The frequency, nature and impact of GP-assessed avoidable delays in a population-based cohort of cancer patients

Factors associated with diagnostic and treatment intervals in colorectal cancer: A linked data study

This research aimed to assess the length of intervals before diagnosis and treatment for colorectal cancer in Australia using linked datasets, and to determine any factors associated with interval length. A colorectal cancer clinical registry was linked to general practice electronic medical record data and routinely collected hospital referral datasets to determine the length of four key intervals in the time before first treatment. Cox proportional hazards regression was used to assess associations between individual characteristics (sociodemographic variables such as age and sex, and disease characteristics such as cancer subtype and treatment approach) and the length of each interval. Sample sizes available for analysis varied by interval, ranging from 99 to 9359. The median interval length ranged from 21 (IQR 5-38) days for the time between diagnosis and treatment to 63 (IQR 24-218) days for the time between first presentation and diagnosis. Overall, few measured characteristics were associated with the lengths of any of the intervals. Of note, shorter diagnostic intervals were associated with presenting to the general practitioner with alarm symptoms, and people proceeding to surgery as initial treatment had shorter times to treatment than any other treatment modality. Given disease and medical system factors were associated with interval length, broad improvements to the overall efficient functioning of the healthcare system are likely to improve timeliness. More targeted interventions could focus on processes at the transitions between different levels of the healthcare system and implementing recommended maximum lengths of intervals along the diagnostic and treatment pathway.

Exploring Artificial Intelligence Biases in Predictive Models for Cancer Diagnosis

The American Society of Clinical Oncology (ASCO) has released the principles for the responsible use of artificial intelligence (AI) in oncology emphasizing fairness, accountability, oversight, equity, and transparency. However, the extent to which these principles are followed is unknown. The goal of this study was to assess the presence of biases and the quality of studies on AI models according to the ASCO principles and examine their potential impact through citation analysis and subsequent research applications. A review of original research articles centered on the evaluation of predictive models for cancer diagnosis published in the ASCO journal dedicated to informatics and data science in clinical oncology was conducted. Seventeen potential bias criteria were used to evaluate the sources of bias in the studies, aligned with the ASCO's principles for responsible AI use in oncology. The CREMLS checklist was applied to assess the study quality, focusing on the reporting standards, and the performance metrics along with citation counts of the included studies were analyzed. Nine studies were included. The most common biases were environmental and life-course bias, contextual bias, provider expertise bias, and implicit bias. Among the ASCO principles, the least adhered to were transparency, oversight and privacy, and human-centered AI application. Only 22% of the studies provided access to their data. The CREMLS checklist revealed the deficiencies in methodology and evaluation reporting. Most studies reported performance metrics within moderate to high ranges. Additionally, two studies were replicated in the subsequent research. In conclusion, most studies exhibited various types of bias, reporting deficiencies, and failure to adhere to the principles for responsible AI use in oncology, limiting their applicability and reproducibility. Greater transparency, data accessibility, and compliance with international guidelines are recommended to improve the reliability of AI-based research in oncology.

Analysis of early diagnostic pathway for prostate cancer in Slovenia

BACKGROUND

Prostate cancer (PCa) is a prevalent male malignancy globally. Prolonged diagnostic intervals are associated with poorer outcomes, emphasizing the need to optimize this process. This study aimed to evaluate the doctor and primary care interval, research their impact on patient survival and explore opportunities to improve PCa diagnostic pathway in primary care.

PATIENTS AND METHODS

A retrospective cohort study using cancer patients' anonymised primary care data and data of the Slovenian Cancer Registry.

RESULTS

The study found that the doctor interval had a median duration of 0 days (interquartile range ([IQR] 0-6) and primary care interval a median duration of 5 days (IQR 0-58). Longer intervals were observed in patients with more than two comorbidities, where general practitioners didn't have access to laboratory diagnostic tests within their primary health care centre and when patients first presented with symptoms (reported symptoms at first presentation: dysuria, lower urinary tract symptoms [LUTS], abdominal pain). The analysis also revealed a statistically significant association between lower 5-year survival rate and the accessibility of laboratory and ultrasound diagnostics in primary healthcare centres and a shorter 5-year survival of symptomatic patients in comparison to patients who were identified by elevated levels of prostate specific antigen (PSA).

CONCLUSIONS

This study shows that treating suspected PCa in primary care has a significant impact on 5-year survival. Several factors contribute to better survival, including easy access to laboratory and abdominal ultrasound in primary care centres. The study highlights the complex array of factors shaping PCa diagnosis, beyond individual clinicians' skills, encompassing test and service availability.

