, 12 of whom invited their relatives to take part. Interviews were audio-recorded and qualitative analysis undertaken. RESULTS Pre-diagnostic awareness of myeloma was minimal. Disease onset was typically described as gradual, and health changes vague but progressive, with increasing loss of function. A wide range of symptoms was reported, with the similarity of these to self-limiting conditions failing to raise suspicion of myeloma among patients and GPs. Patients tended to normalise symptoms at first, although all eventually sought GP advice. GPs often initially suggested benign diagnoses, which were sometimes only revised after multiple consultations with persistent/worsening symptoms. Referrals were made to various hospital specialities, and haematology if associated with abnormal blood tests suggestive of myeloma. Once in secondary care, progress towards diagnosis was generally rapid. CONCLUSIONS Accounts confirmed that pathways to diagnosis could be difficult, largely due to the way myeloma presents, and how symptoms are interpreted and managed by patients and GPs. Recognition of 'normal' health and consultation patterns for the individual could promote appropriate help-seeking and timely referral when changes occur, and may be more effective than raising awareness about the myriad of potential symptoms associated with this disease.
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Affiliation(s)
- Debra A. Howell
- Epidemiology & Cancer Statistics Group, Department of Health Sciences, University of York, York, United Kingdom
| | - Ruth I. Hart
- Epidemiology & Cancer Statistics Group, Department of Health Sciences, University of York, York, United Kingdom
| | - Alexandra G. Smith
- Epidemiology & Cancer Statistics Group, Department of Health Sciences, University of York, York, United Kingdom
| | - Una Macleod
- The Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Russell Patmore
- Department of Haematology, Queen’s Centre for Oncology and Haematology, Castle Hill Hospital, Cottingham, Hull, United Kingdom
| | - Gordon Cook
- Department of Haematology, St. James’s Institute of Oncology, St James’s University Hospital, Leeds, United Kingdom
| | - Eve Roman
- Epidemiology & Cancer Statistics Group, Department of Health Sciences, University of York, York, United Kingdom
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250
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Palin RP, Devine AT, Hicks G, Burke D. Association of pretreatment neutrophil-lymphocyte ratio and outcome in emergency colorectal cancer care. Ann R Coll Surg Engl 2018; 100:308-315. [PMID: 29364006 PMCID: PMC5958849 DOI: 10.1308/rcsann.2017.0232] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2017] [Indexed: 12/20/2022] Open
Abstract
Introduction The association between the neutrophil-lymphocyte ratio (NLR) and outcome in elective colorectal cancer surgery is well established; the relationship between NLR and the emergency colorectal cancer patient is, as yet, unexplored. This paper evaluates the predictive quality of the NLR for outcome in the emergency colorectal cancer patient. Materials and Methods A total of 187 consecutive patients who underwent emergency surgery for colorectal cancer were included in the study. NLR was calculated from the haematological tests done on admission. Receiver operating characteristic analyses were used to determine the most suitable cut-off for NLR. Outcomes were assessed by mortality at 30 and 90 days using stepwise Cox proportional hazards regression. Results An NLR cut-off of 5 was found to have the highest sensitivity and specificity. At 30 days, age and time from admission to surgery were associated with increased mortality; a high NLR was associated with an increased risk of mortality in univariate but not multivariate analysis. At 90 days, age, NLR, time from admission to surgery and nodal status were all significantly associated with increased mortality on multivariate analysis. Conclusions Pre-operative NLR is a cheap, easily performed and useful clinical tool to aid prediction of outcome in the emergency colorectal cancer patient.
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Affiliation(s)
- RP Palin
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - AT Devine
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - G Hicks
- Department of Colorectal Surgery, St James’ University Hospital, Leeds, UK
| | - D Burke
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
- Department of Colorectal Surgery, St James’ University Hospital, Leeds, UK
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