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Bosch X, Montori-Palacin E, Calvo J, Carbonell I, Naval-Álvarez J, Moreno P, López-Soto A. Time intervals and previous primary care consultations in the pathway to emergency cancer diagnosis. Cancer Epidemiol 2023; 86:102445. [PMID: 37651939 DOI: 10.1016/j.canep.2023.102445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Time intervals and number of prior consultations in primary care (PC) are recognised metrics of diagnostic timeliness of cancer and are interrelated. However, whether and how the two measures correlate with each other in the emergency diagnostic pathway is unknown. We investigated the association between the number of prereferral consultations and the length of intervals from PC presentation to cancer diagnosis following emergency referral to hospital. METHODS Patients were eligible if they first consulted in PC and were diagnosed with cancer following emergency or nonemergency referral to hospital. We analysed for differences in PC and diagnostic intervals and number of consultations between emergency and nonemergency presenters and determined their associations by cancer type. Differences in presenting symptoms and stage at diagnosis between populations and according to number of consultations were also examined. RESULTS There were 796 emergency and 865 nonemergency presenters with comparable sociodemographic and comorbidity data. Correlation analysis in emergency presenters revealed a strong positive association between number of consultations and intervals for seven of 13 different cancers, including cancers characterised by high proportions of > 3 consultations and long intervals (pancreatic, lung, and colorectal cancer) and vice versa for others (e.g., endometrial, cervical, or oesophageal cancer). Additionally, emergency presenters with > 3 consultations were more likely than those with 1-2 to report nonspecific symptoms (60 vs. 40%, respectively) and to be diagnosed at a later stage. CONCLUSION System level interventions are needed to reduce unnecessary delays in the emergency diagnostic pathway, particularly in cancer patients with multiple prereferral consultations. The findings also suggest opportunities to reduce the proportion of emergency diagnoses by targeting symptomatic individuals pre-presentation.
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Affiliation(s)
- Xavier Bosch
- Department of Internal Medicine, Hospital Clínic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Clínic Foundation for Biomedical Research (FCRB), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain.
| | - Elisabet Montori-Palacin
- Department of Internal Medicine, Hospital Clínic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Clínic Foundation for Biomedical Research (FCRB), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Julia Calvo
- Department of Internal Medicine, Hospital Clínic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Clínic Foundation for Biomedical Research (FCRB), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Irene Carbonell
- Department of Internal Medicine, Hospital Clínic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Clínic Foundation for Biomedical Research (FCRB), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - José Naval-Álvarez
- Department of Internal Medicine, Hospital Clínic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Clínic Foundation for Biomedical Research (FCRB), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Pedro Moreno
- Department of Internal Medicine, Hospital Clínic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Clínic Foundation for Biomedical Research (FCRB), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Alfonso López-Soto
- Department of Internal Medicine, Hospital Clínic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Clínic Foundation for Biomedical Research (FCRB), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
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Koo MM, von Wagner C, Abel GA, McPhail S, Hamilton W, Rubin GP, Lyratzopoulos G. The nature and frequency of abdominal symptoms in cancer patients and their associations with time to help-seeking: evidence from a national audit of cancer diagnosis. J Public Health (Oxf) 2018; 40:e388-e395. [PMID: 29385513 PMCID: PMC6166582 DOI: 10.1093/pubmed/fdx188] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 12/18/2017] [Accepted: 12/22/2017] [Indexed: 12/28/2022] Open
Abstract
Background Raising awareness of possible cancer symptoms is important for timely help-seeking; recent campaigns have focused on symptom groups (such as abdominal symptoms) rather than individual alarm symptoms associated with particular cancer sites. The evidence base supporting such initiatives is still emerging however; understanding the frequency and nature of presenting abdominal symptoms among cancer patients could inform the design and evaluation of public health awareness campaigns. Methods We examined eight presenting abdominal symptoms (abdominal pain, change in bowel habit, bloating/distension, dyspepsia, rectal bleeding, dysphagia, reflux and nausea/vomiting) among 15 956 patients subsequently diagnosed with cancer in England. We investigated the cancer site case-mix and variation in the patient interval (symptom-onset-to-presentation) by abdominal symptom. Results Almost a quarter (23%) of cancer patients presented with abdominal symptoms before being diagnosed with one of 27 common and rarer cancers. The patient interval varied substantially by abdominal symptom: median (IQR) intervals ranged from 7 (0-28) days for abdominal pain to 30 (4-73) days for dysphagia. This variation persisted after adjusting for age, sex and ethnicity (P < 0.001). Conclusions Abdominal symptoms are common at presentation among cancer patients, while time to presentation varies by symptom. The need for awareness campaigns may be greater for symptoms associated with longer intervals to help-seeking.