Rapid diagnostic pathways for prostate cancer: A realist synthesis

INTRODUCTION

The NHS Long-term Plan outlines a number of approaches to address delays and diagnose three out of four cancers at an early stage, and yet patients regularly experience delays to diagnosis. Attempts to address such delays include the implementation of a number of rapid diagnosis pathways (RDPs). This realist review explores rapid diagnosis pathways for prostate cancer, identifying approaches to RDPs, as well as generating theories regarding what works, for whom and under which circumstances.

METHODS

This is a realist evidence synthesis. The questions and approach are informed by patient and public involvement (PPI). We conducted a scoping review to generate initial programme theories and then refined these through further search processes. As a realist review, we do not focus on a specific data type or outcome, rather we include qualitative and quantitative data to inform theories comprised of contexts, mechanisms, and outcomes (CMO chains).

RESULTS

Six studies were included in our scoping review; twenty studies were included in the second review. The studies include qualitative and quantitative data. We identified three broad themes: Primary care, organizational factors, and patient experience.

CONCLUSIONS/ RECOMMENDATIONS

We recommend the involvement of adjoining services (e.g. general practice and radiology) in the planning of prostate cancer RDPs and emphasize the importance of clear communication with patients.

Interventions to improve timely cancer diagnosis: an integrative review

Cancer will affect more than one in three U.S. residents in their lifetime, and although the diagnosis will be made efficiently in most of these cases, roughly one in five patients will experience a delayed or missed diagnosis. In this integrative review, we focus on missed opportunities in the diagnosis of breast, lung, and colorectal cancer in the ambulatory care environment. From a review of 493 publications, we summarize the current evidence regarding the contributing factors to missed or delayed cancer diagnosis in ambulatory care, as well as evidence to support possible strategies for intervention. Cancer diagnoses are made after follow-up of a positive screening test or an incidental finding, or most commonly, by following up and clarifying non-specific initial presentations to primary care. Breakdowns and delays are unacceptably common in each of these pathways, representing failures to follow-up on abnormal test results, incidental findings, non-specific symptoms, or consults. Interventions aimed at 'closing the loop' represent an opportunity to improve the timeliness of cancer diagnosis and reduce the harm from diagnostic errors. Improving patient engagement, using 'safety netting,' and taking advantage of the functionality offered through health information technology are all viable options to address these problems.

'ThinkCancer!': randomised feasibility trial of a novel practice-based early cancer diagnosis intervention

BACKGROUND

UK cancer deaths remain high; primary care is key for earlier cancer diagnosis as half of avoidable delays occur here. Improvement is possible through lower referral thresholds, better guideline adherence, and better safety-netting systems. Few interventions target whole practice teams. We developed a novel whole-practice team intervention to address this.

AIM

To test the feasibility and acceptability of a novel, complex behavioural intervention, 'ThinkCancer!', for assessment in a subsequent Phase III trial.

DESIGN & SETTING

Pragmatic, superiority pilot randomised controlled trial (RCT) with an embedded process evaluation and feasibility economic analysis in Welsh general practices.

METHOD

Clinical outcome data were collected from practices (the unit of randomisation). Practice characteristics and cancer safety-netting systems were assessed. Individual practice staff completed evaluation and feedback forms and qualitative interviews. The intervention was adapted and refined.

RESULTS

Trial recruitment and workshop deliveries took place between March 2020 and May 2021. Trial progression criteria for recruitment, intervention fidelity, and routine data collection were met. Staff-level fidelity, retention, and individual level data collection processes were reviewed and amended. Interviews highlighted positive participant views on all aspects of the intervention. All practices set out to liberalise referral thresholds appropriately, implement guidelines, and address safety-netting plans in detail.

CONCLUSION

'ThinkCancer!' appears feasible and acceptable. The new iteration of the workshops was completed and the Phase III trial has been funded to assess the effectiveness and cost-effectiveness of this novel professional behaviour change intervention. Delivery at scale to multiple practices will likely improve fidelity and reach.

Hidden systems in primary care cancer detection: an embedded qualitative intervention development study

BACKGROUND

UK cancer mortality is worse than in many other high-income countries, partly because of diagnostic delays in primary care.

AIM

To understand beliefs and behaviours of GPs, and systems of general practice teams, to inform the Think Cancer! intervention development.

DESIGN AND SETTING

An embedded qualitative study guided by behaviour change models (COM-B [Capability, Opportunity, Motivation - Behaviour] and theoretical domains framework [TDF]) in primary care in Wales, UK.

METHOD

Twenty qualitative, semi-structured telephone interviews with GPs were undertaken and four face-to-face focus groups held with practice teams. Framework analysis was used and results were mapped to multiple, overlapping components of COM-B and TDF.

RESULTS

Three themes illustrate complex, multilevel referral considerations facing GPs and practice teams; external influences and constraints; and the role of practice systems and culture. Tensions emerged between individual considerations of GPs (Capability and Motivation) and context-dependent external pressures (Opportunity). Detecting cancer was guided not only by external requirements, but also by motivational factors GPs described as part of their cancer diagnostics process. External influences on the diagnosis process often resulted from the primary-secondary care interface and social pressures. GPs adapted their behaviour to deal with this disconnect. Positive practice culture and supportive practice-based systems ameliorated these tensions and complexity.

