Symptom Signatures and Diagnostic Timeliness in Cancer Patients: A Review of Current Evidence

Adoption, acceptance, and use of a decision support tool to promote timely investigations for cancer in primary care

BACKGROUND

The complexities of diagnosing cancer in general practice has driven the development of quality improvement (QI) interventions, including clinical decision support (CDS) and auditing tools. Future Health Today (FHT) is a novel QI tool, consisting of CDS at the point-of-care, practice population-level auditing, recall, and the monitoring of QI activities.

OBJECTIVES

Explore the acceptability and usability of the FHT cancer module, which flags patients with abnormal test results that may be indicative of undiagnosed cancer.

METHODS

Interviews were conducted with general practitioners (GPs) and general practice nurses (GPNs), from practices participating in a randomized trial evaluating the appropriate follow-up of patients. Clinical Performance Feedback Intervention Theory (CP-FIT) was used to analyse and interpret the data.

RESULTS

The majority of practices reported not using the auditing and QI components of the tool, only the CDS which was delivered at the point-of-care. The tool was used primarily by GPs; GPNs did not perceive the clinical recommendations to be within their role. For the CDS, facilitators for use included a good workflow fit, ease of use, low time cost, importance, and perceived knowledge gain. Barriers for use of the CDS included accuracy, competing priorities, and the patient population.

CONCLUSIONS

The CDS aligned with the clinical workflow of GPs, was considered non-disruptive to the consultation and easy to implement into usual care. By applying the CP-FIT theory, we were able to demonstrate the key drivers for GPs using the tool, and what limited the use by GPNs.

The effect of comorbidities on diagnostic interval for lung cancer in England: a cohort study using electronic health record data

BACKGROUND

Comorbid conditions may delay lung cancer diagnosis by placing demand on general practioners' time reducing the possibility of prompt cancer investigation ("competing demand conditions"), or by offering a plausible non-cancer explanation for signs/symptoms ("alternative explanation conditions").

METHOD

Patients in England born before 1955 and diagnosed with incident lung cancer between 1990 and 2019 were identified in the Clinical Practice Research Datalink and linked hospital admission and cancer registry data. Diagnostic interval was defined as time from first presentation in primary care with a relevant sign/symptom to the diagnosis date. 14 comorbidities were classified as ten "competing demand" and four "alternative explanation" conditions. Associations with diagnostic interval were investigated using multivariable linear regression models.

RESULTS

Complete data were available for 11870 lung cancer patients. In adjusted analyses diagnostic interval was longer for patients with "alternative explanation" conditions, by 31 and 74 days in patients with one and ≥2 conditions respectively versus those with none. Number of "competing demand" conditions did not remain in the final adjusted regression model for diagnostic interval.

CONCLUSIONS

Conditions offering alternative explanations for lung cancer symptoms are associated with increased diagnostic intervals. Clinical guidelines should incorporate the impact of alternative and competing causes upon delayed diagnosis.

Clinical characterisation of patients diagnosed with cancer following emergency self-referral

BACKGROUND

Despite their frequency and potential impact on prognosis, cancers diagnosed via self-referral to the emergency department are poorly documented. We conducted a detailed analysis of cancer patients diagnosed following emergency self-referral and compared them with those diagnosed following emergency referral from primary care. Given the challenges associated with measuring intervals in the emergency self-referral pathway, we also aimed to provide a definition of the diagnostic interval for these cancers.

METHODS

A retrospective observational analysis was performed on patients diagnosed with 13 cancers, either following emergency self-referral or emergency referral from primary care. We analysed demographics, tumour stage, clinical data (including 28 presenting symptoms categorised by body systems), and diagnostic intervals by cancer site, then testing for differences between pathways.

RESULTS

Out of 3624 patients, 37 % were diagnosed following emergency self-referral and 63 % via emergency referral from primary care. Emergency self-referrals were associated with a higher likelihood of being diagnosed with cancers manifesting with localising symptoms (e.g., breast and endometrial cancer), whereas the likelihood of being diagnosed with cancers featuring nonspecific symptoms and abdominal pain (e.g., pancreatic and ovarian cancer) was higher among patients referred from primary care. Diagnostic intervals in self-referred patients were half as long as those in patients referred from primary care, with most significant differences for pancreatic cancer (28 [95 % CI -34 to -23] days shorter, respectively).

CONCLUSION

These findings enrich the best available evidence on cancer diagnosis through emergency self-referral and showed that, compared with the emergency referral pathway from primary care, these patients had a significantly increased likelihood of presenting with symptoms that are strongly predictive of cancer. Since the starting point for the diagnostic interval in these patients is their emergency presentation, comparing it with that of those referred from primary care as an emergency is likely to result in biased data.

Determining factors of presentation and diagnosis delays in patients with colorectal cancer and the impact on stage: a cross sectional study in Yogyakarta, Indonesia

Background

Early colorectal cancer (CRC) symptom recognition and prompt diagnosis are crucial for the identification of cases in the earliest stage and for improving survival. This study investigates the incidence of presentation and diagnosis delays, their contributing determinants and their impact on the cancer stage at diagnosis.

Methods

This cross-sectional study recruited 227 CRC patients between November 2022 and October 2023. We developed a semi-structured questionnaire to collect information on the factors related to delays in the presentation and diagnosis. Presentation delay was defined as the time between the initial symptoms and the first consultation exceeding 1 month, while diagnosis delay was defined as the time between presentation and the pathological diagnosis confirmation exceeding 4 months. We examined the impact of these delays on the status of the metastatic disease and identified the determinants of the presentation and diagnosis delays.

Results

The median values for presentation and diagnosis delay are 1 and 4 months, respectively. Patients aged ≥60 years were less likely to experience diagnosis delays odds ratio (OR = 0.52, 95% confidence interval (CI) 0.28-0.95, p = 0.035), as opposed to those who were younger. The absence of red flag symptoms at presentation (OR = 2.73, 95% CI 1.47-5.10, p = 0.002), the utilisation of complementary and alternative medicine (OR = 2.01, 95% CI 1.12-3.61, p = 0.019) and ≥3 distinct healthcare facility visits before diagnosis (OR = 3.51, 95% CI 1.95-6.29, p < 0.001) were associated with an increased risk of diagnosis delays. Diagnosis delays were also correlated with a higher risk of metastatic disease at diagnosis (OR = 2.04, 95% CI 1.17-3.53, p = 0.011).

Conclusion

Our CRC patients experience considerable delays in their presentation and diagnosis. Diagnosis delays were observed to increase the likelihood of presenting with metastatic disease. Given the determinants and the patients' perspectives revealed in this study, future research to explore evidence-based approaches to reducing these delays is warranted.

Time to Diagnosis and Presenting Symptoms of Patients Diagnosed With Cancer Through Emergency and Nonemergency Routes: A Large Retrospective Study From a High-Volume Center

PURPOSE

The symptoms with which a patient with cancer presents and the route taken to diagnosis (emergency v nonemergency) may affect the speed with which the diagnosis of cancer is made, thereby affecting outcomes. We examined time to diagnosis by symptom for cancers diagnosed through emergency and nonemergency routes (NERs).

METHODS

We performed a retrospective review of patients diagnosed with 10 solid cancers at Hospital Clínic of Barcelona between March 2013 and June 2023. Cancers were diagnosed through emergency presentation and admission (inpatient emergency route [IER]), emergency presentation and outpatient referral (outpatient emergency route [OER]), and primary care presentation and outpatient referral (NER). We assessed the effect of diagnostic routes on intervals to diagnosis for 19 cancer symptoms.

RESULTS

A total of 5,174 and 1,607 patients were diagnosed with cancer through emergency routes and NERs, respectively. Over 85% of patients presenting with alarm (localizing) symptoms such as hematuria through emergency routes were diagnosed with the expected cancer, whereas those with nonlocalizing symptoms such as abdominal pain had a more heterogeneous cancer-site composition. Median intervals were shorter for alarm than nonlocalizing symptoms and tended to be shorter in IERs than OERs. However, for most symptoms, intervals in both routes were invariably shorter than in the NER. For example, diagnostic intervals for hematuria and abdominal pain were 3 and 5 days shorter in IERs than OERs, but they were 5-8 and 17-22 days shorter than in the NER, respectively.

CONCLUSION

For patients with alarm symptoms, intervals were shorter than for those with nonlocalizing symptoms and, for most symptoms, intervals were shorter when patients were evaluated by emergency routes rather than NERs.

Predictive value of abnormal blood tests for detecting cancer in primary care patients with nonspecific abdominal symptoms: A population-based cohort study of 477,870 patients in England

BACKGROUND

Identifying patients presenting with nonspecific abdominal symptoms who have underlying cancer is a challenge. Common blood tests are widely used to investigate these symptoms in primary care, but their predictive value for detecting cancer in this context is unknown. We quantify the predictive value of 19 abnormal blood test results for detecting underlying cancer in patients presenting with 2 nonspecific abdominal symptoms.

