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Winestone LE, Wilkes JJ, Puccetti D, Keegan THM, Henk HJ, McPheeters J, Kahn JM, Ginsberg J, Wong S, Timberline S, Malogolowkin M, Pollock BH, Alvarez E. Time to diagnosis among young patients with cancer. Pediatr Blood Cancer 2024; 71:e30997. [PMID: 38864147 DOI: 10.1002/pbc.30997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Sociodemographic and clinical factors associated with diagnostic delays in pediatric, adolescent, and young adult cancers are poorly understood. METHODS Using the Optum Labs Data Warehouse's de-identified claims data for commercial health plan enrollees, we identified children (0-14 years) and adolescents/young adults (AYAs) (15-39 years) diagnosed with one of 10 common cancers from 2001 to 2017, who were continuously enrolled for 6 months preceding diagnosis. Time to diagnosis was calculated as days between first medical encounter with possible cancer symptoms and cancer diagnosis date. Median times from first symptom to diagnosis were compared using Wilcoxon rank sum test. Multivariable unconditional logistic regression identified sociodemographic factors associated with longer time (>3 months) to cancer diagnosis (from symptom onset). RESULTS Of 47,296 patients, 87% presented prior to diagnosis with symptoms. Patients with central nervous system (CNS) tumors were most likely to present with symptoms (93%), whereas patients with cervical cancer were least likely (70%). Symptoms varied by malignancy. Of patients with symptoms, thyroid (105 days [range: 50-154]) and cervical (104 days [range: 41-151]) cancer had the longest median time to diagnosis. Females and patients at either end of the age spectrum were more likely to experience diagnosis delays of more than 3 months. CONCLUSION In a commercially insured population, time to diagnosis varies by cancer type, age, and sex. Further work is needed to understand the patient, provider, and health system-level factors contributing to time from symptom onset to diagnosis, specifically in the very young children and the young adult patient population going forward.
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Affiliation(s)
- Lena E Winestone
- Division of Allergy, Immunology, and BMT, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, USA
| | - Jennifer J Wilkes
- Division of Pediatric Hematology and Oncology, University of California Davis School of Medicine, Sacramento, California, USA
- Division of Hematology-Oncology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Diane Puccetti
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Theresa H M Keegan
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, University of California Davis, School of Medicine, Sacramento, California, USA
| | | | - Jeffrey McPheeters
- Health Economics and Outcomes Research, Eden Prairie, Optum, Minnesota, USA
| | - Justine M Kahn
- Department of Pediatrics, Columbia University Irving Medical Center and Herbert Irving Comprehensive Cancer Center, New York, New York, USA
| | - Jill Ginsberg
- Division of Oncology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Samantha Wong
- School of Medicine, University of California Davis, Sacramento, California, USA
| | - Sage Timberline
- Department of Pediatrics, University of California Davis School of Medicine, Sacramento, California, USA
| | - Marcio Malogolowkin
- Division of Pediatric Hematology Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, California, USA
| | - Brad H Pollock
- Department of Public Health Sciences, University of California Davis, School of Medicine, Sacramento, California, USA
| | - Elysia Alvarez
- Division of Pediatric Hematology Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, California, USA
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Tamefusa K, Ochi M, Ishida H, Shiwaku T, Kanamitsu K, Fujiwara K, Tatebe Y, Matsumoto N, Washio K, Tsukahara H. Delayed diagnostic interval and survival outcomes in pediatric leukemia: A single-center, retrospective study. Eur J Haematol 2024; 112:714-722. [PMID: 38152024 DOI: 10.1111/ejh.14162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVE This study primarily focused on the diagnostic interval (DI), defined as the duration from the onset of leukemic symptoms to diagnosis. We investigated whether a prolonged DI is associated with the outcomes of pediatric leukemia. METHODS We retrospectively collected data of children with newly diagnosed pediatric leukemia at Okayama University Hospital from January 2007 to December 2022. Survival analyses were conducted using Kaplan-Meier methods, and an unadjusted analysis to compare differences in survival was performed using the log-rank test. RESULTS In total, 103 children with leukemia were included in the analysis. The median DI was 20 days (interquartile range, 9.5-33.5 days). A prolonged DI (≥30 days) demonstrated no association with either 5-year event-free survival (70.1% for <30 days and 68.3% for ≥30 days, p = .99, log-rank test) or overall survival (84.7% for <30 days and 89.4% for ≥30 days, p = .85, log-rank test). CONCLUSIONS A prolonged DI was not associated with the survival of children with leukemia. If a precise classification of leukemia biology is provided for pediatric patients, a prolonged DI may have little impact on the prognosis of these patients.
