351
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Comparing primary and secondary health-care use between diagnostic routes before a colorectal cancer diagnosis: cohort study using linked data. Br J Cancer 2014; 111:1490-9. [PMID: 25072256 PMCID: PMC4200083 DOI: 10.1038/bjc.2014.424] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 06/20/2014] [Accepted: 07/03/2014] [Indexed: 12/01/2022] Open
Abstract
Background: Survival in cancer patients diagnosed following emergency presentations is poorer than those diagnosed through other routes. To identify points for intervention to improve survival, a better understanding of patients' primary and secondary health-care use before diagnosis is needed. Our aim was to compare colorectal cancer patients' health-care use by diagnostic route. Methods: Cohort study of colorectal cancers using linked primary and secondary care and cancer registry data (2009–2011) from four London boroughs. The prevalence of all and relevant GP consultations and rates of primary and secondary care use up to 21 months before diagnosis were compared across diagnostic routes (emergency, GP-referred and consultant/other). Results: The data set comprised 943 colorectal cancers with 24% diagnosed through emergency routes. Most (84%) emergency patients saw their GP 6 months before diagnosis but their symptom profile was distinct; fewer had symptoms meeting urgent referral criteria than GP-referred patients. Compared with GP-referred, emergency patients used primary care less (IRR: 0.85 (95% CI 0.78–0.93)) and urgent care more frequently (IRR: 1.56 (95% CI 1.12; 2.17)). Conclusions: Distinct patterns of health-care use in patients diagnosed through emergency routes were identified in this cohort. Such analyses using linked data can inform strategies for improving early diagnosis of colorectal cancer.
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352
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Lyratzopoulos G, Saunders CL, Abel GA. Are emergency diagnoses of cancer avoidable? A proposed taxonomy to motivate study design and support service improvement. Future Oncol 2014; 10:1329-33. [PMID: 24983838 DOI: 10.2217/fon.14.80] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Georgios Lyratzopoulos
- Cambridge Centre for Health Services Research, Institute of Public Health, Department of Public Health & Primary Care, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK
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353
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Identifying patients at risk of emergency admission for colorectal cancer. Br J Cancer 2014; 111:577-80. [PMID: 24921910 PMCID: PMC4119975 DOI: 10.1038/bjc.2014.300] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 05/11/2014] [Accepted: 05/12/2014] [Indexed: 01/22/2023] Open
Abstract
Background: Patients whose colorectal cancer is treated after an emergency admission tend to have late-stage cancer and a poor prognosis. We identified risk factors for an emergency admission by linking data from the National Bowel Cancer Audit (NBCA) and the English Hospital Episode Statistics (HES), an administrative database of all admissions to English National Health Service hospitals, which includes data on mode of admission. Methods: We identified all adults included in the NBCA with a primary diagnosis of bowel cancer, excluding cancer of the appendix, between August 2007 and July 2011 whose record could be linked to HES. Multivariable logistic regression was used to estimate adjusted odds ratios (OR) for an emergency admission for colorectal cancer. All risk factors were adjusted for cancer site and calendar year. Results: 97 909 adults were identified with a primary diagnosis of bowel cancer and 82 777 patients could be linked to HES. Patients who were older, female, of a non-white ethnic background, and more socioeconomically deprived, and those with dementia or cardiac, neurologic and liver disease had an increased risk of presenting as an emergency admission. The strongest risk factors were age (90 compared with 70 years: OR 2.99, 95% CI 2.84 to 3.15), dementia (OR 2.46, 2.18 to 2.79), and liver disease (OR 1.87, 1.69 to 2.08). Conclusions: Our study identifies risk factors that may impair health-seeking behaviour and access to healthcare. An earlier recognition of symptoms in patients with these risk factors may contribute to better outcomes.
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354
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Cook N, Thomson G, Dey P. Managing risk in cancer presentation, detection and referral: a qualitative study of primary care staff views. BMJ Open 2014; 4:e004820. [PMID: 24928585 PMCID: PMC4067858 DOI: 10.1136/bmjopen-2014-004820] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES In the UK, there have been a number of national initiatives to promote earlier detection and prompt referral of patients presenting to primary care with signs and symptoms of cancer. The aim of the study was to explore the experiences of a range of primary care staff in promoting earlier presentation, detection and referral of patients with symptoms suggestive of cancer. SETTING Six primary care practices in northwest England. PARTICIPANTS 39 primary care staff from a variety of disciplines took part in five group and four individual interviews. RESULTS The global theme to emerge from the interviews was 'managing risk', which had three underpinning organising themes: 'complexity', relating to uncertainty of cancer diagnoses, service fragmentation and plethora of guidelines; 'continuity', relating to relationships between practice staff and their patients and between primary and secondary care; 'conflict' relating to policy drivers and staff role boundaries. A key concern of staff was that policymakers and those implementing cancer initiatives did not fully understand how risk was managed within primary care. CONCLUSIONS Primary care staff expressed a range of views and opinions on the benefits of cancer initiatives. National initiatives did not appear to wholly resolve issues in managing risk for all practitioners. Staff were concerned about the number of guidelines and priorities they were expected to implement. These issues need to be considered by policymakers when developing and implementing new initiatives.