METHODS AND FINDINGS

Using data from the UK Clinical Practice Research Datalink (CPRD) linked to the National Cancer Registry, Hospital Episode Statistics and Index of Multiple Deprivation, we conducted a population-based cohort study of patients aged ≥30 presenting to English general practice with abdominal pain or bloating between January 2007 and October 2016. Positive and negative predictive values (PPV and NPV), sensitivity, and specificity for cancer diagnosis (overall and by cancer site) were calculated for 19 abnormal blood test results co-occurring in primary care within 3 months of abdominal pain or bloating presentations. A total of 9,427/425,549 (2.2%) patients with abdominal pain and 1,148/52,321 (2.2%) with abdominal bloating were diagnosed with cancer within 12 months post-presentation. For both symptoms, in both males and females aged ≥60, the PPV for cancer exceeded the 3% risk threshold used by the UK National Institute for Health and Care Excellence for recommending urgent specialist cancer referral. Concurrent blood tests were performed in two thirds of all patients (64% with abdominal pain and 70% with bloating). In patients aged 30 to 59, several blood abnormalities updated a patient's cancer risk to above the 3% threshold: For example, in females aged 50 to 59 with abdominal bloating, pre-blood test cancer risk of 1.6% increased to: 10% with raised ferritin, 9% with low albumin, 8% with raised platelets, 6% with raised inflammatory markers, and 4% with anaemia. Compared to risk assessment solely based on presenting symptom, age and sex, for every 1,000 patients with abdominal bloating, assessment incorporating information from blood test results would result in 63 additional urgent suspected cancer referrals and would identify 3 extra cancer patients through this route (a 16% relative increase in cancer diagnosis yield). Study limitations include reliance on completeness of coding of symptoms in primary care records and possible variation in PPVs if extrapolated to healthcare settings with higher or lower rates of blood test use.

CONCLUSIONS

In patients consulting with nonspecific abdominal symptoms, the assessment of cancer risk based on symptoms, age and sex alone can be substantially enhanced by considering additional information from common blood test results. Male and female patients aged ≥60 presenting to primary care with abdominal pain or bloating warrant consideration for urgent cancer referral or investigation. Further cancer assessment should also be considered in patients aged 30 to 59 with concurrent blood test abnormalities. This approach can detect additional patients with underlying cancer through expedited referral routes and can guide decisions on specialist referrals and investigation strategies for different cancer sites.

Trends in primary care blood tests prior to lung and colorectal cancer diagnosis-A retrospective cohort study using linked Australian data

INTRODUCTION

Abnormal results in common blood tests may occur several months before lung cancer (LC) and colorectal cancer (CRC) diagnosis. Identifying early blood markers of cancer and distinct blood test signatures could support earlier diagnosis in general practice.

METHODS

Using linked Australian primary care and hospital cancer registry data, we conducted a cohort study of 855 LC and 399 CRC patients diagnosed between 2001 and 2021. Requests and results from general practice blood tests (six acute phase reactants [APR] and six red blood cell indices [RBCI]) were examined in the 2 years before cancer diagnosis. Poisson regression models were used to estimate monthly incidence rates and examine pre-diagnostic trends in blood test use and abnormal results prior to cancer diagnosis, comparing patterns in LC and CRC patients.

RESULTS

General practice blood test requests increase from 7 months before CRC and 6 months before LC diagnosis. Abnormalities in many APR and RBCI tests increase several months before cancer diagnosis, often occur prior to or in the absence of anaemia (in 51% of CRC and 81% of LC patients with abnormalities), and are different in LC and CRC patients.

CONCLUSIONS

This study demonstrates an increase in diagnostic activity in Australian general practice several months before LC and CRC diagnosis, indicating potential opportunities for earlier diagnosis. It identifies blood test abnormalities and distinct signatures that are early markers of LC and CRC. If combined with other pre-diagnostic information, these blood tests have potential to support GPs in prioritising patients for cancer investigation of different sites to expedite diagnosis.

Nonspecific Signs and/or Symptoms of Cancer: A Retrospective, Observational Analysis from a Secondary Care, US Community Oncology Dataset

To help determine the unmet need for improved diagnostic tools to evaluate patients with nonspecific signs and/or symptoms (NSSS) and suspicion of cancer, we examined patient characteristics, diagnostic journey, and cancer incidence of patients with NSSS within The US Oncology Network (The Network), a secondary care community oncology setting. This retrospective, observational cohort study included patients aged ≥40 years with ≥1 NSSS in their problem list at their first visit within The Network (the index date) between 1 January 2016 and 31 December 2020. Patients were followed longitudinally with electronic health record data for initial cancer diagnosis, new noncancer diagnosis, death, end of study observation period, or 12 months, whichever occurred first. Of 103,984 patients eligible for inclusion, 96,722 presented with only 1 NSSS at index date; 6537/103,984 (6.3%) were diagnosed with 1 primary cancer within 12 months after the index date; 3825/6537 (58.5%) with hematologic malignancy, and 2712/6537 (41.5%) with solid tumor. Among patients diagnosed with cancer (n = 6774), the median time to cancer diagnosis after their first visit within The Network was 5.13 weeks. This study provides a real-world perspective on cancer incidence in patients with NSSS referred to a secondary care setting and highlights the unmet need for improved diagnostic tools to improve cancer outcomes.

Emergency department involvement in the diagnosis of cancer among older adults: a SEER-Medicare study

BACKGROUND

Internationally, 20% to 50% of cancer is diagnosed through emergency presentation, which is associated with lower survival, poor patient experience, and socioeconomic disparities, but population-based evidence about emergency diagnosis in the United States is limited. We estimated emergency department (ED) involvement in the diagnosis of cancer in a nationally representative population of older US adults, and its association with sociodemographic, clinical, and tumor characteristics.

METHODS

We analyzed Surveillance, Epidemiology, and End Results Program-Medicare data for Medicare beneficiaries (≥66 years old) with a diagnosis of female breast, colorectal, lung, and prostate cancers (2008-2017), defining their earliest cancer-related claim as their index date, and patients who visited the ED 0 to 30 days before their index date to have "ED involvement" in their diagnosis, with stratification as 0 to 7 or 8 to 30 days. We estimated covariate-adjusted associations of patient age, sex, race and ethnicity, marital status, comorbidity score, tumor stage, year of diagnosis, rurality, and census-tract poverty with ED involvement using modified Poisson regression.

RESULTS

Among 614 748 patients, 23% had ED involvement, with 18% visiting the ED in the 0 to 7 days before their index date. This rate varied greatly by tumor site, with breast cancer at 8%, colorectal cancer at 39%, lung cancer at 40%, and prostate cancer at 7%. In adjusted models, older age, female sex, non-Hispanic Black and Native Hawaiian or Other Pacific Islander race, being unmarried, recent year of diagnosis, later-stage disease, comorbidities, and poverty were associated with ED involvement.

CONCLUSIONS

The ED may be involved in the initial identification of cancer for 1 in 5 patients. Earlier, system-level identification of cancer in non-ED settings should be prioritized, especially among underserved populations.

Competitive endogenous RNA networks: Decoding the role of long non-coding RNAs and circular RNAs in colorectal cancer chemoresistance

Colorectal cancer (CRC) is recognized as one of the most common gastrointestinal malignancies across the globe. Despite significant progress in designing novel treatments for CRC, there is a pressing need for more effective therapeutic approaches. Unfortunately, many patients undergoing chemotherapy develop drug resistance, posing a significant challenge for cancer treatment. Non-coding RNAs (ncRNAs) have been found to play crucial roles in CRC development and its response to chemotherapy. However, there are still gaps in our understanding of interactions among various ncRNAs, such as long non-coding RNAs (lncRNAs), circular RNAs (circRNAs) and microRNAs (miRNAs). These ncRNAs can act as either oncogenes or tumour suppressors, affecting numerous biological functions in different cancers including CRC. A class of ncRNA molecules known as competitive endogenous RNAs (ceRNAs) has emerged as a key player in various cellular processes. These molecules form networks through lncRNA/miRNA/mRNA and circRNA/miRNA/mRNA interactions. In CRC, dysregulation of ceRNA networks has been observed across various cellular processes, including proliferation, apoptosis and angiogenesis. These dysregulations are believed to play a significant role in the progression of CRC and, in certain instances, may contribute to the development of chemoresistance. Enriching our knowledge of these dysregulations holds promise for advancing the field of diagnostic and therapeutic modalities for CRC. In this review, we discuss lncRNA- and circRNA-associated ceRNA networks implicated in the emergence and advancement of drug resistance in colorectal carcinogenesis.

The presenting symptom signatures of incident cancer: evidence from the English 2018 National Cancer Diagnosis Audit

BACKGROUND

Understanding relationships between presenting symptoms and subsequently diagnosed cancers can inform symptom awareness campaigns and investigation strategies.

METHODS

We used English National Cancer Diagnosis Audit 2018 data for 55,122 newly diagnosed patients, and examined the relative frequency of presenting symptoms by cancer site, and of cancer sites by presenting symptom.