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Affiliation(s)
- Kosuke Tamefusa
- Department of Pediatrics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Motoharu Ochi
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Hisashi Ishida
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Takahiro Shiwaku
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Kiichiro Kanamitsu
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
- Department of Pediatrics, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Kaori Fujiwara
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Yasuhisa Tatebe
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Naomi Matsumoto
- Department of Epidemiology, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Kana Washio
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Hirokazu Tsukahara
- Department of Pediatrics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
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Lopez-Garcia YK, Valdez-Carrizales M, Nuñez-Zuno JA, Apodaca-Chávez E, Rangel-Patiño J, Demichelis-Gómez R. Are delays in diagnosis and treatment of acute leukemia in a middle-income country associated with poor outcomes? A retrospective cohort study. Hematol Transfus Cell Ther 2023:S2531-1379(23)00125-6. [PMID: 37442650 DOI: 10.1016/j.htct.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 02/04/2023] [Accepted: 05/28/2023] [Indexed: 07/15/2023] Open
Abstract
INTRODUCTION Acute leukemias (ALs) are aggressive diseases that lead to death without medical attention. We evaluated the association between delays in diagnosis and poor outcomes in AL by evaluating the symptom onset to treatment intervals in adults with newly diagnosed AL and their effect on an early death (ED). METHODS We assessed adults diagnosed with AL between 2015 and 2020 and evaluated baseline characteristics, the patient interval (PI), diagnostic interval (DI), treatment interval (TI) and the total time interval (TTI) to determine ED-associated factors. MAIN RESULTS We assessed 102 patients with acute lymphoblastic leukemia (ALL), 57 with acute myeloblastic leukemia (AML) and 29 with acute promyelocytic leukemia (APL). Median interval days were PI 14, DI 10, TI 4 and TTI 31.5. The TI and TTI intervals were lower in APL than in ALL and AML; TI 1 vs. 4 and 3 (p = 0.001) and TTI 21 vs. 31 and 35 (p = 0.016). The 30-day and 60-day EDs were 13.8% and 20.7%, mainly infections. ECOG > 2 (OR = 15.0) and PI < 7 days (OR = 4.06) were associated with 30-day ED; AML (OR = 2.69), high-risk (OR = 3.34), albumin < 3.5 g/dl (OR = 5) and platelets < 20 × 103/uL (OR = 2.71) with a 60-day ED. CONCLUSION None of the interval-delays were associated with an ED. Intervals seemed to be longer in patients without an ED, except for the TI, probably because of "the waiting time paradox." Aggressive manifestations of disease may lead to shorter diagnostic intervals, but increased mortality.
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Affiliation(s)
| | | | | | - Elia Apodaca-Chávez
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Juan Rangel-Patiño
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Ding L, Szymczak JE, Evans E, Canepa E, Martin AE, Contractor F, Aplenc R, Joseph G, Winestone LE. Factors that contribute to disparities in time to acute leukemia diagnosis in young people: an in depth qualitative interview study. BMC Cancer 2022; 22:531. [PMID: 35550034 PMCID: PMC9095817 DOI: 10.1186/s12885-022-09547-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 04/11/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Racial and ethnic disparities in outcomes for Black and Hispanic children with acute leukemia have been well documented, however little is known about the determinants of diagnostic delays in pediatric leukemia in the United States. The primary objective of this study is to identify factors contributing to delays preceding a pediatric leukemia diagnosis. METHODS This qualitative study utilized in-depth semi-structured interviews. Parents and/or patients within two years of receiving a new acute leukemia diagnosis were asked to reflect upon their family's experiences preceding the patient's diagnosis. Subjects were purposively sampled for maximum variation in race, ethnicity, income, and language. Interviews were analyzed using inductive theory-building and the constant comparative method to understand the process of diagnosis. Chart review was conducted to complement qualitative data. RESULTS Thirty-two interviews were conducted with a diverse population of English and Spanish speaking participants from two tertiary care pediatric cancer centers. Parents reported feeling frustrated when their intuition conflicted with providers' management decisions. Many felt laboratory testing was not performed soon enough. Additional contributors to delays included misattribution of vague symptoms to more common diagnoses, difficulties in obtaining appointments, and financial disincentives to seek urgent or emergent care. Reports of difficulty obtaining timely appointments and financial concerns were disproportionately raised among low-income Black and Hispanic participants. Comparatively, parents with prior healthcare experiences felt better able to navigate the system and advocate for additional testing at symptom onset. CONCLUSIONS While there are disease-related factors contributing to delays in diagnosis, it is important to recognize there are multiple non-disease-related factors that also contribute to delays. Evidence-based approaches to reduce outcome disparities in pediatric cancer likely need to start in the primary care setting where timeliness of diagnosis can be addressed.