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Affiliation(s)
- Neil Cook
- School of Medicine and Dentistry, University of Central Lancashire, Preston, UK
| | - Gillian Thomson
- School of Health, University of Central Lancashire, Preston, UK
| | - Paola Dey
- School of Medicine and Dentistry, University of Central Lancashire, Preston, UK
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355
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Lyratzopoulos G. Markers and measures of timeliness of cancer diagnosis after symptom onset: a conceptual framework and its implications. Cancer Epidemiol 2014; 38:211-3. [PMID: 24742794 DOI: 10.1016/j.canep.2014.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 03/13/2014] [Accepted: 03/17/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Georgios Lyratzopoulos
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
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356
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Cancer suspicion in general practice: the role of symptoms and patient characteristics, and their association with subsequent cancer. Br J Gen Pract 2014; 63:e627-35. [PMID: 23998843 DOI: 10.3399/bjgp13x671614] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Awareness of detail in ambiguous complaints may help GPs suspect cancer when a malignancy is present. AIM To study the contribution of symptoms and patient characteristics to GPs' suspicions of cancer being present, and to what degree these suspicions were confirmed. DESIGN AND SETTING Prospective cohort study of patients in 283 rural and urban general practices throughout Norway. METHOD During patient consultations (over a period of 10 days) GPs registered whether there was a suspicion of cancer when a patient presented with at least one of seven focal symptoms and three general symptoms commonly considered to be warning signs of cancer. Follow-up questionnaires were sent to GPs 6-7 months later, requesting information on any subsequent diagnosis of cancer in these patients. RESULTS Out of 51 073 patients, 6321 presented with warning signs of cancer; of these, 106 had a subsequent cancer diagnosis. Of the patients presenting with warning signs, 1515 (24%) patients were suspected of having cancer; this was correct for 3.8% of suspected cases. Of the 106 patients diagnosed with cancer who presented with warning signs, cancer was suspected in 58 (54.7%). GPs' correct cancer suspicions were six times more frequent than their erroneous lack of suspicion. Multiple symptoms, previous cancer, comorbidity, and multiple consultations increased the probability of cancer, but only multiple symptoms and previous cancer increased suspicion. Suspicion led to an increase in the number of diagnostic procedures undertaken. The proportion of cancer cases where GPs recorded a lack of suspicion was relatively small, but important. CONCLUSION Selected symptoms appropriately resulted in GPs suspecting cancer. Comorbidity and multiple consultations were underestimated by GPs as factors associated with cancer. Cancer suspicion should rely on symptoms in combination with other relevant information.
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357
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Amri R, Stronks K, Bordeianou LG, Sylla P, Berger DL. Gender and ethnic disparities in colon cancer presentation and outcomes in a US universal health care setting. J Surg Oncol 2014; 109:645-51. [PMID: 24474677 DOI: 10.1002/jso.23567] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 12/31/2013] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Access to care is a pillar of U.S. healthcare reform and could potentially challenge existing ethnic and gender disparities in care. We present a snapshot of these disparities in surgical colon cancer patients in the largest public hospital in Massachusetts, a state leading in providing universal healthcare, to indicate potential changes that might result from universal care access. METHODS All surgical colon cancer patients at Massachusetts General Hospital (2004-2011) were included. Baseline characteristics, perioperative, and long-term outcomes were compared. RESULTS Among 1,071 patients, the 110 (10.3%) minority patients presented with more comorbid (mean Charlson score 0.84 vs. 0.71; P = 0.039), metastatic (21.8% vs. 14%; P = 0.026), and node-positive disease (50% vs. 38.8%; P = 0.014). Women (n = 521; 48.6%) had less screening diagnoses (overall: 17.8% vs. 22.6%; P = 0.049, screening age: 26.4% vs. 32.7%; P = 0.036) with subsequently higher rates of metastatic disease on pathology (11.3% vs. 7.1%, P = 0.02). Multivariate adjustment for baseline staging makes outcome disparities no longer statistically significant. CONCLUSIONS Significant gender and ethnic disparities subsist at baseline despite long-standing low-threshold healthcare access, although seemingly mitigated by enrollment into high-level care, empowering equal chances for underprivileged groups. The outcomes are also a reminder that universal healthcare will not be a panacea for the deeply rooted and dynamic causes of presentation inequalities.
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Affiliation(s)
- Ramzi Amri
- Division of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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358
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Rogers S, Gildea C, Meechan D, Baker R. Access, continuity of care and consultation quality: which best predicts urgent cancer referrals from general practice? J Public Health (Oxf) 2014; 36:658-66. [PMID: 24457226 DOI: 10.1093/pubmed/fdt127] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND For some cancers, late presentation is associated with poor survival. In England, less than half of patients are diagnosed following a general practitioner-initiated urgent referral. We explore whether particular practice or practitioner characteristics are associated with use of the urgent referral system. METHODS The study sample was 603/614 practices in the East Midlands. Logistic regression models were fitted to investigate relationships between cancer detection rate, how easy it is to book appointments quickly, in advance or with a preferred doctor, and whether patients have confidence and trust in the doctor. RESULTS The percentage of patients who definitely have confidence and trust in the doctor was positively associated with the cancer detection rate [odds ratio = 1.08 (95% confidence interval (CI) 1.01, 1.15) per 10 percentage points]. When all four survey variables were modelled together, the percentage of patients who were able to see a preferred doctor was negatively associated with the cancer detection rate [odds ratio = 0.93 (95% CI 0.88, 0.98) per 10 percentage points]. CONCLUSIONS Our analyses suggest that in the UK National Health Service, confidence and trust in the doctor may be more important in cancer detection than the ease of access or whether there is choice of doctor.