RESULTS

Among 38 cancer sites (16 cancer groups), three classes were apparent: cancers with a dominant single presenting symptom (e.g. melanoma); cancers with diverse presenting symptoms (e.g. pancreatic); and cancers that are often asymptomatically detected (e.g. chronic lymphocytic leukaemia). Among 83 symptoms (13 symptom groups), two classes were apparent: symptoms chiefly relating to cancers of the same body system (e.g. certain respiratory symptoms mostly relating to respiratory cancers); and symptoms with a diverse cancer site case-mix (e.g. fatigue). The cancer site case-mix of certain symptoms varied by sex.

CONCLUSION

We detailed associations between presenting symptoms and cancer sites in a large, representative population-based sample of cancer patients. The findings can guide choice of symptoms for inclusion in awareness campaigns, and diagnostic investigation strategies post-presentation when cancer is suspected. They can inform the updating of clinical practice recommendations for specialist referral encompassing a broader range of cancer sites per symptom.

Laboratory practice is central to earlier myeloma diagnosis: Utilizing a primary care diagnostic tool and laboratory guidelines integrated into haematology services

Treatment advances have greatly improved survival, but myeloma is among the worst of all cancers for delayed diagnosis, causing serious morbidities and early deaths. This delay is largely because the symptom profile of myeloma has very low specificity, and in primary care, myeloma is rare. However, initiating the journey to diagnosis simply requires considering myeloma and sending blood to test for monoclonal immunoglobulin. Laboratory tests reliably detect monoclonal immunoglobulin, which is present in 99% of myeloma cases, so why do health care systems have such a problem with delayed diagnosis? The Myeloma UK early diagnosis programme has brought together diverse expertise to investigate this problem, and this article was prepared by the programme's working group for laboratory best practice. It reviews evidence for test requesting, analysis and reporting, for which there is large variation in practice across the United Kingdom. It presents a 'GP Myeloma diagnostic tool' and how it can be integrated into laboratory practice alongside a laboratory best practice tool. It proposes improved requesting and integration with haematology services for reporting and interpretation. Here the laboratory has a central role in creating efficient and cost-effective pathways for appropriate and timely bone marrow examination for myeloma diagnosis.

Urinary Incontinence Following Robotic-Assisted Radical Prostatectomy: A Literature Review

Prostate cancer ranks as one of the most prevalent cancers among men in the United States, contributing significantly to cancer-related mortality. Robot-assisted radical prostatectomy (RARP) has become a cornerstone in the management of localized prostate cancer. This literature review delves into the outcomes of RARP, specifically its impact on urinary incontinence (UI) compared to other surgical methods. We also present the importance of patient perception versus medical reports. Recent studies and trials have unveiled that postoperative UI and erectile dysfunction (ED) remain common concerns following prostatectomy. However, studies have shown that RARP has lower occurrences of UI and ED compared to radical retropubic prostatectomy (RRP). While the choice of surgical method may not drastically affect these outcomes, the review emphasizes that urinary incontinence extends beyond physical symptoms. It profoundly impacts patients' psychological well-being, social interactions, and overall quality of life. Differences in symptom recording and interpretation between patients and healthcare professionals can significantly influence the diagnosis and treatment of prostate cancer. Enhanced patient-physician communication and patient-centered care are essential to providing a holistic approach to prostate cancer management. The choice of surgical methods may not significantly impact postoperative urinary incontinence and erectile dysfunction. Continued research and advancements in treatment and patient care are crucial for improving outcomes and the overall well-being of prostate cancer patients.

Diagnosis, treatment, and survival from kidney cancer: real-world National Health Service England data between 2013 and 2019

OBJECTIVES

To report the NHS Digital (NHSD) data for patients diagnosed with kidney cancer (KC) in England. We explore the incidence, route to diagnosis (RTD), treatment, and survival patterns from 2013 to 2019.

MATERIALS AND METHODS

Data was extracted from the Cancer Data NHSD portal for International Classification of Diseases, 10th edition coded KC; this included Cancer Registry data, Hospital Episode Statistics, and cancer waiting times data.

RESULTS

Registrations included 66 696 individuals with KC. Incidence of new KC diagnoses increased (8998 in 2013, to 10 232 in 2019), but the age-standardised rates were stable (18.7-19.4/100 000 population). Almost half of patients (30 340 [45.5%]) were aged 0-70 years and the cohort were most frequently diagnosed with Stage 1-2 KC (n = 26 297 [39.4%]). Most patients were diagnosed through non-urgent general practitioner referrals (n = 16 814 [30.4%]), followed by 2-week-wait (n = 15 472 [28.0%]) and emergency routes (n = 11 796 [21.3%]), with older patients (aged ≥70 years), Stage 4 KCs, and patients with non-specified renal cell carcinoma being significantly more likely to present through the emergency route (all P < 0.001). Invasive treatment (surgery or ablation), radiotherapy, or systemic anti-cancer therapy use varied with disease stage, patient factors, and treatment network (Cancer Alliance). Survival outcomes differed by Stage, histological subtype, and social deprivation class (P < 0.001). Age-standardised mortality rates did not change over the study duration, although immunotherapy usage is likely not captured in this study timeline.

CONCLUSION

The NHSD resource provides useful insight about the incidence, diagnostic pathways, treatment, and survival of patients with KC in England and a useful benchmark for the upcoming commissioned National Kidney Cancer Audit. The RTD data may be limited by incidental diagnoses, which could confound the high proportion of 'emergency' diagnoses. Importantly, survival outcomes remained relatively unchanged.

Socioeconomic position and the pre-diagnostic interval among patients diagnosed with head and neck squamous cell carcinoma - a population-based study from DAHANCA

BACKGROUND

The socioeconomic differences in survival are pronounced for patients diagnosed with head and neck cancer; disease stage at diagnosis is suggested to be a main driver of this association. This nationwide, population-based study investigates socioeconomic differences in the pre-diagnostic interval and disease stage at diagnosis.

MATERIAL AND METHODS

Information on patient-reported symptoms, symptom onset and disease-specific factors was obtained from the nationwide population-based Danish Head and Neck Cancer Group (DAHANCA) database for patients diagnosed with head and neck squamous cell carcinoma between 2008 and 2019 in Denmark. Socioeconomic position (SEP) was measured by individual-level education, income and cohabitation status obtained from administrative registers. Socioeconomic differences in the interval from symptom onset to diagnosis were investigated in general linear models with 95% confidence intervals (CIs); overall and by subsite, symptom and comorbidity score. Consultation patterns prior to diagnosis were examined using methods for change-point detection. Associations with advanced-stage disease were estimated in logistic regression models.

RESULTS

Patients with low, medium and high SEP had a similar interval from patient-reported symptom onset to diagnosis of 10 weeks. Although this interval varied according to primary symptom and anatomical subsite, no apparent socioeconomic differences were observed within these subgroups. Aligned with the patient-reported symptom onset, a distinct increase in consultation rates was observed at 9 weeks (95% CI [7.3; 10.7]) for patients with low SEP and 7 weeks (95% CI [4.8; 9.2]) for patients with high SEP, with overlapping CIs. Patients with low compared to high SEP had increased odds for advanced-stage glottic and oral cavity squamous cell carcinoma. For the remaining subsites the association varied according to SEP-indicator and TNM-edition.

CONCLUSION

The interval from symptom onset to diagnosis and consultation patterns were similar across SEP groups. Still, socioeconomic differences in stage at diagnosis were observed for some - but not all - subsites.

Time intervals and previous primary care consultations in the pathway to emergency cancer diagnosis

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.

Earlier Diagnosis of Pancreatic Cancer: Is It Possible?

Pancreatic ductal adenocarcinoma has a very high mortality rate which has been only minimally improved in the last 30 years. This high mortality is closely related to late diagnosis, which is usually made when the tumor is large and has extensively infiltrated neighboring tissues or distant metastases are already present. This is a paradoxical situation for a tumor that requires nearly 15 years to develop since the first founding mutation. Response to chemotherapy under such late circumstances is poor, resistance is frequent, and prolongation of survival is almost negligible. Early surgery has been, and still is, the only approach with a slightly better outcome. Unfortunately, the relapse percentage after surgery is still very high. In fact, early surgery clearly requires early diagnosis. Despite all the advances in diagnostic methods, the available tools for improving these results are scarce. Serum tumor markers permit a late diagnosis, but their contribution to an improved therapeutic result is very limited. On the other hand, effective screening methods for high-risk populations have not been fully developed as yet. This paper discusses the difficulties of early diagnosis, evaluates whether the available diagnostic tools are adequate, and proposes some simple and not-so-simple measures to improve it.