CONCLUSION

By exploring individual GP behaviours together with practice systems and culture we contribute new understanding about how cancer diagnosis operates in primary care and how delays can be improved. We highlight commonly overlooked dynamics and tensions that are experienced by GPs as a tension between individual decision making (Capability and Motivation) and external considerations, such as pressures in secondary care (Opportunity).

Cancer in prison: barriers and enablers to diagnosis and treatment

Background

Approximately 82,000 people are in prison annually in England and Wales. Limited research has investigated cancer in this population and none has explored experiences of imprisoned people with cancer. This study aimed to address this gap.

Methods

We conducted 55 semi-structured, qualitative, audio-recorded interviews with: imprisoned people with cancer (n = 24), custodial staff (n = 6), prison healthcare staff (n = 16) and oncology specialists (n = 9). Data were collected 07/10/2019-20/03/2020. Patients were recruited by prison healthcare staff and interviews were conducted face-to-face. Professionals were recruited via professional networks and interviews were conducted face-to-face or via telephone. Transcribed interviews were analysed using reflexive thematic analysis. We also analysed relevant National Cancer Patient Experience Survey (NCPES) questions for those diagnosed in prison (n = 78) and in the general population (n = 390).

Findings

Our findings highlight the complexities of cancer care for imprisoned people. We identified three core themes: control and choice, communication, and care and custody. Whilst people in prison follow a similar diagnostic pathway to those in the community, additional barriers to diagnosis exist including health literacy, the General Practitioner appointment booking system and communication between prison and oncology staff. Tensions between control and choice in prison impacted aspects of cancer care experience such as symptom management and accessing cancer information. NCPES results supported the qualitative findings and showed people in prison reported significantly poorer experiences than in the general population.

Interpretation

Our findings demonstrate the complexity of cancer care in custodial settings, identifying barriers and enablers to equitable cancer care provision and offering insights on how to improve care for this population.

Funding

National Institute for Health and Social Care Research Delivery Research Programme 16/52/53 and Strategic Priorities Fund 2019/20 Research England via University of Surrey.

What would primary care practitioners do differently after a delayed cancer diagnosis? Learning lessons from their experiences

OBJECTIVE

Diagnosis of cancer is challenging in primary care due to the low incidence of cancer cases in primary care practice. A prolonged diagnostic interval may be due to doctor, patient or system factors, or may be due to the characteristics of the cancer itself. The objective of this study was to learn from Primary Care Physicians' (PCP) experiences of incidents when they had failed to think of, or act on, a cancer diagnosis.

DESIGN

A qualitative, online survey eliciting PCP narratives. Thematic analysis was used to analyse the data.

SETTING AND SUBJECTS

A primary care study, with narratives from 159 PCPs in 23 European countries.

MAIN OUTCOME MEASURES

PCPs' narratives on the question 'If you saw this patient with cancer presenting in the same way today, what would you do differently?

RESULTS

The main themes identified were: thinking broadly; improvement in communication and clinical management; use of other available resources and 'I wouldn't do anything differently'.

CONCLUSION (IMPLICATIONS)

To achieve more timely cancer diagnosis, PCPs need to provide a long-term, holistic and active approach with effective communication, and to ensure shared decision-making, follow-up and continuing re-assessment of the patients' clinical conditions.

Cancer care pathways across seven countries in Europe: What are the current obstacles? And how can artificial intelligence help?

BACKGROUND

Cancer poses significant challenges for healthcare professionals across the disease pathway including cancer imaging. This study constitutes part of the user requirement definition of INCISIVE EU project. The project has been designed to explore the full potential of artificial intelligence (AI)-based technologies in cancer imaging to streamline diagnosis and management. The study aimed to map cancer care pathways (breast, prostate, colorectal and lung cancers) across INCISIVE partner countries, and identify bottle necks within these pathways.

METHODS

Email interviews were conducted with ten oncology specialised healthcare professionals representing INCISIVE partner countries: Greece, Cyprus, Spain, Italy, Finland, the United Kingdom (UK) and Serbia. A purposive sampling strategy was employed for recruitment and data was collected between December 2020 and April 2021. Data was entered into Microsoft Excel spreadsheet to allow content examination and comparative analysis.

RESULTS

The analysed pathways all shared a common characteristic: inequalities in relation to delays in cancer diagnosis and treatment. All the studied countries, except the UK, lacked official national data about diagnostic and therapeutic delays. Furthermore, a considerable variation was noted regarding the availability of imaging and diagnostic services across the seven countries. Several concerns were also noted for inefficiencies/inequalities with regards to national screening for the four investigated cancer types.