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Affiliation(s)
- Lucky Ding
- grid.266102.10000 0001 2297 6811University of California San Francisco (UCSF) School of Medicine, San Francisco, CA USA
| | - Julia E. Szymczak
- grid.25879.310000 0004 1936 8972Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Erica Evans
- grid.266102.10000 0001 2297 6811University of California San Francisco (UCSF) School of Medicine, San Francisco, CA USA
| | - Emma Canepa
- grid.266102.10000 0001 2297 6811University of California San Francisco (UCSF) School of Medicine, San Francisco, CA USA
| | - Ashley E. Martin
- grid.239552.a0000 0001 0680 8770Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA USA ,grid.239552.a0000 0001 0680 8770PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Farah Contractor
- grid.239552.a0000 0001 0680 8770Center for Childhood Cancer Research, Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Richard Aplenc
- grid.239552.a0000 0001 0680 8770Center for Childhood Cancer Research, Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA USA ,grid.239552.a0000 0001 0680 8770Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Galen Joseph
- grid.266102.10000 0001 2297 6811Department of Humanities and Social Sciences, UCSF, San Francisco, CA USA ,grid.511215.30000 0004 0455 2953UCSF Helen Diller Family Comprehensive Cancer Center, CA San Francisco, USA
| | - Lena E. Winestone
- grid.511215.30000 0004 0455 2953UCSF Helen Diller Family Comprehensive Cancer Center, CA San Francisco, USA ,Division of Allergy, Immunology & BMT, UCSF Benioff Children’s Hospitals, Mail Stop 0434, 550 16th St, 4th Floor, San Francisco, CA USA
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Lemieux-Sarrasin D, Pelland-Marcotte MC, Simonyan D, Martineau É, Desbiens B, Michon B. Distance to the pediatric oncology center does not affect survival in children with acute lymphoblastic leukemia: a report from CYP-C. Leuk Lymphoma 2020; 62:960-966. [PMID: 33231123 DOI: 10.1080/10428194.2020.1849673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Remoteness is associated with worse survival in adults with cancer. We aimed to determine whether remoteness is associated with cancer outcomes in pediatric acute lymphoblastic leukemia (ALL). Canadian children with ALL entered in the CYP-C registry were included. The predictive impact of remoteness on overall survival (OS), relapse, and treatment-related complications (infections, thrombosis, bleeding, and osteonecrosis) was estimated using multivariate regression models. We included 1383 children, of whom 277 (20.0%) lived remotely (>200 km from the pediatric oncology center). The median latency to see a pediatric oncologist was longer in children living remotely. The 5-year OS (95% CI) was similar for both groups (remote: 95.2% [93.7-96.3%] vs close: 94.1% [90.5-95.2%]). No difference was found in the relapse rate between both groups and in treatment-related complications. Remoteness did not affect survival in pediatric ALL. Further research is needed to determine which models of healthcare organization optimize cancer outcomes and patients' satisfaction.