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Affiliation(s)
| | | | - Gary A Abel
- University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, UK
| | - Sean McPhail
- National Cancer Registration and Analysis Service, Public Health England Zone A, 2nd Floor, Skipton House, 80 London Road, London, UK
| | - William Hamilton
- University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, UK
| | - Greg P Rubin
- Institute of Health and Society, Newcastle University, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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Diagnostic timeliness of cancer in adolescents and young adults. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:159-161. [DOI: 10.1016/s2352-4642(18)30027-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 01/17/2018] [Accepted: 01/17/2018] [Indexed: 01/20/2023]
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Herbert A, Lyratzopoulos G, Whelan J, Taylor RM, Barber J, Gibson F, Fern LA. Diagnostic timeliness in adolescents and young adults with cancer: a cross-sectional analysis of the BRIGHTLIGHT cohort. THE LANCET. CHILD & ADOLESCENT HEALTH 2018; 2:180-190. [PMID: 29503844 PMCID: PMC5824669 DOI: 10.1016/s2352-4642(18)30004-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Adolescents and young adults (AYAs) are thought to experience prolonged intervals to cancer diagnosis, but evidence quantifying this hypothesis and identifying high-risk patient subgroups is insufficient. We aimed to investigate diagnostic timeliness in a cohort of AYAs with incident cancers and to identify factors associated with variation in timeliness. Methods We did a cross-sectional analysis of the BRIGHTLIGHT cohort, which included AYAs aged 12-24 years recruited within an average of 6 months from new primary cancer diagnosis from 96 National Health Service hospitals across England between July 1, 2012, and April 30, 2015. Participants completed structured, face-to-face interviews to provide information on their diagnostic experience (eg, month and year of symptom onset, number of consultations before referral to specialist care); demographic information was extracted from case report forms and date of diagnosis and cancer type from the national cancer registry. We analysed these data to assess patient interval (time from symptom onset to first presentation to a general practitioner [GP] or emergency department), the number of prereferral GP consultations, and the symptom onset-to-diagnosis interval (time from symptom onset to diagnosis) by patient characteristic and cancer site, and examined associations using multivariable regression models. Findings Of 1114 participants recruited to the BRIGHTLIGHT cohort, 830 completed a face-to-face interview. Among participants with available information, 204 (27%) of 748 had a patient interval of more than a month and 242 (35%) of 701 consulting a general practitioner had three or more prereferral consultations. The median symptom onset-to-diagnosis interval was 62 days (IQR 29-153). Compared with male AYAs, female AYAs were more likely to have three or more consultations (adjusted odds ratio [OR] 1·6 [95% CI 1·1-2·3], p=0·0093) and longer median symptom onset-to-diagnosis intervals (adjusted median interval longer by 24 days [95% CI 11-37], p=0·0005). Patients with lymphoma or bone tumours (adjusted OR 1·2 [95% CI 0·6-2·1] compared with lymphoma) were most likely to have three or more consultations and those with melanoma least likely (0·2 [0·1-0·7] compared with lymphoma). The adjusted median symptom onset-to-diagnosis intervals were longest in AYAs with bone tumours (51 days [95% CI 29-73] longer than for lymphoma) and shortest in those with leukaemia (33 days [17-49] shorter than for lymphoma). Interpretation The findings provide a benchmark for diagnostic timeliness in young people with cancer and help to identify subgroups at higher risk of a prolonged diagnostic journey. Further research is needed to understand reasons for these findings and to prioritise and stratify early diagnosis initiatives for AYAs. Funding National Institute for Health Research, Teenage Cancer Trust, and Cancer Research UK.
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Affiliation(s)
- Annie Herbert
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Sciences & Health, University College London, London, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Sciences & Health, University College London, London, UK
| | - Jeremy Whelan
- Cancer Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Rachel M Taylor
- Cancer Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Julie Barber
- Department of Statistical Science, University College London, London, UK
| | - Faith Gibson
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- School of Health Sciences, University of Surrey, Guildford, UK
| | - Lorna A Fern
- Cancer Division, University College London Hospitals NHS Foundation Trust, London, UK
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Sikdar KC, Dickinson J, Winget M. Factors associated with mode of colorectal cancer detection and time to diagnosis: a population level study. BMC Health Serv Res 2017; 17:7. [PMID: 28056946 PMCID: PMC5376684 DOI: 10.1186/s12913-016-1944-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 12/10/2016] [Indexed: 02/07/2023] Open
Abstract
Background Although it is well-known that early detection of colorectal cancer (CRC) is important for optimal patient survival, the relationship of patient and health system factors with delayed diagnosis are unclear. The purpose of this study was to identify the demographic, clinical and healthcare factors related to mode of CRC detection and length of the diagnostic interval. Methods All residents of Alberta, Canada diagnosed with first-ever incident CRC in years 2004–2010 were identified from the Alberta Cancer Registry. Population-based administrative health datasets, including hospital discharge abstract, ambulatory care classification system and physician billing data, were used to identify healthcare services related to CRC diagnosis. The time to diagnosis was defined as the time from the first CRC-related healthcare visit to the date of CRC diagnosis. Mode of CRC detection was classified into three groups: urgent, screen-detected and symptomatic. Quantile regression was performed to assess factors associated with time to diagnosis. Results 9626 patients were included in the study; 25% of patients presented as urgent, 32% were screen-detected and 43% were symptomatic. The median time to diagnosis for urgent, screen-detected and symptomatic patients were 6 days (interquartile range (IQR) 2–14 days), 74 days (IQR 36–183 days), 84 days (IQR 39–223 days), respectively. Time to diagnosis was greater than 6 months for 27% of non-urgent patients. Healthcare factors had the largest impact on time to diagnosis: 3 or more visits to a GP increased the median by 140 days whereas 2 or more visits to a GI-specialist increased it by 108 days compared to 0–1 visits to a GP or GI-specialist, respectively. Conclusion A large proportion of CRC patients required urgent work-up or had to wait more than 6 months for diagnosis. Actions are needed to reduce the frequency of urgent presentation as well as improve the timeliness of diagnosis. Findings suggest a need to improve coordination of care across multiple providers.