Incidence of 'Low-Risk but Not No-Risk' Features of Cancer Prior to High-Risk Feature Occurrence: An Observational Cohort Study in Primary Care

Diagnosing cancer may be expedited by decreasing referral risk threshold. Clinical Practice Research Datalink participants (≥40 years) had a positive predictive value (PPV) ≥3% feature for breast, lung, colorectal, oesophagogastric, pancreatic, renal, bladder, prostatic, ovarian, endometrial or laryngeal cancer in 2016. The numbers of participants with features representing a 1-1.99% or 2-2.99% PPV for same cancer in the previous year were reported, alongside the time difference between meeting the ≥3% criteria and the lower threshold criteria. A total of 8616 participants had a PPV ≥3% feature, of whom 365 (4.2%) and 1147 (13.3%), respectively, met 2-2.99% and 1-1.99% criteria in the preceding year. The median time difference was 131 days (Interquartile Range (IQR) 27 to 256) for the 2-2.99% band and 179 days (IQR 58 to 289) for the 1-1.99% band. Results were heterogeneous across cancer sites. For some cancers, participants may progress from presenting lower- to higher-risk features before meeting urgent referral criteria; however, this was not usually the case. The details of specific features across multiple cancer sites will allow for a tailored approach to future reductions in referral thresholds, potentially improving the efficiency of urgent cancer referrals for the benefit both of individuals and the National Health Service (NHS).

Multi-cancer early detection test in symptomatic patients referred for cancer investigation in England and Wales (SYMPLIFY): a large-scale, observational cohort study

BACKGROUND

Analysis of circulating tumour DNA could stratify cancer risk in symptomatic patients. We aimed to evaluate the performance of a methylation-based multicancer early detection (MCED) diagnostic test in symptomatic patients referred from primary care.

METHODS

We did a multicentre, prospective, observational study at National Health Service (NHS) hospital sites in England and Wales. Participants aged 18 or older referred with non-specific symptoms or symptoms potentially due to gynaecological, lung, or upper or lower gastrointestinal cancers were included and gave a blood sample when they attended for urgent investigation. Participants were excluded if they had a history of or had received treatment for an invasive or haematological malignancy diagnosed within the preceding 3 years, were taking cytotoxic or demethylating agents that might interfere with the test, or had participated in another study of a GRAIL MCED test. Patients were followed until diagnostic resolution or up to 9 months. Cell-free DNA was isolated and the MCED test performed blinded to the clinical outcome. MCED predictions were compared with the diagnosis obtained by standard care to establish the primary outcomes of overall positive and negative predictive value, sensitivity, and specificity. Outcomes were assessed in participants with a valid MCED test result and diagnostic resolution. SYMPLIFY is registered with ISRCTN (ISRCTN10226380) and has completed follow-up at all sites.

FINDINGS

6238 participants were recruited between July 7 and Nov 30, 2021, across 44 hospital sites. 387 were excluded due to staff being unable to draw blood, sample errors, participant withdrawal, or identification of ineligibility after enrolment. Of 5851 clinically evaluable participants, 376 had no MCED test result and 14 had no information as to final diagnosis, resulting in 5461 included in the final cohort for analysis with an evaluable MCED test result and diagnostic outcome (368 [6·7%] with a cancer diagnosis and 5093 [93·3%] without a cancer diagnosis). The median age of participants was 61·9 years (IQR 53·4-73·0), 3609 (66·1%) were female and 1852 (33·9%) were male. The MCED test detected a cancer signal in 323 cases, in whom 244 cancer was diagnosed, yielding a positive predictive value of 75·5% (95% CI 70·5-80·1), negative predictive value of 97·6% (97·1-98·0), sensitivity of 66·3% (61·2-71·1), and specificity of 98·4% (98·1-98·8). Sensitivity increased with increasing age and cancer stage, from 24·2% (95% CI 16·0-34·1) in stage I to 95·3% (88·5-98·7) in stage IV. For cases in which a cancer signal was detected among patients with cancer, the MCED test's prediction of the site of origin was accurate in 85·2% (95% CI 79·8-89·3) of cases. Sensitivity 80·4% (95% CI 66·1-90·6) and negative predictive value 99·1% (98·2-99·6) were highest for patients with symptoms mandating investigation for upper gastrointestinal cancer.

INTERPRETATION

This first large-scale prospective evaluation of an MCED diagnostic test in a symptomatic population demonstrates the feasibility of using an MCED test to assist clinicians with decisions regarding urgency and route of referral from primary care. Our data provide the basis for a prospective, interventional study in patients presenting to primary care with non-specific signs and symptoms.

FUNDING

GRAIL Bio UK.

Presenting Symptoms in Newly Diagnosed Myeloma, Relation to Organ Damage, and Implications for Symptom-Directed Screening: A Secondary Analysis from the Tackling Early Morbidity and Mortality in Myeloma (TEAMM) Trial

Multiple myeloma (MM) patients risk diagnostic delays and irreversible organ damage. In those with newly diagnosed myeloma, we explored the presenting symptoms to identify early signals of MM and their relationships to organ damage. The symptoms were recorded in patients' own words at diagnosis and included diagnostic time intervals. Those seen by a haematologist >6 months prior to MM diagnosis were classified as precursor disease (PD). Most (962/977) patients provided data. Back pain (38%), other pain (31%) and systemic symptoms (28%) predominated. Patients rarely complain of 'bone pain', simply 'pain'. Vertebral fractures are under-recognised as pathological and are the predominant irreversible organ damage (27% of patients), impacting the performance status (PS) and associated with back pain (odds ratio (OR) 6.14 [CI 4.47-8.44]), bone disease (OR 3.71 [CI 1.88-7.32]) and age >65 years (OR 1.58 [CI 1.15-2.17]). Renal failure is less frequent and associated with gastrointestinal symptoms (OR 2.23 [CI1.28-3.91]), age >65 years (OR 2.14 [CI1.28-3.91]) and absence of back pain (OR 0.44 [CI 0.29-0.67]). Patients with known PD (n = 149) had fewer vertebral fractures (p = 0.001), fewer adverse features (p = 0.001), less decline in PS (p = 0.001) and a lower stage (p = 0.04) than 813 with de novo MM. Our data suggest subgroups suitable for trials of 'symptom-directed' screening: those with back pain, unexplained pain, a general decline in health or low-impact vertebral compression fractures.

Identification of Potent Inhibitors Targeting EGFR and HER3 for Effective Treatment of Chemoresistance in Non-Small Cell Lung Cancer

Non-small cell lung cancer (NSCLC) is the most common form of lung cancer. Despite the existence of various therapeutic options, NSCLC is still a major health concern due to its aggressive nature and high mutation rate. Consequently, HER3 has been selected as a target protein along with EGFR because of its limited tyrosine kinase activity and ability to activate PI3/AKT pathway responsible for therapy failure. We herein used a BioSolveIT suite to identify potent inhibitors of EGFR and HER3. The schematic process involves screening of databases for constructing compound library comprising of 903 synthetic compounds (602 for EGFR and 301 for HER3) followed by pharmacophore modeling. The best docked poses of compounds with the druggable binding site of respective proteins were selected according to pharmacophore designed by SeeSAR version 12.1.0. Subsequently, preclinical analysis was performed via an online server SwissADME and potent inhibitors were selected. Compound 4k and 4m were the most potent inhibitors of EGFR while 7x effectively inhibited the binding site of HER3. The binding energies of 4k, 4m, and 7x were -7.7, -6.3 and -5.7 kcal/mol, respectively. Collectively, 4k, 4m and 7x showed favorable interactions with the most druggable binding sites of their respective proteins. Finally, in silico pre-clinical testing by SwissADME validated the non-toxic nature of compounds 4k, 4m and 7x providing a promising treatment option for chemoresistant NSCLC.

Are There Ethnic Differences in Recorded Features among Patients Subsequently Diagnosed with Cancer? An English Longitudinal Data-Linked Study

We investigated ethnic differences in the presenting features recorded in primary care before cancer diagnosis.

METHODS

English population-based cancer-registry-linked primary care data were analysed. We identified the coded features of six cancers (breast, lung, prostate, colorectal, oesophagogastric, and myeloma) in the year pre-diagnosis. Logistic regression models investigated ethnic differences in first-incident cancer features, adjusted for age, sex, smoking status, deprivation, and comorbidity.

RESULTS

Of 130,944 patients, 92% were White. In total, 188,487 incident features were recorded in the year pre-diagnosis, with 48% (89,531) as sole features. Compared with White patients, Asian and Black patients with breast, colorectal, and prostate cancer were more likely than White patients to have multiple features; the opposite was seen for the Black and Other ethnic groups with lung or prostate cancer. The proportion with relevant recorded features was broadly similar by ethnicity, with notable cancer-specific exceptions. Asian and Black patients were more likely to have low-risk features (e.g., cough, upper abdominal pain) recorded. Non-White patients were less likely to have alarm features.

CONCLUSION

The degree to which these differences reflect disease, patient or healthcare factors is unclear. Further research examining the predictive value of cancer features in ethnic minority groups and their association with cancer outcomes is needed.