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Affiliation(s)
- Daphné Lemieux-Sarrasin
- Department of Pediatrics, CHU de Québec - Centre Mère-Enfant Soleil, Quebec City, Quebec, Canada
| | - Marie-Claude Pelland-Marcotte
- Department of Pediatrics, CHU de Québec - Centre Mère-Enfant Soleil, Quebec City, Quebec, Canada.,Centre de recherche du CHU de Québec, Quebec City, Quebec, Canada
| | - David Simonyan
- Centre de recherche du CHU de Québec, Quebec City, Quebec, Canada
| | - Émilie Martineau
- Department of Pediatrics, CHU de Québec - Centre Mère-Enfant Soleil, Quebec City, Quebec, Canada
| | - Barbara Desbiens
- Department of Pediatrics, CHU de Québec - Centre Mère-Enfant Soleil, Quebec City, Quebec, Canada
| | - Bruno Michon
- Department of Pediatrics, CHU de Québec - Centre Mère-Enfant Soleil, Quebec City, Quebec, Canada.,Centre de recherche du CHU de Québec, Quebec City, Quebec, Canada
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Aparicio Rodrigo M, Ruiz Canela J, Buñuel Álvarez JC, García Vera C, Esparza Olcina MJ, Barroso Espadero D, González Rodríguez P, Juanes Toledo B, Martínez Rubio V, Ortega Páez E. Paediatricians provide higher quality care to children and adolescents in primary care: A systematic review. Acta Paediatr 2020; 109:1989-2007. [PMID: 32311805 DOI: 10.1111/apa.15324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 02/26/2020] [Accepted: 04/17/2020] [Indexed: 11/29/2022]
Abstract
AIM The number of primary care paediatricians is decreasing in Europe without a justifiable reason. We aimed to compare the clinical practice of paediatricians and family doctors attending children and adolescents in primary care. METHODS MEDLINE, Embase, CENTRAL, TRIP and Google Scholar were searched from December 2008 to February 2018. No language or study design restrictions were applied. Three reviewers assessed eligibility of the studies. Seven pairs of reviewers performed the data extraction and assessed the methodological quality independently. Discrepancies were resolved by consensus. RESULTS Fifty-four, out of 1150 studies preselected, were included. We found that paediatricians show more appropriate pharmacology prescription patterns for the illness being treated; they achieve higher vaccination rates and have better knowledge of vaccines and fewer doubts about vaccine safety; their knowledge and implementation of different screening tests are better; they prescribe psychoactive drugs more cautiously and more in line with current practice guidelines; their evaluation and treatment of obesity and lipid disorders follow criteria more consistently with current clinical practice guidelines; and they perform fewer diagnostic test, show a more suitable use of the test and request fewer referrals to specialists. CONCLUSION According to published data, in developed countries, paediatricians provide higher quality care to children than family doctors.
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7
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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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Widger K, Sutradhar R, Rapoport A, Vadeboncoeur C, Zelcer S, Kassam A, Nelson K, Liu Y, Wolfe J, Earle CC, Pole JD, Gupta S. Predictors of Specialized Pediatric Palliative Care Involvement and Impact on Patterns of End-of-Life Care in Children With Cancer. J Clin Oncol 2018; 36:801-807. [DOI: 10.1200/jco.2017.75.6312] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The impact of specialized pediatric palliative care (SPPC) teams on patterns of end-of-life care is unknown. We sought to determine (1) which children with cancer access SPPC and (2) the impact of accessing SPPC on the risk of experiencing high-intensity end-of-life care (intensive care unit admission, mechanical ventilation, or in-hospital death). Methods Using a provincial childhood cancer registry, we assembled a retrospective cohort of Ontario children with cancer who died between 2000 and 2012 and received care through pediatric institutions with an SPPC team. Patients were linked to population-based administrative data capturing inpatient, outpatient, and emergency visits. Children were classified as having SPPC, general palliative care, or no palliative care on the basis of SPPC clinical databases, physician billing codes, or inpatient diagnosis codes. Results Of the 572 children, 166 (29%) received care from an SPPC team for at least 30 days before death, and 100 (17.5%) received general palliative care. SPPC involvement was significantly less likely for children with hematologic cancers (OR, 0.3; 95% CI, 0.3 to 0.4), living in the lowest income areas (OR, 0.4; 95% CI, 0.2 to 0.8), and living further from the treatment center (OR, 0.5; 95% CI, 0.4 to 0.5). SPPC was associated with a five-fold decrease in odds of intensive care unit admission (OR, 0.2; 95% CI, 0.1 to 0.4), whereas general palliative care had no impact. Similar associations were seen with all secondary indicators. Conclusion When available, SPPC, but not general palliative care, is associated with lower intensity care at the end of life for children with cancer. However, access remains uneven. These results provide the strongest evidence to date supporting the creation of SPPC teams.