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Affiliation(s)
- Stephen Rogers
- Public Health Department, Northamptonshire County Council, Guildhall Road, Northampton NN1 5DN, UK Department of Health Sciences, University of Leicester, 22-28 Princess Road West, Leicester LE1 6TP, UK
| | - Carolynn Gildea
- Knowledge and Intelligence Team (East Midlands), Public Health England, 5 Old Fulwood Road, Sheffield S10 3TG, UK
| | - David Meechan
- Knowledge and Intelligence Team (East Midlands), Public Health England, 5 Old Fulwood Road, Sheffield S10 3TG, UK
| | - Richard Baker
- Department of Health Sciences, University of Leicester, 22-28 Princess Road West, Leicester LE1 6TP, UK
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359
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Banks J, Hollinghurst S, Bigwood L, Peters TJ, Walter FM, Hamilton W. Preferences for cancer investigation: a vignette-based study of primary-care attendees. Lancet Oncol 2014; 15:232-40. [PMID: 24433682 DOI: 10.1016/s1470-2045(13)70588-6] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The UK lags behind many European countries in terms of cancer survival. Initiatives to address this disparity have focused on barriers to presentation, symptom recognition, and referral for specialist investigation. Selection of patients for further investigation has come under particular scrutiny, although preferences for referral thresholds in the UK population have not been studied. We investigated preferences for diagnostic testing for colorectal, lung, and pancreatic cancers in primary-care attendees. METHODS In a vignette-based study, researchers recruited individuals aged at least 40 years attending 26 general practices in three areas of England between Dec 6, 2011, and Aug 1, 2012. Participants completed up to three of 12 vignettes (four for each of lung, pancreatic, and colorectal cancers), which were randomly assigned. The vignettes outlined a set of symptoms, the risk that these symptoms might indicate cancer (1%, 2%, 5%, or 10%), the relevant testing process, probable treatment, possible alternative diagnoses, and prognosis if cancer were identified. Participants were asked whether they would opt for diagnostic testing on the basis of the information in the vignette. FINDINGS 3469 participants completed 6930 vignettes. 3052 individuals (88%) opted for investigation in their first vignette. We recorded no strong evidence that participants were more likely to opt for investigation with a 1% increase in risk of cancer (odds ratio [OR] 1·02, 95% CI 0·99-1·06; p=0·189), although the association between risk and opting for investigation was strong when colorectal cancer was analysed alone (1·08, 1·03-1·13; p=0·0001). In multivariable analysis, age had an effect in all three cancer models: participants aged 60-69 years were significantly more likely to opt for investigation than were those aged 40-59 years, and those aged 70 years or older were less likely. Other variables associated with increased likelihood of opting for investigation were shorter travel times to testing centre (colorectal and lung cancers), a family history of cancer (colorectal and lung cancers), and higher household income (colorectal and pancreatic cancers). INTERPRETATION Participants in our sample expressed a clear preference for diagnostic testing at all risk levels, and individuals want to be tested at risk levels well below those stipulated by UK guidelines. This willingness should be considered during design of cancer pathways, particularly in primary care. The public engagement with our study should encourage general practitioners to involve patients in referral decision making. FUNDING The National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Jonathan Banks
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | | | - Lin Bigwood
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Tim J Peters
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Fiona M Walter
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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360
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Treatment decisions and survival for people with small-cell lung cancer. Br J Cancer 2014; 110:908-15. [PMID: 24398511 PMCID: PMC3929890 DOI: 10.1038/bjc.2013.812] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 12/05/2013] [Accepted: 12/06/2013] [Indexed: 11/09/2022] Open
Abstract
Background: Chemotherapy improves survival for many patients with SCLC, and hence it is important to understand variations in practice and outcomes for this treatment strategy. Methods: We used the National Lung Cancer Audit and Hospital Episodes Statistics to determine the proportion of patients who received chemotherapy for SCLC, and assess the effects of patient and organisational factors on the odds of receiving chemotherapy and of completing four cycles. We calculated median survival and used Cox regression to determine factors that predicted survival. Results: Of 15 091 cases of SCLC, 70% received at least one cycle of chemotherapy. More deprived people were less likely to receive chemotherapy, but patients were more likely to receive chemotherapy, and to complete ⩾four cycles, if they were referred to the lung cancer team by their GP. Median survival for those treated with chemotherapy was 12.9 months for limited and 7.3 months for extensive stage disease. Conclusions: The Linked NLCA and HES data provide real-life measures of survival in people treated with chemotherapy and show how this is influenced by patient and tumour characteristics. These data show the characteristics of patients who are less likely to complete a full course of treatment, an adverse predictor of survival.
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361
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Neal RD, Nafees S, Pasterfield D, Hood K, Hendry M, Gollins S, Makin M, Stuart N, Turner J, Carter B, Wilkinson C, Williams N, Robling M. Patient-reported measurement of time to diagnosis in cancer: development of the Cancer Symptom Interval Measure (C-SIM) and randomised controlled trial of method of delivery. BMC Health Serv Res 2014; 14:3. [PMID: 24387663 PMCID: PMC3922822 DOI: 10.1186/1472-6963-14-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 12/20/2013] [Indexed: 01/12/2023] Open
Abstract
Background The duration between first symptom and a cancer diagnosis is important because, if shortened, may lead to earlier stage diagnosis and improved cancer outcomes. We have previously developed a tool to measure this duration in newly-diagnosed patients. In this two-phase study, we aimed further improve our tool and to conduct a trial comparing levels of anxiety between two modes of delivery: self-completed versus researcher-administered. Methods In phase 1, ten patients completed the modified tool and participated in cognitive debrief interviews. In phase 2, we undertook a Randomised Controlled Trial (RCT) of the revised tool (Cancer Symptom Interval Measure (C-SIM)) in three hospitals for 11 different cancers. Respondents were invited to provide either exact or estimated dates of first noticing symptoms and presenting them to primary care. The primary outcome was anxiety related to delivery mode, with completeness of recording as a secondary outcome. Dates from a subset of patients were compared with GP records. Results After analysis of phase 1 interviews, the wording and format were improved. In phase 2, 201 patients were randomised (93 self-complete and 108 researcher-complete). Anxiety scores were significantly lower in the researcher-completed group, with a mean rank of 83.5; compared with the self-completed group, with a mean rank of 104.0 (Mann-Whitney U = 3152, p = 0.007). Completeness of data was significantly better in the researcher-completed group, with no statistically significant difference in time taken to complete the tool between the two groups. When comparing the dates in the patient questionnaires with those in the GP records, there was evidence in the records of a consultation on the same date or within a proscribed time window for 32/37 (86%) consultations; for estimated dates there was evidence for 23/37 consultations (62%). Conclusions We have developed and tested a tool for collecting patient-reported data relating to appraisal intervals, help-seeking intervals, and diagnostic intervals in the cancer diagnostic pathway for 11 separate cancers, and provided evidence of its acceptability, feasibility and validity. This is a useful tool to use in descriptive and epidemiological studies of cancer diagnostic journeys, and causes less anxiety if administered by a researcher. Trial registration ISRCTN04475865
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Affiliation(s)
- Richard D Neal
- North Wales Centre for Primary Care Research, Bangor University, Gwenfro Unit 5, Wrexham Technology Park, Wrexham LL13 7YP, UK.