Perceived barriers to early presentation and symptom-specific time to seek medical advice for possible colorectal cancer symptoms among Palestinians

This study explored the anticipated time to seek medical advice for possible colorectal cancer (CRC) signs/symptoms and its association with CRC symptom awareness. In addition, it examined perceived barriers that may delay seeking medical advice. Palestinian adults were recruited from hospitals, primary healthcare centers, and public spaces in 11 governorates. A modified, translated-into-Arabic version of the validated Bowel Cancer Awareness Measure was used. The questionnaire comprised three sections: sociodemographics, assessment of CRC symptom awareness and time to seek medical advice, and barriers to early presentation. A total of 4623 participants were included. The proportion that reported seeking immediate medical advice for possible CRC signs/symptoms with blood or mass ranged from 47.1% for 'blood in stools' to 59.5% for 'bleeding from back passage'. Less than half of the participants reported immediate seeking of medical advice for non-specific symptoms (ranging from 5.4% for 'loss of appetite' to 42.0% for 'anemia') and other gastrointestinal symptoms (ranging from 7.7% for 'feeling persistently full' to 35.7% for 'change in bowel habits'). Good CRC symptom awareness was associated with higher likelihood of seeking medical advice within a week from recognizing a CRC symptom. About 13.0% reported a delay to visit their doctor after recognizing a CRC symptom. The most reported barriers were practical with 'would try some herbs first' (50.9%) as the leading barrier. CRC symptoms with blood or mass prompted earlier help seeking. Participants with good CRC awareness were more likely to seek medical advice within a week.

Symptoms and signs of lung cancer prior to diagnosis: case-control study using electronic health records from ambulatory care within a large US-based tertiary care centre

OBJECTIVE

Lung cancer is the most common cause of cancer-related death in the USA. While most patients are diagnosed following symptomatic presentation, no studies have compared symptoms and physical examination signs at or prior to diagnosis from electronic health records (EHRs) in the USA. We aimed to identify symptoms and signs in patients prior to diagnosis in EHR data.

DESIGN

Case-control study.

SETTING

Ambulatory care clinics at a large tertiary care academic health centre in the USA.

PARTICIPANTS, OUTCOMES

We studied 698 primary lung cancer cases in adults diagnosed between 1 January 2012 and 31 December 2019, and 6841 controls matched by age, sex, smoking status and type of clinic. Coded and free-text data from the EHR were extracted from 2 years prior to diagnosis date for cases and index date for controls. Univariate and multivariable conditional logistic regression were used to identify symptoms and signs associated with lung cancer at time of diagnosis, and 1, 3, 6 and 12 months before the diagnosis/index dates.

RESULTS

Eleven symptoms and signs recorded during the study period were associated with a significantly higher chance of being a lung cancer case in multivariable analyses. Of these, seven were significantly associated with lung cancer 6 months prior to diagnosis: haemoptysis (OR 3.2, 95% CI 1.9 to 5.3), cough (OR 3.1, 95% CI 2.4 to 4.0), chest crackles or wheeze (OR 3.1, 95% CI 2.3 to 4.1), bone pain (OR 2.7, 95% CI 2.1 to 3.6), back pain (OR 2.5, 95% CI 1.9 to 3.2), weight loss (OR 2.1, 95% CI 1.5 to 2.8) and fatigue (OR 1.6, 95% CI 1.3 to 2.1).

CONCLUSIONS

Patients diagnosed with lung cancer appear to have symptoms and signs recorded in the EHR that distinguish them from similar matched patients in ambulatory care, often 6 months or more before diagnosis. These findings suggest opportunities to improve the diagnostic process for lung cancer.

What causes delays in diagnosing blood cancers? A rapid review of the evidence

OBJECTIVE

We undertook a rapid review of literature relating to the diagnosis of blood cancers, to find out what factors contribute to delays in diagnosis, including symptom recognition, appraisal and help-seeking behaviours.

METHODS

We used rapid review methodology following Tricco et al. to synthesise current literature from two electronic databases. We searched for studies about symptom appraisal help-seeking for all blood cancers published between 2001 and 2021, written in English.

RESULTS

Fifteen studies were included in the review, of which 10 were published in the United Kingdom. We found a number of factors associated with delays in blood cancer diagnosis. These included patient factors such as gender, age and ethnicity, as well as health system factors such as poor communication and seeing a locum clinician in primary care. A narrative synthesis of the evidence produced four types of symptom interpretation by patients: (1) symptoms compatible with normal state of health, (2) event-linked problems, (3) mild or chronic illness and (4) non-specific unwell state. These four interpretations were linked to different help-seeking behaviours. After seeking help, patients often experienced delays due to healthcare professionals' (HCPs') non-serious interpretation of symptoms, misleading blood tests, discontinuity of care and other barriers in the diagnostic pathway.

CONCLUSION

Blood cancers are difficult to diagnose due to non-specific heterogeneous symptoms, and this is reflected in how those symptoms are interpreted by patients and managed by HCPs. It is important to understand how different interpretations affect delays in help-seeking, and what HCPs can do to support timely follow-up for patients.

Factors influencing the timeliness of care for patients with lung cancer in Bangladesh

BACKGROUND

This study explored the factors associated with timeliness of care in the healthcare seeking pathway among patients with lung cancer in Bangladesh.

METHODS

A structured questionnaire was used for data collection from 418 patients with lung cancer through face-to-face interviews in three tertiary care hospitals. Log-rank tests were performed to test differences in the length of intervals between points in healthcare by socioeconomic characteristics and care seeking behaviours of the patients. Cox Proportional Hazard (PH) regression analysis was performed to identify the predictors of the intervals after adjustment for variations in other variables.

RESULTS

A higher education level was associated significantly (p < 0.05) with a shorter interval between first contact with a healthcare provider (HCP) and diagnosis (median 81 days) and initiation of treatment (median 101 days). Higher monthly household income was associated significantly with a shorter time from first contact and diagnosis (median 91 days), onset of symptom and diagnosis (median 99 days), onset of symptom and treatment (median 122 days), and first contact with any HCP to treatment (median 111 days). Consulting with additional HCPs prior to diagnosis was associated significantly with longer intervals from first contact with any HCP and diagnosis (median 127 days), onset of symptom and diagnosis (median 154 days), onset of symptom and treatment (median 205 days), and first contact with any HCP to treatment (median 174 days). Consulting with informal HCPs was associated significantly with a longer time interval from symptom to treatment (median 171 days). Having more than one triggering symptom was associated significantly with a shorter interval between onset of symptoms and first contact with any HCP.

CONCLUSION

The predictors for timeliness of lung cancer care used in this study affected different intervals in the care seeking pathway. Higher education and income predicted shorter intervals whereas consulting informal healthcare providers and multiple providers were associated with longer intervals.

Development and Internal Validation of a Risk Prediction Model to Identify Myeloma Based on Routine Blood Tests: A Case-Control Study

Myeloma is one of the hardest cancers to diagnose in primary care due to its rarity and non-specific symptoms. A rate-limiting step in diagnosing myeloma is the clinician considering myeloma and initiating appropriate investigations. We developed and internally validated a risk prediction model to identify those with a high risk of having undiagnosed myeloma based on results from routine blood tests taken for other reasons. A case-control study, based on 367 myeloma cases and 1488 age- and sex-matched controls, was used to develop a risk prediction model including results from 15 blood tests. The model had excellent discrimination (C-statistic 0.85 (95%CI 0.83, 0.89)) and good calibration (calibration slope 0.87 (95%CI 0.75, 0.90)). At a prevalence of 15 per 100,000 population and a probability threshold of 0.4, approximately 600 patients would need additional reflex testing to detect one case. We showed that it is possible to combine signals and abnormalities from several routine blood test parameters to identify individuals at high-risk of having undiagnosed myeloma who may benefit from additional reflex testing. Further work is needed to explore the full potential of such a strategy, including whether it is clinically useful and cost-effective and how to make it ethically acceptable.

Examining methodology to identify patterns of consulting in primary care for different groups of patients before a diagnosis of cancer: An exemplar applied to oesophagogastric cancer

BACKGROUND

Current methods for estimating the timeliness of cancer diagnosis are not robust because dates of key defining milestones, for example first presentation, are uncertain. This is exacerbated when patients have other conditions (multimorbidity), particularly those that share symptoms with cancer. Methods independent of this uncertainty are needed for accurate estimates of the timeliness of cancer diagnosis, and to understand how multimorbidity impacts the diagnostic process.

METHODS

Participants were diagnosed with oesophagogastric cancer between 2010 and 2019. Controls were matched on year of birth, sex, general practice and multimorbidity burden calculated using the Cambridge Multimorbidity Score. Primary care data (Clinical Practice Research Datalink) was used to explore population-level consultation rates for up to two years before diagnosis across different multimorbidity burdens. Five approaches were compared on the timing of the consultation frequency increase, the inflection point for different multimorbidity burdens, different aggregated time-periods and sample sizes.

RESULTS

We included 15,410 participants, of which 13,328 (86.5 %) had a measurable multimorbidity burden. Our new maximum likelihood estimation method found evidence that the inflection point in consultation frequency varied with multimorbidity burden, from 154 days (95 %CI 131.8-176.2) before diagnosis for patients with no multimorbidity, to 126 days (108.5-143.5) for patients with the greatest multimorbidity burden. Inflection points identified using alternative methods were closer to diagnosis for up to three burden groups. Sample size reduction and changing the aggregation period resulted in inflection points closer to diagnosis, with the smallest change for the maximum likelihood method.