CONCLUSIONS

Delays in cancer diagnosis and treatment are an ongoing challenge and a source for inequalities. It is important to have systematic reporting of diagnostic and therapeutic delays in all countries to allow the proper estimation of its magnitude and support needed to address it. Our findings also support the orientation of the current policies towards early detection and wide scale adoption and implementation of cancer screening, through research, innovation, and technology. Technologies involving AI can have a great potential to revolutionise cancer care delivery.

POLICY SUMMARY

This study highlights the widespread delay in cancer diagnosis across Europe and supports the need for, systematic reporting of delays, improved availability of imaging services, and optimised national screening programs. The goal is to enhance cancer care delivery, encourage early detection, and implement research, innovation, and AI-based technologies for improved cancer imaging.

Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis. A qualitative study

BACKGROUND

While primary care physicians (PCPs) play a key role in cancer detection, they can find cancer diagnosis challenging, and some patients have considerable delays between presentation and onward referral.

AIM

To explore European PCPs' experiences and views on cases where they considered that they had been slow to think of, or act on, a possible cancer diagnosis.

DESIGN & SETTING

A multicentre European qualitative study, based on an online survey with open-ended questions, asking PCPs for their narratives about cases when they had missed a diagnosis of cancer.

METHOD

Using maximum variation sampling, PCPs in 23 European countries were asked to describe what happened in a case where they were slow to think of a cancer diagnosis, and for their views on why it happened. Thematic analysis was used to analyse the data.

RESULTS

A total of 158 PCPs completed the questionnaire. The main themes were as follows: patients' descriptions did not suggest cancer; distracting factors reduced PCPs' cancer suspicions; patients' hesitancy delayed the diagnosis; system factors not facilitating timely diagnosis; PCPs felt that they had acted wrongly; and problems with communicating adequately.

CONCLUSION

The study identified six overarching themes that need to be addressed. Doing so should reduce morbidity and mortality in the small proportion of patients who have a significant, avoidable delay in their cancer diagnosis. The 'Swiss cheese' model of accident causation showed how the themes related to each other.

Priorities for implementation research on diagnosing cancer in primary care: a consensus process

BACKGROUND

The early detection and diagnosis of cancer to reduce avoidable mortality and morbidity is a challenging task in primary health care. There is a growing evidence base on how to enable earlier cancer diagnosis, but well-recognised gaps and delays exist around the translation of new research findings into routine clinical practice. Implementation research aims to accelerate the uptake of evidence by health care systems and professionals. We aimed to identify priorities for implementation research in early cancer diagnosis in primary care.

METHODS

We used a RAND/UCLA modified Delphi consensus process to identify and rank research priorities. We asked primary care physicians, patients and researchers to complete an online survey suggesting priorities for implementation research in cancer detection and diagnosis. We summarised and presented these suggestions to an 11-member consensus panel comprising nine primary care physicians and two patients. Panellists independently rated the importance of suggestions on a 1-9 scale (9 = very high priority; 1 = very low priority) before and after a structured group discussion. We ranked suggestions using median ratings.

RESULTS

We received a total of 115 suggested priorities for implementation research from 32 survey respondents (including 16 primary care professionals, 11 researchers, and 4 patient and public representatives; 88% of respondents were UK-based). After removing duplicates and ineligible suggestions, we presented 37 suggestions grouped within 17 categories to the consensus panel. Following two rounds of rating, 27 suggestions were highly supported (median rating 7-9). The most highly rated suggestions concerned diagnostic support (e.g., access to imaging) interventions (e.g., professional or patient education), organisation of the delivery of care (e.g., communication within and between teams) and understanding variations in care and outcomes.

CONCLUSIONS

We have identified a set of priorities for implementation research on the early diagnosis of cancer, ranked in importance by primary care physicians and patients. We suggest that researchers and research funders consider these in directing further efforts and resources to improve population outcomes.

A taxonomy of early diagnosis research to guide study design and funding prioritisation

Researchers and research funders aiming to improve diagnosis seek to identify if, when, where, and how earlier diagnosis is possible. This has led to the propagation of research studies using a wide range of methodologies and data sources to explore diagnostic processes. Many such studies use electronic health record data and focus on cancer diagnosis. Based on this literature, we propose a taxonomy to guide the design and support the synthesis of early diagnosis research, focusing on five key questions: Do healthcare use patterns suggest earlier diagnosis could be possible? How does the diagnostic process begin? How do patients progress from presentation to diagnosis? How long does the diagnostic process take? Could anything have been done differently to reach the correct diagnosis sooner? We define families of diagnostic research study designs addressing each of these questions and appraise their unique or complementary contributions and limitations. We identify three further questions on relationships between the families and their relevance for examining patient group inequalities, supported with examples from the cancer literature. Although exemplified through cancer as a disease model, we recognise the framework is also applicable to non-neoplastic disease. The proposed framework can guide future study design and research funding prioritisation.