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362
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Comparison of cancer diagnostic intervals before and after implementation of NICE guidelines: analysis of data from the UK General Practice Research Database. Br J Cancer 2013; 110:584-92. [PMID: 24366304 PMCID: PMC3915139 DOI: 10.1038/bjc.2013.791] [Citation(s) in RCA: 154] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 11/04/2013] [Accepted: 11/19/2013] [Indexed: 12/18/2022] Open
Abstract
Background: The primary aim was to use routine data to compare cancer diagnostic intervals before and after implementation of the 2005 NICE Referral Guidelines for Suspected Cancer. The secondary aim was to compare change in diagnostic intervals across different categories of presenting symptoms. Methods: Using data from the General Practice Research Database, we analysed patients with one of 15 cancers diagnosed in either 2001–2002 or 2007–2008. Putative symptom lists for each cancer were classified into whether or not they qualified for urgent referral under NICE guidelines. Diagnostic interval (duration from first presented symptom to date of diagnosis in primary care records) was compared between the two cohorts. Results: In total, 37 588 patients had a new diagnosis of cancer and of these 20 535 (54.6%) had a recorded symptom in the year prior to diagnosis and were included in the analysis. The overall mean diagnostic interval fell by 5.4 days (95% CI: 2.4–8.5; P<0.001) between 2001–2002 and 2007–2008. There was evidence of significant reductions for the following cancers: (mean, 95% confidence interval) kidney (20.4 days, −0.5 to 41.5; P=0.05), head and neck (21.2 days, 0.2–41.6; P=0.04), bladder (16.4 days, 6.6–26.5; P⩽0.001), colorectal (9.0 days, 3.2–14.8; P=0.002), oesophageal (13.1 days, 3.0–24.1; P=0.006) and pancreatic (12.6 days, 0.2–24.6; P=0.04). Patients who presented with NICE-qualifying symptoms had shorter diagnostic intervals than those who did not (all cancers in both cohorts). For the 2007–2008 cohort, the cancers with the shortest median diagnostic intervals were breast (26 days) and testicular (44 days); the highest were myeloma (156 days) and lung (112 days). The values for the 90th centiles of the distributions remain very high for some cancers. Tests of interaction provided little evidence of differences in change in mean diagnostic intervals between those who did and did not present with symptoms specifically cited in the NICE Guideline as requiring urgent referral. Conclusion: We suggest that the implementation of the 2005 NICE Guidelines may have contributed to this reduction in diagnostic intervals between 2001–2002 and 2007–2008. There remains considerable scope to achieve more timely cancer diagnosis, with the ultimate aim of improving cancer outcomes.
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363
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Martins T, Hamilton W, Ukoumunne OC. Ethnic inequalities in time to diagnosis of cancer: a systematic review. BMC FAMILY PRACTICE 2013; 14:197. [PMID: 24359157 PMCID: PMC3878039 DOI: 10.1186/1471-2296-14-197] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 12/18/2013] [Indexed: 11/23/2022]
Abstract
Background Minimising diagnostic delays in cancer may help improve survival. Ethnic minorities have worse outcomes in some cancer types when compared to the majority; this may relate in part to differences during the diagnostic phase. Only a few British studies have specifically explored this relationship, and no synthesis of these exists. The present study aimed to systematically review evidence on ethnic inequalities in cancer diagnosis, focussing on patient and primary care intervals of diagnosis. Methods Six electronic databases were searched. Included studies were those conducted in the UK or elsewhere (where access to healthcare is comparable to the NHS) and those that described a time element during diagnosis. Study quality was evaluated using the Critical Appraisal Skills Programme (CASP) checklist for cohort studies and synthesis method was narrative. Results Seven of 8,520 studies retrieved by our search met the review criteria; six conducted in the UK, and one in New Zealand. Five (including one covering several sites) focused on breast cancer, one on prostate, and one on oesophagogastric cancer. The studies employed different methods of ascertainment and definition of ethnic groups and defined diagnostic delay in a non-standardised way; therefore, narrative synthesis was performed. In breast cancer, three studies reported longer diagnostic intervals among ethnic minorities and two found no evidence of differences by ethnicity. There was some evidence of longer diagnostic and referral intervals among ethnic minorities in oesophagogastric and colorectal cancers, but no evidence of this in prostate, non-Hodgkin’s lymphoma, lung, and ovarian cancers. None of the studies identified shorter patient or primary care intervals in ethnic minorities. Conclusions Existing studies provide insufficient evidence to confirm or refute ethnic inequalities in diagnostic intervals of cancer. Further studies are necessary to examine common cancer types including those frequently found in ethnic minorities (in addition to those covered here) and using current definitions of intervals in cancer diagnosis.
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Affiliation(s)
- Tanimola Martins
- University of Exeter Medical School, Veysey Building, Salmon Pool Lane, Exeter, UK.