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Affiliation(s)
- Kimberley Widger
- Kimberley Widger, Rinku Sutradhar, Adam Rapoport, Alisha Kassam, and Sumit Gupta, University of Toronto; Kimberley Widger, Adam Rapoport, Alisha Kassam, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Rinku Sutradhar, Ying Liu, Craig C. Earle, Jason D. Pole, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Christina Vadeboncoeur, Children’s Hospital of Eastern
| | - Rinku Sutradhar
- Kimberley Widger, Rinku Sutradhar, Adam Rapoport, Alisha Kassam, and Sumit Gupta, University of Toronto; Kimberley Widger, Adam Rapoport, Alisha Kassam, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Rinku Sutradhar, Ying Liu, Craig C. Earle, Jason D. Pole, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Christina Vadeboncoeur, Children’s Hospital of Eastern
| | - Adam Rapoport
- Kimberley Widger, Rinku Sutradhar, Adam Rapoport, Alisha Kassam, and Sumit Gupta, University of Toronto; Kimberley Widger, Adam Rapoport, Alisha Kassam, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Rinku Sutradhar, Ying Liu, Craig C. Earle, Jason D. Pole, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Christina Vadeboncoeur, Children’s Hospital of Eastern
| | - Christina Vadeboncoeur
- Kimberley Widger, Rinku Sutradhar, Adam Rapoport, Alisha Kassam, and Sumit Gupta, University of Toronto; Kimberley Widger, Adam Rapoport, Alisha Kassam, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Rinku Sutradhar, Ying Liu, Craig C. Earle, Jason D. Pole, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Christina Vadeboncoeur, Children’s Hospital of Eastern
| | - Shayna Zelcer
- Kimberley Widger, Rinku Sutradhar, Adam Rapoport, Alisha Kassam, and Sumit Gupta, University of Toronto; Kimberley Widger, Adam Rapoport, Alisha Kassam, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Rinku Sutradhar, Ying Liu, Craig C. Earle, Jason D. Pole, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Christina Vadeboncoeur, Children’s Hospital of Eastern
| | - Alisha Kassam
- Kimberley Widger, Rinku Sutradhar, Adam Rapoport, Alisha Kassam, and Sumit Gupta, University of Toronto; Kimberley Widger, Adam Rapoport, Alisha Kassam, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Rinku Sutradhar, Ying Liu, Craig C. Earle, Jason D. Pole, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Christina Vadeboncoeur, Children’s Hospital of Eastern
| | - Katherine Nelson
- Kimberley Widger, Rinku Sutradhar, Adam Rapoport, Alisha Kassam, and Sumit Gupta, University of Toronto; Kimberley Widger, Adam Rapoport, Alisha Kassam, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Rinku Sutradhar, Ying Liu, Craig C. Earle, Jason D. Pole, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Christina Vadeboncoeur, Children’s Hospital of Eastern
| | - Ying Liu
- Kimberley Widger, Rinku Sutradhar, Adam Rapoport, Alisha Kassam, and Sumit Gupta, University of Toronto; Kimberley Widger, Adam Rapoport, Alisha Kassam, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Rinku Sutradhar, Ying Liu, Craig C. Earle, Jason D. Pole, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Christina Vadeboncoeur, Children’s Hospital of Eastern
| | - Joanne Wolfe
- Kimberley Widger, Rinku Sutradhar, Adam Rapoport, Alisha Kassam, and Sumit Gupta, University of Toronto; Kimberley Widger, Adam Rapoport, Alisha Kassam, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Rinku Sutradhar, Ying Liu, Craig C. Earle, Jason D. Pole, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Christina Vadeboncoeur, Children’s Hospital of Eastern
| | - Craig C. Earle
- Kimberley Widger, Rinku Sutradhar, Adam Rapoport, Alisha Kassam, and Sumit Gupta, University of Toronto; Kimberley Widger, Adam Rapoport, Alisha Kassam, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Rinku Sutradhar, Ying Liu, Craig C. Earle, Jason D. Pole, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Christina Vadeboncoeur, Children’s Hospital of Eastern
| | - Jason D. Pole