Cancer care at the time of the fourth industrial revolution: an insight to healthcare professionals' perspectives on cancer care and artificial intelligence

BACKGROUND

The integration of Artificial Intelligence (AI) technology in cancer care has gained unprecedented global attention over the past few decades. This has impacted the way that cancer care is practiced and delivered across settings. The purpose of this study was to explore the perspectives and experiences of healthcare professionals (HCPs) on cancer treatment and the need for AI. This study is a part of the INCISIVE European Union H2020 project's development of user requirements, which aims to fully explore the potential of AI-based cancer imaging technologies.

METHODS

A mixed-methods research design was employed. HCPs participating in cancer care in the UK, Greece, Italy, Spain, Cyprus, and Serbia were first surveyed anonymously online. Twenty-seven HCPs then participated in semi-structured interviews. Appropriate statistical method was adopted to report the survey results by using SPSS. The interviews were audio recorded, verbatim transcribed, and then thematically analysed supported by NVIVO.

RESULTS

The survey drew responses from 95 HCPs. The occurrence of diagnostic delay was reported by 56% (n = 28/50) for breast cancer, 64% (n = 27/42) for lung cancer, 76% (n = 34/45) for colorectal cancer and 42% (n = 16/38) for prostate cancer. A proportion of participants reported the occurrence of false positives in the accuracy of the current imaging techniques used: 64% (n = 32/50) reported this for breast cancer, 60% (n = 25/42) for lung cancer, 51% (n = 23/45) for colorectal cancer and 45% (n = 17/38) for prostate cancer. All participants agreed that the use of technology would enhance the care pathway for cancer patients. Despite the positive perspectives toward AI, certain limitations were also recorded. The majority (73%) of respondents (n = 69/95) reported they had never utilised technology in the care pathway which necessitates the need for education and training in the qualitative finding; compared to 27% (n = 26/95) who had and were still using it. Most, 89% of respondents (n = 85/95) said they would be opened to providing AI-based services in the future to improve medical imaging for cancer care. Interviews with HCPs revealed lack of widespread preparedness for AI in oncology, several barriers to introducing AI, and a need for education and training. Provision of AI training, increasing public awareness of AI, using evidence-based technology, and developing AI based interventions that will not replace HCPs were some of the recommendations.

CONCLUSION

HCPs reported favourable opinions of AI-based cancer imaging technologies and noted a number of care pathway concerns where AI can be useful. For the future design and execution of the INCISIVE project and other comparable AI-based projects, the characteristics and recommendations offered in the current research can serve as a reference.

Lung cancer in never smokers (LCINS): development of a UK national research strategy

INTRODUCTION

Lung cancer in never smokers (LCINS) accounts for 15% of lung cancers diagnosed in the UK, making it the 8th most common cancer. There are few robust studies specific to the LCINS population making data surrounding the incidence and mortality of LCINS incomplete, leaving many gaps in our understanding of the needs of this population.

METHODS

To address a lack of research in this important area, the UK National Cancer Research Institute Lung Study Group (NCRI-LSG) undertook a national survey and hosted a research strategy day to define key research priorities. A wide cross section of stakeholders, including patient advocates, the charitable sector, basic and translational researchers, and multi-disciplinary healthcare professionals contributed highlighting their research priorities.

RESULTS

One-hundred twenty-seven surveys were completed (52 by patients/patient advocates) prior to the strategy day. These identified themes for expert review presentations and subsequent workshop discussions at the national research strategy day, which registered 190 attendees (50 patients/patient advocates). The four key themes that emerged to form the basis of a research strategy for LCINS are (1) Raising awareness, (2) Risk assessment and early detection, (3) Disease biology, (4) Living with and beyond.

CONCLUSION

This paper summarises current evidence and important gaps in our knowledge related to LCINS. We present recommendations for a national research strategy aimed at improving outcomes for patients.

Evolution of community health workers: the fourth stage

Introduction

Comprehensive primary care is a key component of any good health system. Designers need to incorporate the Starfield requirements of (i) a defined population, (ii) comprehensive range, (iii) continuity of services, and (iv) easy accessibility, as well as address several related issues. They also need to keep in mind that the classical British GP model, because of the severe challenges of physician availability, is all but infeasible for most developing countries. There is, therefore, an urgent need for them to find a new approach which offers comparable, possibly even superior, outcomes. The next evolutionary stage of the traditional Community health worker (CHW) model may well offer them one such approach.