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364
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Duffy S, Richards M, Selby P, Lawler M. Addressing cancer disparities in Europe: a multifaceted problem that requires interdisciplinary solutions. Oncologist 2013; 18:e29-30. [PMID: 24336123 DOI: 10.1634/theoncologist.2013-0438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Sean Duffy
- Medical Directorate National Health Service England, Leeds, United Kingdom
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365
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Howell DA, Wang HI, Smith AG, Howard MR, Patmore RD, Roman E. Place of death in haematological malignancy: variations by disease sub-type and time from diagnosis to death. BMC Palliat Care 2013; 12:42. [PMID: 24245578 PMCID: PMC4175093 DOI: 10.1186/1472-684x-12-42] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 11/12/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The reasons patients with haematological malignancies die in hospital more often than those with other cancers is the subject of much speculation. We examined variations in place of death by disease sub-type and time from diagnosis to death, to identify groups of 'at-risk' patients. METHODS The study is based in the United Kingdom within the infrastructure of the Haematological Malignancy Research Network (HMRN), a large on-going population-based cohort including all patients newly diagnosed with haematological malignancies in the north of England. Diagnostic, demographic, prognostic, treatment and outcome data are collected for each patient and individuals are 'flagged' for death. This study includes all adults (≥18 years) diagnosed 1st September 2004 to 31st August 2010 (n = 10,325), focussing on those who died on/before 31st August 2012 (n = 4829). RESULTS Most deaths occurred in hospital (65.9%), followed by home (15.6%), nursing home (11%) and hospice (7.5%) and there was little variation by diagnostic sub-type overall. Differences in place of death were, however, observed by time from diagnosis to death, and this was closely related to sub-type; 87.7% of deaths within a month of diagnosis happened in hospital and these largely occurred in patients with acute myeloid leukaemia, diffuse large B-cell lymphoma and myeloma. Patients surviving longer, and particularly beyond 1 year, were less likely to die in hospital and this corresponded with an increase in the proportion of home deaths. CONCLUSIONS Time from diagnosis to death was clearly a major determinant of place of death and many patients that died within three months of diagnosis did so in hospital. This was closely related to disease sub-type, with early deaths occurring most notable in the more aggressive diseases. This is likely to be due to a combination of factors including acute presentation, rapid disease progression without transition to a palliative approach to care and complications of treatment. Nonetheless, hospital deaths also occurred frequently in indolent diseases, suggesting that other factors were likely to contribute to the large proportion of hospital deaths overall. More evidence is needed to fully understand these complex cancers.
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Affiliation(s)
- Debra A Howell
- Department of Health Sciences, University of York, York YO10 5DD, UK
| | - Han-I Wang
- Department of Health Sciences, University of York, York YO10 5DD, UK
| | - Alexandra G Smith
- Department of Health Sciences, University of York, York YO10 5DD, UK
| | - Martin R Howard
- York Teaching Hospital NHS Foundation Trust, Wigginton Road, York YO31 8HE, UK
| | - Russell D Patmore
- Queens Centre for Oncology, Castle Hill Hospital, Cottingham, Hull HU16 5JQ, UK
| | - Eve Roman
- Department of Health Sciences, University of York, York YO10 5DD, UK
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366
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Beckett P, Tata LJ, Hubbard RB. Risk factors and survival outcome for non-elective referral in non-small cell lung cancer patients--analysis based on the National Lung Cancer Audit. Lung Cancer 2013; 83:396-400. [PMID: 24457105 DOI: 10.1016/j.lungcan.2013.10.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 09/27/2013] [Accepted: 10/16/2013] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Survival after diagnosis of lung cancer is poor and seemingly lower in the UK than other Western countries, due in large part to late presentation with advanced disease precluding curative treatment. Recent research suggests that around one-third of lung cancer patients reach specialist care after emergency presentation and have a worse survival outcome. Confirmation of these data and understanding which patients are affected may allow a targeted approach to improving outcomes. METHODS We used data from the UK National Lung Cancer Audit in a multivariate logistic regression model to quantify the association of non-elective referral in non-small cell lung cancer patients with covariates including age, sex, stage, performance status, co-morbidity and socioeconomic status and used the Kaplan-Meier method and Cox proportional hazards model to quantify survival by source of referral. RESULTS In an analysis of 133,530 cases of NSCLC who presented 2006-2011, 19% of patients were referred non-electively (following an emergency admission to hospital or following an emergency presentation to A&E). This route of referral was strongly associated with more advanced disease stage (e.g. in Stage IV - OR: 2.34, 95% CI: 2.14-2.57, p<0.001) and worse performance status (e.g. in PS 4 - OR: 7.28, 95% CI: 6.75-7.86, p<0.001), but was also independently associated with worse socioeconomic status, and extremes of age. These patients were more likely to have died within 1 year of diagnosis (hazard ratio of 1.51 (95% CI: 1.49-1.54) after adjustment for key clinical variables. CONCLUSION Our data confirm and quantify poorer survival in lung cancer patients who are referred non-electively to specialist care, which is more common in patients with poorer performance status, higher disease stage and less advantaged socioeconomic status. Work to tackle this late presentation should be urgently accelerated, since its realisation holds the promise of improved outcomes and better healthcare resource utilisation.
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Affiliation(s)
- P Beckett
- Burton Hospitals NHS Foundation Trust, UK.