- Kimberley Widger, Rinku Sutradhar, Adam Rapoport, Alisha Kassam, and Sumit Gupta, University of Toronto; Kimberley Widger, Adam Rapoport, Alisha Kassam, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Rinku Sutradhar, Ying Liu, Craig C. Earle, Jason D. Pole, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Christina Vadeboncoeur, Children’s Hospital of Eastern
| | - Sumit Gupta
- Kimberley Widger, Rinku Sutradhar, Adam Rapoport, Alisha Kassam, and Sumit Gupta, University of Toronto; Kimberley Widger, Adam Rapoport, Alisha Kassam, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Rinku Sutradhar, Ying Liu, Craig C. Earle, Jason D. Pole, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Christina Vadeboncoeur, Children’s Hospital of Eastern
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Widger K, Vadeboncoeur C, Zelcer S, Liu Y, Kassam A, Sutradhar R, Rapoport A, Nelson K, Wolfe J, Earle C, Pole JD, Gupta S. The Validity of Using Health Administrative Data To Identify the Involvement of Specialized Pediatric Palliative Care Teams in Children with Cancer in Ontario, Canada. J Palliat Med 2017; 20:1210-1216. [DOI: 10.1089/jpm.2017.0028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kimberley Widger
- Paediatric Advanced Care Team, The Hospital for Sick Children, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Christina Vadeboncoeur
- Palliative Care Team, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Roger Neilson House Children's Hospice, Ottawa, Ontario, Canada
| | - Shayna Zelcer
- Hematology and Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Ying Liu
- Cancer Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Alisha Kassam
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Southlake Regional Health Centre, Newmarket, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Cancer Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Adam Rapoport
- Paediatric Advanced Care Team, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Emily's House Children's Hospice, Toronto, Ontario, Canada
| | - Katherine Nelson
- Paediatric Advanced Care Team, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute for Health Policy, Evaluation and Management, University of Toronto, Toronto, Ontario, Canada
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Craig Earle
- Cancer Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Jason D. Pole
- Cancer Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Pediatric Oncology Group of Ontario, Toronto, Ontario, Canada
| | - Sumit Gupta
- Cancer Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Evaluation and Management, University of Toronto, Toronto, Ontario, Canada
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Abstract
BACKGROUND Pediatric cancer is rare and its symptoms are often ambiguous. The aims of this study were to investigate the time needed to make a diagnosis, assess the frequency of misdiagnosis, and to determine whether these factors affected survival. METHODS A review of records of 364 pediatric patients diagnosed with cancer at the University of Rochester Golisano Children's Hospital between 2004 and 2012 was conducted. Data were extracted on patient and health care system-related factors and clinical outcomes. RESULTS The median time from symptom onset to diagnosis was shortest for leukemia (18.5 d) and longest for bone tumors (86.5 d). Tumor type was the only factor associated with time to diagnosis. In 52% of cases an incorrect nononcological diagnosis was initially made. Soft tissue sarcomas and brain tumors were misdiagnosed most often. Neither prolonged time to diagnosis nor initial misdiagnosis was associated with reduced survival. Tumor type and presence of metastatic disease at diagnosis were significantly associated with survival. CONCLUSIONS There is significant variation in the time from symptom onset to diagnosis of pediatric cancers, and incorrect initial diagnostic impressions are common. Despite this there is no impact of prolonged time to diagnosis on survival.