Methods

We suggest that there are potentially four stages in the evolution of the CHW - the health messenger, the physician extender, the focused provider, and the comprehensive provider. In the latter two stages, the physician becomes much more of an adjunct figure, unlike in the first two, where the physician is at the center. We examine the comprehensive provider stage (stage 4) with the help of programs that have attempted to explore this stage, using Qualitative Comparative Analysis (QCA) developed by Ragin. Starting with the 4 Starfield principles, we first arrive at 17 potential characteristics that could be important. Based on a careful reading of the six programs, we then attempt to determine the characteristics that apply to each program. Using this data, we look across all the programs to ascertain which of these characteristics are important to the success of these six programs. Using a truth table, we then compare the programs which have more than 80% of the characteristics with those that have fewer than 80%, to identify characteristics that distinguish between them. Using these methods, we analyse two global programs and four Indian ones.

Results

Our analysis suggests that the global Alaskan and Iranian, and the Indian Dvara Health and Swasthya Swaraj programs incorporate more than 80% (> 14) of the 17 characteristics. Of these 17, there are 6 foundational characteristics that are present in all the six stage 4 programs discussed in this study. These include (i) close supervision of the CHW; (ii) care coordination for treatment not directly provided by the CHW; (iii) defined referral pathways to be used to guide referrals; (iv) medication management which closes the loop with patients on all the medicines that they need both immediately and on an ongoing basis (the only characteristic which needs engagement with a licensed physician); (v) proactive care: which ensures adherence to treatment plans; and (vi) cost-effectiveness in the use of scarce physician and financial resources. When comparing between programs, we find that the five essential added elements of a high-performance stage 4 program are (i) the full empanelment of a defined population; (ii) their comprehensive assessment, (iii) risk stratification so that the focus can be on the high-risk individuals, (iv) the use of carefully defined care protocols, and (v) the use of cultural wisdom both to learn from the community and to work with them to persuade them to adhere to treatment regimens.

Primary care blood tests before cancer diagnosis: National Cancer Diagnosis Audit data

BACKGROUND

Blood tests can support the diagnostic process in patients with cancer but how often they are used is unclear.

AIM

To explore use of common blood tests before cancer diagnosis in primary care.

DESIGN AND SETTING

English National Cancer Diagnosis Audit data on 39 752 patients with cancer diagnosed in 2018.

METHOD

Common blood test use (full blood count [FBC], urea and electrolytes [U&E], and liver function tests [LFTs]), variation by patient and symptom group, and associations with the primary care interval and the diagnostic interval were assessed.

RESULTS

At least one common blood test was used in 41% (n = 16 427/39 752) of patients subsequently diagnosed with cancer. Among tested patients, (n = 16 427), FBC was used in 95% (n = 15 540), U&E in 89% (n = 14 555), and LFTs in 76% (n = 12 414). Blood testing was less common in females (adjusted odds ratio versus males: 0.92, 95% confidence interval [CI] = 0.87 to 0.98) and Black and minority ethnic patients (0.89, 95% CI = 0.82 to 0.97 versus White), and more common in older patients (1.12, 95% CI = 1.06 to 1.18 for ≥70 years versus 50-69 years). Test use varied greatly by cancer site (melanoma 2% [ n = 55/2297]; leukaemia 84% [ n = 552/661]). Fewer patients presenting with alarm symptoms alone were tested (24% [ n = 3341/13 778]) than those with non-alarm symptoms alone (50% [ n = 8223/16 487]). Median primary care interval and diagnostic interval were longer in tested than non-tested patients (primary care interval: 10 versus 0 days; diagnostic interval: 49 versus 32 days, respectively, P<0.001 for both), including among tested patients with alarm symptoms (primary care interval: 4 versus 0 days; diagnostic interval: 41 versus 22 days).

CONCLUSION

Two-fifths of patients subsequently diagnosed with cancer have primary care blood tests as part of their diagnostic process. Given variable test use, research is needed on the clinical context in which blood tests are ordered.

Concordance with urgent referral guidelines in patients presenting with any of six 'alarm' features of possible cancer: a retrospective cohort study using linked primary care records

BACKGROUND

Clinical guidelines advise GPs in England which patients warrant an urgent referral for suspected cancer. This study assessed how often GPs follow the guidelines, whether certain patients are less likely to be referred, and how many patients were diagnosed with cancer within 1 year of non-referral.

METHODS

We used linked primary care (Clinical Practice Research Datalink), secondary care (Hospital Episode Statistics) and cancer registration data. Patients presenting with haematuria, breast lump, dysphagia, iron-deficiency anaemia, post-menopausal or rectal bleeding for the first time during 2014-2015 were included (for ages where guidelines recommend urgent referral). Logistic regression was used to investigate whether receiving a referral was associated with feature type and patient characteristics. Cancer incidence (based on recorded diagnoses in cancer registry data within 1 year of presentation) was compared between those receiving and those not receiving referrals.