| | - L J Tata
- Nottingham Respiratory Research Unit, University of Nottingham, City Hospital, Nottingham, UK
| | - R B Hubbard
- Nottingham Respiratory Research Unit, University of Nottingham, City Hospital, Nottingham, UK
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367
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Howell DA, Smith AG, Jack A, Patmore R, Macleod U, Mironska E, Roman E. Time-to-diagnosis and symptoms of myeloma, lymphomas and leukaemias: a report from the Haematological Malignancy Research Network. BMC BLOOD DISORDERS 2013; 13:9. [PMID: 24238148 PMCID: PMC4176985 DOI: 10.1186/2052-1839-13-9] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 10/22/2013] [Indexed: 11/23/2022]
Abstract
Background Prior to diagnosis, patients with haematological cancers often have multiple primary care consultations, resulting in diagnostic delay. They are less likely to be referred urgently to hospital and often present as emergencies. We examined patient perspectives of time to help-seeking and diagnosis, as well as associated symptoms and experiences. Methods The UK’s Haematological Malignancy Research Network (http://www.hmrn.org) routinely collects data on all patients newly diagnosed with myeloma, lymphoma and leukaemia (>2000 annually; population 3.6 million). With clinical agreement, patients are also invited to participate in an on-going survey about the circumstances leading to their diagnosis (presence/absence of symptoms; type of symptom(s) and date(s) of onset; date medical advice first sought (help-seeking); summary of important experiences in the time before diagnosis). From 2004–2011, 8858 patients were approached and 5038 agreed they could be contacted for research purposes; 3329 requested and returned a completed questionnaire. The duration of the total interval (symptom onset to diagnosis), patient interval (symptom onset to help-seeking) and diagnostic interval (help-seeking to diagnosis) was examined by patient characteristics and diagnosis. Type and frequency of symptoms were examined collectively, by diagnosis and compared to UK Referral Guidelines. Results Around one-third of patients were asymptomatic at diagnosis. In those with symptoms, the median patient interval tended to be shorter than the diagnostic interval across most diseases. Intervals varied markedly by diagnosis: acute myeloid leukaemia being 41 days (Interquartile range (IQR) 17–85), diffuse large B-cell lymphoma 98 days (IQR 53–192) and myeloma 163 days (IQR 84–306). Many symptoms corresponded to those cited in UK Referral Guidelines, but some were rarely reported (e.g. pain on drinking alcohol). By contrast others, absent from the guidance, were more frequent (e.g. stomach and bowel problems). Symptoms such as tiredness and pain were common across all diseases, although some specificity was evident by sub-type, such as lymphadenopathy in lymphoma and bleeding and bruising in acute leukaemia. Conclusions Pathways to diagnosis are varied and can be unacceptably prolonged, particularly for myeloma and some lymphomas. More evidence is needed, along with interventions to reduce time-to-diagnosis, such as public education campaigns and GP decision-making aids, as well as refinement of existing Referral Guidelines.
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Affiliation(s)
- Debra A Howell
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York YO10 5DD, UK.
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368
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Ashley L, Jones H, Thomas J, Newsham A, Downing A, Morris E, Brown J, Velikova G, Forman D, Wright P. Integrating patient reported outcomes with clinical cancer registry data: a feasibility study of the electronic Patient-Reported Outcomes From Cancer Survivors (ePOCS) system. J Med Internet Res 2013; 15:e230. [PMID: 24161667 PMCID: PMC3841364 DOI: 10.2196/jmir.2764] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 08/13/2013] [Accepted: 09/07/2013] [Indexed: 01/08/2023] Open
Abstract
Background Routine measurement of Patient Reported Outcomes (PROs) linked with clinical data across the patient pathway is increasingly important for informing future care planning. The innovative electronic Patient-reported Outcomes from Cancer Survivors (ePOCS) system was developed to integrate PROs, collected online at specified post-diagnostic time-points, with clinical and treatment data in cancer registries. Objective This study tested the technical and clinical feasibility of ePOCS by running the system with a sample of potentially curable breast, colorectal, and prostate cancer patients in their first 15 months post diagnosis. Methods Patients completed questionnaires comprising multiple Patient Reported Outcome Measures (PROMs) via ePOCS within 6 months (T1), and at 9 (T2) and 15 (T3) months, post diagnosis. Feasibility outcomes included system informatics performance, patient recruitment, retention, representativeness and questionnaire completion (response rate), patient feedback, and administration burden involved in running the system. Results ePOCS ran efficiently with few technical problems. Patient participation was 55.21% (636/1152) overall, although varied by approach mode, and was considerably higher among patients approached face-to-face (61.4%, 490/798) than by telephone (48.8%, 21/43) or letter (41.0%, 125/305). Older and less affluent patients were less likely to join (both P<.001). Most non-consenters (71.1%, 234/329) cited information technology reasons (ie, difficulty using a computer). Questionnaires were fully or partially completed by 85.1% (541/636) of invited participants at T1 (80 questions total), 70.0% (442/631) at T2 (102-108 questions), and 66.3% (414/624) at T3 (148-154 questions), and fully completed at all three time-points by 57.6% (344/597) of participants. Reminders (mainly via email) effectively prompted responses. The PROs were successfully linked with cancer registry data for 100% of patients (N=636). Participant feedback was encouraging and positive, with most patients reporting that they found ePOCS easy to use and that, if asked, they would continue using the system long-term (86.2%, 361/419). ePOCS was not administratively burdensome to run day-to-day, and patient-initiated inquiries averaged just 11 inquiries per month. Conclusions The informatics underlying the ePOCS system demonstrated successful proof-of-concept – the system successfully linked PROs with registry data for 100% of the patients. The majority of patients were keen to engage. Participation rates are likely to improve as the Internet becomes more universally adopted. ePOCS can help overcome the challenges of routinely collecting PROs and linking with clinical data, which is integral for treatment and supportive care planning and for targeting service provision.
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Affiliation(s)
- Laura Ashley
- School of Social, Psychological and Communication Sciences, Faculty of Health and Social Sciences, Leeds Metropolitan University, Leeds, United Kingdom.
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369
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Round T, Steed L, Shankleman J, Bourke L, Risi L. Primary care delays in diagnosing cancer: what is causing them and what can we do about them? J R Soc Med 2013; 106:437-40. [PMID: 24108536 DOI: 10.1177/0141076813504744] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Thomas Round
- Primary Care and Public Health Sciences, King's College London, Capital House, London SE1 3QD, UK
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370
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Emergency presentation of cancer and short-term mortality. Br J Cancer 2013; 109:2027-34. [PMID: 24045658 PMCID: PMC3798965 DOI: 10.1038/bjc.2013.569] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 08/09/2013] [Accepted: 08/26/2013] [Indexed: 01/08/2023] Open
Abstract
Background: The short-term survival following a cancer diagnosis in England is lower than that in comparable countries, with the difference in excess mortality primarily occurring in the months immediately after diagnosis. We assess the impact of emergency presentation (EP) on the excess mortality in England over the course of the year following diagnosis. Methods: All colorectal and cervical cancers presenting in England and all breast, lung, and prostate cancers in the East of England in 2006–2008 are included. The variation in the likelihood of EP with age, stage, sex, co-morbidity, and income deprivation is modelled. The excess mortality over 0–1, 1–3, 3–6, and 6–12 months after diagnosis and its dependence on these case-mix factors and presentation route is then examined. Results: More advanced stage and older age are predictive of EP, as to a lesser extent are co-morbidity, higher income deprivation, and female sex. In the first month after diagnosis, we observe case-mix-adjusted excess mortality rate ratios of 7.5 (cervical), 5.9 (colorectal), 11.7 (breast ), 4.0 (lung), and 20.8 (prostate) for EP compared with non-EP. Conclusion: Individuals who present as an emergency experience high short-term mortality in all cancer types examined compared with non-EPs. This is partly a case-mix effect but EP remains predictive of short-term mortality even when age, stage, and co-morbidity are accounted for.