DISCUSSION

Existing methods to identify changes in consultation rates can introduce substantial bias which depends on sample size and aggregation period. The direct maximum likelihood method was less prone to this bias than other methods and offers a robust, population-level alternative for estimating the timeliness of cancer diagnosis.

Underlying cancer risk among patients with fatigue and other vague symptoms: a population-based cohort study in primary care

BACKGROUND

Presenting to primary care with fatigue is associated with slightly increased cancer risk, although it is unknown how this varies in the presence of other 'vague' symptoms.

AIM

To quantify cancer risk in patients with fatigue who present with other 'vague' symptoms in the absence of 'alarm' symptoms for cancer.

DESIGN AND SETTING

Cohort study of patients presenting in UK primary care with new-onset fatigue during 2007-2015, using Clinical Practice Research Datalink data linked to national cancer registration data.

METHOD

Patients presenting with fatigue without co-occurring alarm symptoms or anaemia were identified, who were further characterised as having co-occurrence of 19 other 'vague' potential cancer symptoms. Sex- and age-specific 9-month cancer risk for each fatigue-vague symptom cohort were calculated.

RESULTS

Of 285 382 patients presenting with new-onset fatigue, 84% (n = 239 846) did not have co-occurring alarm symptoms or anaemia. Of these, 38% (n = 90 828) presented with ≥1 of 19 vague symptoms for cancer. Cancer risk exceeded 3% in older males with fatigue combined with any of the vague symptoms studied. The age at which risk exceeded 3% was 59 years for fatigue-weight loss, 65 years for fatigue-abdominal pain, 67 years for fatigue-constipation, and 67 years for fatigue-other upper gastrointestinal symptoms. For females, risk exceeded 3% only in older patients with fatigue-weight loss (from 65 years), fatigue-abdominal pain (from 79 years), or fatigue-abdominal bloating (from 80 years).

CONCLUSION

In the absence of alarm symptoms or anaemia, fatigue combined with specific vague presenting symptoms, alongside patient age and sex, can guide clinical decisions about referral for suspected cancer.

Relationship between ethnicity and stage at diagnosis in England: a national analysis of six cancer sites

OBJECTIVES

Cancer stage at diagnosis is a determinant of treatment options and survival. Previous research has shown differences in barriers to presentation with cancer between ethnic groups. The completeness and quality of cancer stage and ethnicity data has improved markedly over recent years in England, allowing for comparison of stage distributions at diagnosis between ethnic groups. This study aimed to assess relationships between ethnic group and two outcomes: unknown stage cancer and late stage (stages 3 and 4) cancer, after adjustment for confounders.

DESIGN AND SETTING

A retrospective secondary data analysis using data from NHS Digital's National Cancer Registration and Analysis Service and Hospital Episode Statistics records from 2012 to 2016.

PARTICIPANTS

This study analysed newly diagnosed breast, colon, non-small cell lung cancer (NSCLC), ovary, prostate and uterine cancers in white British, Caribbean, African, Chinese and Asian patients aged 15-99 in England.

RESULTS

Caribbean, African and Asian women with breast or ovarian cancer, Caribbean and African women with uterine or colon cancer, Caribbean women with NSCLC and Caribbean men with colon cancer had increased odds of late-stage disease at diagnosis compared with the white British cohort. In contrast, Caribbean and African men with prostate cancer had decreased odds of late-stage cancer. Where stage was known, there were variations in late-stage cancer by ethnic group.

CONCLUSIONS

Low symptom awareness and barriers to presentation can cause delays, resulting in later stage diagnosis. Targeted intervention campaigns to help raise awareness of cancer signs and symptoms and the benefits of early diagnosis, along with removing barriers to appropriate referrals, could help to improve these inequalities.

Women's experiences along the ovarian cancer diagnostic pathway in Catalonia: A qualitative study

BACKGROUND

Early detection of symptoms and prompt diagnosis of ovarian cancer are considered important avenues for improving patient experiences and outcomes.

METHODS

This qualitative study used a phenomenological approach to perform patient interviews, collecting individual accounts of the prediagnostic phase in women diagnosed and treated for ovarian cancer in 2016-2017. Purposive sampling was used to obtain a diverse sample of 24 participants, while thematic content analysis was used to extract themes and subthemes from interview data.

RESULTS

Three themes and nine subthemes were identified. The first theme was women's delay in recognizing symptoms and seeking care, with subthemes on the lack of knowledge about early signs of ovarian cancer, gender-related barriers and false reassurance from negative test results. A second theme was missed opportunities during healthcare encounters, due to misattribution of women's symptoms by their physicians, underestimation of symptom severity and need for mediation and inadequate tests and/or false negative results. Finally, interviews highlighted the use of resources and alternative healthcare pathways, including complementary/alternative medicines, access to private health care and women's capacity for action and decision-making (agency) about their health.

CONCLUSION

Delayed diagnosis of ovarian cancer is rooted in both individual factors (lack of health literacy, reluctance to seek care) and systemic issues (missed opportunities in healthcare encounters, access to timely specialist care). Further research is needed to investigate the extent to which traditional gender roles and socioeconomic inequalities condition women's ability to manage their own health and to interact with health professionals and the health system.

PATIENT AND PUBLIC CONTRIBUTION

In addition to the patient participation during the interviews, one author was a representative of a patient association.

How Timely Is Diagnosis of Lung Cancer? Cohort Study of Individuals with Lung Cancer Presenting in Ambulatory Care in the United States

The diagnosis of lung cancer in ambulatory settings is often challenging due to non-specific clinical presentation, but there are currently no clinical quality measures (CQMs) in the United States used to identify areas for practice improvement in diagnosis. We describe the pre-diagnostic time intervals among a retrospective cohort of 711 patients identified with primary lung cancer from 2012-2019 from ambulatory care clinics in Seattle, Washington USA. Electronic health record data were extracted for two years prior to diagnosis, and Natural Language Processing (NLP) applied to identify symptoms/signs from free text clinical fields. Time points were defined for initial symptomatic presentation, chest imaging, specialist consultation, diagnostic confirmation, and treatment initiation. Median and interquartile ranges (IQR) were calculated for intervals spanning these time points. The mean age of the cohort was 67.3 years, 54.1% had Stage III or IV disease and the majority were diagnosed after clinical presentation (94.5%) rather than screening (5.5%). Median intervals from first recorded symptoms/signs to diagnosis was 570 days (IQR 273-691), from chest CT or chest X-ray imaging to diagnosis 43 days (IQR 11-240), specialist consultation to diagnosis 72 days (IQR 13-456), and from diagnosis to treatment initiation 7 days (IQR 0-36). Symptoms/signs associated with lung cancer can be identified over a year prior to diagnosis using NLP, highlighting the need for CQMs to improve timeliness of diagnosis.

A systematic review of interventions to recognise, refer and diagnose patients with lung cancer symptoms

Patients with lung cancer (LC) often experience delay between symptom onset and treatment. Primary healthcare professionals (HCPs) can help facilitate early diagnosis of LC through recognising early signs and symptoms and making appropriate referrals. This systematic review describes the effect of interventions aimed at helping HCPs recognise and refer individuals with symptoms suggestive of LC. Seven studies were synthesised narratively. Outcomes were categorised into: Diagnostic intervals; referral and diagnosis patterns; stage distribution at diagnosis; and time interval from diagnosis to treatment. Rapid access pathways and continuing medical education for general practitioners can help reduce LC diagnostic and treatment delay. Awareness campaigns and HCP education can help inform primary HCPs about referral pathways. However, campaigns did not significantly impact LC referral rates or reduce diagnostic intervals. Disease outcomes, such as LC stage at diagnosis, recurrence, and survival were seldom measured. Review findings highlight the need for longitudinal, powered, and controlled studies.

Measured weight loss as a precursor to cancer diagnosis: retrospective cohort analysis of 43 302 primary care patients

BACKGROUND

Unexpected weight loss is a presenting feature of cancer in primary care. Data from primary care are lacking to quantify how much weight loss over what period should trigger further investigation for cancer. This research aimed to quantify cancer diagnosis rates associated with measured weight change in people attending primary care.

METHODS

Retrospective cohort study of primary care electronic health records data linked to the Surveillance, Epidemiology, and End Results cancer registry (Integrated healthcare delivery system in Washington State, United States). Multivariable Cox regression incorporating time varying covariates using splines to model non-linear associations (age, percentage weight change, and weight change interval). Fifty thousand randomly selected patients aged 40 years and over followed for up to 9 years (1 January 2006 to 31 December 2014). Outcome measures are hazard ratios (95% confidence intervals) to quantify the association between percentage weight change and cancer diagnosis for all cancers combined, individual cancer sites and stages; percentage risk of cancer diagnosis within 6 months of the end of each weight change episode; and the positive predictive value for cancer diagnosis.