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11
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Kassam A, Sutradhar R, Widger K, Rapoport A, Pole JD, Nelson K, Wolfe J, Earle CC, Gupta S. Predictors of and Trends in High-Intensity End-of-Life Care Among Children With Cancer: A Population-Based Study Using Health Services Data. J Clin Oncol 2017; 35:236-242. [DOI: 10.1200/jco.2016.68.8283] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Children with cancer often receive high-intensity (HI) medical care at the end-of-life (EOL). Previous studies have been limited to single centers or lacked detailed clinical data. We determined predictors of and trends in HI-EOL care by linking population-based clinical and health-services databases. Methods A retrospective decedent cohort of patients with childhood cancer who died between 2000 and 2012 in Ontario, Canada, was assembled using a provincial cancer registry and linked to population-based health-care data. Based on previous studies, the primary composite measure of HI-EOL care comprised any of the following: intravenous chemotherapy < 14 days from death; more than one emergency department visit; and more than one hospitalization or intensive care unit admission < 30 days from death. Secondary measures included those same individual measures and measures of the most invasive (MI) EOL care (eg, mechanical ventilation < 14 days from death). We determined predictors of outcomes with appropriate regression models. Sensitivity analysis was restricted to cases of cancer-related mortality, excluding treatment-related mortality (TRM) cases. Results The study included 815 patients; of these, 331 (40.6%) experienced HI-EOL care. Those with hematologic malignancies were at highest risk (odds ratio, 2.5; 95% CI, 1.8 to 3.6; P < .001). Patients with hematologic cancers and those who died after 2004 were more likely to experience the MI-EOL care (eg, intensive care unit, mechanical ventilation, odds ratios from 2.0 to 5.1). Excluding cases of TRM did not substantively change the results. Conclusion Ontario children with cancer continue to experience HI-EOL care. Patients with hematologic malignancies are at highest risk even when excluding TRM. Of concern, rates of the MI-EOL care have increased over time despite increased palliative care access. Linking health services and clinical data allows monitoring of population trends in EOL care and identifies high-risk populations for future interventions.
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Affiliation(s)
- Alisha Kassam
- Alisha Kassam, Kimberley Widger, Adam Rapoport, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Alisha Kassam, Kimberley Widger, Adam Rapoport, and Sumit Gupta, University of Toronto; Rinku Sutradhar, Jason D. Pole, Craig C. Earle, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; and Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Alisha Kassam, Southlake Regional Health Centre, Newmarket, Ontario, Canada; and
| | - Rinku Sutradhar
- Alisha Kassam, Kimberley Widger, Adam Rapoport, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Alisha Kassam, Kimberley Widger, Adam Rapoport, and Sumit Gupta, University of Toronto; Rinku Sutradhar, Jason D. Pole, Craig C. Earle, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; and Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Alisha Kassam, Southlake Regional Health Centre, Newmarket, Ontario, Canada; and
| | - Kimberley Widger
- Alisha Kassam, Kimberley Widger, Adam Rapoport, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Alisha Kassam, Kimberley Widger, Adam Rapoport, and Sumit Gupta, University of Toronto; Rinku Sutradhar, Jason D. Pole, Craig C. Earle, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; and Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Alisha Kassam, Southlake Regional Health Centre, Newmarket, Ontario, Canada; and
| | - Adam Rapoport
- Alisha Kassam, Kimberley Widger, Adam Rapoport, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Alisha Kassam, Kimberley Widger, Adam Rapoport, and Sumit Gupta, University of Toronto; Rinku Sutradhar, Jason D. Pole, Craig C. Earle, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; and Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Alisha Kassam, Southlake Regional Health Centre, Newmarket, Ontario, Canada; and
| | - Jason D. Pole
- Alisha Kassam, Kimberley Widger, Adam Rapoport, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Alisha Kassam, Kimberley Widger, Adam Rapoport, and Sumit Gupta, University of Toronto; Rinku Sutradhar, Jason D. Pole, Craig C. Earle, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; and Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Alisha Kassam, Southlake Regional Health Centre, Newmarket, Ontario, Canada; and
| | - Katherine Nelson
- Alisha Kassam, Kimberley Widger, Adam Rapoport, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Alisha Kassam, Kimberley Widger, Adam Rapoport, and Sumit Gupta, University of Toronto; Rinku Sutradhar, Jason D. Pole, Craig C. Earle, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; and Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Alisha Kassam, Southlake Regional Health Centre, Newmarket, Ontario, Canada; and