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371
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von Stempel C, Perks C, Corcoran J, Grayez J. Cardio-respiratory failure secondary to ectopic Cushing's syndrome as the index presentation of small-cell lung cancer. BMJ Case Rep 2013; 2013:bcr-2013-009974. [PMID: 23946525 DOI: 10.1136/bcr-2013-009974] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 79-year-old woman, a smoker, presented to the emergency department with a 2-week history of progressive dyspnoea and peripheral oedema, preceded by flu-like symptoms that had failed to improve despite antibiotics. Examination identified severe hypertension and signs consistent with severe fluid overload. Baseline chest X ray showed a right-sided abnormality. In the context of an extensive smoking history CT thorax was indicated which demonstrated a right-sided hilar mass and lymphadenopathy. Blood tests showed an unexplained metabolic alkalosis with partial respiratory compensation and hypokalaemia prompting endocrinological tests investigating Cushing's syndrome. Urinary cortisol was measured at 3174 nmol/L/24 h (normal<560), serum adrenocorticotropic hormone (ACTH) of 215 ng/L (normal<46). Pleural fluid cytology confirmed a diagnosis of small-cell lung cancer (SCLC). The patient's condition deteriorated despite intravenous diuretics and nitrates, metyrapone and non-invasive ventilation. Treatment was withdrawn 1 week after admission. The clinical course in the presence of biochemical derangement and SCLC is highly suggestive of paraneoplastic ectopic ACTH secretion.
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Affiliation(s)
- Conrad von Stempel
- Department of General Medicine, Oxford University Hospitals, Banbury, UK.
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372
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Tsang C, Bottle A, Majeed A, Aylin P. Cancer diagnosed by emergency admission in England: an observational study using the general practice research database. BMC Health Serv Res 2013; 13:308. [PMID: 23941140 PMCID: PMC3751722 DOI: 10.1186/1472-6963-13-308] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 08/09/2013] [Indexed: 11/18/2022] Open
Abstract
Background Patients diagnosed with cancer by the emergency route often have more advanced diseases and poorer outcomes. Rates of cancer diagnosed through unplanned admissions vary within and between countries, suggesting potential inconsistencies in the quality of care. To reduce diagnoses by this route and improve patient outcomes, high risk patient groups must be identified. This cross-sectional observational study determined the incidence of first-ever diagnoses of cancer by emergency (unplanned) admission and identified patient-level risk factors for these diagnoses in England. Methods Data for 74,763 randomly selected patients at 457 general practices between 1999 and 2008 were obtained from the General Practice Research Database (GPRD), including integrated Hospital Episode Statistics (HES) data and Office for National Statistics (ONS) mortality data. The proportion of first-ever diagnoses by emergency admission out of all recorded first cancer diagnoses by any route was analysed by patient characteristics. Results Diagnosis by emergency admission was recorded in 13.9% of patients diagnosed with cancer for the first time (n = 817/5870). The incidence of first cases by the emergency route was 2.51 patients per 10,000 person years. In adjusted regression analyses, patients of older age (p < 0.0001), living in the most deprived areas (RR 1.93, 95% CI 1.51 to 2.47; p < 0.0001) or who had a total Charlson score of 1 compared to 0 (RR 1.34, 95% CI 1.06 to 1.69; p = 0.014) were most at risk of diagnosis by emergency admission. Patients with more prior (all-cause) emergency admissions were less at risk of subsequent diagnosis by the emergency route (RR 0.31 per prior emergency admission, 95% CI 0.20 to 0.46; p < 0.0001). Conclusions A much lower incidence of first-ever cancer diagnoses by emergency admission was found compared with previous studies. Identified high risk groups may benefit from interventions to reduce delayed diagnosis. Further studies should include screening and cancer staging data to improve understanding of delayed or untimely diagnosis and patient care pathways.
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Affiliation(s)
- Carmen Tsang
- Dr Foster Unit at Imperial, Ground Floor 3 Dorset Rise, EC4Y 8EN, London, England.
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373
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Rutherford MJ, Hinchliffe SR, Abel GA, Lyratzopoulos G, Lambert PC, Greenberg DC. How much of the deprivation gap in cancer survival can be explained by variation in stage at diagnosis: an example from breast cancer in the East of England. Int J Cancer 2013; 133:2192-200. [PMID: 23595777 DOI: 10.1002/ijc.28221] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 04/11/2013] [Indexed: 12/12/2022]
Abstract
Socioeconomic differences in cancer patient survival exist in many countries and across cancer sites. In our article, we estimated the number of deaths in women with breast cancer that could be avoided within 5 years from diagnosis if it were possible to eliminate socioeconomic differences in stage at diagnosis. We analysed data on East of England women with breast cancer (2006-2010). We estimated survival for different stage-age-deprivation strata using both the observed and a hypothetical stage distribution (assuming all women acquired the stage distribution of the most affluent women). Data were analysed on 20,738 women with complete stage information (92%). Affluent women were less likely to be diagnosed in advanced stage. Relative survival decreased with increasing level of deprivation. Eliminating differences in stage at diagnosis could be expected to nearly eliminate differences in relative survival for women in deprivation groups 3 and 4, but would only approximately halve the difference in relative survival for women in the most deprived group (5). This means, for a typical cohort of women diagnosed in a calendar year with breast cancer, eliminating deprivation differences in stage at diagnosis would prevent ∼40 deaths in the East of England from occurring within 5 years from diagnosis. Using appropriate weighting we estimated the respective number of avoidable deaths for the whole of England to be ∼450. The findings suggest that policies aimed at reducing inequalities in stage at diagnosis between women with breast cancer are important to reduce inequalities in breast cancer survival.