RESULTS

48 715 patients were included, of which 40% (n=19 670) received an urgent referral within 14 days of presentation, varying by feature from 17% (dysphagia) to 68% (breast lump). Young patients (18-24 vs 55-64 years; adjusted OR 0.20, 95% CI 0.10 to 0.42, p<0.001) and those with comorbidities (4 vs 0 comorbidities; adjusted OR 0.87, 95% CI 0.80 to 0.94, p<0.001) were less likely to receive a referral. Associations between patient characteristics and referrals differed across features: among patients presenting with anaemia, breast lump or haematuria, those with multi-morbidity, and additionally for breast lump, more deprived patients were less likely to receive a referral. Of 29 045 patients not receiving a referral, 3.6% (1047) were diagnosed with cancer within 1 year, ranging from 2.8% for rectal bleeding to 9.5% for anaemia.

CONCLUSIONS

Guideline recommendations for action are not followed for the majority of patients presenting with common possible cancer features. A significant number of these patients developed cancer within 1 year of their consultation, indicating scope for improvement in the diagnostic process.

Role of primary care physician factors on diagnostic testing and referral decisions for symptoms of possible cancer: a systematic review

BACKGROUND

Missed opportunities for diagnosing cancer cause patients harm and have been attributed to suboptimal use of tests and referral pathways in primary care. Primary care physician (PCP) factors have been suggested to affect decisions to investigate cancer, but their influence is poorly understood.

OBJECTIVE

To synthesise evidence evaluating the influence of PCP factors on decisions to investigate symptoms of possible cancer.

METHODS

We searched MEDLINE, Embase, Scopus, CINAHL and PsycINFO between January 1990 and March 2021 for relevant citations. Studies examining the effect or perceptions and experiences of PCP factors on use of tests and referrals for symptomatic patients with any cancer were included. PCP factors comprised personal characteristics and attributes of physicians in clinical practice.

DATA EXTRACTION AND SYNTHESIS

Critical appraisal and data extraction were undertaken independently by two authors. Due to study heterogeneity, data could not be statistically pooled. We, therefore, performed a narrative synthesis.

RESULTS

29 studies were included. Most studies were conducted in European countries. A total of 11 PCP factors were identified comprising modifiable and non-modifiable factors. Clinical judgement of symptoms as suspicious or 'alarm' prompted more investigations than non-alarm symptoms. 'Gut feeling' predicted a subsequent cancer diagnosis and was perceived to facilitate decisions to investigate non-specific symptoms as PCP experience increased. Female PCPs investigated cancer more than male PCPs. The effect of PCP age and years of experience on testing and referral decisions was inconclusive.

CONCLUSIONS

PCP interpretation of symptoms as higher risk facilitated testing and referral decisions for possible cancer. However, in the absence of 'alarm' symptoms or 'gut feeling', PCPs may not investigate cancer. PCPs require strategies for identifying patients with non-alarm and non-specific symptoms who need testing or referral.

PROSPERO REGISTRATION NUMBER

CRD420191560515.

Investigating the inequalities in route to diagnosis amongst patients with diffuse large B-cell or follicular lymphoma in England

INTRODUCTION

Diagnostic delay is associated with lower chances of cancer survival. Underlying comorbidities are known to affect the timely diagnosis of cancer. Diffuse large B-cell (DLBCL) and follicular lymphomas (FL) are primarily diagnosed amongst older patients, who are more likely to have comorbidities. Characteristics of clinical commissioning groups (CCG) are also known to impact diagnostic delay. We assess the association between comorbidities and diagnostic delay amongst patients with DLBCL or FL in England during 2005-2013.

METHODS

Multivariable generalised linear mixed-effect models were used to assess the main association. Empirical Bayes estimates of the random effects were used to explore between-cluster variation. The latent normal joint modelling multiple imputation approach was used to account for partially observed variables.

RESULTS

We included 30,078 and 15,551 patients diagnosed with DLBCL or FL, respectively. Amongst patients from the same CCG, having multimorbidity was strongly associated with the emergency route to diagnosis (DLBCL: odds ratio 1.56, CI 1.40-1.73; FL: odds ratio 1.80, CI 1.45-2.23). Amongst DLBCL patients, the diagnostic delay was possibly correlated with CCGs that had higher population densities.

CONCLUSIONS

Underlying comorbidity is associated with diagnostic delay amongst patients with DLBCL or FL. Results suggest a possible correlation between CCGs with higher population densities and diagnostic delay of aggressive lymphomas.

Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review

OBJECTIVE

To estimate the incidence of avoidable significant harm in primary care in England; describe and classify the associated patient safety incidents and generate suggestions to mitigate risks of ameliorable factors contributing to the incidents.

DESIGN

Retrospective case note review. Patients with significant health problems were identified and clinical judgements were made on avoidability and severity of harm. Factors contributing to avoidable harm were identified and recorded.

SETTING

Primary care.

PARTICIPANTS

Thirteen general practitioners (GPs) undertook a retrospective case note review of a sample of 14 407 primary care patients registered with 12 randomly selected general practices from three regions in England (total list size: 92 255 patients).