| | - Joanne Wolfe
- Alisha Kassam, Kimberley Widger, Adam Rapoport, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Alisha Kassam, Kimberley Widger, Adam Rapoport, and Sumit Gupta, University of Toronto; Rinku Sutradhar, Jason D. Pole, Craig C. Earle, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; and Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Alisha Kassam, Southlake Regional Health Centre, Newmarket, Ontario, Canada; and
| | - Craig C. Earle
- Alisha Kassam, Kimberley Widger, Adam Rapoport, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Alisha Kassam, Kimberley Widger, Adam Rapoport, and Sumit Gupta, University of Toronto; Rinku Sutradhar, Jason D. Pole, Craig C. Earle, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; and Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Alisha Kassam, Southlake Regional Health Centre, Newmarket, Ontario, Canada; and
| | - Sumit Gupta
- Alisha Kassam, Kimberley Widger, Adam Rapoport, Katherine Nelson, and Sumit Gupta, The Hospital for Sick Children; Alisha Kassam, Kimberley Widger, Adam Rapoport, and Sumit Gupta, University of Toronto; Rinku Sutradhar, Jason D. Pole, Craig C. Earle, and Sumit Gupta, Institute for Clinical Evaluative Sciences; Adam Rapoport, Emily’s House Children’s Hospice; and Jason D. Pole, Pediatric Oncology Group of Ontario, Toronto; Alisha Kassam, Southlake Regional Health Centre, Newmarket, Ontario, Canada; and
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12
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Gupta S. Comment On: Use of Patient Registries and Administrative Datasets for the Study of Pediatric Cancer. Pediatr Blood Cancer 2016; 63:367. [PMID: 26505636 DOI: 10.1002/pbc.25788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 09/11/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Sumit Gupta
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, and Faculty of Medicine, Toronto, Canada
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13
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Rubin G, Berendsen A, Crawford SM, Dommett R, Earle C, Emery J, Fahey T, Grassi L, Grunfeld E, Gupta S, Hamilton W, Hiom S, Hunter D, Lyratzopoulos G, Macleod U, Mason R, Mitchell G, Neal RD, Peake M, Roland M, Seifert B, Sisler J, Sussman J, Taplin S, Vedsted P, Voruganti T, Walter F, Wardle J, Watson E, Weller D, Wender R, Whelan J, Whitlock J, Wilkinson C, de Wit N, Zimmermann C. The expanding role of primary care in cancer control. Lancet Oncol 2015; 16:1231-72. [PMID: 26431866 DOI: 10.1016/s1470-2045(15)00205-3] [Citation(s) in RCA: 355] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 07/25/2015] [Accepted: 07/27/2015] [Indexed: 12/21/2022]
Abstract
The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.
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Affiliation(s)
- Greg Rubin
- School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK.
| | - Annette Berendsen
- Department of General Practice, University of Groningen, Groningen, Netherlands
| | | | - Rachel Dommett
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Craig Earle
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Jon Emery
- Department of General Practice, University of Melbourne, Melbourne, VIC, Australia
| | - Tom Fahey
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Luigi Grassi
- Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy
| | - Eva Grunfeld
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Sumit Gupta
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | | | | | - David Hunter
- School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK
| | | | - Una Macleod
- Hull-York Medical School, University of Hull, Hull, UK
| | - Robert Mason
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Geoffrey Mitchell
- Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, QLD, Australia
| | - Richard D Neal
- North Wales Centre for Primary Care Research, Bangor University, Bangor, Wales
| | | | - Martin Roland
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Bohumil Seifert
- Department of General Practice, Charles University, Prague, Czech Republic
| | - Jeff Sisler
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Stephen Taplin
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Peter Vedsted
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Teja Voruganti
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Fiona Walter
- Department of General Practice, University of Groningen, Groningen, Netherlands
| | - Jane Wardle
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Eila Watson
- Department of Clinical Health Care, Oxford Brookes University, Oxford, UK
| | - David Weller
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Jeremy Whelan
- Research Department of Oncology, University College London, London, UK
| | - James Whitlock
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research, Bangor University, Bangor, Wales
| | - Niek de Wit
- Department of General Practice, University Medical Center Utrecht, Utrecht, Netherlands
| | - Camilla Zimmermann
- Division of Medical Oncology and Haematology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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