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Affiliation(s)
- Khokan C Sikdar
- Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, G 214 HSC, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.
| | - James Dickinson
- Departments of Family Medicine and Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Canada
| | - Marcy Winget
- Department of Medicine, Stanford University, Stanford, CA, 94305, USA
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Lyratzopoulos G, Liu MPH, Abel GA, Wardle J, Keating NL. The Association between Fatalistic Beliefs and Late Stage at Diagnosis of Lung and Colorectal Cancer. Cancer Epidemiol Biomarkers Prev 2015; 24:720-6. [PMID: 25650183 PMCID: PMC4384982 DOI: 10.1158/1055-9965.epi-14-0969] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 01/07/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Fatalistic beliefs may be implicated in longer help-seeking intervals, and consequently, greater risk of advanced stage at cancer diagnosis. METHODS We examined associations between fatalism and stage at diagnosis in a population-based cohort of 4,319 U.S. patients with newly diagnosed lung or colorectal cancer participating in the Cancer Care Outcomes and Research Surveillance (CanCORS) study. Fatalistic beliefs were assessed with an established measure. A fatalism score (range, 4-16) was created by summing Likert scale responses to four items. Cancer stage at diagnosis was abstracted from medical records by trained staff. Logistic regression was used to assess the association between fatalism score and advanced stage at diagnosis (IV vs. I-III), adjusting for sociodemographic and clinical characteristics. RESULTS Overall, 917 (21%) patients had stage IV cancers (lung: 28%, colorectal: 16%). The mean fatalism score was 10.7 (median = 11; interquartile range, 9-12). In adjusted analyses, a higher fatalism score was associated with greater odds of stage IV diagnosis (OR per unit increase in fatalism = 1.05; 95% confidence interval 1.02-1.08; P = 0.003). Patients with the highest fatalism score had an adjusted 8.9% higher frequency of stage IV diagnosis compared with patients with the lowest score (25.4% vs. 16.5%). DISCUSSION In this large and socioeconomically, geographically, and ethnically diverse population of patients with lung and colorectal cancer, fatalistic beliefs were associated with higher risk of advanced stage at diagnosis. Longitudinal studies are needed to confirm causation. IMPACT These findings support the value of incorporating information about the curability of early-stage cancers in public education campaigns.
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Affiliation(s)
- Georgios Lyratzopoulos
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, Institute of Public Health, Cambridge, United Kingdom. Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, Gower Street, London, United Kingdom.
| | | | - Gary A Abel
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, Institute of Public Health, Cambridge, United Kingdom
| | - Jane Wardle
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, Gower Street, London, United Kingdom
| | - Nancy L Keating
- Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts. Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Rutherford MJ, Abel GA, Greenberg DC, Lambert PC, Lyratzopoulos G. The impact of eliminating age inequalities in stage at diagnosis on breast cancer survival for older women. Br J Cancer 2015; 112 Suppl 1:S124-8. [PMID: 25734394 PMCID: PMC4385985 DOI: 10.1038/bjc.2015.51] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Older women with breast cancer have poorer relative survival outcomes, but whether achieving earlier stage at diagnosis would translate to substantial reductions in mortality is uncertain. METHODS We analysed data on East of England women with breast cancer (2006-2010) aged 70+ years. We estimated survival for different stage-deprivation-age group strata using both the observed and a hypothetical stage distribution (assuming that all women aged 75+ years acquired the stage distribution of those aged 70-74 years). We subsequently estimated deaths that could be postponed beyond 5 years from diagnosis if women aged 75+ years had the hypothetical stage distribution. We projected findings to the English population using appropriate age and socioeconomic group weights. RESULTS For a typically sized annual cohort in the East of England, 27 deaths in women with breast cancer aged 75+ years can be postponed within 5 years from diagnosis if their stage distribution matched that of the women aged 70-74 years (4.8% of all 566 deaths within 5 years post diagnosis in this population). Under assumptions, we estimate that the respective number for England would be 280 deaths (5.0% of all deaths within 5 years post diagnosis in this population). CONCLUSIONS The findings support ongoing development of targeted campaigns aimed at encouraging prompt presentation in older women.