MAIN OUTCOME MEASURES

The incidence of significant harm considered at least 'probably avoidable' and the nature of the safety incidents.

RESULTS

The rate of significant harm considered at least probably avoidable was 35.6 (95% CI 23.3 to 48.0) per 100 000 patient-years (57.9, 95% CI 42.2 to 73.7, per 100 000 based on a sensitivity analysis). Overall, 74 cases of avoidable harm were detected, involving 72 patients. Three types of incident accounted for more than 90% of the problems: problems with diagnosis accounted for 45/74 (60.8%) primary incidents, followed by medication-related problems (n=19, 25.7%) and delayed referrals (n=8, 10.8%). In 59 (79.7%) cases, the significant harm could have been identified sooner (n=48) or prevented (n=11) if the GP had taken actions aligned with evidence-based guidelines.

CONCLUSION

There is likely to be a substantial burden of avoidable significant harm attributable to primary care in England with diagnostic error accounting for most harms. Based on the contributory factors we found, improvements could be made through more effective implementation of existing information technology, enhanced team coordination and communication, and greater personal and informational continuity of care.

Interventions to reduce the time to diagnosis of brain tumours

BACKGROUND

Brain tumours are recognised as one of the most difficult cancers to diagnose because presenting symptoms, such as headache, cognitive symptoms, and seizures, may be more commonly attributable to other, more benign conditions. Interventions to reduce the time to diagnosis of brain tumours include national awareness initiatives, expedited pathways, and protocols to diagnose brain tumours, based on a person's presenting symptoms and signs; and interventions to reduce waiting times for brain imaging pathways. If such interventions reduce the time to diagnosis, it may make it less likely that people experience clinical deterioration, and different treatment options may be available.

OBJECTIVES

To systematically evaluate evidence on the effectiveness of interventions that may influence: symptomatic participants to present early (shortening the patient interval), thresholds for primary care referral (shortening the primary care interval), and time to imaging diagnosis (shortening the secondary care interval and diagnostic interval). To produce a brief economic commentary, summarising the economic evaluations relevant to these interventions.

SEARCH METHODS

For evidence on effectiveness, we searched CENTRAL, MEDLINE, and Embase from January 2000 to January 2020; Clinicaltrials.gov to May 2020, and conference proceedings from 2014 to 2018. For economic evidence, we searched the UK National Health Services Economic Evaluation Database from 2000 to December 2014.

SELECTION CRITERIA

We planned to include studies evaluating any active intervention that may influence the diagnostic pathway, e.g. clinical guidelines, direct access imaging, public health campaigns, educational initiatives, and other interventions that might lead to early identification of primary brain tumours. We planned to include randomised and non-randomised comparative studies. Included studies would include people of any age, with a presentation that might suggest a brain tumour.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles identified by the search strategy, and the full texts of potentially eligible studies. We resolved discrepancies through discussion or, if required, by consulting another review author.

MAIN RESULTS

We did not identify any studies for inclusion in this review. We excluded 115 studies. The main reason for exclusion of potentially eligible intervention studies was their study design, due to a lack of control groups. We found no economic evidence to inform a brief economic commentary on this topic.

AUTHORS' CONCLUSIONS

In this version of the review, we did not identify any studies that met the review inclusion criteria for either effectiveness or cost-effectiveness. Therefore, there is no evidence from good quality studies on the best strategies to reduce the time to diagnosis of brain tumours, despite the prioritisation of research on early diagnosis by the James Lind Alliance in 2015. This review highlights the need for research in this area.

What is Elective Oncologic Surgery in the Time of COVID-19? A Literature Review of the Impact of Surgical Delays on Outcomes in Patients with Cancer

Background

The impact of the COVID-19 pandemic has spread beyond those infected with SARS-CoV-2. Its widespread consequences have affected cancer patients whose surgeries may be delayed in order to minimize exposure and conserve resources.

Methods

Experts in each surgical oncology subspecialty were selected to perform a review of the relevant literature. Articles were obtained through PubMed searches in each cancer subtype using the following terms: delay to surgery, time to surgery, outcomes, and survival.

Results

Delays in surgery > 4 weeks in breast cancer, ductal carcinoma in situ, T1 pancreatic cancer, ovarian cancer, and pediatric osteosarcoma, negatively impacted survival. Studies on hepatocellular cancer, colon cancer, and melanoma (Stage I) demonstrated reduced survival with delays > 3 months.

Conclusion

Studies have shown that short-term surgical delays can result in negative impacts on patient outcomes in multiple cancer types as well as in situ carcinoma. Conversely, other cancers such as gastric cancer, advanced melanoma and pancreatic cancer, well-differentiated thyroid cancer, and several genitourinary cancers demonstrated no significant outcome differences with surgical delays.