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Affiliation(s)
- M J Rutherford
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom.
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374
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Improving survival in colorectal cancer: what role for general practice? Br J Gen Pract 2013; 63:179-80. [PMID: 23540454 DOI: 10.3399/bjgp13x665116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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375
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Integrated research efforts are needed to better understand how to reduce the proportion of patients with cancer who are diagnosed as emergencies. Br J Cancer 2013; 108:1550-1. [PMID: 23481181 PMCID: PMC3629419 DOI: 10.1038/bjc.2013.105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
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376
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Colorectal Cancer in the Elderly: How Do We Tailor Treatment with Chemotherapy and Radiotherapy Most Appropriately? CURRENT COLORECTAL CANCER REPORTS 2013. [DOI: 10.1007/s11888-013-0163-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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377
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Bellamy D, Peake M, Williams A. The role of primary care as part of the multidisciplinary team (MDT) in the management of lung cancer: the "Dream MDT" report - new guidance from the UK Lung Cancer Coalition. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2013; 22:3-4. [PMID: 23358648 PMCID: PMC6442775 DOI: 10.4104/pcrj.2013.00007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- David Bellamy
- Retired general practitioner; member of the UK Lung Cancer Coalition
- 8 Littledown Drive, Bournemouth, BH7 7AQ Tel: +44 (0)1202 394443 E-mail:
| | - Mick Peake
- Consultant and Senior Lecturer in Respiratory Medicine, University Hospitals of Leicester, Leicester, UK; Clinical Lead for the UK National Cancer Intelligence Network (NCIN) and the UK National Lung Cancer Audit Programme (NLCA); Chairman, clinical section of the UK Lung Cancer Coalition
| | - Andrea Williams
- General practitioner, King Street Surgery, Hereford, UK; GP adviser for Herefordshire Clinical Commissioning Group; GP spokesperson for the UK Lung Cancer Coalition
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378
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Early mortality from colorectal cancer in England: a retrospective observational study of the factors associated with death in the first year after diagnosis. Br J Cancer 2013; 108:681-5. [PMID: 23287990 PMCID: PMC3593544 DOI: 10.1038/bjc.2012.585] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The United Kingdom performs poorly in international comparisons of colorectal cancer survival with much of the deficit owing to high numbers of deaths close to the time of diagnosis. This retrospective cohort study investigates the patient, tumour and treatment characteristics of those who die in the first year after diagnosis of their disease. Methods: Patients diagnosed with colon (n=65 733) or rectal (n=26 123) cancer in England between 2006 and 2008 were identified in the National Cancer Data Repository. Multivariable logistic regression was used to investigate the odds of death within 1 month, 1–3 months and 3–12 months after diagnosis. Results: In all, 11.5% of colon and 5.4% of rectal cancer patients died within a month of diagnosis: this proportion decreased significantly over the study period. For both cancer sites, older age, stage at diagnosis, deprivation and emergency presentation were associated with early death. Individuals who died shortly after diagnosis were also more likely to have missing data about important prognostic factors such as disease stage and treatment. Conclusion: Using routinely collected data, at no inconvenience to patients, we have identified some important areas relating to early deaths from colorectal cancer, which merit further research.
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379
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Palser TR, Cromwell DA, Hardwick RH, Riley SA, Greenaway K, van der Meulen JHP. Impact of route to diagnosis on treatment intent and 1-year survival in patients diagnosed with oesophagogastric cancer in England: a prospective cohort study. BMJ Open 2013; 3:bmjopen-2012-002129. [PMID: 23408076 PMCID: PMC3585975 DOI: 10.1136/bmjopen-2012-002129] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To investigate the relationship between the route to diagnosis, patient characteristics, treatment intent and 1 -year survival among patients with oesophagogastric (O-G) cancer. SETTING Cohort study in 142 English NHS trusts and 30 cancer networks. PARTICIPANTS Patients diagnosed with O-G cancer between October 2007 and June 2009. DESIGN Prospective cohort study. Route to diagnosis defined as general practitioner (GP) referral-urgent (suspected cancer) or non-urgent, hospital consultant referral, or after an emergency admission. Logistic regression was used to estimate associations and adjust for differences in casemix. MAIN OUTCOME MEASURES Proportion of patients diagnosed by route of diagnosis; proportion of patients selected for curative treatment; 1-year survival. RESULTS Among 14 102 cancer patients, 66.3% were diagnosed after a GP referral, 16.4% after an emergency admission and 17.4% after a hospital consultant referral. Of the 9351 GP referrals, 68.8% were urgent. Compared to urgent GP referrals, a markedly lower proportion of patients diagnosed after emergency admission had a curative treatment plan (36% vs 16%; adjusted OR=0.62, 95% CI 0.52 to 0.74) and a lower proportion survived 1 year (43% vs 27%; OR 0.78; 95% CI 0.68 to 0.89). Urgency of GP referral did not affect treatment intent or survival. Routes to diagnosis varied across cancer networks, with the adjusted proportion of patients diagnosed after emergency admission ranging from 8.7 to 32.3%. CONCLUSIONS Outcomes for cancer patients are worse if diagnosed after emergency admission. Primary care and hospital services should work together to reduce rates of diagnosis after emergency admission and the variation across cancer networks.
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Affiliation(s)
- Thomas R Palser
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
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380
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Affiliation(s)
- W Hamilton
- Primary care diagnostics, Discovery unit, University of Exeter, Veysey Building, Salmonpool Lane, Exeter EX2 4SG, UK
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