RESULTS

There were 43 302 included in the analysis after exclusions. Over 287 858 patient-years of follow-up, including 24 272 (56.1%) females, 23 980 (55.4%) aged 40 to 59 years, 15 113 (34.9%) 60 to 79 years, and 4209 (9.7%) aged 80 years and over. Adjusted hazard ratios (95% confidence interval) for cancer diagnosis in a 60 years old ranged from 1.04 (1.02 to 1.05, P < 0.001) for 1% weight loss to 1.44 (1.23 to 1.68, P < 0.001) for 10%. An independent linear association was observed between percentage weight loss and increasing cancer risk. The absolute risk of cancer diagnosis increased with increasing age (up to 85 years) and as the weight change measurement interval decreased (<1 year). The positive predictive value for a cancer diagnosis within 1 year of ≥5% measured weight loss in a 60 to 69 years old was 3.41% (1.57% to 6.37%) in men and 3.47% (1.68% to 6.29%) in women. The risk of cancer diagnosis was significantly increased for pancreatic, myeloma, gastro-oesophageal, colorectal, breast, stage II and IV cancers.

CONCLUSIONS

Weight loss is a sign of undiagnosed cancer regardless of the interval over which it occurs. Guidelines should resist giving an arbitrary cut-off for the interval of weight loss and focus on the percentage of weight loss and the patient's age. Future studies should focus on the association between diagnostic evaluation of weight change and risk of cancer mortality.

The patient, diagnostic, and treatment intervals in adult patients with cancer from high- and lower-income countries: A systematic review and meta-analysis

BACKGROUND

Longer time intervals to diagnosis and treatment are associated with worse survival for various types of cancer. The patient, diagnostic, and treatment intervals are considered core indicators for early diagnosis and treatment. This review estimated the median duration of these intervals for various types of cancer and compared it across high- and lower-income countries.

METHODS AND FINDINGS

We conducted a systematic review with meta-analysis (prospectively registered protocol CRD42020200752). Three databases (MEDLINE, Embase, and Web of Science) and information sources including grey literature (Google Scholar, OpenGrey, EThOS, ProQuest Dissertations & Theses) were searched. Eligible articles were published during 2009 to 2022 and reported the duration of the following intervals in adult patients diagnosed with primary symptomatic cancer: patient interval (from the onset of symptoms to first presentation to a healthcare professional), diagnostic interval (from first presentation to diagnosis), and treatment interval (from diagnosis to treatment start). Interval duration was recorded in days and study medians were combined in a pooled estimate with 95% confidence intervals (CIs). The methodological quality of studies was assessed using the Aarhus checklist. A total of 410 articles representing 68 countries and reporting on 5,537,594 patients were included. The majority of articles reported data from high-income countries (n = 294, 72%), with 116 (28%) reporting data from lower-income countries. Pooled meta-analytic estimates were possible for 38 types of cancer. The majority of studies were conducted on patients with breast, lung, colorectal, and head and neck cancer. In studies from high-income countries, pooled median patient intervals generally did not exceed a month for most cancers. However, in studies from lower-income countries, patient intervals were consistently 1.5 to 4 times longer for almost all cancer sites. The majority of data on the diagnostic and treatment intervals came from high-income countries. Across both high- and lower-income countries, the longest diagnostic intervals were observed for hematological (71 days [95% CI 52 to 85], e.g., myelomas (83 days [47 to 145])), genitourinary (58 days [50 to 77], e.g., prostate (85 days [57 to 112])), and digestive/gastrointestinal (57 days [45 to 67], e.g., colorectal (63 days [48 to 78])) cancers. Similarly, the longest treatment intervals were observed for genitourinary (57 days [45 to 66], e.g., prostate (75 days [61 to 87])) and gynecological (46 days [38 to 54], e.g., cervical (69 days [45 to 108]) cancers. In studies from high-income countries, the implementation of cancer-directed policies was associated with shorter patient and diagnostic intervals for several cancers. This review included a large number of studies conducted worldwide but is limited by survivor bias and the inherent complexity and many possible biases in the measurement of time points and intervals in the cancer treatment pathway. In addition, the subintervals that compose the diagnostic interval (e.g., primary care interval, referral to diagnosis interval) were not considered.

CONCLUSIONS

These results identify the cancers where diagnosis and treatment initiation may take the longest and reveal the extent of global disparities in early diagnosis and treatment. Efforts should be made to reduce help-seeking times for cancer symptoms in lower-income countries. Estimates for the diagnostic and treatment intervals came mostly from high-income countries that have powerful health information systems in place to record such information.

Time intervals in the care pathway to cancer diagnosis during the COVID-19 pandemic: A large retrospective study from a high-volume center

Despite extensive research on cancer care during the COVID-19 pandemic, evidence on the impact on prediagnostic time intervals is lacking. To better understand how COVID-19 changed the pathway to diagnosis of cancer, we examined the length of intervals from symptom onset to diagnosis for 13 common cancer types with known clinical stage over 1-year nonpandemic period (March 2019 to March 2020; N = 844) and three biannual COVID periods (March 2020 to September 2021; N = 1172). We analyzed the patient interval (from first symptoms to presentation to a physician), the primary care/emergency department interval (from presentation with relevant symptoms to a primary care or emergency department physician to referral to a hospital-based diagnosis center) and the hospital interval (from referral to diagnosis). Compared to nonpandemic data, there were significant changes across COVID periods. The pandemic mostly impacted patient intervals for cancers diagnosed over the first 6 months after onset in March 2020. Overall median patient intervals were longest in the early COVID period (39 [IQR 22-64] days) and shortest in the nonpandemic period (20 [IQR 13-30] days; Kruskal-Wallis test [χ² ], P < .0001). Differences in clinical stage between periods were relevant, with cancers from the mid-period (September 2020 to March 2021) showing the most advanced stage. A shift to later stage was plausibly a result of delayed intervals in the early COVID period. Since intervals are eventually relevant to prognosis, our results provide a baseline against which the impact of improvement strategies to minimize the negative outcomes of COVID-19-associated cancer delays can be assessed and implemented.

Artificially Intelligent Nanoarray Detects Various Cancers by Liquid Biopsy of Volatile Markers

Cancer is usually not symptomatic in its early stages. However, early detection can vastly improve prognosis. Liquid biopsy holds great promise for early detection, although it still suffers from many disadvantages, mainly searching for specific cancer biomarkers. Here, a new approach for liquid biopsies is proposed, based on volatile organic compound (VOC) patterns in the blood headspace. An artificial intelligence nanoarray based on a varied set of chemi-sensitive nano-based structured films is developed and used to detect and stage cancer. As a proof-of-concept, three cancer models are tested showing high incidence and mortality rates in the population: breast cancer, ovarian cancer, and pancreatic cancer. The nanoarray has >84% accuracy, >81% sensitivity, and >80% specificity for early detection and >97% accuracy, 100% sensitivity, and >88% specificity for metastasis detection. Complementary mass spectrometry analysis validates these results. The ability to analyze such a complex biological fluid as blood, while considering data of many VOCs at a time using the artificially intelligent nanoarray, increases the sensitivity of predictive models and leads to a potential efficient early diagnosis and disease-monitoring tool for cancer.

Cancer; Pathophysiology and Stress Modulation (Cancer, Therapeutic Interventions)

OBJECTIVE

The purpose of this review is to describe the myriad complications of cancer and its therapies to emphasize the pathophysiological need for prehabilitation.

DATA SOURCES

The information presented in this review is from applicable, peer-reviewed scientific articles.

CONCLUSION

Cancer itself renders negative effects on the body, most notably unintentional weight loss and fatigue. Cancer treatments, especially surgical interventions, can cause detrimental short- and long-term impacts on patients, which translate to suboptimal treatment outcomes. Prehabilitation can be used to improve patient health prior to anticancer therapies to improve treatment tolerance and efficacy.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play an important role in the treatment of patients with cancer throughout the cancer care continuum. Many nurses are already aiding their patients in cancer prehabilitation through education. By describing common impairments amenable to multimodal prehabilitation, nurses may better advocate for their patients and can become even more involved in this aspect of care.

Geographic variation in referral practices for patients with suspected head and neck cancer: A survey of general practitioners using a clinical vignette

INTRODUCTION

General practitioners (GPs) play a crucial role in cancer care and GPs are often the first doctor that patients with symptoms suggestive of cancer will encounter. Head and neck cancer (HNC) is a relatively uncommon presentation in primary care, and evidence suggests that times to diagnosis and treatment of HNC vary based on geographical location of patients. This may be due to barriers to referral faced by regional or rural GPs as compared to those in metropolitan cities in Australia.

OBJECTIVE

To investigate the effect of geographical location of GPs on management of patients with symptoms suggestive of HNC.

DESIGN

This was a descriptive, analytical, cross-sectional survey. Surveys were sent to GPs at practices in two primary health care networks in New South Wales, Australia (Mid North Coast Primary Healthcare Network and the Central and Eastern Sydney Primary Healthcare Network) between February and May 2020. Main outcome measures were perceived time from referral to specialist appointment, factors affecting timeliness of patient help-seeking, and awareness and use of clinical guidelines.