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MESH Headings
- Age Factors
- Aged
- Aged, 80 and over
- Breast Neoplasms/diagnosis
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Carcinoma, Ductal, Breast/diagnosis
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Lobular/diagnosis
- Carcinoma, Lobular/mortality
- Carcinoma, Lobular/pathology
- Cohort Studies
- England
- Female
- Health Status Disparities
- Healthcare Disparities
- Humans
- Socioeconomic Factors
- Survival Rate
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Affiliation(s)
- M J Rutherford
- Department of Health Sciences, University of Leicester, Leicester LE1 7RH UK
| | - G A Abel
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
| | - D C Greenberg
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
- National Cancer Registration Service, Public Health England, Eastern Office, Cambridge CB22 3AD, UK
| | - P C Lambert
- Department of Health Sciences, University of Leicester, Leicester LE1 7RH UK
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stocholm SE-171 77, Sweden
| | - G Lyratzopoulos
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, UCL, 1-19 Torrington Place, London WC1E 6BT, UK
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Christophe V, Leroy T, Seillier M, Duthilleul C, Julieron M, Clisant S, Foncel J, Vallet F, Lefebvre JL. Determinants of patient delay in doctor consultation in head and neck cancers (Protocol DEREDIA). BMJ Open 2014; 4:e005286. [PMID: 25063460 PMCID: PMC4120429 DOI: 10.1136/bmjopen-2014-005286] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Reducing the time between the onset of the first symptoms of cancer and the first consultation with a doctor (patient delay) is essential to improve the vital prognosis and quality of life of patients. Longer patient delay is linked to the already known sociodemographic, socioeconomic, socioeducational, sociocultural and socioprofessional factors. However, recent data suggest that some sociocognitive and emotional determinants may explain patient delay from a complementary point of view. The main objective of this study is to assess whether, in head and neck cancer, patient delay is linked to these sociocognitive and emotional factors, in addition to previously known factors. METHODS AND ANALYSIS We intend to include in this study 400 patients with a not yet treated head and neck cancer diagnosed in one of six health centres in the North of France region. The main evaluation criterion is 'patient delay'. Sociocognitive, emotional, medical, sociodemographic, socioeconomic, educational, professional and geographic factors will be assessed by means of (1) a case report form, (2) a questionnaire completed by the clinical research associate together with the patient, (3) a questionnaire completed by the patient and (4) a recorded semidirective interview of the patient by a psychologist (for 80 patients only). The collected data will be analysed to underline the differences between patients who consulted a doctor earlier versus those who consulted later. ETHICS The study has obtained all the relevant authorisations for the protection of patients enrolled in clinical trials (CCTIRS, CCP, CNIL), does not involve products mentioned in article L.5311-1 of the French Code of Public Health, and does not imply any changes in the medical care received by the patients. The study began in October 2012 and will end in June 2015. TRIAL REGISTRATION ID-RCB 2012-A00005-38.
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Affiliation(s)
- Véronique Christophe
- Lille 3 University—URECA EA1059, Villeneuve d'Ascq cedex, France
- U1086 INSERM “Cancers & Préventions”, Université de Caen Basse-Normandie, Avenue de la côte de Nacre, Caen Cedex 5, France
- SIRIC ONCOLille—Maison Régionale de la Recherche Clinique, Lille Cedex, France
| | - Tanguy Leroy
- Lille 3 University—URECA EA1059, Villeneuve d'Ascq cedex, France
- Aix-Marseille University—Public Health and Chronic Diseases, 3 SIRIC ONCOLille, EA 3279, Marseille cedex 05, France
| | - Mélanie Seillier
- Lille 3 University—URECA EA1059, Villeneuve d'Ascq cedex, France
- CERFEP, CARSAT Nord Pas de Calais Picardie, Villeneuve d'Ascq cedex, France
| | | | - Morbize Julieron
- Centre Oscar Lambret—Cervicofacial Oncology Department, Lille cedex, France
| | - Stéphanie Clisant
- Centre Oscar Lambret—Cervicofacial Oncology Department, Lille cedex, France
| | - Jérôme Foncel
- Lille 3 University—EQUIPPE EA 4018, Villeneuve d'Ascq cedex, France
| | - Fanny Vallet
- Lille 3 University—URECA EA1059, Villeneuve d'Ascq cedex, France
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