FINDINGS

A total of 1803 GPs were sampled, of which 196 responded (45 regional GPs and 151 metropolitan GPs). Less than half (48%) of regional GPs reported patients could expect to be seen by a specialist within 2 weeks of referral, compared to 70% of metropolitan GPs (p = 0.001). Most metropolitan GPs stated they would refer a patient with suspected HNC to a surgeon subspecialising in HNC. Regional GPs were split between ear, nose, and throat (ENT) and general surgeons. Availability of services was the most common factor influencing referral practices for regional GPs, whereas for metropolitan GPs, this was the patient's symptoms. Awareness of government resources for cancer referrals was generally low.

DISCUSSION

Regional GPs report patients with HNC are less likely to be seen by a specialist within optimal time frames compared to metropolitan GPs. Respondents reported different barriers to early referral of patients with suspected HNC, with regional GPs more often citing system-level factors while metropolitan GPs more often cited patient-level factors.

CONCLUSION

Evaluating service provision and uptake with respect to community need, and addressing of barriers to implementation, may minimise unwarranted clinical variation.

Morbidity and measures of the diagnostic process in primary care for patients subsequently diagnosed with cancer

BACKGROUND

There is uncertainty regarding how pre-existing conditions (morbidities) may influence the primary care investigation and management of individuals subsequently diagnosed with cancer.

METHODS

We identified morbidities using information from both primary and secondary care records among 11,716 patients included in the English National Cancer Diagnosis Audit (NCDA) 2014. We examined variation in 5 measures of the diagnostic process (the primary care interval, diagnostic interval, number of pre-referral consultations, use of primary care-led investigations, and referral type) by both primary care- and hospital records-derived measures of morbidity.

RESULTS

Morbidity prevalence recorded before cancer diagnosis was almost threefold greater using the primary care (75%) vs secondary care-derived measure (28%). After adjustment, there was limited variation in the primary care interval and the number of pre-referral consultations by either definition of morbidity. Patients with more severe morbidities were less likely to have had a primary care-led investigation before cancer diagnosis compared with those without any morbidity (adjusted odds ratio, OR [95% confidence interval]: 0.72 [0.60-0.86] for Charlson score 3+ vs 0; joint P < 0.001). Patients with multiple primary care-recorded conditions or a Charlson score of 3+ were more likely to have diagnostic intervals exceeding 60 days (aOR: 1.26 [1.10-1.45] and 1.19 [>1.00-1.41], respectively), and more likely to receive an emergency referral (aOR: 1.60 [1.26-2.02] and 1.61 [1.26-2.06], respectively).

CONCLUSION

Among cancer cases with up to 2 morbidities, there was no evidence of differences in diagnostic processes and intervals in primary care but higher morbidity burden was associated with longer time to diagnosis and higher likelihood of emergency referral.

Healthcare use in the year preceding a diagnosis of pancreatic cancer: a register-based cohort study in Denmark

OBJECTIVE

To describe the use of healthcare prior to a diagnosis of pancreatic cancer in Denmark.

DESIGN

A population-based cohort study using prospectively recorded data from Danish National Health Registries.

SETTING

Danish general practice and hospitals.

SUBJECTS

A total of 5926 patients diagnosed with pancreatic cancer in 2012-2018 and 59,260 matched references without pancreatic cancer from the Danish general population.

MAIN OUTCOME MEASURES

The monthly frequency of healthcare use (contacts and tests in general practice and contacts and diagnostic investigations in hospitals) during the 12 months preceding the pancreatic cancer diagnosis and a corresponding index date assigned to the references.

RESULTS

Compared to the references, the patients had increased contacts and diagnostic tests, especially blood glucose testing, in general practice from 7 to 12 months before diagnosis. Hospital contacts and diagnostic imaging increased from 5 months before the diagnosis.

CONCLUSIONS

The pattern of increasing healthcare contacts before a diagnosis of pancreatic cancer may represent a window of opportunity to diagnose pancreatic cancer earlier. The increased use of blood glucose test in general practice may represent an important sign of an underlying disease. Key pointsPancreatic cancer is a rapidly progressing and highly lethal disease. Focus on early diagnosis is essential to improve the prognosis.Patients with pancreatic cancer had increased number of healthcare contacts from 7 months before the diagnosis.Patients with pancreatic cancer had increased number of blood glucose tests taken throughout almost the entire year before the diagnosis.The results may indicate that a window of opportunity exists to diagnose pancreatic cancer earlier.

Risk of cancer following primary care presentation with fatigue: a population-based cohort study of a quarter of a million patients

BACKGROUND

The management of adults presenting with fatigue presents a diagnostic challenge, particularly regarding possible underlying cancer.

METHODS

Using electronic health records, we examined cancer risk in patients presenting to primary care with new-onset fatigue in England during 2007-2013, compared to general population estimates. We examined variation by age, sex, deprivation, and time following presentation.

FINDINGS

Of 250,606 patients presenting with fatigue, 12-month cancer risk exceeded 3% in men aged 65 and over and women aged 80 and over, and 6% in men aged 80 and over. Nearly half (47%) of cancers were diagnosed within 3 months from first fatigue presentation. Site-specific cancer risk was higher than the general population for most cancers studied, with greatest relative increases for leukaemia, pancreatic and brain cancers.

CONCLUSIONS

In older patients, new-onset fatigue is associated with cancer risk exceeding current thresholds for urgent specialist referral. Future research should consider how risk is modified by the presence or absence of other signs and symptoms. Excess cancer risk wanes rapidly after 3 months, which could inform the duration of a 'safety-netting' period. Fatigue presentation is not strongly predictive of any single cancer, although certain cancers are over-represented; this knowledge can help prioritise diagnostic strategies.

Referring patients with suspected lung cancer: a qualitative study with primary healthcare professionals in Ireland

Lung cancer is the leading cause of cancer death globally. Most cases are diagnosed late. Primary healthcare professionals are often the first point of contact for symptoms of concern. This study explored primary healthcare professionals’ experience of referring individuals with signs and symptoms suggestive of lung cancer along the appropriate healthcare pathway and explored strategies to help primary healthcare professionals detect lung cancer early. Focus groups and individual interviews were conducted with 36 general practitioners, community pharmacists, practice nurses, and public health nurses. Data were analysed thematically. Participants identified typical lung cancer signs and symptoms such as cough and coughing up blood (i.e., haemoptysis) as triggers for referral. Atypical/non-specific signs and symptoms such as back pain, pallor, and abnormal blood tests were perceived as difficult to interpret. Participants often refrained from using the word ‘cancer’ during conversations with patients. Ireland’s Rapid Access Lung Clinics were perceived as underused, with some general practitioners referring patients to these clinics only when clear and definitive lung cancer signs and symptoms are noted. Lack of communication and the resulting disruption in continuity of care for patients with suspected lung cancer were highlighted as healthcare system flaws. Education on early referral can be in the form of communications from professional organizations, webinars, interdisciplinary meetings, education by lung specialists, and patient testimonials. Lung cancer referral checklists and algorithms should be simple, clear, and visually appealing, either developed as standalone tools or embedded into existing primary care software/programmes.

Primary healthcare professionals' perspectives on patient help-seeking for lung cancer warning signs and symptoms: a qualitative study

BACKGROUND

Lung cancer is the leading cause of cancer incidence and mortality worldwide. Prompt patient help-seeking for signs and symptoms suggestive of lung cancer is crucial for early referral, diagnosis, and survivorship. However, individuals with potential lung cancer symptoms tend to delay help-seeking. This qualitative study explored perceived barriers to patient help-seeking and strategies to enhance help-seeking for lung cancer warning signs and symptoms from the perspective of primary healthcare professionals.

METHODS

Semi-structured focus groups and individual interviews were conducted with 36 primary healthcare professionals. Data were collected via videoconferencing. Inductive thematic analysis was conducted.

RESULTS

The following two themes were created from the data: (i) perceived barriers to patient help-seeking for signs and symptoms of concern and (ii) facilitating early patient presentation for signs and symptoms of concern. Some participants believed that the high cost of a general practitioner visit, long waiting times, and previous bad experiences with the healthcare system would deter patients from seeking help for symptoms of lung cancer. Perceived patient-related barriers to help-seeking related to the different emotions associated with a potential cancer diagnosis as well as stigma, embarrassment, and guilt felt by smokers. Sociodemographic factors such as drug use, homelessness, living in rural areas, and being male and older were also perceived to impede patient help-seeking. The negative impact of the COVID-19 pandemic on cancer help-seeking also featured strongly. Participants recommended several strategies to enable patients to seek help for symptoms of concern including targeted educational campaigns focussing on symptoms (e.g., cough) rather than behaviours (e.g., smoking), accessible and free health services, and using patients' support networks.

CONCLUSIONS

Patient-related and healthcare system-related barriers to help-seeking for lung cancer warning signs and symptoms include cost of healthcare, cancer fear, and various sociodemographic factors. Participants suggested that increased awareness and early patient help-seeking for symptoms of concern could be achieved through targeted patient education, national campaigns, the use of community support networks, and free and accessible targeted screening services.